Replies to This Discussion

Permalink Reply by Tim Baker on December 20, 2011 at 6:12pm

What do you mean by an acute disc lesion and what evidence do you have for that diagnosis (or even suspicion)?

TB

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Permalink Reply by Quatermass on December 22, 2011 at 6:55pm

Hi Rafalka,

Just coming back to a few of the themes that have emerged...

Firstly, the pathology and its relevance to treatment. Rafalka, your question asked about the "acute disc lesion", a generic descriptor. Some have taken this to mean prolapsed intervertebral disc - a more specific diagnosis. But degenerative disc disease (DDD) is a spectrum of pathology (one outcome of which may be frank prolapse) and acute symptoms may be associated with different stages of its evolution. So it is possible that contributors comments may not always refer to the same context. We have to question the frequent assumption that acute symptoms, in the context of DDD, may be attributed to the disc. Clearly such attribution becomes more realistic the larger the bulge/prolapse, but at earlier stages in the evolution of DDD there is no one-to-one relationship between MRI abnormalities and the degree, or presence, of symptoms. Some of the pain characteristics and tests mentioned by David will help to implicate discs, but they won't always behave as per textbook. Many other factors beside the disc will combine to produce a context in which certain characteristics appear or not.

Secondly, treatment strategies. We have to treat the patient, not the MRI, and Rafalka, you say that you treat what you find (and indeed can only treat what you can find). One could add that you can only find what you look for, and you will only look for what you have come to believe (or been taught to believe) is relevant. Evidently from the contributions here and elsewhere, different people focus their attention on different phenomena with different priorities and from different perspectives. Hence different treatments. Some have insisted on the requirement to treat whole body patterns, to move them as a whole towards normal physiology. Others (from their descriptions) treat all over the body, but more in the way of this bit, that bit rather than overall according to an overall vision, having looked for dysfunctional bits rather than a dysfunctional whole. In that case, I suppose there would be two possible conceptions: (a) attempt to understand the connections between the abnormalities one has found, and trust in the healing organism; or (b) simply trust in the healing organism. You asked for others views, and mine is that I like to try to understand how the general fits with the particular, and how the particular fits with the general, so the focus of attention will vary according to the moment, according to the phase of treatment, and from case to case. That doesn't mean the exclusive attention, just the focus.

Which brings us to "treating discs". Is there any need to treat according to pathology? Some contributors (like yourself Rafalka) have mentioned techniques they use for discs. I have not really done this in my practice, except in avoidance (strong torsion, positions causing pain, force - which I avoid anyway), though I suppose I might use traction a little more if I'm thinking of the disc (unsure if this has ever made a difference, though). That said, I can understand that if you have found a certain technique to be both effective in reducing pain and harmless, this must be welcome to the patient in acute pain.

You asked about treatment strategy though, so I don't know why we have got hung up on techniques. I would suggest that strategy should be different in acute cases (disc or no disc) than in chronic ones. Chronics require a long-term and wider reaching plan from the word go, and manual treatment will address more extensive patterns in the body. Acutes require our help to have less pain as soon as possible, if possible. The patient is in your room, crying from distress through pain and lack of sleep. If there are things that we believe we can do to help her with that, we are bound to do them. We will have discovered those things empirically. Some may fit with our theory perfectly or derive directly from it, some may derive from a more limited working hypothesis, some may be purely empirical, chosen by heuristic. Either way, no harm will be done in the short or long term if we are gentle. If there is a time for being pragmatic, this is it. Acute on chronic, or the common case of the last straw, or when there are obvious wider issues, will require much more extensive care, but not here and now. The bigger plan can wait till the pain is bearable.

Thirdly, nutrition. This means nutrient supply at organism level (diet) and tissue level (osteopathy). But what of supplements? Certain supplements have been recommended for degenerative discopathy in this thread on the "acute disc lesion". Will supplements have a bearing on acute pain? Vitamins C & D have been mentioned, I suppose for their roles in connective tissue metabolism and prevention of long term oxidative damage. But isn't there something conceptually incongruous, as osteopaths, in prescribing supplements per pathology? I would imagine that if outside of some kind of integrative scheme of things in nutritional biochemistry, pathology-specific prescribing were likely to risk long-term disadvantages for the organism.

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Permalink Reply by Small Fry on December 22, 2011 at 7:30pm

QM, just briefly; I tend not to recommend supplements for a particular pathology, but because I suspect either a need or an increased need for that person - the evidence they may be low in something is that they are unwell, it does not matter this has shown up in the disc or anywhere else.  The aim is not to 'medicate' with a nutrient, but to supply in a quantity the body will welcome.  The rationale for vitamin D and vitamin C is that our patient is quite probably low in both (there is enough literature on this to satisfy me of that point), and not because being high in either will confer some superhuman advantage (it doesn't).  Excess does not bring about an amazing recovery, it's that if they continue to be low recovery will be that much harder (it may be a factor already in the failure that has brought them to us), inflammation will be excessive, prolonged or unresolved, immunity will be impaired, both have direct consequences for a damaged disc.  Animal models suggest that most mammals produce the bodyweight equivalent of around 4g per day of vitamin C in a human (I forget exactly without going to the literature), but increasing in any kind of stress, sickness or injury.  The RDA for vitamin D is 400iu, yet it takes ten times that amount just to keep levels from backsliding (let alone restoring a depleted reserve of a fat-soluble ie stored substance).  Most people are low in C because of modern food production, storage, processing and distribution, let alone dietary habits, and low in D because we work in offices, when our forebears worked outside and tended the garden.  This is not treating with nutriceuticals, it is supplying a basic need.

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Permalink Reply by indikate on December 22, 2011 at 8:11pm

I tend to put my patients onto optimal levels of vit c and D3 when I feel they need it for the reasons given by Small Fry. QM I agree with your comment re pathology, it is the absence of Health and the nutritional approach described supports the health. I have found a difference in the strength of the health in patients who are optimally nourished, ie when I put my hands on and feel the health directly it feels stronger/more powerful. This convinced me to continue.

It is obvious that you think and care greatly. peace and goodwill for the holidays

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Permalink Reply by Quatermass on December 22, 2011 at 10:00pm

Thanks both. My best wishes too.

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Permalink Reply by rafalkra on December 23, 2011 at 11:59am

Thanks for the analysis, actually I've been about to do it and read carefully the whole thread one more time. Anyway, according to Karel Lewit, Geoffrey Maitland and many others (I think I said it somewhere that I derive from many sources without fixing myself on to something particular although osteopathy is the closest to my heart) there are so called 'clinical patterns' which, for many other reasons, help us to distinguish the most likely pathology as these share some common features in every individual. It is of course starting point from which one can begin a more detailed investigation as to what structural-functional interactions make this patient to suffer (and here I'd like to quote S.Sandler: "why this patient, why this problem, why now"). Following some suggestions I've started to ask my 'acute' patients to supplement vit C&D and added Mg to that mixture. I am really interested in what this will bring back:) Not that I am going to do it as a must 'otherwise-get-lost', this is simply a trial if it is worth doing and I base this on history taking questions ie 'where do you work', 'how much time do you spend in the office', 'do you drink coffee' etc. My strategy is now set upon calming down the patient, bringing the pain down by any means and restoration of function which is rather a long-term goal assuming that a stability training I made up for my patients a year or so ago takes +/- 8-12 weeks.
Merry Christmas to All of you, and greetings from Poland:)

Rafal

Quatermass said:

Hi Rafalka,

Just coming back to a few of the themes that have emerged...

Firstly, the pathology and its relevance to treatment. Rafalka, your question asked about the "acute disc lesion", a generic descriptor. Some have taken this to mean prolapsed intervertebral disc - a more specific diagnosis. But degenerative disc disease (DDD) is a spectrum of pathology (one outcome of which may be frank prolapse) and acute symptoms may be associated with different stages of its evolution. So it is possible that contributors comments may not always refer to the same context. We have to question the frequent assumption that acute symptoms, in the context of DDD, may be attributed to the disc. Clearly such attribution becomes more realistic the larger the bulge/prolapse, but at earlier stages in the evolution of DDD there is no one-to-one relationship between MRI abnormalities and the degree, or presence, of symptoms. Some of the pain characteristics and tests mentioned by David will help to implicate discs, but they won't always behave as per textbook. Many other factors beside the disc will combine to produce a context in which certain characteristics appear or not.

Secondly, treatment strategies. We have to treat the patient, not the MRI, and Rafalka, you say that you treat what you find (and indeed can only treat what you can find). One could add that you can only find what you look for, and you will only look for what you have come to believe (or been taught to believe) is relevant. Evidently from the contributions here and elsewhere, different people focus their attention on different phenomena with different priorities and from different perspectives. Hence different treatments. Some have insisted on the requirement to treat whole body patterns, to move them as a whole towards normal physiology. Others (from their descriptions) treat all over the body, but more in the way of this bit, that bit rather than overall according to an overall vision, having looked for dysfunctional bits rather than a dysfunctional whole. In that case, I suppose there would be two possible conceptions: (a) attempt to understand the connections between the abnormalities one has found, and trust in the healing organism; or (b) simply trust in the healing organism. You asked for others views, and mine is that I like to try to understand how the general fits with the particular, and how the particular fits with the general, so the focus of attention will vary according to the moment, according to the phase of treatment, and from case to case. That doesn't mean the exclusive attention, just the focus.

Which brings us to "treating discs". Is there any need to treat according to pathology? Some contributors (like yourself Rafalka) have mentioned techniques they use for discs. I have not really done this in my practice, except in avoidance (strong torsion, positions causing pain, force - which I avoid anyway), though I suppose I might use traction a little more if I'm thinking of the disc (unsure if this has ever made a difference, though). That said, I can understand that if you have found a certain technique to be both effective in reducing pain and harmless, this must be welcome to the patient in acute pain.

You asked about treatment strategy though, so I don't know why we have got hung up on techniques. I would suggest that strategy should be different in acute cases (disc or no disc) than in chronic ones. Chronics require a long-term and wider reaching plan from the word go, and manual treatment will address more extensive patterns in the body. Acutes require our help to have less pain as soon as possible, if possible. The patient is in your room, crying from distress through pain and lack of sleep. If there are things that we believe we can do to help her with that, we are bound to do them. We will have discovered those things empirically. Some may fit with our theory perfectly or derive directly from it, some may derive from a more limited working hypothesis, some may be purely empirical, chosen by heuristic. Either way, no harm will be done in the short or long term if we are gentle. If there is a time for being pragmatic, this is it. Acute on chronic, or the common case of the last straw, or when there are obvious wider issues, will require much more extensive care, but not here and now. The bigger plan can wait till the pain is bearable.

Thirdly, nutrition. This means nutrient supply at organism level (diet) and tissue level (osteopathy). But what of supplements? Certain supplements have been recommended for degenerative discopathy in this thread on the "acute disc lesion". Will supplements have a bearing on acute pain? Vitamins C & D have been mentioned, I suppose for their roles in connective tissue metabolism and prevention of long term oxidative damage. But isn't there something conceptually incongruous, as osteopaths, in prescribing supplements per pathology? I would imagine that if outside of some kind of integrative scheme of things in nutritional biochemistry, pathology-specific prescribing were likely to risk long-term disadvantages for the organism.

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Permalink Reply by indikate on December 23, 2011 at 6:42pm

Hi Rafalkra  you can combine the Mg and Vit c by giving magnesium ascorbate

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Permalink Reply by Harry on December 23, 2011 at 11:18pm

Merry Christmas and Happy New Year Rafal.

Best wishes,

HH
 
rafalkra said:

Merry Christmas to All of you, and greetings from Poland:)

Rafal

 

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