悟理治療部落

本篇我以周崇頌主任的Cyriax Concepts為主軸, 配合Tsai's McKenzie之觀念試著為大家拼湊出一完整的LBP的治療全貌
Cyriax和McKenzie都強調disc對LBP之重要
但更精確的來說
Cyriax主要是以Discodural為基礎而發展出來的治療方式 　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　

而McKenzie's主要是以Nuclear Reduction為為基礎而發展出來的治療方式

只強調其中之一將無法完整的了解Discogenic Therapy之原貌

讓我從Disc說起

Natural History of Aging Disc:

• 首先, there must be some degeneration of the disc, 導致weakness of the annular fibers 而產生 radiating fissures.
• 其次, repeated wear and tear, 伴隨著 shearing forces and slight decrease of disc height 造成一些 ligamentous  laxity, 進而導致 整個 ’motion segment’的instability.
• 第三, 由於disc macromolecules 的enzymatic depolymerization, 使 disc 的oncotic pressure短暫增加而壓迫dura (Cyriax Bias)或outer layers of annulus (McKenzie Bias).------>Discogenic Pain.
  
  
  

一般下背痛分為兩種Symptom分類(Cyriax)： 1.Lumbago: 　   2.Backache:
分述如下

Lumbago：簡單的說指的是突然(sudden)產生的下背劇痛且Disc Protrusion大
兩種
＊Annular” lumbago(相當於Derangement 2,4,6)：常發生於acute event （於一個簡單的動作過程中,如:coming up after bending, rising from a chair or picking up a light object.  此種lumbago病人常抱怨 sitting and bending forward會更痛.

Nuclear” lumbago(相當於Derangement 2,4,6)：漸進式惡化,可能數天或數小時內. 病人常有lumbar kyphosis (immobilized in flexion )或Lateral Shift之情形; 且當病人試著要伸直他的背時,在lumbar area and the buttocks會有agonizing twinge 的感覺.


Clinical Examination of Lumbago:

 1. Bone Signs (Static and Dynamic Posture Observation):以nuclear lumbago最常見
Flexion Deformity (kyphosis): 且sacrospinal muscle tightness.
Lateral Shift: 常發生在L3或L4

2. Joint Signs(Movement Tests):
Extension: 因為disc之posterior displacement引起extension時會在背部有 block的感覺
Sidebending: 若 side bending towards the pain is more limited(obstruction), manipulation通常無效; 但若 pain is felt more on the side away from which the patient bends (restriction), manipulative reduction 通常有效.

Flexion: 在 acute lumbago的情況下,此方向的動作是相當疼痛且受限,usually the last movement to become free after a manipulation session.

3. Dural Tests: Dural Signs (Lumbago常有）
Passive Neck Flexion:（可站著也可躺著）若 hurts in the lower back, 可證明the involvement of the dura mater in the origin of the pain.
Straight leg raising: is a dural sign.通常limitation of SLR is an indication of the size of the protrusion. (我們一般不太願意相信Painless and full SLR的人會有displaced disc)

４．Root Signs：不要忽略 a compression of the S4 root. (Cauda Equina之主要傷害在此). 
Because it lies centrally, partly protected by the posterior longitudinal ligament, a central protrusion can endanger it, especially if the protrusion overstretches the ligament. 
Signs of S4 involvement: If pain deep in the sacral area, pain and paraesthesia in the penis, vagina or rectum, numbness in the saddle area or problems with continence are mentioned, damage to the fourth sacral root should be considered.

Treatment of Lumbago:

1. Psoas Position: disc壓力可降到30Kpa (約站立的25%)
2. Annular Lumbago: 通常manipulation (如強調distraction的rotation strain)非常有效
3. Nuclear Lumbago: 通常需要time和gravity, 以McKenzie之手法：先correct deformity,再以PAL原則將Disc擠回去. manipulation無效居多.


Backache:
＊＊＊與lumbago相比less acute,因為discodural interaction 較緩和. (Protrusion很小(Cyriax)甚或沒有(McKenzie之Internal Derangement). 
＊＊＊因此通常少見dural signs

Backache之Mechanism:  increased load in a flexed spine shifts the disc material backwards. (*人的姿勢基本上都是flexed, 所以容易產生disc後側之問題）

Backache之History:
症狀通訊 spread to the iliac crest, the trochanteric area and groin, 但絕少beyond the gluteal folds.且常在兩側shifting.
若有centralization則表示disc之復原良好

 Backache之分類：

1. Annular Backache (類似Flexion Dysfunction), the patient may describe a sudden sensation of something giving way in his back. Which may have been accompanied by an audible click or ‘thud’ in the low back, associated with a twinge of pain
2. Nuclear Backache (類似Derangement 1), the initial symptoms will have been slight, with little disability, the patient was with a only minor backache.

Clinical Examination of Discodural Backache
1.Bone Signs (Static and Dynamic Posture Observation): 很少見deformity,除非很嚴重

2. Joint Signs (Movement Tests):
Extension: 通常會有End-range pain in the centre of the lumbosacral area, 若 the protrusion lies centrally,則其ROM會limited.
Side Bending:通常出現End-range pain 在單側,有時有paiful arc.
Forward bending (Flexion): the most painful and limited movement (Annular backache: 易有End-range pain; Nuclear backache: 易ROM limit 或Pain during motion).小的Protrusion易有Painful arc.
**Painful arcIt always means that a small fragment of disc tissue impinges momentarily against the dura mater.　



Treatment of Backache:
1. Reduction of Displacement (or Derangement)
*Traction(指sustained): 對nuclear backache之患者效果較好, 尤其是  trunk side flexion towards the painful side increases the pain(obstruction)效果好過manipulation.
*Manipulation (指rotation strain 或extension strain):最適用於annular backache 或Protrusion.  L3 and L4 levels respond best to rotatory maneuvers, whereas at the L5 level extension maneuvers are usually more effective.
2. McKenzie's Approach:
Annular Backache: towards the pain
Nuclear Backache: away from the pain.