Transcript The Internal Disc Derangement Syndrome

The Internal Disc Derangement
Syndrome
Using self directed movement for
evaluation & management
Michael N. Brown, DC, MD, DABPMR-PAIN
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The lumbar disc in health & disease
The nature of low back pain
• Elusive diagnosis for specific causative lesion
• Lends itself to speculation, theory, patho-anatomical
models
• 80% of low back pain will spontaneously resolve on its own
any course of time.
– Depending on length of care anything will work some of
the time thereby fueling a myriad of alternative therapies
that may have little merit or evidence to support its use.
Care depends upon the model
• Manual therapist:
– Manipulation, traction, massage
– FOCUS = facet joint, sacroiliac joint,
trigger points, etc.
• Physical therapy:
– Exercise, conditioning
– Physical modalities
• Physician:
– Muscle relaxants – muscle spasm
– NSAIDs – inflammation
• Pain specialist:
– Narcotics, epidural steroids, facet joint
steroids
Value of imaging & routine
orthopedic exam
•
•
•
•
•
Motor function: Normal
Sensory exam: Normal
Reflexes: Normal
Dural tension signs: Normal
Provocative orthopedic tests:
– Employ endrange loading to provoke symptoms.
– Positive when it elicits signs or symptoms on
which the test is predicated.
• How often are these routine tests valuable?
Finding the nociceptive pain foci: can the
average clinician accomplish this?
• How often is an MRI diagnostic?
• In the absence of disc herniation and
neurologic deficit comprehensive
physical assessment, diagnostic
technology (MRI, EMG, etc.)
identifies cause of low back pain
______% of the time?
Manchikenti L, Singa V, Pampati V, et al. Evaluation of the relative contributions of various
structures in chronic low back pain. Pain Phys 2000; 4:308-16
Can it rapidly be resolved?
The acute low back pain
episode
Subjective response
to static and end
range spinal loading.
Using principles classically taught by McKenzie et al.
Case #1
• 20 spanish speaking male:
– Painter, working for painting contractor.
– Contractor reqested consult
– Pt. brought in by bilingual sister.
HPI:
• Injured low back lifting air compressor into back of
pickup.
• Immediate onset of low back pain, which worsened next
day.
• Seen at the occupational health clinic. Xrays neg.
– Rx: vicodin, flexiril
– TTD
– Physical therapy
Case #1 continued
• Subjective:
– Low back pain over LS spine that radiates into
right thigh and calf.
– Pain constant worsened with standing, rising
out of chair, stooping, bending, lifting.
– Pain not improved with therapy, medications
and time.
– Family concerned, employer concerned…
Case #1 continued…
Exam:
– Thin tall male sitting with antalgic lean, appeared to be
uncomfortable.
– Rises slowly out of chair.
– MSR: +2 and symetrical in LE
– Motor: 5/5 in LE
– Sensory exam intact
– Pain on all standing spinal motions.
– Had pain laying in prone position.
– Tenderness over LS spine and erector spinae muscles.
– Pressure over LS spine painful.
– Sitting SLR, Suppine SLR causes back pain but no frank dural
tension signs including Bowstring.
Outcome of the exam & intervention???
• REIL – 100% of leg pan resolved imediately.
– 70% of LBP resolved immediate
FU:
• Prevention
• Education
• How to resolve recurrance
• Return to work
–Modified for 5 days
–RTW regular U&C thereafter.
Intra- discal motion
dynamics
• Important concept in evaluating low
back pain patient.
– Centralization phenomena
• Concept of Creep.
– Applied to sitting.
– Sustained flexion positions.
• Can be used in making discogenic
pain diagnosis and categorization.
• Can be used in both conservative
and interventional treatment
management.
Internal Disc Derangement
Minimal bulge
Normal MRI
No secondary gain
Good psychometrics
Normal x-rays
No response to Tx
Entrapment of nuclear
material with defect in
the annulus?
Internal Disc Derangement
Patient care…
• Patient generated movement
– Rx: Motion that centralized the pain
– 10 reps every 2 hours
– Sit in lordosis
• Driving
• Get out and
walk every hour on the trip
– Flying:
• Isle seat and get up and walk
• Warning signs:
– You know that “feeling”  Centralize
Internal disc derangement
treatment continued…
• Self directed control of pain…
– Internal locus of control
– Puts the patient back in charge of controlling
symptoms
– Is a powerful psychosocial intervention
– Avoids fear avoidance behavior
• Kinesophobia
Trust me…
- warn the patient
Internal disc derangement
Patient education
• Passive end-range extension may cause pain…
– This is NORMAL
– One the third rep it usually gets easier
– Do not make determination of whether this movement
is beneficial or not until after they get up and move
around.
• DID IT CENTRALIZE ???
• If so for how long
• Patient held accountable for exacerbation or
flair…
– If you go out and stoop then you have to give
me 10…. Centralize…. Empowers them
Fear avoidance
Advanced diagnosis and categorization of
low back syndromes…
• Understanding the subjective response to end
range loading provides a means to categorize …
–
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–
Diagnosis
Change strategies for management
Plan management and procedures
Predict imaging findings long before you obtain them.
• Avoid unnecessary imaging
• Predict outcome … prognosis
Advanced diagnosis using
McKenzie Principles
Categorizing lumbar disc & low back pain
syndromes
Lets practice
• 42-year-old presents with acute low back
pain.
• Back pain predominantly in lumbosacral
region.
• Patient in the lateral shift antalgic posture. Rises out
of chair in slow and guarded manner.
• Severe pain with spinal extension and standing.
• Patient tolerates lumbar extension in prone position
with REIL x 10 reps relieving lower back pain.
– REIL resolves the lateral shift posture.
Internal disc deragement
in lateral shift posure
• Entrapment is unilateral right or left
Have patient to combined
side glide and extension
What if…
The pain comes right back…?
Derangement
• Reducible
phenomena
• Improves w/ end
range loading in
directional preference
• Phenomena of
recurrence
• Need for education of
patients.
• Empowers patient
• Reduces dependence
Lets practice
• 43-year-old female with history of low back
pain in the past generally relieved with
chiropractic manipulation.
• Presents with low back pain with some
peripheral buttock and thigh pain bilaterally.
• Negative dural tension signs
• Back pain relieved with REIL but when she
stands pain returns within two minutes.
Lets practice
• 47-year-old male with history of
episodes of back pain generally
improved with chiropractic care in the past.
• Patient presents with low back and peripheral leg
pain with positive dural tension signs.
• REIL relives leg pain but does not relieve low back
pain.
Lets practice
• 47-year-old with previous history of low
back pain generally relieved with
chiropractic manipulation in the past.
• Presents with low back and peripheral
leg pain with positive dural tension signs.
• Low back pain and leg pain unrelieved
by REIL.
• Peripheral leg pain worsens with REIL.
Non-contained disc …
Lets practice
• 50-year-old female presents with chronic low
back pain of seven years duration.
• Back pain occurs over most of lower lumbar
spine extends over the posterior buttock and
proximal thigh.
• Neurological examination normal.
• Back pain does not improve with REIL, RFIL,
Side glides nor manipulation.
• Marked desiccation and disc space narrowing
at L4 L5, and L5-S1.
IDD
In Summary…
• Low back pain patient is complex.
– Many causes
– Many syndromes
– Common source of back pain is the lumbar disc.
• Disc syndromes can be categorized for better
management and intervention to improve outcomes.
• Internal disc derangement is one of many categories of
disc syndromes.
– Centralizes with end range movement usually extension
– Can be taught principles of self management
– Reduces cost, disability
• Provides a means to predict prognosis.
• Share with these patients the handout you can obtain on
my website: michaelnbrownmd.com
Thank you
Michael N. Brown, MD
Previous McKenzie model:
• Was helpful in a rehabilitation setting and
manual medicine paradigm.
• Was helpful in determining if a patient was
amenable to manual therapy.
• Was helpful to predict recovery and set up the
parameters of the rehabilitation process.
• But not adapted by most interventional pain
physicians who know little about manual
medicine and how to interpret the findings of the
examination process.
Derangement syndrome
• Has been the focus of orthopedic, neurosurgical and
interventional physicians who do understand the model.
• The model gave us a number of concept:
– Concept of “directional preference.”
– Centralization response to in range loading.
• First popularized by McKinsey
• Now firmly entrenched in the literature as optimistic
prognosticator of intradiscal complaints.
• Centralization occurs when symptoms radiating
peripheral from the spine resolved towards the “center”
as a result of patient generated in range loading.
• Can be transient
• May cause increase in central discomfort.
Centralization used to predict disco
Donelson et al
• Centralization of pain occurred in 31 (49%) patients
during the McKenzie evaluation.
– Those that did centralize – 74% had positive
dicography.
– Of 16 patients whose symptoms peripheralized,
• 11 had positive discography.
– Centralization has sensitivity 0.92, specificity 0.64,
and positive likelihood ratios of 2.5.
– Peripheralization of Sensitivity 0.69, Specificity 0.64,
and positive likelyhood ratio of 1.9
– Collectively these two signs have sensitivity 0.92,
specificity 0.52, and positive likelihood ratios of 1.96
Pain Center Case 1
HISTORY OF PRESENT ILLNESS:
• 38-year-old female referred by Nelson Hager, MD who had insidious
onset of low back pain in February 2012. There was no inciting event,
however she states she did have fusion of her left foot back in October
2011 and when she was an inactive for about 8 weeks. She then was
attending classes in February and required to sit for 8 hours a day, and
felt severe, deep, aching, stabbing pain in the lower back region, right
greater than left, that has not subsided since this time.
• 3 months of severe pain in her lower back.
• It occasionally radiates a little bit up her spine with occasional shooting
pains and some deep aching pain into her hips and anterior thighs.
However, her most disabling pain is in the right lower back. Her pain is
constant. 7/10
• It is somewhat relieved by standing up and walking. It is exacerbated
by bending forward or sitting. She has some difficulty falling asleep and
it does wake her from sleep.
Pain Center Case 1
• She denies any anxiety or depression. GAD-7 score is 0,
negative for anxiety, and PHQ-9 score is 4, negative for
depression.
• She had a trigger point injection in May 2012 with no relief.
• She also is undergoing physical therapy, which does seem to
help minimally, and she sees a chiropractor, which was
helping initially and then a recent adjustment led her to the
emergency room the following day.
• Progressive relaxation techniques helped.
• Percocet 5/325 mg started in March escalated to MS Contin
15 mg by mouth 2 times a day + Dilaudid when necessary,
and Robaxin
Can it last?
Pt follow up 6 weeks later
INTERIM HISTORY:
• Upon evaluation 6 weeks ago this patient demonstrated centralization
of low back and peripheral leg pain with marked improvement on
repeated in range extension loading of the disc.
• Because of this she appeared to have a reducible disc arrangement
and she was placed on specific corrective exercise movements based
on McKenzie protocols.
• She relates that she had rapid improvement over the course of 3-5
days after seeing us while performing these exercises. She is
continued to perform the exercises and has had a dramatic
improvement of her low back pain.
• She relates that for the most part she has resolved the majority of her
back complaints and feels like she is in control of the back pain. She is
extremely happy about the progress that she is made.
• Today she relates that she does not have any low back issues to
discuss but came in to discuss problems that she has been having with
her right knee a new complaint.
Pain Center Case 2
HISTORY OF PRESENT ILLNESS:
• 57-year-old Caucasian female with known
multiple sclerosis, with a long-standing history of
chronic widespread pain syndromes including
pain in her head, widespread myalgia
complaints in the past which was diagnosed as
fibromyalgia, and most bothersome chronic low
back pain.
Pain Center Case 2
•
LOW BACK:
– Spontaneous onset of lower back pain approximately 10 years ago.
She's had chronic back pain ever since.
– Orthopedic specialist who felt she may have degenerative disc
disease and possible underlying spondyloarthropathy secondary to
psoriatic arthritis. He had no treatment recommendations.
– She returned back to her primary care physician who started:
• fentanyl patch later escalated over time to 100 mcg/hour.
• She remained on fentanyl for some time until her insurance
discontinued the fentanyl.
• Changed PMD who started MS Contin and HC.
• Remained on high dose MS contin and frequent HC to managed
LBP.
• Opioids not taken for FMS symptoms but rather her low back
pain !!
Pain Center Case 2
• Typically if she has leg pain the pain radiates down the
posterior thigh but usually does not radiate below the
knee. She has no known motor or sensory deficits of the
lower extremities.
• Patient want higher dose!
• Now consult requested.
• MRI:
– DDD
– Multilevel facet
arthrosis.
Pain Center Case 2
• Pain intensity of lumbar spine today 9/10
• Exam:
– Tender, Tender, Tender…
– Normal neuro…
– Pain on Kemps, Nachlas, Ely, ROM, etc.
– MCKENZIE: Subjective response in the range spinal
loading in prone lumbar extension was evaluated.
The patient had immediate centralization of all axial
back pain following 7 repetitions of prone lumbar
extension in lying maneuver. Patient had pain from
8/10 reduced to level of 0-1/10 after the maneuver.
Pain Center Case 2
Conclusions
• Patient was instructed on methods to control her low
back pain and most importantly her recurrences of
severe flare that requires her to continue to seek
opioid medications.
• Psychosocial intervention.
• Internal locus of control given back to the patient.
• Responsibility of control of symptoms now back with
the patient rather than the prescription bottle.
• Patient provided extremely positive patient
satisfaction survey and yet, walked out without
further opioid prescription!
Pain Center Case 3:
HISTORY OF PRESENT ILLNESS
• This patient is a 38-year-old petite no Caucasian female who developed
insidious onset of rather significant low back pain in February 2012. She had no
precipitating event. She did have a foot injury in a accident she had in October
she had no back pain at that time. Her back pain was for the most part to the
right of midline overlying the right sacroiliac joint. She describes a constant
aching sensation and sharp stabbing pain with movement. She cannot tolerate
sitting. She stands most of the time were to avoid increased back pain. Because
of persistent pain she was referred here for comprehensive pain consultation
and was seen initially by Dr. Bristow. She scheduled diagnostic injections of the
right sacroiliac joint and medial branch blocks of the L3, L4 and posterior
primary rami block of L5-S1 rule out lumbar facet and sacroiliac origin of the
pain. I personally attended these procedures and assisted with them with Dr.
Bristow. She had no symptomatic relief with lumbar medial branch blocks. She
had no symptomatic relief with the right sacroiliac joint block. She comes in
today continuing to experience significant low back pain. Her pain is unchanged.
She desperately wants to know what the next step is going to be to try to
resolve this for her.
Opioids… of course
• Percocet 5/325 mg tablets every 4 hours.
• MS Contin 15 mg PO every 12 hours.
SI joint injections…
• L3, L4 MMB and L5 DRB
– No improvement of LBP
• SI Joint block:
– No improvement of LBP
– But what about this block?
• The job here is to put it
• So what do we do?
– Repeat exam !!!
– Do a more careful history…
all together !!!
Pain Center Case 3
Lesson in failed McKenzie…
• Pt had been doing McKenzie exercise without
good response !!
– PT told the patient if she had pain on
extension to stop !
• No… if you have peripheral pain you stop.
• You are EXPECTED to have end-range
pain…
• It is the symptomatic response after you
are looking for !!!!
Patient response to REIL?
• Physical therapist and stopped the patient from
doing REIL because of endrange pain
• Physical therapist restricted end range pain and
told her to stop any further extension within
onset of pain.
• FINDING:
– Patient had partial relief of pain after 10
repetitions when performed properly.
“My sacroiliac will hold”
• 49-year-old Caucasian male with history of
pain over the right sacroiliac joint.
• Pain provocation maneuvers such as:
– Kemps
– Ganslens
QUACK
– Yoemans
Brown, Derby, Weins 1992
Pain Center Case 4
• 37-year-old Hispanic male referred for low back pain and
peripheral right leg pain.
• Pain extends down S1 dermatome.
• Positive dural tension signs:
– Sitting straight leg raise
– Supine straight leg raise
– Bowstring sign
• Patient of course does not have MRI study with him.
• McKenzie:
– Patient’s peripheral leg pain worsens with each repetition
of prone extension. Discontinued on third rep.
Contained, reducible
Pain Center Case 5
• 58 year old CM previous construction worker with long standing
history of low back pain.
– MRI: moderate DDD, some loss of disc space. Bilevel disc
bugle, some foraminal narrowing but…
• Pain is axial with only occasional leg complaints.
– Exam: tender, tender, tender
• Greatest over L4-5, L5-S1
– RFIL: Not painful but does not relieve the pain when standing.
– REIL: Pt has end range pain and increased back pain after 10
reps once standing.
Relief of pain via MMB of lumbar spine
Intrinsic properties of a
lumbar disk
• Snook et al. demonstrated controlling early
morning lumbar flexion reduced pain and
cost associated with chronic, nonspecific
low back pain.
• Larson et al. demonstrated it is possible to
reduce back pain prevalence, at low cost,
among Danish military recruit after
education concerning McKenzie extension
principles, including lordotic sitting
postures and drill sergeant ordered prone
extension.
Directional preference
• Long et al.showed that the McKenzie
assessment identified a large subgroup of
acute, subacute and chronic low back pain
patient’s that have a directional preference.
– The response to contracting exercise
prescriptions was significantly different.
– Exercises matching the direction of
preference significantly and rapidly
decreased pain and medication use and
improved disability, degree of recovery,
depression and worked interferent outcomes.
– The majority of subjects required an
extension component to the loading strategy.
A prospective study of centralization of lumbar and referred pain. A
predictor of symptomatic discs and annular competence.
• CONCLUSION: The McKenzie
assessment process reliably
differentiated discogenic from
nondiscogenic pain (P < 0.001)
as well as competent from an
incompetent annulus (P < 0.042)
in symptomatic discs and was
superior to magnetic resonance
imaging in distinguishing painful
from nonpainful discs.
Donelson R; Aprill C; Medcalf R; Grant W
Spine 1997 May 15;22(10):1115-22
Directional preference
• Long et al. showed that the McKenzie
assessment identified a large subgroup of
acute, subacute and chronic low back
pain patient’s that have a directional
preference.
– The response to correct exercise prescriptions
was significantly different.
– Exercises matching the direction of preference
significantly and rapidly decreased pain and
medication use and improved disability,
degree of recovery, depression and outcomes.
– The majority of subjects required an extension
component to the loading strategy.
Can we acurately sort out discogenic
pain syndromes?
• Experienced clinicians using
this system can use to develop
catagorization of low back pain
syndromes.
– Unique to what can be extracted
from routine ortho / neuro exam.
– Can assist in developing
interventions and rehab programs.
The exam
• Repeated flexion in
standing.
• Have the patient
bend over 10 times
and touch their
toes.
• Evaluate pain on 010 scale before
and after.
Standing extension
• Repeated
extension in
standing.
• Eval pain 0-10
before and after
The side glide
• Lateral shift:
• Concept of the antalgic
gait.
• Various methods of
performing lateral shift.
• Against wall.
• Standing away from wall.
• Use 10 reps and evaluate
pain before and after.
Side glide with over pressure
• This is a powerful
maneuver for both
evaluation and
management of certain
derangement syndromes.
• Eval pain and posture
before and after.
• Repeat 10 times.
Repeated flexion in lying
• Knee to chest 10
times.
• Eval pain before
and after.
• NOTE:
– You can use
combination of
flexion, side glide.
– Flexion, rotation.
Repeated extension in lying
• REIL:
– Repeat 10 times
– Evaluate level of pain
before and after.
– Evaluate posture
before and after.
• NOTE:
– You can use
combination of side
glide and REIL.
REIL with overpressure
• Again 10 reps with
extension and
clinician provides
overpressure.
• Eval pain before
and after.
Repeated rotation in lying.
• RRIL:
– Assisted rotation in
lying.
– Done 10 reps
– Eval pain before
and after.
The SI joint eval
• Repeated knee
flexion in standing.
• Repeated knee
flexion in lying.
• Lunge
• Lunge with
overpressure.
Is your client's back pain "rapidly reversible"?
Improving low back care at its foundation.
PURPOSE/OBJECTIVES:
• To convey a valuable and greatly misunderstood paradigm for
evaluating and treating low back pain (LBP) and its extensive
scientific evidence.
• PRIMARY PRACTICE SETTING(S):
• Low back pain is a highly prevalent and very expensive health
dilemma. But by using a paradigm called Mechanical Diagnosis and
Therapy (a.k.a. McKenzie methods), it is now possible to identify a
very large LBP subgroup whose pain is rapidly reversible, meaning
that it can often be eliminated quickly, with return to full function
using a single, patient-specific direction of simple, yet precise, endrange low back exercises and some posture modifications. This
interesting subgroup includes patients with both acute and chronic
LBP as well as both LBP-only and sciatica with neural deficits.
Prof Case Manag. 2008 Mar-Apr;13(2):87-96.
Is your client's back pain "rapidly reversible"?
Improving low back care at its foundation.
FINDINGS/CONCLUSIONS:
• This special form of clinical assessment can detect which patients are in
this large, rapidly reversible subgroup and which ones are not. Of the
numerous studies targeting Mechanical Diagnosis and Therapy (MDT),
three have focused on patients whose persisting pain had led to
recommendations of disc surgery where 50% were then found to still
have a rapidly reversible disc problem with high rates of
nonsurgical rapid recovery. If patients are never assessed in this
way, this reversibility remains undiscovered and these patients
commonly undergo potentially unnecessary surgery.
IMPLICATIONS FOR CASE MANAGEMENT PRACTICE:
• Armed with knowledge of this subgroup, how to identify it, the
considerable supportive scientific evidence and strongly beneficial
implications of utilizing this MDT paradigm, case managers are
positioned to have an immensely positive impact on the care of LBP.
Tremendous cost savings and greatly improved clinical outcomes are
available by utilizing this form of evidence-based MDT care.
Donelson R. Prof Case Manag. 2008 Mar-Apr;13(2):87-96.