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    6/ What is Spinal Decompressive mobilisation technique ( SDMT ) ?

    Clinical Algorithms are used to determine where in the treatment protocol patients with back pain are initially placed for therapy. These clinical algorithms are researched and documented. Protocols are specifically designed for each patient presentation however a distinction is made that separates patients into 2 groups;

     

    1/  Low back pain only

    2/ Low back pain with leg pain/ pins and needles / altered sensation

     

    SDMT is applied by a 'My Spine' specialist with the aid of a specially engineered, computer assisted treatment plinth. The My-Spine Specialist utilises minimal leverage in multiple vectors via the plinth to deliver specific decompression forces to individual spinal segments.

     

    7/ What are the benefits of using a precise engineered computer assisted treatment plinth over “manual techniques alone” ?

     

    De-compressive Mobilisation technique is administered with a specially engineered, computer assisted treatment plinth allows the use of multiple vectors; flexion, extension, lateral flexion, rotation and circumduction with an option of combining additional decompression vectors simultaneously to targeted spinal joints.

    This complex multi-vector mobilisation procedure can be achieved whilst the consultant examines, palpates and monitors the affected spinal segment with their hands. This level of contact ensures patient comfort and safety whilst monitoring effectiveness . 

     

    This combination of multiple vector mobilisation and segmental palpation would be impossible to achieve with purely manual technique alone.  Once the desired multiple vectors are achieved the computer can set parameters for computer assisted mobilisation. This protocol is precisely reproducible and documented so that results can be monitored and recorded in our continual commitment toward evidence based practise.

     

    8/ Who is suitable to make an appointment for a consultation ( progression through the rehabilitation phases will depend upon the result of clinical evaluation)

     

    ·         Patients who suffer from back pain with or without leg pain.

     

     

    9/ Who is not suitable; Patients are contraindicated for treatment if they suffer:

    • ·         Cauda Equina -Bladder and bowel symptoms

    • ·         Trauma, fracture of spinal segments, spinal instability. Disease predisposing spinal fracture severe Osteoporosis etc

    • ·         Spinal tumour, Spinal metastases, cancer.

    • ·         Advancing neurological symptoms.

    • ·         Active acute inflammatory pathology.

    • ·         Bacterial / viral infection.

    • ·         Recent surgical intervention

    Most cases of back pain are described as ‘mechanical low back pain’ and is suitable for treatment

     

     

    10/ What to expect at your first consultation; Clinical Diagnosis

    Diagnosis starts with an appointment and clinical evaluation with a 'My Spine' specialist.  The type of pain that you have with a herniated disc can be similar to the symptoms of several types of disorders. Accurately determining the correct source of your pain and predisposing factors is critical to successful treatment.

    ·         Begins with a thorough clinical evaluation.

    ·         Including a complete medical history, analysis of your symptoms, and a physical examination.

    ·         Further testing may include; clinical provocation tests, neurological tests ( reflex’s, sensation and muscle power tests) x-rays, MRI , CT scans, blood tests , urine tests, referral to other specialists for further evaluation to rule out pathology and trauma.

    ·        

     

    Patients are advised to wear loose clothing to allow for access to the full length of the spine, the arms and the legs. Patients may be accompanied by a chaperone should they feel appropriate.

    Please call us to make an appointment if you have mechanical low back pain with or without leg pain and would like our opinion on whether it is right for you.

     

     

    11/ What to expect in subsequent sessions;

    My Spine ‘Phases' of rehabilitation;

     

    As patients experience a reduction in their symptoms they generally reduce the frequency of appointments. In addition treatments move progressively through 5 ‘phases’ of treatment and rehabilitation;

    1.            Phase 1 Reduction of pain and Inflammation

    2.            Phase 2 Improved range of movement

    3.            Phase 3 Restore the quality of the movement by improving stability and strength through prescriptive rehabilitation exercise.

    4.            Phase 4 Return to desired activity in work, home and in the community

    5.            Phase 5 Adoption of an active lifestyle with sport, hobbies and pastimes- achieve new physical goals.  

     

     

    12/ The aims and goals of SDMT are to:   What does SDMT do? ; What is the research?

    ·        

    1. Improves disc health of Degenerative Disc Disease by reducing intra-disc pressure; De-compress the intervertebral disc height to improve distortions of the pain sensitive outer portion of the disc (18-20) and allow the nucleus to assume a more central position within the annulus (21-22) Flexion mobilisation increases metabolite transport to the disc (20)

    2. ·Reduce the pressure on ‘compressed’ or ‘pinched nerves’; Flexion mobilisation opens the vertebral canal by 2mm or 3.5 to 6mm (28,29), Inter-vertebral foramina openings enlarge, giving patency to the spinal nerve or dorsal root ganglion (30)

    3. ·         Increase mobility in spinal joints; Flexion mobilisation opens the apophyseal facet joints and reduces disc stress (20 ,30)

    4. ·         Mobilise muscles and ligaments; Flexion mobilisation stretches the spinal muscles and ligamentum flavum to reduce stenosis (24,25)

    5. ·         Improve spinal biomechanics; Flexion mobilisation reduces disc protrusion and reduces stenosis (22,24,25,27-29)

     

    The application of SDMT is gentle with many patients finding sessions restful it relaxing.

     

    In the early stages clinicians remain ‘hands on’ ensuring appropriate delivery of SDMT and assuring the appropriate tissue changes during treatment. As conditions improve the computer is calibrated to repeat the movements best suited to the patient as determined by the operating specialist clinician.  This option allows for repeatable and reproducible treatment modalities that are documented and used to support ongoing clinical research. 

     

    It is the combination of decompression and multiple vector mobilisation applied to targeted spinal segments that is the mainstay of SDMT technique and central to the treatment protocol for managing mechanical low back pain.

     

    13/ Frequency of Decompression mobilisation therapy rehabilitation:

    The frequency of appointments will depend upon individual cases and symptoms.

    Frequency of care is influenced by severity and chronicity of symptoms. Sciatica symptoms with high levels of pain on a Visual Analogue Scale (VAS)  may require treatment daily, whereas patients with less severe non-sciatic pain may be treated two or three times per week. Response to treatment is monitored on each visit and a 50% reduction in symptoms triggers a reduction of treatment frequency.

    Regular re-evaluation is important to ensure that patient recovery meets the clinical algorithms and in the unusual case that these recovery rates are not met then early referral or further investigation is sort to determine future treatment options.

    14/ History and development

    ‘Flexion- distraction’ therapy originated from the work of Drs Mc Manis in the USA and Alan Stoddard  in the UK.  The quintessential later development of flexion- distraction therapy has been undertaken by Dr J. Cox et al in the USA.

    Spinal De-compressive- Mobilisation Technique is so named as it places emphasises on the effects of flexion- distraction therapy with the important addition of using multiple mobilisation vectors .

    15/ The Purpose of SDMT.

    SDMT is part of a protocol of conservative management for patients with  mechanical low back pain .Conservative management guidelines are outlined by ‘NICE’ (2)as a reference for Consultants to consider when formulating treatment protocols for patients with low back pain in conjunction with a patient’s preference to supplement with additional complimentary or alternative interventions.

     

    SDMT takes a central role, aiming to improve mobility, in patients when moving from Phase 1 through to Phase 4 and aims to allow the patient to reach Phase 5 as described by National Institute for health and care excellence .( NICE)

    NICE provide guidelines for the treatment of mechanical low back pain for Consultants, Doctors and specialist clinicians working in both private practice and the NHS across the UK. Those recommendations advocate mobilisation techniques as part of a treatment protocol for mechanical low back pain (1). 

    The NICE guideline for Manual therapy states:

    “Consider manual therapy manipulation, mobilisation or soft tissue techniques for managing low back pain with or without sciatica, as part of a treatment package including exercise, with or without psychological therapy.” (1) ove.

     

    16/ Conservative Treatments.

    Conservative Management Vs.. Surgery for the treatment of low back pain.

    ·         Approximately 2% of patients with low back pain undergo surgery for disc herniation (2)

    ·         90% of patients with mechanical low back pain will be managed with conservative therapy

    Conservative treatment includes (1) :

    ·         Spinal Mobilisation. My Spine specialists are trained in manual mobilisation and computer assisted ‘Spinal De-compressive Mobilisation techniques’

    ·         Spinal Manipulation. My Spine specialists are skilled in modern ‘minimal lever and thrust’ spinal manipulation techniques.

    ·        

              Manual techniques. My Spine specialists are trained in various neuro-muscular and massage ‘hands on’ soft tissue therapies

    ·        

              Exercise therapy: ‘My Spine School’ provides rehabilitation exercise prescriptions tailored to meet individual patient conditions. This is not a generalised photocopied hand out but a set of exercises given specifically to meet an individual condition.

     

    The goal is to teach patients how to help themselves to manage their back pain.

    First, knowledge of normal spine anatomy and biomechanics is taught, together with the mechanisms of injury. Then, the diagnosis is explained to the patient, making use of one or more of the following teaching tools;

    ·         spine models

    ·         computer animation

    ·         downloadable video presentations

    ·         verbal description

    ·         pictures, diagrams and text.

              My Spine School ; Personalised Rehabilitation exercise'

     

    Different types of exercises are prescribed, depending on each patient's diagnosis. For example floor exercises, may consist of abdominal bracing, modified sit-ups, double-knee-to-chest or low back stretches, seat lifts, mountain and sag exercises, knee-to-elbow exercises, hamstring stretches, extension exercises, and extension flexibility exercises.

    Aerobic and anaerobic exercises improve endurance and strength when performed consistently. Relaxation exercises are good for relieving muscular tension that may aggravate back pain and are useful to relieve stress.

    My Spine school’ ; teaches the patient basic body mechanics, such as the correct posture for standing, standing at a desk or drawing board, sitting, brushing teeth, washing the face, pushing and pulling a weight, lifting a weight, getting in and out of bed, sleeping, getting into a car, and sitting in a car.

     

    My Spine school’; teaches patients ergonomic approaches for sitting, bending forward, lying down, coughing, or sneezing when their back is painful.

     

    ·Pharmaceutical interventions. 'My Spine' specialists may lease with pharmacists, Medical Doctors and consultants regarding the prescription of pain relief and anti- inflammatory medications.

    · Psychological Interventions. ‘My Spine school’ encourages patients to participate in a variety of practices including CBT, Mindfulness and relaxation techniques. 

     

    ·Patient choice.

     

    As part of our commitment to  patient choice ‘My Spine’ consultants respect the wishes of our patients regarding their choice of treatment options. Some patients are keen to explore a variety of complementary and alternative treatments (eg; acupuncture, electrotherapy, nutritional management, cryotherapy etc ) in addition to the recommended guideline protocols (2). Where applicable we will be happy to assist in discussing these options with patients and in some cases administering these interventions where applicable.

     

    We utilise algorithms based on clinical research to form protocols for patient management of mechanical spinal pain.

     

     

     Traction vs. Spinal Decompressive Mobilisation.

    Traction:

    Patients usually lie on their back with a straps or harnesses attached and a weight or pully used to create a static traction force directed in a single vector direction (usually longitudinally). Traction forces are therefore dissipated over many spinal segments and therefore not localised and the target segment is not monitored by the attending clinician. This therapy is NOT a recommendation supported by the current NICE guidelines (1).

    De-compressive Mobilisation Technique:

    In contrast, patients experiencing SDMT have a choice to lie comfortably on their front, face down (prone) or on their side (lateral recumbent) depending on preference. In this position the attending 'My Spine' Specialist   can physically contact the patient’s spine and monitor by hand the range of movement and tissue tension directed to specific spinal segments. Patients can easily feedback to the clinician and adjustments made to optimise comfort and mobilisation vectors.  In this position the affected spinal segment can be precisely targeted and specific mobility vectors can be applied.  De-compression, flexion, extension, lateral bending and circumduction are options for the operating  consultant.

    Therapy emphasises mobilisation  techniques with the option of adding the important additional vectors of decompression when appropriate.  Multiple mobilisation vectors may be specifically applied in combination to best suit the patient’s symptoms. Mobilisation therapy IS supported by the NICE guidelines for mechanical low back pain (1)

     

     

    Who are your ‘My-Spine' Specialists

    The consultants are from a variety of professional backgrounds recognised by NICE as specialists in providing manipulation, mobilisation and rehabilitation as described (2) for patients suffering mechanical low back pain eg ; Doctors of Osteopathy, Chiropractic and Physiotherapy or those clinicians registered in the UK with the relevant Statutory body as well as and Medical Doctors specialising and qualified in the conservative treatment and rehabilitation of mechanical low back pain. In addition My Spine MSD consultants are trained in the use of Spinal De-compressive Mobilisation therapy ( SDMT) and consult with patients on its appropriate use in accordance with the guidelines regarding patient presentations.

     A four to five year training resulting in a Master’s degree is normal for Registered Osteopaths to complete initial training. Osteopaths benefit from protected title and are governed by the statutory body; the ‘General Osteopathic Council’ ( GOSC ) with Chiropractors governed by the ‘General Chiropractic council’ and Physiotherapists the Health and care professions council( HCPC) . Doctors of medicine are governed by the General medical council (GMC)

    References::

    1/http://pathways.nice.org.uk/pathways/low-back-pain-and-sciatica Pathway last updated: 13 December 2016

    2/ http://www.hse.gov.uk/Statistics/causdis/musculoskeletal/msd.pdf.

    11/ Deyo R , Kent D. What can the history and physical examination tell us about low back pain? JAMA 1990;268(6);760-765.

     

    17/ Stoddard A. Manual of Osteopathic Technique. London; Hutchinson medical publications, 1961.

    18/Brown T, Hanson R, Yorra A. Some mechanical tests on the lumbosacral spine with reference to the intervertebral discs. J Joint Surgery Am 1957;39(5);1135-1162

    19/ Lindblom K Intervertebral disc degeneration considered as a pressure atrophy. J Bone Joint Surgery Am 1957;39;933-934

    20/ Adams M, Hutton W. The effect of pressure on the Lumbar spine. J Bone Joint Surgery Br.1985;67; 625-629

    21/Ramos G. Martin W. Effects of vertebral axial decompression of intradiscal pressure. J Neurosurgery 1994; 81:350-353

    22/ Burton C. Gravity Lumbar reduction. New York: Churchill Livingstone, 1983.  

    24/ Onel D. Tuzlaci M, Sari H, et al. Computerised tomographic investigation of the effect of traction on Lumbar spine disc herniation’s. Spine 1989;14(1):82-90 

    25/ FinnesonB Low Back Pain. Philadelphia; JB Lippincott,1973.

    27/ Epstein N, Hyman R, Epstein JA, et al. Technical note; Dynamic MRI study of the cervical spine. Spine 1988;13(8);937-938.

    28/ Schonstrom N, Lindarl S, Willen J, et al Dynamic changes in the dimensions of the Lumbar canal; an experimental study in vitro. J Orthop Res 1989;7: 115-121

    29/ Liyangi D, Yinkan X, Wenming Z, et al. The effect of flexion – extention motion of the lumbar spine on the capacity of the spinal canal. Spine 1989;14(5);523-525.

    30/ Penning L, Wilmink J. Posture dependant on bilateral compression of L4 on L5 nerve roots in facet hypertrophy; a dynamic CT – MYELOGRAPHIC STUDY. Spine 1987;12(5):488.

    Spinal De-compressive Mobilisation: Qs. and As.