Since having posted the article on Intersegmental Micro-Instability (ISMI), a few days ago, I have received educational and valuable comments on the subject. Interestingly, majority of these have been sent privately, which I would have preferred them to be on the open forum.
This article was meant to be a review or perhaps a reminder that we as Chiropractic Clinicians should not be overeager to remove every fixation / hypo-mobility we find on motion palpation. We should in-fact use that information in combination with other clinical and imaging findings to first arrive at a correlative diagnosis (Working Dx), rule out differential diagnosis, and only then decide on the proper treatment protocol.
It is important to note; that diagnosis of Intersegmental Instability, is not necessarily a contra indication to Chiropractic treatment.
In-fact almost every case of structural IVD pathology with neurological presentations, that constitutes more than 90% of my personal practice, present with some level of instability, which naturally coincides with degenerative changes.
However; recognition of ISMI or its more advanced form of ISI are empirical components of correlative diagnosis & treatment protocols for radiculopathy / radiculitis induced by IVD structural pathology, as failure to attribute its complications not only can significantly alter the final treatment result, but it can also have medico-legal implications.
I have no doubt that regardless of the preferred non-invasive technique we as clinicians apply in management of ISMI, as long as we keep in mind the clinical presentation, and implications of this bio-mechanical entity, it would have a favorable prognosis.
However; I do feel this bio-mechanical disorder does require closer attention as in early stages it can present as psudo-hypomobility of the involved segment, and subsequent mis-diagnosis.
I am sure that you have also observed many cases of recurrent low back pain with minimal initial imaging findings (in some cases advanced imaging findings included), with diagnosis ranging from sprain / strain….. to psycho-somatic etiology, with little attention being paid to the often insidious recurrences. This is not to say the ISMI is the etiology in every case, but it should be emphasized in the differential diagnosis.
Interestingly enough, in majority of these cases depending on the type of treatment patient had initially received, Medical, or Chiropractic – almost the very same medication or Chiropractic treatment protocol is repeated regardless of the number of recurrences, particularly if they happen farther apart and in a longer time frame.
At least until there is appearance of new clinical / neurological presentation, which obviously coincides with further bio-mechanical regression, that could have been avoided.
In closer the CCCPG will be focusing more on this subject and its clinical implications, as requested.
H. Sabbagh D.C.
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