Multi-Specialty Case Reviews: Degenerative disc disease

Degenerative disc disease: chiropractor viewpoint

As a chiropractor, the first issue I would assess is to determine the position that creates the least amount of pain, or, the patient’s biased posture. After determining if they are biased (or improved) in flexion or extension, I would then base my chiropractic treatment around their biased posture.

The history in this case includes pain in flexion, which suggests extension biased. Bilateral leg pain, but no neurological loss suggests surgical criteria, in this case, are not met. This is an important "triage" issue in a non-surgical specialty such as chiropractic and must be carefully considered in order to avoid delay of a necessary surgery. In my experience, most surgical options are considered only after an adequate trial of 4-6 weeks of conservative/non-surgical care has been attempted unless progressive neurological losses or bowel/bladder control loss occur, in which case emergency surgery may be indicated.

Recommended chiropractic treatment program
Assuming this patient felt best in extension, and especially if leg pain improves, extension therapies both at their home and at the office are utilized. This chiropractic-recommended exercise is accomplished at home by teaching the patient the use of several exercises where lumbar extension is performed. These can be performed by the chiropractic patient from a standing position and bending backwards, prone (lying on the stomach) with the chest held off the floor, or prone with the lower half of the trunk being held off the floor. This is performed frequently based on the chiropractic patient’s tolerance and response. In the office, I position the patient in the prone position with the lumbar spine extended. Manipulation within patient tolerance is gently applied into extension while monitoring the patient’s symptoms. I then evaluate for muscle imbalances that usually are present in chiropractic patients with this type of presentation.

A trial of 3-5 chiropractic appointments in the first week is appropriate and 3 times in the second week. If patient-satisfying and clinical improvements are noted during the course of chiropractic care, especially leg pain reduction, continuation of this method is appropriate, adding additional exercises that address self-stretch of the overly tight muscles and facilitation or strengthening of the weak trunk muscles. Specific tests to determine the need for such exercises are utilized for proper identification during chiropractic treatment and for follow-up after exercises are prescribed to determine if improvement in muscle length and/or strength is occurring with the prescribed exercises. If a patient-satisfying result is not obtained at the 2-week point of chiropractic care, a re-assessment followed by a treatment change is considered.

Important issues for chiropractic treatment
Issues that can delay a prompt recovery with chiropractic treatment include faulty biomechanics or postural faults such as pelvic obliquity caused by leg-length deficiency and correcting this by the use of heel, arch or a combination of lifting on the deficient side can be very effective. Addressing psychosocial issues such as poor coping strategies, high anxiety, depression, job dissatisfaction, marital distress, and financial distress may also be needed by an appropriate health care approach if these issues exist and a poor chiropractic outcome is present. Identifying these psychometric "yellow flags" is therefore very important in the non-responsive patient, and a multidiscipline treatment program (that includes a chiropractor and medical spine specialists) may be the best management/treatment approach in these cases.

The main issues in treatment of the patient characterized in this case from a chiropractic perspective include:

1. Determine the biased or favored posture and treat accordingly

2. Addressing the faulty biomechanics such as vertebral fixation/subluxation, pelvic obliquity, muscle imbalances, and postural habits, especially on the job

3. Prescribing a home treatment approach to involve the chiropractic patient in the rehabilitation process

4. Emphasize prevention methods including exercise, diet and lifestyle adjustments (home and work) where needed during chiropractic care

By: Steven G. Yeomans, DC, FACO
July 20, 2000