Gathering place for osteopaths
Treatment strategy for an Acute Disc Lesion
Hello Musers,
I would like to begin a discussion about treatment strategy in the case of an acute disc lesion, say, of a week and more duration. What are the things that you normally do in such cases.
One may be surprised by why such question is being posted but if you look carefully at the number of strategies available from different sources and some outstanding (and some not) results (which we all know result from different,yet not always understood facts) there is no consistency in it, from bed rest to 'stay active' which I prefer for my patients. But I am more interested in some specific treatment approach giving as an example Thierry Collot's hold-relax-like sequence in side lying position to drain an inter-vertebral foramen's content.
Thank you in advance for sharing some of your golden rules:)
Rafal (PL)
Tags: acute, degenerative disc disease, disc, low back pain, osteopathic approach, osteopathy, treatment
Replies to This Discussion
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Permalink Reply by Rikamortis on
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Hi Rafal,
For an acute disc with no leg symptoms initially i adjust it daily if not more this achieves the same result you describe above i.e removing congestion from inflammation, i dont do anything else as this tends to aggrivate. These patients are in a lot of pain and seeing them daily can do them the world of good they feel like there is someone there for them.
As symptoms improve i reduce the frequency of adjustments. Everyone is different but i have found there is usually an improvement in pain scale and rom in 7-10 days although obviously 100% imp wont happen for months.
I try to do the adjustment along the plane of the disc to remove pressure on the posterior aspect. Whether this happens or not i dont know but thats what i tell myself.....I advise ice ice ice and more ice then just general disc management procedures dont bend, dont lift, dont sit longer that 10-15mins, try to lie flat on front or back (which ever is more comfortable) for 10mins a couple of times a day, sit on a high backed seat, take Nsaid's and analgesics if its codine based make sure they take a laxative or up their fiber.
Explain the situation and the time frame, why it will take so long to heal and make sure the patient understands that although it will take wks/months it will get better....
Longer term as symptoms improve i advise rehab exx swimming etc to give them the confidence to move again...
Thats my approach and so far its worked very well for me...
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Permalink Reply by Small Fry on -
I would start by looking for causation, both internal and external to the body. Forces can be focussed onto stressed tissues for many reasons, some of those reasons are quite remote and distant. I wouldn't adjust quite so frequently as that as I don't think it's necessary, but I would be available by phone at all times and expect daily contact at first. I tend to work from distant to near, getting closer to the damage as the condition improves. I think this is safer than and just as effective as heroic maneouvres to acutely inflammed tissues. All the same 7-10 days to get out of initial trouble and on the way to recovery is about what to expect, 4-6 weeks to be out of significant pain, and another 6 months or so for full restoration of strength, all going well. Remember, this is not a lazy person's problem: stop the patient doing what they are doing that has created this, and some improvement is assured. The drawbacks to painkillers are many - it detaches people from the cause and effect of their situation; NSAIDs interfere with connective tissue repair; codeine etc are toxic to the liver and affect nutritional status, which may already be a factor in the aetiology of the problem. I don't see this as a mechanical problem, living tissue is always a general health problem. Hence hydration and nutrition are huge also, a dehydrated disc will bulge and crack like a tyre losing air. Deficiencies of any kind will affect recovery and regeneration, and may exacerbate the inflammatory response above what is needed to repair the damage.
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Permalink Reply by rafalkra on -
Hi Rik,
Thanks for reply. One thing seems particularly interesting, namely "adjustment along the plane of the disc".
1) can you describe it?
And more:
2) how do you think HVTs work? do you still stick up to the neural loop and reflexive response? if so, and this is the biggest 'unknown' (IMO), how this affect a patient's perception of pain? muscle's spasm (another 'unknown' fact as short paravertebral muscles seem to be totally inhibited rather than tensed) cannot explain the amount of pain those people experience (inflammation fits much better in the picture.
Rik Fulton said:Hi Rafal,
For an acute disc with no leg symptoms initially i adjust it daily if not more this achieves the same result you describe above i.e removing congestion from inflammation, i dont do anything else as this tends to aggrivate. These patients are in a lot of pain and seeing them daily can do them the world of good they feel like there is someone there for them.
As symptoms improve i reduce the frequency of adjustments. Everyone is different but i have found there is usually an improvement in pain scale and rom in 7-10 days although obviously 100% imp wont happen for months.
I try to do the adjustment along the plane of the disc to remove pressure on the posterior aspect. Whether this happens or not i dont know but thats what i tell myself.....I advise ice ice ice and more ice then just general disc management procedures dont bend, dont lift, dont sit longer that 10-15mins, try to lie flat on front or back (which ever is more comfortable) for 10mins a couple of times a day, sit on a high backed seat, take Nsaid's and analgesics if its codine based make sure they take a laxative or up their fiber.
Explain the situation and the time frame, why it will take so long to heal and make sure the patient understands that although it will take wks/months it will get better....
Longer term as symptoms improve i advise rehab exx swimming etc to give them the confidence to move again...
Thats my approach and so far its worked very well for me...
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Permalink Reply by rafalkra on
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Small Fry,
your comments are, as always, very valuable. I think I'm closest to your approach, i.e. from distant to near, without the unnecessary maneuvers although I do manipulate if a patient reacts positively to a near-to-thrust position. Sometimes it works.
My biggest concern has always been loss of strength in a foot as far as an HVT is concerned. Is your decision, to adjust it or not, based entirely on your experience or some other premise?
Rafal
Small Fry said:I would start by looking for causation, both internal and external to the body. Forces can be focussed onto stressed tissues for many reasons, some of those reasons are quite remote and distant. I wouldn't adjust quite so frequently as that as I don't think it's necessary, but I would be available by phone at all times and expect daily contact at first. I tend to work from distant to near, getting closer to the damage as the condition improves. I think this is safer than and just as effective as heroic maneouvres to acutely inflammed tissues. All the same 7-10 days to get out of initial trouble and on the way to recovery is about what to expect, 4-6 weeks to be out of significant pain, and another 6 months or so for full restoration of strength, all going well. Remember, this is not a lazy person's problem: stop the patient doing what they are doing that has created this, and some improvement is assured. The drawbacks to painkillers are many - it detaches people from the cause and effect of their situation; NSAIDs interfere with connective tissue repair; codeine etc are toxic to the liver and affect nutritional status, which may already be a factor in the aetiology of the problem. I don't see this as a mechanical problem, living tissue is always a general health problem. Hence hydration and nutrition are huge also, a dehydrated disc will bulge and crack like a tyre losing air. Deficiencies of any kind will affect recovery and regeneration, and may exacerbate the inflammatory response above what is needed to repair the damage.
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Permalink Reply by Small Fry on
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O golly, too many variables to give a universal answer. Suffice to say the first rule is always not to make the situation worse. After that, manipulation is not the object of the exercise, and how they are in a few weeks' time is much more important than how they are in 20 minutes. If it's one percent better after treatment that's a result, one percent worse is a fail. That doesn't mean maniuplation is a no-no, it means that approaching complex systems take a different set of questions. The EBM mindset - trying to find the best formula in advance - still hasn't told us whether ice or heat is better for a sprained ankle, the world's breath is no longer bated even on that. What you describe is a sensitive and responsive approach, finding out what the tissues tolerate or need at that given moment in order to make the situation better at a big-picture level. That requires a mental construct of where treatment is heading, a responsive approach but not a reactive one. Much better IMHO than working it all out with a formula, loosening off all the tight bits, and hoping it's right.
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Permalink Reply by Quatermass on -
My preference in very acute cases is minimal, locally specific intervention using MET or positional release methods, three times in the first week then see. I am very "structural" in this phase, looking for better alignment of the structures local to the involved disc and any other structures upon which they immediately depend (e.g. pelvis in the case of a lumbar disc). The reasoning is simple, remove mechanical strain from the disc, inflammation resolves. As things improve I widen the potential target of treatment to the whole body - now harmony and coordination of motion are as important as alignment - as well as addressing behavioural and environmental precipitating and predisposing factors. My time frame concurs with what others have expressed.
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Permalink Reply by Small Fry on
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Any structural engineers here? I'm wondering if it follows necessarily that nearby structural relationships are more important than distant ones in focussing forces. I have never assumed this to be true. I see the head as being like a melon waving around on a stick: if the movement or force is excessive, or not well dissipated by the spine, then the 'hand' gripping the bottom of the stick has to work very hard. Just testing now, moving my chin two inches towards my computer screen, I can feel the muscles at the base of my spine working harder.
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Permalink Reply by Small Fry on
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Maybe the prognosis for a disc is 30 days with local treatment, a month with distant treatment, and 4 weeks with no treatment. And relapse or setback if the patient does anything silly. So perhaps getting the patient to avoid doing anything silly is the most important element.
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Permalink Reply by DeadlyJedly on -
I'm the MD osteopath wannabe from the states. I am putting this out there just for input. I focus on treating restrictions in the area that I can. e.g. visceral scars that might interact with the disc, the T-L junction, S-I joints, and hips typically. I also typically check the left kidney as mobilizing that is the best I can do to facilitate drainage via the left renal vein and lumbar veins for decreasing inflammatory pressure in the region. I will mobilize the sciatic nerve with induction or if necessary direct release based on listening, I avoid tugging on the nerve or neural glides but I want to try to create some freedom of movement so the nerve is not tethered and fluids can move. I might also try to decompact the affected level if I sense that is needed.
Any criticism in my approach is welcome
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Permalink Reply by rafalkra on
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Thanks. No criticism is necessary as long as your treatment brings about positive results. It is not us to judge it but a patient, at the end. I just wonder how such a small 'tip' like mobilizing a kidney can affect a patient's condition significantly, in the case we are talking about now. Can you expand your though?
Rafal
DeadlyJedly said:I'm the MD osteopath wannabe from the states. I am putting this out there just for input. I focus on treating restrictions in the area that I can. e.g. visceral scars that might interact with the disc, the T-L junction, S-I joints, and hips typically. I also typically check the left kidney as mobilizing that is the best I can do to facilitate drainage via the left renal vein and lumbar veins for decreasing inflammatory pressure in the region. I will mobilize the sciatic nerve with induction or if necessary direct release based on listening, I avoid tugging on the nerve or neural glides but I want to try to create some freedom of movement so the nerve is not tethered and fluids can move. I might also try to decompact the affected level if I sense that is needed.
Any criticism in my approach is welcome
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Permalink Reply by Theodore Jordan on -
My person preference, in a very acute case, is work peripherally to centrally. I think of the whole kinetic chain, and for low back, the feet are a good place to start. ...or the head/neck/arms/hands. An acutely flared low back is part of an agitated system, anything to calm the system is a good place to start. Likely, the low back itself will not tolerate too much perturbation.
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Permalink Reply by rafalkra on
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Well, what seems to have emerged so far here is a picture/pre-conclusion that ALBP is something that we don't have tools that are good enoughto treat it directly and what is left is to provide the body with the best care throughout the entire process of its repair until it subsides by itself...isn't it a philosphy of osteopathy?:))
Theodore Jordan said:My person preference, in a very acute case, is work peripherally to centrally. I think of the whole kinetic chain, and for low back, the feet are a good place to start. ...or the head/neck/arms/hands. An acutely flared low back is part of an agitated system, anything to calm the system is a good place to start. Likely, the low back itself will not tolerate too much perturbation.
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