The Internal Disc Derangement Syndrome Using self directed movement for evaluation & management Michael N. Brown, DC, MD, DABPMR-PAIN Patient education handout & contact • michaelnbrownmd.com » Go to patient education section » Article: Internal Disc Derangement (PDF) » Office: 206 550-2014 » [email protected] » [email protected] 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 … – – – – 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.