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Mechanical Low Back Pain

Progression of Treatment


Derangement Syndrome

Typical treatment progression: Derangement one
Day Treatment
One
  • Assessment and conclusion/diagnosis.
  • Explanation of cause of derangement and treatment approach.
  • Reduction of derangement: commence with lying prone, lying prone in extension, extension in lying.
  • Instruct to maintain lordosis at all times, must sit with lordosis and insert lumbar support. May benefit from supportive roll in bed.
  • Repeat extension procedures each hour to maintain reduction and prevent recurrence.
  • If extension in lying is not possible, it must be replaced by extension in standing.
  • On recurrence of symptoms watch maintenance of lordosis even more, and immediately perform extension in lying.
  • Demonstrate the use of lumbar supports in siting and lying.
Two
  • Confirm diagnosis.
  • Check sitting posture and exercises.
  • If improving then change nothing other than reducing extension in lying to once every two hours; replace extension in lying with extension in standing when necessary.
  • If no improvement at all then check that exercises are performed far enough into extension, often enough during the day, and that the lordosis is well kept.
  • Add extension mobilization, possibly rotation mobilization in extension.
  • Warn for 'new pains.'
Three
  • Check sitting posture and exercises.
  • If improving continue with procedures as directed.
  • Once constant pain has changed to intermittent pain, Stop lying prone and lying prone in extension; start the slouch-over correct exercise.
  • If no improvement, concentrate on mobilization techniques and add extension manipulation.
Four
  • Check exercises and progress.
  • If progress is satisfactory, reduce treatment to three times per week.
  • Continue with the same program until pain free for three days at least.
  • If progress is unsatisfactory, repeat mobilization and manipulation technique.
Five
and Seven
  • Check exercises and progress.
  • Once pain free for three days, reduce extension in lying to three times per day and replace it by extension in standing whenever necessary during the day.
  • Commencing flexion in lying; take all necessary precautions.
  • Flexion in lying must be followed by extension in lying.
Further
treatments
  • I prefer to see patients with derangement every day until the reduction is stable and patients are in control. This may take up to five days. Then the treatment might be reduced to alternate days.
  • Once reduction of derangement proves stable and the patient has been pain free for at least three days, flexion exercises may be started to recover function.
  • All flexion exercises must be followed by extension in lying; if this is not possible extension in standing must be performed.
  • When no further flexion can be gained with flexion in lying, the patient must start flexion in standing.
  • When function is recovered flexion in standing may cease.
  • The patient is advised to continue with the exercises for another six weeks to prevent recurrence: he will do extension in lying in the morning; flexion in lying followed by extension in lying in the evening; extension in standing whenever necessary during the day; and possibly the slouch--over correct exercise, whenever becoming negligent regarding sitting.
  • Before discharge, prophylaxis and self-treatment must be discussed in detail. We must emphasize that self-treatment is infinitely preferable to dependence on therapy.

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Last Update: September 11 2012