Documenting your Disc
Back pain episodes are frequently separated
by long intervals between painful events. For that reason,
it is easy to forget the site of the displaced disc material
or, more importantly, the particular MANEUVER or sequence
of movements that successfully alleviated that unique pain.
So as to give your back its best chance for the earliest
recovery, take notes to document the major components of
the pain. By identifying the areas of pain for future reference,
any particular pain pattern can be reasonably assumed to
be originating from the same disc in the same position when
it recurs. Therefore, if a particular site is identified
and a unique MANEUVER (the MANEUVERS are to be described
later) is successful, you can document both the level and
direction of the displaced material as well as the movements
that were most successful in alleviating that pain. Then,
when an identical pain recurs at some time in the distant
future, that MANEUVER or sequence can be immediately employed
to occasion relief without relying solely on the memory
or trial-and-error.
It is best to characterize the pain in a systematic fashion.
First, locate it by level of the spine where the pain is
greatest. Certainly, you wouldn't be expected to be successful
doing the same corrective MANEUVER for a problem centered
at the high Thoracic level on the left that you would do
for a pain originating at the Low Lumbar region on the right.
So, it makes sense to keep track of where the problem is
physically located so that the proper MANEUVER can be chosen
later.
Next, on a diagram like the one provided here (Figure
5), cross hatch the exact region (level) of the particular
spinal pain where it seems to be centered and to where it
radiates. Note where the sharpest pain is the most severe
and any movements or positions which increase the pain.
 Figure
5 Posterior view of back with spine superimposed
|
After that, on a view that looks down upon the disc, draw
a triangular "piece of pie" over the area which
brings on the sharp pain during the DIAGNOSTIC CIRCUMDUCTIONAL
motions described above in "SELF-DIAGNOSING YOUR DISC".
It matters little whether you choose a format like a clock
or a 360 degree circle to diagram the wedge shaped area
of arrested motion so long as it is in some way recognized,
understood, and documented. I find it advantageous to draw
a diagram like a pie chart so that the areas with pain-free
range of motion are distinguished from the areas where range
of motion is arrested and pain is elicited (Figure 6).
 Figure
6 "Pie Chart" superimposed
upon an intervertebral disc space showing arrested
range of motion area. |
Keeping such documentation helps to recall the exact location
of the de-centralized disc material so one needn't repeat
the testing every time. You will appreciate the necessity
for documenting or fixing in your mind the exact location
of the displaced disc material, later, as the MANEUVERS
are described because you will also (later in the book)
be asked to document the exact MANEUVER that gets you out
of pain; and you will want to reference a particular drawing
to a particular MANEUVER. The diagrams provided in this
book (Figures 3 and 5) can be copied and drawn on to serve
that purpose. Like writing down the description and combination
to a safe, this becomes especially helpful and necessary
if you have multi-level disc problems or if the disc is
particularly difficult to re-centralize.
Documentation becomes especially important whenever there
are complex cases in which the pain appears to move from
side to midline, side to side, or from midline to the side
during a WEIGHTED CIRCUMDUCTIONAL movement. This can mean
that you have a mobile piece of disc material moving laterally
through a concentric tear or a piece of disc material moving
within a space between the laminations of the annulus fibrosus
or between the capsule (the ligamentous peripheral layer
of the disc) and the annulus fibrosus (as portrayed in Figure
7).
 Figure
7 Disc material trapped between layers of
annulus fibrosus |
In that event, a recollection of where the original pain
started and where it went to during any particular MANEUVER
may give a clue as to the location of the disc material.
Sometimes such a method can elaborate the original tract
through which the disc material traveled. The eventual goal
is, then, to design or describe a means by which you can
work the material back to the center of the disc as though
you were playing a "BB in a maze" game.
If the degree of disc degeneration is
extensive and the product of multiple traumatic events the
goal becomes not highly unlike moving a BB through a circular
type maze game. In order to get the BB to the center you
have to move the BB centrally at precisely the right instant
where a gap in the walls will allow its movement to proceed
centrally. In order to get to that gap, the BB has to be
caused to move circumferentially by progressive application
of forces directed to allow its movement to proceed in the
ideal direction. In this analogy, the walls of the maze
are the laminar array of the fractured annulus fibrosus
laminations contained within the intervertebral capsule
ligaments and the BB is the solidified central disc material
that once was the liquid nucleus pulposus. Unfortunately,
you cannot see the BB to know when it is in the ideal position
to move centrally. This causes you to rely upon trial and
error. When you are successful, it probably is in your best
interests to document what you did to succeed so as to reproduce
that same series of movements the next time.
This is a potentially important distinction to be made
and documented because if one has a disc like that seen
in Figure 7, a DIAGNOSTIC CIRCUMDUCTION in a counter clockwise
direction can result in the pain changing from the left
posterior to the right posterior. You should take note of
this type of reaction when documenting your disc pain. The
significance of this will become apparent in later reading
on MANEUVERS.
Don't get frustrated by reading this because of its apparent
complexity and not knowing yet what constitutes a MANEUVER.
Statistically speaking, you probably don't have a disc of
this configuration; but, if you do, and the simple efforts
don't seem to work, you may have to resort to a more complex
strategy. In that case, the first effort would be made to
return the disc fragment to the site where the pain originated,
then find the tract through which it traveled so it can
be moved back to the center. This may require a gentle WEIGHT-BEARING
CIRCUMDUCTIONAL movement before an unweighted flexion in
a certain position then followed by a directed extension.
Specifically writing down the exact sequence of movements
correlated with the disc map and paying particular attention
to the successful positions that ultimately result in the
relief of pain can save hours of ineffective movements being
repeated if and when your back goes "out" again.
Even though I'm getting ahead of myself by discussing MANEUVERS,
the nature of which are still obscure to the reader who
has not yet read Chapter 5, a discussion describing documentation
of a "puzzle" would not be complete without including
a recommendation to retain in writing the solution to the
puzzle, or if you will, the combination to your "safe".
In summary, it is important to take a few notes to describe
both the pain pattern and the directions for the ideal MANEUVER
that gets you out of that particular pain pattern. Later,
as you are exposed to the MANEUVERS, the necessity for this
consideration and the means to accomplish it will become
obvious.
1. Leblan K, et al. Report of the Quebec
task force on spinal disorders. Spine. 1987;12:S1-S8.
2. Op.Cit. Chapter One, Endnote #2;AHCRP
publication 95-0643.
3. Helms CA, Pearson DO, Neck and Spine,
Patient Care, (1996) Sept. 30: 55-74
4. Sward L, Hellstrom M, Jacobsson B,
et al, Gothenburg University, Gothenburg, Sweden, and King
Faisal Specialist Hospital and Research Center, Riyadh,
Saudi Arabia. Back pain and radiologic changes in the
thoraco-lumbar spine of athletes, Spine. Feb 1990;15:124-129.
5. Deyo R, Diehl AK, quoted in Lower
Back Pain: When do you order X-Rays?, Emergency Medicine;
October 30, 1989:63-66.
6. Bowden SD, Davis DO, Dina TS, et
al. Abnormal magnetic resonance scans of lumbar spine in
asymptomatic subjects. J Bone Joint Surg. 1990;
72:403.
Further Reading:
Damage / Pain Scenerio
Traditional
Diagnostic Methods
Self Diagnosing
your Disc
Documenting your disc
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