Manipulative Therapy in Rehabilitation of the Locomotor System, Third Edition

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Dedicated to my wife Butterworth-Heincmann L i n a c r e H o u s e , J o r d a n Hill, Oxford O X 2 8 D P 225 W i l d w o o d A v e n u e , W o b u r n , M A 0180-2041 A division of R e e d E d u c a t i o n a l and Professional Publishing Ltd A m e m b e r of the R e e d Elsevier pic g r o u p

All rights r e s e r v e d . No p a r t of this publication m a y be r e p r o d u c e d in any m a t e r i a l form (including p h o t o c o p y i n g or storing in any m e d i u m by e l e c t r o n i c m e a n s a n d w h e t h e r o r n o t transiently o r incidentally t o s o m e o t h e r use of this p u b l i c a t i o n ) without t h e written p e r m i s s i o n of t h e copyright h o l d e r except in a c c o r d a n c e with the provisions of the Copyright, D e s i g n s a n d P a t e n t s A c t 1988 or u n d e r the t e r m s of a licence issued by t h e C o p y r i g h t Licensing A g e n c y L t d , 9 0 T o t t e n h a m C o u r t R o a d , L o n d o n , E n g l a n d W 1 P 9 H E . A p p l i c a t i o n s for t h e copyright h o l d e r ' s w r i t t e n p e r m i s s i o n to r e p r o d u c e any part of this publication s h o u l d be a d d r e s s e d to t h e publishers

First published 1985 R e p r i n t e d 1987, 1988 Second edition 1991 R e p r i n t e d 1996, 1997 T h i r d edition 1999 © R e e d E d u c a t i o n a l and Professional Publishing Ltd 1999 Line drawings: © G e r d a Istler 1985 P h o t o g r a p h s : © Jaroslav Cmi'ral 1985 British Library Cataloguing in Publication Data A catalogue record for this b o o k is available from t h e British Library Library of Congress Cataloguing in Publication Data A catalogue r e c o r d for this b o o k is available from the Library of Congress ISBN 0 7506 2964 9

P r i n t e d and b o u n d in G r e a t Britain

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1 Introduction

Pain - especi al ly in the locomotor system - is man k ind

suffered.

It

a

curse

been

control is

b ased

largely on reflex action, precise

the

information about wbere, how and w hy we should

commonest reason for his calls for hel p , answered

app ly one or the other method may be very useful

has always

of diverse treatments . To

and give us better insight into the various method s ,

the ortbodox the cure. it seems, can often be 'left to

as well as more reliable p ractica l results. As these

by a bewildering

m ul t itude

has

nature', sometimes assisted by rest in bed and the

methods are most

mixed blessing of pharmacotherapy, but there are

conditions, it may be useful to begin with the reflex

frequently applied in painful

many other methods (all si n cerely held by some to

response to nociceptive (painful) stimulation.

be singularly effe ctiv e ) that belong mainly, although

Any localized painful stimulation will act in the

not exclusively, to the realm of physical therapy.

segment to which the stimulated structure belongs.

These

In this segment there is usually a byperalgesic zone

include

local

anaesthesia

and

needling,

massage, electrotherapy, manipulation, local cold or

in the skin, muscle spasm (trigger point TrP), painf u l

hot applications, more recently the laser and the

periosteal points, movement restriction of the spinal

magnet, remedial exercise, hypnother a py, counter

segment

irritative poultices and even leeches. All of these are

visceral organ (Figure

used for mor e or less the sa me type of disorder, and

both of recogni z i ng clinically which of these changes

and

(perhaps)

some

1.1).

dysfunction

of

a

Th.is provides a means

we may ask if any one of them should be prefe rred ,

is present and of using some of the methods avail

especial ly since in practi ce we very often find that

able either upon the skin, the musc les (periosteal

the therapist uses the method he or she knows best.

points), the spinal segment or the visceral organ

The common feature of all these methods is that

involved. We may also try to find out which of these

they act reflexly, that is they act on sensory recep

structures is the source of the painful stimulus, in

tors - usually in the region where the pain is felt or.

which structure the changes are more intense, and

even better, where it originates - to produce a reflex

so on.

re s p onse . They may thus be te rme d 'methods of

However, these reflex changes are not confined to

reflex therapy'. Assuming the reflex nature of the

a single segment. A vis ceral disturbance is accom

action of this type of treatment, we may then ask

panied by viscerovisceral reflexes: for example, pain

which receptors are acted up on and w hic h structures

in the region of the gall bladder causes anorexia;

are

subserved

by

those

rec e p tors.

As

nervous

pain in the region of the h eart ,

viscus

t

I I I I I skin

I

.- -------------------------

Figure 1.1 Reflex relalions within the segment

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a

sense of oppression,

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1l1froduclion

3

lively by post-isometric relaxation, by warmtll or by

atic fashion and, as we would do when making

infiltration. Periosteal points may be reached by soft

neurological examination, start at the peripheral

a

tissue techniques, deep massage, by needling, or, if

level and work up to the central, applying treatment

they are the insertion points of muscles, by post

according to our findings,

isometric relaxation of the muscle. The most suitable

At times, however, the results fall far below what

treatment for joint or spinal segment movement

we might expect from our premises. One of the chief

restriction is manipulation: that for disturbed motor

reasons why this happens in this type of therapy is

patterns is remedial exercise.

the

presence

of a lesion

which

causes

intense

Furthermore, we must decide which of the affected

nociceptive stimulation and so dominates the clinical

structures is the most important and which less so;

picture without the patient being aware of it. The

which is likely to be primary and which secondary.

German literature uses the term

The severity of the change may be significant. Even

of disturbance. This is frequently an old scar after

Siorungsj(!ld,

focus

at the segmental level, however, there is a sort of

injury or operation, often a tonsillectomy scar. This

hierarchy: there may be a primary visceral disorder

focus-scar is usually tender on examination, with

and there may be blockage of a spinal segment.

pain spots, and surrounded by a hyperalgesic zone.

Changes in muscle can be secondary and in the skin

If the 'normal' therapy fails, the existence of such a

this is the rule. But in the locomotor system itself,

scar acting like a 'saboteur' must be considered;

and in the spinal column, there are regions of greater

treatment by local anaesthesia or simply by needling

and of lesser importance, regions in which

primary

the pain spots or stretching the scar tissue by soft

lesion occurs more readily than in others. It is vital

tissue techniques can be most rewarding. Another

a

to recognize those faulty central motor patterns

reason for poor results in patients treated for pain

which, if significant, will cause relapses at the peri

may be undiagnosed masked depression, which must

phery. In this connection psychological factors play

then be treated as such.

a major part, as motor patterns are to a certain degree expressions of the state of mind: anxiety,

Disturbed

function of the

locomotor

system,

together with the reflex changes it produces, may

depression and an inability to relax will greatly

aptly be called the 'functional pathology of the loco

influence motor patterns: no less important is the

motor system'. [n this connection the unfortunate

subject's psychological attitude to pain, as it is the

but frequent use of the term

most frequent symptom in our patients.

synonym or euphemism for 'psychological' is most

'functional'

as a

In addition to the importance of the changes

regrettable - it implies a grave underestimation of

diagnosed, there is also a practical or technical

the importance of function and changes of function

aspect to be considered, as not all of the methods

consequent on pathological changes. In rehabilita

used are equally effective or 'economical'. Thus

tion we are primarily concerned with the restoration

needling of a periosteal pain spot (or infiltration) is

of impaired function even in those conditions where

usually more economical than periosteal massage

there is underlying structural pathology, This is

(deep friction), but wherever possible it is prefer

understandable because structural lesions neces

able to use post-isometric relaxation of the muscle

sarily produce disturbances of function. Indeed, so

(if the periosteal point is a point of muscle insertion)

fundamental is the distinction between morphological

soft tissue techniques because they are painless

lesions and function, that it can aptly be compared

or

and the patient can usually be taught to do it him

to that between computer hard- and software.

self. The attractiveness of manipulation techniques

The greatest obstacle to the practical application

lies mainly in the fact that they are effective and not

of these apparently simple principles is a general

time consuming.

lack of clinical understanding of functional disorders

We can see from this that the choice of treatment

of the locomotor system or even of their reflex

is very broad. We can decide which to use by

manifestations, which are, in fact, the most typical

diagnosing each lesion in turn, and from this make

clinical manifestations of pain. The lesions that are

calls the palhogenelische

the most frequent, as well as being the object of

Alwwiiliilsdiagnose, the diagnosis of the lesion that

what

Gutmann

(1975)

manipulative therapy, are those affecting the spinal

is the most important link in the chain of pathology

column; the term vertebrogenic lesion is often used

at a given moment. We must do this, otherwise we

to describe them, but this is now believed to be not

may, for example, apply a method which acts on skin

quite

receptors when there are no signs of a hyperalgesic

include

zone, act on a muscle when there is no change in

spondylitis, osteoporosis, tumours, etc., while our

appropriate: such

vertebrogenic

pathological

states

disorders as

also

ankylosing

tension, manipulate a spinal segment with normal

main concern is with disturbed function. However,

mobility,

function is not confined to the spinal column but in

or give

remedial

exercise

for

normal

movement patterns. Such very varied methods of

volves muscles, nervous control and very frequently

treatment should be applied only after full clinical

the extremities. It is therefore more appropriate to

examination and analysis, and with careful testing of

speak of disturbed function of the locomotor system,

the results of treatment. We must act in a system-

rather than of vertebrogenic disturbance.

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4

Manipulative

Therapy in Rehabilitation of the Locomotor System

What is the present place of reflex therapy? This question is as difficult to answer as the question of

should be applied to all other methods of reflex therapy.

the place of pharmacotherapy. Whereas pharmaco therapy has developed into an exact and sophisti cated science, methods of reflex (physical) therapy

History

have for the most part remained empirical, with largely overlapping and even chaotic indications.

It might be as well to say something of the history

From what has already been said it is possible to

of manipulative therapy in order to explain the

formulate

anomalous position it holds in p resent-day medicine.

one

important principle:

we

do

not

prescribe treatment for a particular disease, but for

I will also consider its prospects and take the oppor

those changes that are of pathogenic significance in

tunity to warn against some of the worst pitfalls.

the dis e a se. If, for example, headache is due to

It seems that some forms of manipulative therapy

muscular tension alone, then muscular relaxation by

are as old as the history of mankind, and it was, and

whatever may be the most effective method is the

is to this day, part of folk healing in Europe and

correct treatment. However, if this muscular tension

elsewhere. However, it is noteworthy that the father

is due to blockage of a motor segment of the cervi

of European medicine, Hippocrates, saw 'rhachio

cal spine, manipulation will be more suitable; if

therapy' as one of the cornerstones of medicine, on

faulty posture is the cause, remedial exercise may

a par with surgery and drug the r a py. According to

be the answer. However, the great advantages of

Waerland (1950), Hippocrates repeatedly pointed

this type of therapy over pharmacotherapy are that

out the imporlance of knowing all about tbe spinal

(I) the mainly physiological methods used cause a

(2)

column, since so many disorders are related to it.

minimum of side-effects if properly applied, and

Hippocrates is quoted as saying that manipulation

as most methods of reflex therapy act immediately,

of the spinal column was an old art, and that he

their effectiveness can be checked at once.

thought highly of those who first discovered its

It is worth saying a few words here about the role

importance and who would follow him in furthering

of pharmacotherapy in those lesions that mainly

the art of natural healing. Writing about articula

affect the functioning of the locomotor system. It

tions, Hippocrates described 'pararthremata " similar

would be difficult to conceive of a drug that could

to slight dislocation or subluxation, in which the

restore a specific motor function, but drugs may alle

vertebrae are only slightly shifted, and went on to

viate spasm, influence pain and damp down some of

say that the 'eyes and hands of the experienced

the reflex reactions involved, and thus facilitate the

physician should not miss anything which could be

restoration of function. Additionally, they are of

helpful in adjusting the shifted vertebra without

course necessary for the treatment of depression and

harming the patient .

anxiety symptoms.

. if treatment is performed lege artis, the patient can come to no harm'. .

There are numerous relief carvings and other

To sum up, neither the clinical diagnosis nor our findings in themselves suffice as the basis for decid

illustrations

ing the most appropriate therapy. O nly an analysis

traction as performed in classical antiquity (see

showing

manipulative

therapy

and

of pathogenesis enables us to determine the lesion

Frontispiece). The patient was usually prone on a

that is the most important at a given moment. After

specially constructed table while traction was applied

treatment the patient must be re-examined to gauge

to both the head and the feet. The physician then

any immediate effect, and from this we can see at

dealt with a specific vertebra. Galen, too, knew that

once whether our hypothesis about the pathology

nerves originated from the spinal column and could

was correct and can adjust treatment accordingly.

be

If treatment has been effective, then at the next

description of his treatment of the philosopher

examination

the

picture

should

have

changed

and again we have to determine which lesion has

damaged

Pausanius.

at

this site,

as we see

from

the

But while treatment with herbs dev

eloped into modern pharmacotherapy, and surgery

become the most important. Thus therapy is never

became

a monotonous routine; at the same time it is always

manipulation remained unchanged throughout the

the

In

field

of

specialized

practitioners,

verifiable, which encourages the therapist to take an

centuries.

objective scientific approach.

manipulations was a 'bonesetter': in France he was

Manipulative th e ra p y which is one of the most ,

England

the

layman

performing

'Ie raboteur'.

effective and important of tbe various methods of

The first important school teaching manipulation

reflex therapy, is concerned with impaired function

on a professional basis in modern times was the

of the locomotor system. Because we can define its

osteopathic school founded by Andrew Sti ll

purpose (treatment of blockage) it serves to show

1828): he served as a surgeon in the American Civil

(born

that methods of reflex therapy are more effective it

War and then worked as a general practitioner. He

we know exactly on which type of lesion they act,

founded his school in Kirksville in 1897, and trained

and that they are improperly used if this is not

lay manipulators.

known. This is fundamental to our approach, and it

lasted for 2 year s

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Initially, courses at the school ,

but

later the curriculum was

IntroduClion sCllools,

extended to 4 years, and is now the same

study in time

university faculties osteopathic schools were private institutions,

in

recent years Colleges of Osteopathic Medicine have

been established at some American universities, the

less, for some

5

generation of

willlI1g to co-

chiropractors not

have been

operate with the

encouraged to refer patients to specialists when

advisable.

Chiropractic

colleges now

teach

and

undertake research on a modern scientific basis, are

first being that of the Michigan State University at

consistently overcoming their cherished ideology,

these colleges give full medical training and gradu ates are recognized in most of the states of the USA

system considering themselves specialists of the

istration; this entitles them to carry on medical practice.

pharmacotherapy

East Lansing. In addition to osteopathic techniques,

as DO (doctor of osteopathy) by the state admin

Soon after S till founded

grocer

(D. D.

practic'.

Palmer)

Born in

and limit their activities to problems of the locomotor 'neuro-musculo-skeletal system'.

The fact that chiropractors are taught neither

greater adherence manipUlation is

nor

wrote that it was a

they also prescnbe and use soft-tiSSUe

indeed - only a

chiropractors arc,

were trained. At first

being set up in

dollars! By 1911 courses lasted I year, and now schools

also

give

students a 4-year course of training.

their

There are to this day some differences between osteopaths and chiropractors. The former have full medical training plus manipulation training, and are entitled to work not only as general practitioners but

also as gynaecologists, surgeons, eye specialists, etc. In this way they have become part of the medical profession and the

little,

if at all, to manipulal

are

who remain faithful

something of an elite

physthrust

icians. They rely much

techniques

in

much

so that than

certainly rely mOle

lI:ik"

chiropractic

results

by osteopaths.

College of Chiropraclic

American

surgery

day,

than

tech II iques,

preferring mobilization active (,muscle energy')

sophisticated, they

form the most active and numerous body of manip

ulating physicians. The development of modern medicine in Europe,

in particular, has shown that an uncompromisingly

negative attitude to manipulation is not shared by

the whole of the medical profession. The discovery

of the mechanical role of disc prolapse in root

syndromes made doctors aware of the possibilities of traction and even of other methods of mechanical

treatment, including

somewhat paradoxical the osteopaths and

by the medical prolession ing sophisticated doctors began to

lation, even employing It is no coincidence

a common aim or denominator: to obtain myotascial release.

men who devoted themselves La the an at malllpuiation were

profession has been crossed only gradually. To quote

Naegeli, who used very effective traction manipula

The rift between chiropractic and the medical

a typical example: ' Chiropractic flourishes where

ignorance

prevails.

Chiropractic

will

Europeans. One of the first was a Swiss doctor,

tion on the cervical spine, which was particularly

disappear

effective in the treatment of headache. His book

and common sense. Testimonials are but hypnotic

lished 1954, 1979) makes good reading to this day.

because its time has come. Chiropractic defies logic multiples of zero in an empty vacuum .. .' (Angrist, 1973). Today chiropractors.

which he also is in a way

nor surgery. In fact,

Cyriax, whose

American Medical

iated Medical Societies

IIh:mbcrs to

cooperate with

chiro-

'llIegal

practors took the rnatte I

conspiracy', and won their case

III

! 01::;:; the AMA is

now obliged by law to allow cooperation between chiropractors.

The most important pioneer of medical manipula tion, however. was J. A. MennelJ (1952, 1964), an

outspoken protagolJlsl

curriculum enabling I their students are

doctors and

Nervenleiden lind Nervenschmerzen (1903, repub

It should be

noted,

however, that in the past the chiropractors themselves showed little interest in such cooperation. Neverthe-

techniques physloti1aapists. It

his

disciple Medicine

(1977,1978) remains

assessment of molOl

decessor in

This gap was

also graduated in medicine and whose Manual of Osteopathic Technique remains the classic in its field

(Stoddard, 1961). The London Coll ege of Osteo

pathy (now the London Co.I.lege of Osteopathic Medicine) was the first institution where osteopathic

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6

i?chohlill£iliol1 of

Manipulative

qualified

techniques originally

the Locomotor System doctors,

of this College

have plaYfil

obvious reasons a rift

Poland

medicine, or between

an

of manipulattve medicine throughout Europe and

school of thought, was not likely to develop in all exclusively State-run

prominent. Working under De Seze he succeeded in

tbe interest of some members of his staff at the

medical practitioners (mainly specialists in physical

system, and in the potential of 'unconventional'

the development

particularly in France, where Maigne is the most

giving courses in manipulation at the Medical Faculty of the University of Paris, attended by medicine) but not by physiotherapists.

At the same time, i.e. shortly after 1945, a group of

German doctors became interested in manipulation, mainly under !\merican-trained chiropractors SCllldberg). Unlike Maigne, doctors in private

service.

Neurological. broad field of

Professor

Henner

rehabilitation

of

encouraged

the locomotor

methods, among them manipulation. Svehla, Obrda,

Stary, Miratsky, Jirout and the present author, and later Janda and Vele, worked on these lines. Here the of the most prominent country, and it is in

the Czech Republic

were

team-work in research in

manipulation

doctors): the MWE

economy of manipu

Extremitalcntherllpie]

bv Sell and the FAC

practice;

groups

medical

III

mg and teaching

formed wl1h

[(Gesellscilal!)

(Forschungs

Wlrbelsaulen-

und

und Arbcitsgemeinschaft fOr Chiro

therapie) with Biedermann, Cramer, Gutmann and

H.-D. Wolff.

Unlike

France and Great Britain,

where courses for doctors lasted months or even a year. in Germany doctors were given weekly courses at intervals, arranged in a series of at first 4 and later

8 separate weeks. With this system it has been

progress.

Ministry

curriculurn ot the lll�tllutes of Postgraduate Train

ning which run refresher courses tor specialists in all

fields of medicine. Doctors are thus trained in each of the fields, the 'teachers' receiving additional preparation. Teaching began in Czechoslovakia in 1961, and on the same lines in East Germany in 1965 (three courses of 2 weeks each, at 6-month

possible to teach manipulation techniques to far

intervals).

Austria, Holland

ment of

more doctors in Germany, and also in Switzerland,

into hundreds. united to Medicine,

heir numbers run

German groups

There is another striking feature of the develop-

with rehabilitation of

particular with techniques

developed

on high-velocity thrusts gentler osteopathic

aroused a

being overCClmc,

mcdicine in Czechoslovakia -

As';(xlation of Manual

simpler chiropractic

have been formed

outside the predominant

the Czechoslova k

incorporate it in the

which is only slowly 1113ny counlries of Western

improved muscular

were in turn greatly

addition of neuro-

Europe important groups of medical men have

inhibition techniques, it became obvious that team-work by qualified doctors

performed by

cal necessity for maximum effectiveness. Therefore.

promoted the idea that manipulation should be

exception of

qualified doctors only.

Maigne in France they

With

the

bave not,

however, succeeded in adding manipulative tech

niques to the medical curriculum at universities and

teaching hospitals. They thus belong to what we may call 'unofficial' trends in medicine;

remains rather

support of (NonnenbruclL Schuler and 01

of the univt:r'dl outside

some of the

manipulation

'outsider's' method, despite the German professors

together with trained physiotherapists was a practi

with the exception of high-velocity thrusts, manipu lative techniques are now being taught ever more

widely to physiotherapists who work with doctors.

During the 1980s great interest in mal1!pulative therapy also appeared in the former Soviet Union.

ZUCk,c!lwc:rdt, Junghanns,

Collea:'l1es frol11 Czechos!mJkia. the GDR and Bulgall<'l ilild systematic training has belen cities under the aegis

qualify in courses

held there in 1986 and

reluctant attitude

remunerated

companies.

institutions. Symposia on

for

medicine in

coulltries has followed

different lines. The first country where manipulation

was Llsed and taught on a large scale was Czecho slovakia, where the model that was created has since been adopted by former East Germany, Bulgaria,

1991.

ne, doctors in differ

began

interested in manipulation first international meet

ing took place in Switzerland in 1958. At the next meeting, in Nice in 1962, it was decided to form an

international body; this came about in 1965. when

the I nternational Federation of Manual Medicine

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2 Theoretical· considerations

Morphological aspects

It is, however. the very abundance of what are called 'degenerative changes' that makes it difficult

Chapter 1 showed clearly that manipulation and

to

most of the methods of reflex therapy are used in a

changes

vast number of cases of pain in the locomotor

particular, occurs most often between the fourth and

define

their

relation

increase

with

to

age,

pain. but

Degenerative back

pain,

in

system, including back pain, even though the cause

sixth decade, to become less common in old age. Not

and therefore the therapy remain controversial. For

only do we find subjects

a long time these pains were generally considered to

showing considerable degenerative changes: a person

in perfect health but

be of inflammatory origin, for the simple reason that

with these changes and severe pain may recover

this aetiology could best explain the main symptom,

completely from the latter, whereas his degenerative

the pain itself.

For the same reason they were

changes continue to increase with advancing age. On

sometimes called 'rheumatic pains'. The many terms

the other hand, there can be severe pain symptoms

ending in '-itis' bear witness to this attitude (spondy

in young patients with no degenerative changes at

litis, arthritis, radiculitis. neuritis, fibrositis, myositis,

all. Even more important, the significance of what

panniculitis, etc.) as does 'soft-tissue rheumatism'.

are known as degenerative changes appears to be

However, as inflammation is a well-defined patho

very ill defined. On the one hand there are destruct ive lesions in extremity joints, e.g. coxarthrosis and

logical condition, it has to be proved, or disproved, by the objective methods of pathological anatomy,

gonarthrosis, the great clinical significance of which

and

the

nobody will doubt. On the other hand there are

inflammation theory: it had to be abandoned for lack

changes that probably correspond to what may

of evidence.

be called inevitable 'wear and tear'; then again

this

in

the

long

run

was

fatal

for

Pathological anatomy and 'pathology in vivo' (X

there may be merely a compensatory process, or

rays) generously compensated clinicians for the loss

adaptation, as in scoliosis and hypermobility.

of this simple theory by demonstrating in abundance

spondylolisthesis

what are called 'degenerative changes'. Instead of

spinal column better stability than an orthopaedic

a

In

large osteophyte may give the

terms ending in '-itis' we were then offered spondy

operation. Changes resulting from trauma can be

losis, arthrosis, 'discopathy' and the like. There were

very similar to what is otherwise termed degen

apparently even theoretical reasons for degeneration,

erative. One should therefore ask specifically in each

in particular of the disc: its vascularization is reduced

case of degenerative change whether this change is

early

in

decreases

the ontogenesis and its water content rather

rapidly

during

the

first

three

decades of life (from 90% to 70%). According to

relevant or not; it is ilJ advised to draw clinical conclusions from the mere existence of degenerative changes in a radiograph.

Schmorl and Junghanns (1953),60% of women and 80% of men show evidence of degenerative changes

There is,

however, some correlation between

degenerative change and disc prolapse which may

at 50 while by the age of 70 the figure is 95% for

be of clinical importance. for, with

both sexes. No wonder that under the dominating

prolapse occurs mainly in discs already showing

a

few exceptions.

influence of the pathological anatomist the term

some degenerative change. The discovery that disc

'degenerative disease' is frequently heard.

prolapse could cause root syndromes was undoubtedly

8

Copyrighted Material

Theoretical considerations

9

a landmark: it m ade the medical p ub l i c aware of the impo rtance of the spina l c o l u m n and of t h e

wor k s wi l l give us s o m e c l u e s as to w hat cause s pai n

possi b i l ity o f m e c han ical d i s t u rbance the re. O n t h e

in the loco m otor system when there is no defin i te

o t h er hand, t h e s t r iking success of s urg ical treat m e n t

pat h o l ogy .

i n fe r that

unde rstand i n g of how manipUlation

an

for some t i m e d i s c le s i o n s a n d disc

The firs t, naive explanat i o n of manipulative therapy

prolap s e were h e l d respo n s i b l e for a l m ost e v ery

was 're positi oning', and t h erefo r e something l ike a

mea n t that disturbance

rela ted

to

the

s p i nal

co l u m n .

The

dis l ocat i o n or 'su b l u xati on' had to be assumed. This

reasoning w a s straightforward: i f root compress i o n

'the ory' was l o n g h eld by c h i ro p rac t o rs; S t ill m ust

in the lower lumbar reg i o n was found t o b e d u e t o

have b e l ieved in it, a s did Hippocrates, and pro b a b l y

disc pro lapse, t hen l umbago t hat occurs be fore root

a l l l ay m an i p u l ators down the age s - j ust

compres sio n is like l y to have t h e sa m e c a u s e . If root

right s o m e t hing t h a t was o u t of p l ace'. In fact, if a

compression in the l umbar reg i o n i s due t o the d i s c

pat i e n t with an acute w ry n eck or l umb ago, unable

t h e s a m e sho u l d a p p l y to t h e cerv ical spine a nd, b y

t o stra i g h ten up, is s u ccessfu l l y m a n i p ulated so t h a t

a n a l ogy,

to n e c k pai n; and a s ne c k pain i s frequently

'

putt i ng

h e i m m ediate l y s tands erect , it is l i t t l e w o n der t h a t

ass ociated w i t h headache, root co m p re s s i on may

s o m e t h i n g l i k e 're p o s i t ion i ng'

even be the ca use of c e r v i cal headac he. 'Discopathy'

e x p lanatio n . The reas o n w h y t h i s t h e o r y has bee n

was the fash i o nable w o rd t h e n, not vertebroge n i c nor spondyloge nic diseas e . S u rgical p r ac t ice soo n corrected t his vie w, t ho u g h

seemed the

likely

abandoned by p h y s i c i ans , as we l l as by m o d e rn o s t e o paths and e v e n chiropractors, i s that wit h few exc e p tions ne i t h e r d i s l ocat ion (,malalig n m e nt', 'sub

by d e fault. Although disc surgery became a r o u t ine

l u xation' )

procedure for l u mbar root syndromes, it remained

m a n i p u l a t i o n can be proved. O n e of t h e meri ts o f

l u m bago, as well a s in

ro u t ine radiogra p h y i s tha t t h e s u b l u x a t i o n t h e o r y

the e x c e p t i o n

in simple

ce rv i ca l root s yndro m es, and is prac t i ca l l y n e v e r used in the trea t m ent of pai n i n t he n e c k o r other

nor

reposi tio n ing

('adj u s t m ent' )

after

h a s had t o b e abandoned fo r l ack o f evide n c e . Rece n t l y i t h a s bee n s h o w n b y M . Be rge r (pe rsonal

non-radicular cerv ica l s y n d r o m es. No r can disc prol a pse be the only cause o f root syndromes in the l u mbar regi o n : in o p e ration sta t i s t ics no disc herniat i o n is fo u nd in abo u t 10% of the cases; the

comm u n i cat i o n )

large maj o r i t y of root sy ndro mes resolve w i th o u t

Jirout

operat i o n , a n d this i s t r u e even of cas es w i t h typical

s yn k i n e sis in t he sagi t tal plane aft e r s i d e - b e n di ng, to

findings

at

r adiograph

the

m y e l og r a phy .

shown

has

the

sam e

2.1a,b).

e ffect

for

the effe ct that the rela t ive h e ight o f t h e spi n o u s

w i th

case s

(1979)

processes was n o t t he same be fore a n d after s ide

made

s u ch

t o an extreme p o s i t i o n a n d b a c k , so t h a t i t n eed n o t re t u rn to the same n e u tral positio n ( F i g u re

the

is

in

on cineradiography of t h e

i s repeated after cli n i cal recov e r y (an d

myelography

[f

tha t

c e r vical s p i n e t h e re i s h yste re sis i f t h e h ead m o v e s

non-resorbable

con tras t oi l) , it has repeated l y bee n fo u nd t ha t t h e disc p r o l apse remai n s u n c hanged , j u s t a s i t was at

be ndi n g in

a

n e u t ral p o s ition. [n o t h e r w o rds, t h e re

is no absolute n e u tral positi o n . T h e flaw in t h i s ' re p ositio n' the o ry i s that i t

t he t i m e of maxi m u m pai n . It was, howeve r, show n

implies

i n man y, but n o t in a l .

dis p l aced, i.e .

man i p u lat i o n

of

a

ve r tebra

which

is

i n a ce rtain d i rect i o n , w h ereas in

longer fo u nd at c o m p uted to m ography after t he

reality we o n l y

pa tient is free from pai n . On tbe other han d, if disc

verte brae , as is e x p l a ined late r. Tec h n i ca l l y, t h i s i s

p rolapse i s fo und, e s pecial l y in s u bjects with o u t root

q u i t e a d ifferent p r o p o s i tion. In fact, as there is no

syndromes, it can be c o n s i de red irrelevant.

absol ute n e u tral posi t i o n , we can ass u me t ha t v e r te

Reviewing t h ose morph o l o g i c a l changes t h a t are u s ua l l y related to back pai n and assoc i a ted c o n

restore m o v e m e n t b e t w e e n

two

brae always return t o t h e req u i red n e utral p os i t i o n

ditio ns, w e can readily see t h a t t h e y do not e x plai n

i f tbey c a n move freely . Fascinat i o n w i t h t h e

the com plaints o f the vast majori ty o f our patients .

explanation fo r the effect of manip ulat i o n ( S toddard,

This is a l s o t h e reas o n w h y this ty p e of pa t i e n t is some times

vague l y

'idio pathic back

des cribed

as

suffe r i n g

from

pai n ' o r j ust 'pain without any

disc

also

p r ov i ded

an

1961; Mai g n e , 1968; C y riax, 1977), a l t h o u gh it i s d i ffic u lt t o s e e how man i p u l atio n c o u l d ac h i eve re p o s i t i oning of a p r o l apse the exact p o s i t i o n of w hich

patho logy' or eve n 'wi t h out a n y diagnosis' ('non

can n o t

specific bac k pai n '; Jayso n, 1970); in view o f t h e

app roac h is that m an i p u lation is not ap p l i ed t o the

n u m e rica l impo r tance o f t h i s g ro u p of pat i e n ts this

spinal

is l i t t l e to the cred i t of clin i cal m edi c i n e .

t reat m e n t o f e x trem i ty jo i n ts, a n d p a r t i c u larly s o at

be

known .

colu mn

The

o n ly:

it

grea t is

also

wea k n e s s effect ive

of in

this the

the c ra n i ocervical junctio n, o n t h e r i b s a n d at t h e sacro iliac joint, where t h e re i s n o q u e s t i o n o f d i s c s . C l i nica l experie n ce also shows qu ite c l e ar l y t h a t

Theoretical implications of manipulation

manip u l a t i o n i s most effective i n c o n d iti o n s wh ere we do not expect

If manipu l ative t reatme n t is succes s f u l it u s ua l l y produces immed i a te re l i e f o f pai n . W e may t h e refore

to

find disc l es ions , and l e ss

effect i v e in true disc prolapse. The sophisticated d i ag n ost ic techniques deve l oped

Copyrighted Material

10

Manipu/o(ive Therapy il1 Rehaoili({ffiOI1

of (he Lucul1Io(or Sys(em

by the os te opath s have pro vided what we believe to be rel e vant clinical evidence of how manipulation really works: we apply m a nipu l ation where we find s ign s of mo vem e nt restriction, whether in an ex t re m i t y joint, a rib, or a ver t eb ra l movement segment, and if mani p u l a ti o n is s u cce ssfu l , mobility is always restored. In o t h er w ords . ma n i p u l ati o n does not achieve a c h ange o f structure, a s Still thought, but normalization of function. This is even

true i n cases of wry neck or acute lumbago: the crooked position of the neck or the back in such c as es is itself p hysiological, and it is only the fact that the patient is fixed in this position ( head rotation plus incl i nat i o n in wry neck) th at is p atho lo gica l . Manipul ation merely frees mo bil ity and th u s enables the p a tie nt to r eturn to the n eutra l p os itio n . In this, wry neck and lumbago are the ex ce pti o n to the rule; in the vast maj ority of cases movement rest r ictio n is fo und wh ere j oin ts are in the neutral pos itio n and t here is d i rn culty in pro ceed i ng th rou g h the whole range of move ment.

Functional aspects

(a)

The most important theoretical inference from clinical experience with m a n ip u l a tio n can be formu l ated thus: if one a pp lies ma n i p u lat io n only after a d eq uate clinical exa mina tion of mob i li t y and is careful t o re -examine after treatment. then one regular l y finds that successful m ani p ulation achieves normalization of restricted motor fu n ctio n . and that this goes hand in hand with relief of symptoms. Thi, theoretical inference should then logically be valid not only for pas sive m ob i l i t y , but also for a ctive muscle function. We owe to Janda (1967) the proof that this is true in particular for faul ty motor patte rns ( motor ste r eoty p es) producing o v ers tra i n in the motor system. This is in keeping with the sim p l e observation that e xcessive st rai n causes sympto ms. whatever the ca u se of the strain. In addition to active motor patterns. there is another imp orta n t function, disturbance of which frequ ently ca u s es symptoms: this is body statics. In fact . in modern s o ciet y static overstrain may be at I.east as frequent as faulty mobility, and a g a i n we find that co rr e c t i o n of f a ul ty sta tics frequently brings relief. Thus, m anipu l at i o n pioneered our involvement w i t h fau l ty functioning of the locomotor system and with its normalizatio n, as we shall sec thr o ughout this book. Indeed, faulty fu n ct io n alone is the ca use of frequent symptoms; this c an be sh o wn in ch i l d re n . Morphological change s. on the other hand. do not e x c l u de c h a n ges in function. This is pa rticul a r l y true f o r disc lesions and may explain spontaneous recovery and reco very al"ter conservative treatment (including man ipulation ) . This is of great im portance for rehabi l it a tio n in traumatology, where our primary aim is to improve fun ction d es p it e mo r pho logical changes, in o rder to achieve compensation. As will be shown later. function and its d i st u rb ance s a re rarel y confined to one site or structu re . and therefore diagnosis must take in the locomotor system as a wh ole. The term 'vert ebroge nic' or 'spondylogenic' is thus no l o nge r appropriate, a s even in back pain w e must take into a ccou n t muscle funct i o n and its n er v o u s control as well as the fu n ct io n of the pe lvi s and the extremities. As

(b) Figure 2.1

(0)

In this X-ray of the upper cervical spine in C2 is slightly rotated to the left with the spinous process deviating to the right. (0) [n the same neutral position there is marked rotation with deviation or the same spi nous process; the subject had held his head in maximum left rotation before returning to the neutral position.

neutral position (reverse or false 'reposition')

Copyrighted Material

The clinical segmental

'vertebrogenic' disea,," deAned

pathologicil spondylitis or osteopOlo,i;" the application of mampulatlOn and other measures aimed at restoring function is whether the patient's complaint is due (mainly or exclusively) to changes of function, or to changes of structure (patholog y). This is

a

more difficult matter than it may seem:

it requires a systematic assessment and a technique of examination that has not yet been formulated. It is the great

weakness of

manipulative therilpy,

remedial exercise, etc. - methods concerned with improving the function

they have been, anel tor 1 mainly concerned with

that

I are,

(Figure

2.2).

These consist of (1) hypermobility and

(2) movement restriction; obviously, manipulative therapy is concerned only with the latter.

importance; they include changes in quantity as well as in quality, of which the f o r m e r - taking the form of restricted mohility - is certainly the more straight forward. It is

extremity joint, much more the spinal of great

column. Change!;

to remedy. This is

increased

diagnostic value.

the paradox that in well

recognized, whereas function is panlmount, thiS ium.lamcl1tal aspect is rarely considered. However, the functioning of the locomotor system is extremely c o m plex, as we shall see, and diagnosis of disturbed function is it highly sophisticated p roceeding carried out, as it were, in a c.linical no man's land. There is an additional disadvantage in that it can be investigated only by clinical methods, for the most part, and these are at present regarded as 'subjective', whereas 'modern' research puts its faith y.

The

principal (clinical) characteristics are of the utmost

with

clinical diagnosis of till

importance of change-s

We may now turn back to the intervertebral motor segment and disturbances in its functioning

'binding'):

resistance during

Ihe lack of

the most striking springing in the motor s egment ;

ed joint or I!l

position is never

a normal joint the extreme

reached abruptly, and a slight

increase of pressure increases the range of movement. There is no absolute limit. In a joint with restricted mobility, this springing or giving way has been lost and we abruptly encounter a barrier. This has given rise to the term 'blocking', or blockage, and is, rerhaps, the most easily diagnosed sign. In the osteopathic literature the barrier concert is further elucid;ilcd: 'anatomical barrier' ligament. Activ(' range than passive, elastic barrier.

reaches the 111

capsule

or

:,ollh'what smaller

I

l.imited by an restriction we the range of

e n c o unter a 're s l nel movement; this quality, being abrupt, with no harrier may even change the neulral position or a Joint. In the direction of the pathological barrier, 'binding' may be found on motion palpation. It should be pointed out that although the barrier concept is most freC]uently applied to joints, it may also be used with respect to soft tissues and muscles (Figure 2.3) . It should always be borne in mind that the barrier has a protective function.

Figure 2.2 The mobile

: 955)

Ph

A

Figure 2.3 The barrier phenomenon: the anatomical, physiological and pathological barriers

Copyrighted Material

Hanipullllive

Rehabilillllion

locomotor Syw:ril

The physi ological barr i er which i s most important from the practical point of v i ew i s the most ill defined. In the osteopathi c glossary (1997) it is the of acti ve motion.

only is this definition cannot be

for soft

passi ve exami nation of joints, pl <.l y

According to the latest chiropractic publication this barrier is reached at the very end of

passive

motion. This

definition,

again,

is

2.5),

these

2.6).

mobili!v

thus be clinic:iliv

It

normal joint movement;

a

restoring nonncli

most cUcetive and gentle

normal

(1995)

as is well illus

shifting movements as well as distraction are

inferred

.

(2),

use springing techniques; and

trated by MennelJ's d i agram (Figure

the prerequisite Its dlslurbance can b..:

likened to a drawer that has stuck, and needs to be eased out.

most

unfortunate, beGlUse both (thrust) rnobili zati on C
restriction and reflex

however, i s

stretch reflex

With good relaxation and spontaneous re l ease . For an optimu m gentle technique we have to reach the

Blockage III an articulation and particularly III a vertebral motor segment goes hand in hand with

barri er by the patient relaxing, the resistance of a

reflex changes mainly in the same

joint in neutral range being practically n i l. This is

These affect the dermatome as well as the muscles,

where sprillgmg

IIy true for ant for both

release

most

segment.

changes is

complex

(989)

and treatmenL Thne the very little springi ng at the range of The same for

called

at

coined the term 'segmental facilitation'. In movement

the

barrier,

which,

agai n,

requires

maximum relaxation. addition,

good

dysfunction' (Greenman,

is characteri zed by asymmelcy, ahnormal range of motIOn

soft tissue

restriction,

This is quite as true for soft tissues as for joi nts. In

etc.

spi na l

palpation

is

mandatory

muscular

Korr

tension

or spasm

is

(1

most

important because it may fix the joi nt and may be a

for

very significant factor callsing restri ction; this can

of

be seen from a pOSitive straight leg goes for the antalgesi c posture'

(1998) showed that mcreased pressure produced

bendllJg of the whole lumbar spme prevent allY

increased stiffness of the lumbar spine.

attempt by the patient to straighten up.

and for sensing release: the is, however, than very

used.

s,yntlromes,

whc:n antcl'icxi on and

For all these reasons the correct definition of the

To quote Korr (1975), who has devoted most of

physiological barrier is the point where the first of

his work to the implicati ons of manipulativc me rapy : as the motors of thi nking of 'Whi le

a to

is

is met. Thi s of the examiner hallmark of his

very probably

contractiun.

nroduci ng motion to remember

force,

libo used to

therefore proposed that it i s that a muscle may become a major and highly

Joint play and movement restriction

variable

impediment

to mobility of a

lesioned

"joi nt"'. After giving a thorough explanation of the ilre

are two types PLlssive by movement l es,nctlOn

the IS functional moverm:nt', i.e. movement earned out by thc subject; joint play is passive movement. whi ch cannot be carried out by the subject and

role Korr

lIluscle spindle and

gamma syslenl

'The h i gh

with,

s an explanllllOn resistance [0 moti on ("b ind") in une direction ... They [the muscles] would also be provoked into stronger and stronger contraction by the exaggerated

comprises a translatory (sliding) movement of one

spindle discharges as motions that tend to lengthen

joi nt surface agai nst the other, or even rotati on. and Thus we d istraction

the affected muscles occur' found cli n i cal explained not

finger, whereas the metacaqul

any

direction, rotated, or distracted by axial pull. These movements are not only felt, but can be demonstrated radiographically (induding distracti on, F igure

2.4).

Joi nt play is by no means of academic interest only: practical clinical blockage at normal, winch

lies in

) it

r,.1sponsi ble for joint, but by the organ

To put it brieny. the mOl/llment restriction struct ure thl,! mobility, i.e, active movement, the

muscle. That is why osteopaths do not use the term 'blockage' for movement restriction bu t in order not ,

to commit themsclves, speak of 'osteopathic lesi ons', or more

1978)

The

Copyrighted Material

of ' somatic

unction' (Green m l l lL

of shortened

in movement

Theoretical considerations

13

restriction has been demonstrated by J a nda (1967) .

Muscle relaxation order to mobilize

techniques are widely used in

j o ints

.

The question must there

joint in

fore be put: what is the role of the

pa s s i v e

movement restriction?

Blockage as an articular phenomenon The

si m p l i s t i c

entirely

view

or mainly an

that

passive

a rt ic ul a r

movement

is

phenomenon should

be abandoned. In fact. as K or r has shown , most by which we recognize movement restriction in a j o int or vertebral motor segment might be explained by muscle ac tivi t y induced by

cli n ical pheno me n a

the m u s c l e pro pri ocep tors and the gam m a syste m . What evidence remains t o show that the j o i nt has a r ol e

of any importance')

There is one

obvious weakness in the purely

'mu sc u l ar' theory: it does not e x p l a in what s timu lates the receptors: in other words, if m u scle activ i t y is

a

reflex response, which n obody doubts, where

does the s t i mulu s come from? The pu re l y e m pir i c al

techniques

of

manipulati o n

are

base d

on j o i nt

a n a tomy . It is surprising that osteo paths, who a re the

(a)

(b)

(c) Figure 2.4 (a.

originators

of

most of these

very carefully

worked out and exactly taught techniques, appear

(d) b) Distraction of the metacarpophalangeal joint: (c. d) medial and lateral gapping of the knee Joint.

visualized by X-ray

Copyrighted Material

14

lv/anipulative Therapy in

Rehabilitation of the Locomotor System ar t i cula r

p he n omenon .

But t here

is e v e n

direct

evidence:

J. T h ere are three joints lhat are not moved by muscles, nor can t heir movement be opposed by them:

these are

the sacroiliac,

the

acromio

cl a vicula r and t he tibiofibular joints. Yet these joints show typica l signs of blockage and their

tre atment by pa ssi v e mobilization is particularly

(b)

(a)

Figure 2.5 Importance of joint play. (a) Gliding

movement is ess e n tial for join t function: if gliding is disturbed

(b)

forceful movement may injure the joint

(MenneJl. 1964)

therapy

effective.

2. I n order to prove (or dispro v e ) the rol e of the arti culation we undertoo k the followi n g experiment: in 10 patients the cervic al spine was examined before operat ion ( mainly abdominal surgery) and re-examined under anae s the s i a with myorelaxants and intubation with artificial respiration. Tn all cases movement restriction remained uncha nge d and was even more easi ly r ecog ni z ab le d ur ing narcosis, as the patient was completely relaxed.

Possible mechanism of joint blockage and manipulation fixation

The importance of the experiment just referred to

mobilization

lies not only in proving that movement restriction,

too, is an artic u lar p henomenon, but also in that it

prove d that we have to deal with a mech ani cal obstacle in the joint. It was Emminger first

suggested

that

such an

(1967)

who

obstacl e migh t

be

attributed to the me n iscoid s previ ously described by

therapy Figure 2.6 The direction of gliding mobilization. showing

how

movement and joint

this depends on whether the

pro x im a l or d i st a l partner is

concave

or convex (After

Kaltenborn. 1976)

very little aware of their theoretical implications. More indirect evidence lies in the importance of

joint play as a prerequisite of normal joint function: there is no doubt that muscles have a far stronger ,

direct influence on functional movement, which is in fact induced by muscles and can for the same reason

be inhibited by muscles, than on the m o v eme n ts of joint play. If, therefore, the muscular factor was the decisive one, functional movement would be affe cted

first, and not join t play. We know, however, that

Figure 2.7 Entrapment of a meniscoid at the edge of a

the reverse is the case. Further evidence comes from analysis of the h igh - v elocity t hrus t t echni q ues

joint space, according to the joint blockage theory of

producing gapping of the joi n t surfaces, together

position (a) has m ov ed between the joint facets and its

wit h a po pp ing sound, or 'click'. There are distraction high-velocity thrusts which cause hardly any dis tension of the muscles, the j oint remaining in the

n eut r a l pos ition , and the cl i ck itself is certainl y an

Wolf

(1975). Top. tbe meoiscoid nor m all y lying in

hard edge has impinged: (b) bollom, it has returned to

n orm al pos i tion after treatment. A groove (c-d) remains for a s h o rt time, but b eing flat it offers only minor resistance to slipping back

Copyrighted Material

1:;

Theoretical comiderallom Tbndury (J 948) in intervertebral j oin t s , and later

found by Kos (1968) even in extremity joints: the

meniscoids may get caught between the moving joint facets, Indeed,

most

joints have very incong ruou s

produces a cavity i n the cartilage Hnd is trapped in

it (Figure 2.7).

The implications for the theory of ma nip u l a ti o n

are clear: if we sepa r a te the joint facets by high

facets and smooth mobility is possible only if some

velocity th rust techniq ues, the meniscoid can slip

additional tissue call fill the redundant space, To do

out. Figure 2.7 shows that the tr app e d edge of the

joint facets, and may meet with difficulties, Kos and

overcome, cons is ti ng of two very shallow grooves

this the meniscoid must move freely between

the

Wolf (1972) have further elaborated this theory,

showing why the mechanism is easily di s tu rbed : ( 1) the me niscoid h a s a soft base and

a

hard edge, which

ca n no t easily be comp r e ssed and (2) joint c a rtil a g e

is hard and elastic only if the force that acts on it

does so rapid ly , If, however, we subj ect the ca r til a ge to

pressure, it that pr essu re as

constant

exerting

therefo r e ,

the

adapts to

the material

though it were Auid. If.

meniscoid is

caught

gliding surfaces of the joint f acets,

between the the hard edge

me

n iscoid

has

only

a

very

slight

r esist a nce

to

that open smoothly into the wedge-shaped space

between the c a r tilage surfaces. I n repetitive mobil ization meeting

back-and-Forth

a

greater

m ove m e

resistance

in

nt

the

takes

place,

direction

of

incarceration than in that of liberation. After the last resistance has been g r ad u ally overcome, the meni scoid

s lips

back into its original position. Fig ure 2.8

a lso illustrates how resistance becomes less with each movement that increases the space between the dotted lines.

(8)

Figure 2.8 The effect of therapy. (a) Gapping of the joint by high-velocity thrust, making it possible for the meniscoid to slip back. (b) Repetitive mobilization enabling the meniscoid to move back into its original position, first by small degrees and then more rapidly

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of

(01

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17

Theoretical considerations

�'j

�

4

6 E E

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5

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c

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c

Q 4 ro ;;;

Q. Q) Ul

3 2

-.---- . . -- .

r

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./

Crack

L�-.--.-.I 2

, 4

, 6

10 8 12 Tension in kg

14

16

18

Tension in kg Figure 2.11 The effect of the 'click' prod u ced by distraction of a metacarpophalangeal joint, according to Roston and Wheeler-Haines (1947)

Trauma

Figme 2.10 Distraction of a metacarpophalangeal joint; below after a thrust ( i n to traction)

above before,

The second cause of disturbed locomotor function is trauma. It is important to point out that there are borderline cases between trauma and overstrain due to a great variety of causes, because it is not always

important factor in spinal and locomotor function is

easy to say what is and what is not an injury for the

obviously the musculature and its nervous control.

spinal column.

Usually trauma is defined as an

This control is expressed by motor patterns and

exogenous force acting on the body for a short time

posture, formed in a highly characteristic way in

and capable of damaging structure or function. Even

every individual. As Janda (1967) has shown, there

uncler normal conditions the forces acting on the

is a certain balance between various muscle groups (see p. 26) that move j o i nt s or vertebral motor

segments, and if this balance is disturbed the normal

spinal column arc considerable. If these forces are suddenly increased because of sharp, ill-balanced movement, the line between the two groups of

functioning of the joint suffers.

causes appears to be rather arbitrarily drawn.

Modern civilization brings with it very one-sided, forced movements, causing muscular imbalance, and this is no less true of posture - in fact, one of the

characteristic features of modern life is lack of movement accompanying static or postural over

Reflex action Blockage may be of reflex origin due to changes in

a segment. As stated in Chapter 1, the spinal column

strain. Therefore the first and most fre q ue n t cause

is involved in disease wherever it occurs in the

of blockage is a faulty movement pattern due to

organism. Visceral disease causing nociceptive stimuli

muscular imbalance, ancl postural overstrain.

is followed by reflex spasm in the relevant segment

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18

Manipulative Therapy in Rehabiliwtion of the Locomotor Syslenl

Figure 2.12 Electromyogram showing an increase in muscle activity (force) in the triceps brachia during cervical traction

(muscular defence) a n d in particular in th e deep l a ye rs of the erect o r sp i n ae muscle. This is likely to fix the vertebral motor segment as well as to interfere with normal mobility of the trunk. If such a spasm is of sufficiently long duration, blockage is lik e l y to occur. H a nsen and Schliack (1962) d es c r i b e characteristic sc ol iosi s in visceral d is ea s e . As is shown in Chapter 7 (p. 282), we recognize a number

Figure 2.\3 Electromyogram t a k en from three leads in

a

of

characteristic ' spi n a l patterns' in visceral disease, showing that there are certain p a thogen etic rules. A st r i king feature of this type of blockage is its recurrence if the internal disease relapses or ex a cerbates . rn fact, we seem to k now m ore about visceral influence upon the spi n a l column than about the influence of the sp ina l column on visceral di s eas e .

C8 root syndrome (a) before and (b) after cervical (thrust)

manipulation

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20

Manipula tive Th erapy in Rehab ilita tion of {h e Locomotor System heavy

head

on

the

fragile

cervical

spi n e .

P h ysiologica l l y , t h i s is t h e s i t e o f t h e t o n i c n e c k

r e A e x e s , a n d i n fl u e nces m u s c l e to n e t h ro u g h o u t

t h e p o s t u r a l t ru n k m u sc u l a t u re . I f fu n c t i o n h e re

is d i s t u r b e d . t h e re is m o s t fre q u e n t l y h y p e r t o n u s

of t h e pos t u r a l m u sc l e s , d i s t u r b a n c e s o f e q u i l i b

t h e o t h e r e n d o f t h e s p i n a l c o l u m n . o r ev e n i n t h e e x t re m i t i e s . T o l e a v e s u ch a

l e s i o n u n tre a t e d

r i s k i n g t h e r a pe u t i c fai l u re a n d rc l a pse .

is

The impo rtan ce of nervous co ntrol

to be

The s p i n a l co l u m n c o u l d not a c t as a f u n c t i o n a l u n i t

i m p o r t a n t for r o ta t i o n . as o n l y t h e a t l a n to a x i a l

u n d e r n e r v e c o n t ro l . The r o l.e o f m o v e m e n t p a t te rn s

o f t h e c e rv i c a l s p i n e i s t h u s fo rced to t a k e o v e r a

t h i s i s the most s i g n i fi ca n t cause o f b l oc k a g e i n a

rium

and

l o c o m o t o r d e fi c i t w h i c h

has

c o m p e n s a te d b y t h e cervical s p i n e . T h i s i s m o s t j o i n t i s i d e a l l y a d a p t e d for rota t i o n , a n d t h e r e s t fu n c t i o n

fo r

w h ic h

it

is

poorl y

fi t t e d .

The

t e m p o ro m a n d i b u l a r j o i n t w i t h t h e m a s t i c a t o r y

m u sc l e s a n d t h e d ig a s t r i c u s a re c l os e l y r e l a te d t o

the cra n i o cerv i c a l j u nc t i o n .

2 . T h e l u m b o s a c ro i l i a c j u n c t i o n for m s t h e b a s e o f t h e s p i n a l col u m n a n d t h e refore d e te r m i n es b o d y

s t a t i c s . A t t h e s a me t i m e i t t r a n s m its mov e m e n t from t h e l e g s t o t h e s p i n a l c o l u m n a n d a c t s a s a

shock absorbe r.

3. The

c e r v i c o th o r a c i c j u n c t i o n

is

the

regi o n

u n l ess a l l i t s r e a c t i o n s w e re coord i n a ted b y m us c l e s

a n d t h e i r d i s t u r b a nce h a s al r e a d y b e e n st ressed . as

v e r t e b ra l m otor segm e n t . J a n d a

( 1 978)

has shown

t h a t t h e q u a l i t y o f m ov e m e n t p a t t e r n s v a ri e s from one i n d i v i d u a l t o a n o t h e r , a n d t h i s goes h a n d in

h a n d w i t h v a r y i n g s u s ce p t i b i l i t y t o v e r t e b roge n i c

d is t u rb a n c e . O n t h e o t h e r h a n d , a n y d i s t u r b a n c e o f f u n c t i o n i n a s i ngle m o t o r segm e n t w i l l h a v e i t s r e p e r c u s s i o n s t h r o u g h o u t the b o d y a x i s a n d m u s t be

compe n s a te d . Here a ga i n , n e rv o u s c o n t rol p l a y s a

d e c i s i v e p a rt . T h i s is no l e ss t h e case w i t h pa i n . o n c e t h e l e s i o n b e c o m e s p a i n fu l , fo r i t is the n e rv o u s

in w h ich t h e m o s t m o bi l e s e c t i o n o f t h e sp i n a l

s y s t e m th a t d e t e r m i n e s h o w i n t e n se l y t h e s e g me n t

s p i n e a n d w h e re the p o w e rfu l

o t h e r w o r d s , i t i s t h e n e rv o u s s y s tem t h a t d e t e r m i n e s

co l u m n i s j o i n e d t o t h e re l a t i v e l y r i g i d t h o ra c i c muscles o f t h e

wi l l react, and

w

he re

t h e t h re s h o l d o f p a i n l i es. I n

u p p e r e x t r e m i t i e s a n d s h o u l d e r girdle insert .

wheth e r

is well seen i n the transition ve rtebra T12 w h e r e

i n te n s e , d i s t u r b e d f u n c t i o n i n o n e m o t o r segm e n t

4. T h e g re a t s t ra i n on t h e t h o raco l u m b a r j u nc ti o n

t h e u p p e r a po p h ys e a l j o i n ts r e t a i n t h e t h o r a c i c

patte r n whereas the lower j o i nts have t h e l u m b a r p a t t e r n , i . e . w h e r e o n e type o f fu n c t i o n c h a n ge s

a b r u p t l y to a n o t h e r . I f d u r i n g wa l k i n g t h e p e l v i s

c l i n i ca l l y .

d i s t u rb e d

fu n c t i o n

I f reaction

to

will

m a n i fe s t

nociceptive

i t se l f

s ti m u l us

is

wi l l prod uce a n a n ta l g e s i c response a n d a lt e r t h e n o r m a l m o t o r p a t t e r n , h e nce p r o d u c i n g fi x a t i o n of a

c h a nge in fu n c t i o n . Co n trol

by

the

n e rv o u s s y s t e m

thus

has

two

t i lts from o n e s i d e t o t h e o t h e r , t h e l u m b a r s p i n e

a s p e c t s : i t s u b s e r v e s n o r m a l fu n c t i o n b y t h e m a i n

l ie s a t t h e leve l o f L3, t h e t h o raco l u m b a r j u nction

d i s t u r b e d fu n c t i o n . O n t h e o t h e r h a n d , a n i n t e n se

s i d e - be n d s s o th a t t h e vertex o f t h e s co l i o t i c c u r v e r e m a i n i n g in l i n e with the s a c r u m ; t h i s t o o , c a n

t e n a n ce of correct motor p a t te rn s , a n d i t comp e n s a t e s

b e s e e n i f th e s u bj e c t m a r ks t i m e b e fo r e a n

and c h r o n i c p a i n fu l s t i m u l u s d is t u rbs n o r m a l motor p a t t e rn s a n d m a y then cause alte red . p a t h ological

i n te n s e s p a s m n o t o n l y of b a c k m u s c l e s , b u t i n

the d i s e a s e process.

X - ra y screen .

D i s t u r b a nce

of function

p a r t i c u l a r of t h e psoas m u sc l e

causes

( K u b i s , 1 969),

the

m o t o r pa t t e r n s t o b e c o m e fi x e d , thus p e r p e t u a t i n g It is,

t h e r e fo r e , n o c o i n c i d e nce

that d i s t u rb e d

q u a d ra t u s l u m b o ru m , t h e thoraco l u m b a r e re c t o r

fu n c t i o n o f the motor s y s t e m is m o re l i k e l y to be

t h i s t ra n s i t i o n a l r e g i o n u n l i k e t h e o t h e r th r e e ,

a re a s a rule psyc h o l ogica l l y l a b i l e a s we l l . In t h i s

s p i n a e and even the stra igh t a b d o m i n a Is, because

co n n e cts t w o v er y m o b i l e sec t i o n s o f t h e s p i n a l c o l u m n . I m mob i l i za t i o n o f t h i s j u n c t i o n the refo re m a kes s e v e r e m u s c u l a r s p a s m n e c e s s a r y .

5 . I n h u m a n s t h e fe e t a r e t h e b a s e o f b o d y s t a t i cs

a n d g a i t ; a t t h e s a m e t i m e t h e y a r e t h e s o u rce of

fo u n d in s u bj ects w i t h l a b i l e n e r v o u s regu l a t i o n . who

con n e c t i o n i t i s o f i n te re s t t h a t S t a ry

Figar

severe

( 1 970)

(1 970)

and

w e r e a b l e to s h ow t h a t p a t i e n ts w i t h

radicu l a r

s y n dromes

very

easi l y

fo rmed

co n d i ti o n e d rene x e s to a d d i t i o n a l pain s t i m u l i , and

tha t t b e s e reAexes w e re m o r e d i ffi c u l t to e x t i n g u i s h

t h e most powe rfu l p r o p r i oce p t i ve , e x t e roc e p t i v e

t h a n i n h e a l thy c o n t ro l s . F u r t h e rm o r e , K u n c el al.

s e n s ory orga n s .

p l a y s a m a j o r p a r t i n recove r y a fte r d i sc o p e r a t i o n .

and

n o c ice p t i v e

imputs,

comparable

to

o ur

( 1 955)

s h owed t h a t the m e n t a l con d i t i o n of p a t i e n ts

G u tzeit ( 1 95 1 ) In

view

of

their

i m po r t a n ce

and

t h e i r great

factor

is

fo u n d t h a t a pro m i n e n t psyc h o l og i c a l

c h a r a c t e r istic

fo r

v e r t e broge n i c

pain

v u l n e r a b i l i t y , t h e s e k e y r e g i o n s a re u s u a l l y t h e p l a ce

p a t i e n ts . S nl c e k a n d S k ra b a l ( 1 97 5 ) c o m p a red two

o b s e r v e d i n c h i l d re n . D i s t u rb a n c e of fu n c tion a t

s i g n s o f a nx i e ty a n d d e p ressio n . a n d 2 5 sch i zop h re n ics

col u m n ( a n d t h e motor syste m ) a s

c e rv i c a l

w h e re t h e s p i n a l c o l u m n s u ffers firs t , as c a n

b es t be

s u c h p o i n t s j e o p a r d i z e s t h e f u n c t i o n i n g o f the s p i n a l seco n d a ry l e s i o n s . S u c h

a

a

whole, causing

d is t u r b a nce s h o u l d never

b e ov c r lo o k e d e v e n i f t h e s y m p toms a re m a n i fest a t

t y p e s of m e n t a l p a t i e n t s : 50 c a s e s o f n e u rosis w i t h

w i t h l o w e m o ti v i t y . B lo c k a g e . m o s t freq ue n t l y in t h e spine, was

a bse n t

in only

fi ve n e u ro t i c 1 6 sch izop h renic p a t i e n ts . The seg m e n t m o s t fre q u e n t l y a ffe ct e d w a s p a t ie n t s , b u t w a s n o t fo u n d

Copyrighted Material

in

Th eoretical considerations the a t l a n t o - occi p i ta l ; t h e d i ffe r e n ce w a s s i gn i fi c a n t

w e l l a pp l i e d , s h o u ld g i v e i m me d i a te

a t the P = O. O l level.

is

A ga i n , obse r v a t i o n s by J a n d a ( 1 978) a re o f g r e a t relev a n ce : inclined fo u n d

p a r t i cu l a r l y

true

for

the

new

21

rel ief. This

n e u ro m u s c u l a r

tec h n i q u e s .

i n p a t i e n t s wi t h poor m o t o r p a t t e r n s ,

The m o s t n u m e r o u s c h i l d p a t i e n ts , p r e s e n t i n g a

t o i m b a l a nce o f t h e m u s c l e g ro u p s , h e

r e a l probl e m , a r e t h ose w h o s u ffer from h e a d ac h e ,

(1)

m i n o r n e u r o l o g i c a l d i s t u r b a nces w h i c h h e

t h e cerv ic a l spi n e b e i n g o n e o f the m o s t freq u e n t

te rmed ' m icrospa s t i c i ty ' , i n w h i c h move m e n ts w e r e

causative

n o t fu l l y coord i n a ted a n d a p pe a re d c l u m s y ; ( 2 ) s l i g h t

h e a d a c h e , i ncl u d i n g m igra i n e .

s e n s o r y i m p a i rm e n t , i n p a r t i c u l a r o f prop rioce p t i o n ;

c h i l d re n s u ffe r i ng from n o n - m ig r a i n o u s h e a d a c h e ,

( 3 ) worse a d a p t a t i o n to s t ress s i t u a t i o n s a s a re s u l t

m a n i p u l a t i o n g a v e e x ce l l e n t res u l ts , w i t h o n l y two

o f poo r l y coord i n a t e d b e h a v i o u r .

A l l t h i s corre

sites. T h i s is t r u e o f v a rious types of In

a g r o u p o f 30

fa i l u r e s , w h i l e in a group o f 27 c h i l d re n s u ffe r i n g

spo n d s t o a ( re l a t i v e l y ) n e w c l i n i c a l e n t i t y , m i n i m a l

from

bra i n dysfu n c t i o n , w h i c h i s fo u n d i n 1 0-1 5 % o f t h e

exce l l e n t resu l ts i n 24 c a s e s . T h e s e fi n d ings w e re

m i g ra i n e

t h e re

w e re

three

fa i l u re s ,

and

( 1 966) .

c h i l d pop u l a t i o n . J a n d a c o m p a re d t h e s o m a t i c a n d

co n fi rm e d by K a b a t n fk o v a a n d Kaba t n f k

psych o l ogica l fi n d i ngs i n

these c h i l d r e n w i t h t h e

p a r t i c u l a r l y i m p o r ta n t type o f h e a d a c h e i n c h i l d r e n ,

fi n d i ngs i n a d u l t pa t i e n t s w h o h a d v e ry u n fa v o u ra b l e

k n o w n a s ' sc h o o l h e a d a c h e ' , form e r l y b e l i e v e d t o b e

m o t o r pa t t e rn s t h a t produced re l a p s i n g v e r t e b ro

o f p s y c h o l o g i c a l o r i g i n , w a s p ro v e d b y G u tm a n n

g e n i c d i sorders, a n d c o n c l u d e d t h a t s u c h c h i l d re n

( 1 968) t o b e d u e t o h e a d a nt e fl e x i o n d u r i n g s c h o o l

A

become those p a tie n ts w h o prese n t th e ms e l v e s i n

h o urs, w h e n

a d u l t l i fe

d e s k s . T h i s w a s c o n fi r m e d b y L e wi t a n d K u ncova

with

the

principal

symptom

of

pain,

p a t i e n t s were be n t

o v e r h o ri z o n t a l

beca use of s m a l l n e u ro l o g i c a l c h a nges w h i c h d o n o t

( 1 97 1 ) .

d isap p e a r d u ri n g a d o l esce n ce b u t i n s t e a d t a k e t h e

fu n c t i o n i n the l u m b o s a c r a l regi o n is dys m e n o r rh o e a

form o f d i s t u rbed f u n c t i o n o f t h e m o t o r syste m , w i t h

or a l go m e n o r r h o e a

resu l t i n g p a i n .

fi n d i n gs i n y o u n g g i r l s , freq u e n t l y s t a rti n g a t t h e

N e v e r th e l ess, however i m po r t a n t m o t o r i m b a l a n ce may b e , it is n o t i d e n ti c a l to i m p a i re d j o i n t fu n c t i o n or

b l ockage of

v e rt e b r a l mo t o r s e g me n t . S uc h

a

lesions d o a p p e a r e v e n

i n s u bj e c t s w i t h

perfect

m o to r p a t t e r n s , w h e re a s they may be m i ss i n g i n

One

c l i n ica l

m a n i fe s t a t i o n with

negative

of

d i s t u rb e d

g y n a e co l ogi c a l

m e n a r c h e . Pa i n i s u s u a l ly fe l t i n the l o w b a c k a nd i n the

abdome n .

Not o n l y

is

t h i s type

of p a i n

a m e n a b le t o ma n i p u l a tive t r e a t m e n t ; i t i s freq u e n tl y t h e first s i g n o f d i s t u rb e d fu n c t i o n i n t h e l u m b o s a c r a l reg i o n i n wo m e n .

p a t i e n ts w i t h seve re n e u ro l o g i c a l d i s e a s e . I n 1 420

True l u m b a g o i s m u c h l e s s fre q u e n t i n c h i ld h oo d ,

patie n ts with d i s se m i n a ted scle ros i s , Sc h a l te n b r a n d

b u t t h e r e e x i s t r a re c a s e s o f t r u e d i sc h e r n i a ti o n a s

( 1 938) fo u n d 22 . 3 % to be s u ffe r i n g from b a c k a c h e .

e a r l y a s p u be rt y . W i t h t h e exce p t i o n o f a c u t e w r y

I n o u r e x p e r i e n c e b a c k a c h e i s t h e r u l e i n P a r k i n so n ' s

n e c k , d i s t u rb a n ce of fu ncti o n i n t h e sp i n a l co l u m n

d is e a se ,

m a n i fe s t s

u nd e rs t a n d a b l y

in

view

of

the

m u sc l e

rigi d i ty i n t h i s co n d itio n . However, n o m a t t e r h o w s e v e r e t h e n e u rologica l d i sord e r , i t is n o t t a n t a m o u n t to p a i n

due

fu n c t i o n o f t h e colu m n , s u c h restricted

to d is t u r b a n ce o f a

m o t o r system a n d

as

i ncreased

m o b i l i ty

of

a

or

joint

t h e ve r t e b r a l

(more or

s p ec i fi c

fre q u e n tly)

s p i n al

motor

i t s e l f i n d i re c t l y ,

for t h e m o s t

p a rt

as

h e a d a c h e , a n d i n you n g g i r l s a s a l go m e n o rr h o e a . For

this

reason

I

was

i nt e rested

to

see

how

freq u e n t l y d i s t u r b a n c e s o f fu n c t i o n c o u l d be fo u n d i n c h i ld r e n o f d i ffe r e n t a g e g r o u p s . T h e m o s t s t r i k i n g p he n o m e n o n fo u n d espec i a l ly fre q u e n tl y i n c h i l d r e n a nd a d o l esce n ts i s p e l v i c d i s t o r t i o n w h i c h i s d e a l t w i t h i n l a t e r c h a pters. I fo u n d i t i n 1 1 o f 8 0 c h i l d r e n

segm e n t .

( 1 4--41 D isturbance of fu nction ( blockage) in ch ildhood

m o nt h s o l d ) ex a m i n e d i n cre c h e s , i n 8 1 o u t

o f 1 8 1 c h i l d r e n ( a g e d 3-6 y e a rs ) i n n u rs e ry s c h o o l and in

1 99

o u t of

ages o f 9 and

15.

459

s c h o o l c h i l d re n b e t w e e n the

S t a t is t i c a l e v a l u a t i o n s h o w e d no

s i g n i fi c a n t d i ffe r e n c e between t h e i n c i d e nc e i n boys From w h a t h a s b e e n s a i d it fo l l ows t h a t d i st u r b a n c e s of function m a y

(J )

and g i r l s . From n u rs e ry s c h o o l age o n w a rd s , p e l v i c

by t h e m s e l v e s c a u s e sym p t o m s

d i s t o r t i o n i s fo u n d i n a b o u t o n e - t h i rd t o o n e - h a l f o f

a n d (2) a p p e a r m uch s o o n e r t h a n struct u r a l ( m o r

t h e c h i l d re n . I n c o n t r a s t , I fo u n d m o ve m e n t restric

p h o l ogica l ) c h a n g e s . Fo r t h i s r e a s o n I h a v e b e e n

t i o n in the cerv i c a l s p i n e ( m a i n l y a t the c r a n i o c e r v i c a l

p a r t i c u l a rl y i n t e re s t e d i n d i s t u rb a nces o f f u n c t i o n i n

j u n c t i o n ) i n n o n e o f t h e i n fa n ts i n c r e c h e s , i n o n l y

c h i l d h ood . Sch o n ( 1 95 6 ) a n d l a t e r G u t m a n n a n d

e i g h t o u t o f 1 8 1 n u rsery-sc h o o l c h i l d re n , a n d i n 7 3

W o l ff ( 1 95 9 ) h a v e s h ow n t h a t c l i n i c a l s y m p t o m s a s

out of

we l l as cha nges i n f u n c t i o n v i s i b l e i n c i n e r a d i o

459

schoolch i ldren o v e r t h e a g e of 9 years.

The s e i n v e s t i ga t i o n s d a t e fro m 30 y e a rs a g o , w h e n

gra phic s t u d i e s a p p e a r a b o u t 1 0 y e a r s e a r l i e r t h a n

t h e t e c h n i q u e o f exa m i n a t i o n fo r t h e u p p e r c e rv i c a l

d e ge n e ra t i v e c h a n ge s .

s p i n e was much less sophisticated than i t is today.

T h e m o s t t y p i c a l v e r t e b roge n i c l e si o n i n chi l d r e n i s a c u te wry n e c k .

A l th o u g h i t i s a se l f- l i m i t i n g

co n d i t i o n , t r a c t i o n a n d m o b i l i z a t i o n tec h n i q u e s , i f

Our

c u rre n t

tec h n i q u e s ,

cli n ica l

has

shown

experience, that

pelvic

using

s u b t ler

d i s torti o n

in

c h i l d re n goes h a n d i n h a n d w i t h b l oc k a g e , m a i n l y a t

Copyrighted Material

22

Manip uia live Therapy in Rehab iiilalioll of

Ih e Locotl1 o/Or Syslem

the a t l a n to-occ i p i t a l j o i n t , a n d a l so t h a t after m a n i p u l a t i o n o f t h i s j o i n t , pelvic d is t o r t i o n d i s a p p e a rs. I n 1 98 2 I the refore exa m i n e d a g ro u p of 7 5 n u rsery school c h i l d r e n ( aged 3-6 years) a n d fou n d p e l v i c d is t o r t i o n i n 24 , of w h o m 23 h a d m o v e m e n t restri ction a t t h e a t l a n to-occ i pi t a l j o i n t ' I n 1. 2 o f t h e se m a n i p u l a t i o n w a s c a rried out ( a t l as-occi p u t ) ; t h e pe l v i c d i stortion d is a ppe a red s i m u l ta n e o u s l y . T h e r e i s thus good r e a s o n to be l ieve t h a t m o s t of the c h i l d re n in w h o m we fou n d pelvic d istortion 30 y e a rs ago also s u ffe red fro m b l ockage at t h e cra n i o cerv i ca l j u n c t i o n . S o m e scoli otic deform i ty w a s fo u n d i n 1 7 5 o f the 4 5 9 schoo l c h i l d re n t h e n e x a m i ned, i n 1 5 out o f the 1 8 1 n u rse ry-school c hi ldre n . a n d in o n l y one of the 80 c h i l d re n i n c rech es. T h e pri m a ry i m portance o f t h e c r a n iocervica l j u nction is i n keeping w i t h import a n t observ a t ions by K u b i s , con fi rmed i n 1 093 new-born b a b i e s by S e i fert ( 1 975 ) . Post u ra l n e c k reflexes ca n be e x a m i ned i n the n e w b o r n : o n t u r n i n g the head to one s i d e , t h e pe l v i s t u rns t o t h e opposite s i d e i f t h e c r a n i ocerv ical j u nction fu nctions nor m a l l y . [ t was a b norma l in 298 o f t h e 1093 ex a m i ne d . In 5 8 per ce n t o f t h i s group, using the normal tec h n i q u es , Se i fert d i a g n osed b l ockage a t t h e cra n i ocervica l j un c t i o n , betwee n t h e ages of 4 a n d 9 m o n t h s . A n o t h e r i m p o r ta n t gro u p of c h i ld r e n of a l l ages w h o showed blockage m a i nly of t h e a t l a n to-occ i p i t a l j o i n t a re t hose with re la psi ng o r c h ro n i c t o n s i l l i t i s : i n a group o f 7 6 such cases e xa m i ned and fo l l owed up by L e w i t a n d

pelvic d i s t o r s i o n 35

A b r a h a m o v i c ( 1 976 ) , 70 ( 92 p e r ce n t) h a d m o ve ment restrict i o n at the c ra n ioce rvical j u nctio n , m a i n ly at t h e CO-C 1 l e v e l . I n o r d e r to esta b l i s h w h e t h e r these fi n d i ngs i n c h i l d r e n a r e fort u i to u s or fa i r ly consta n t , a gro u p o f chi l d re n w h o s t a rted sc hoo l a t te n d a nce i n 1 960 w e r e systematica l l y fol l owed u p fo r 8 years ; h a l f the n u m b e r s h owing some i m p a i re d function were trea ted , a n d t h e o t h e r h a l f l e ft as con t ro l s . [ n a d d i t i o n t o t h e s p i n a l col u m n , t h e extre m i t i es a n d parti c u l a rly t h e m usc u l a t u re were t h o rough l y tested. The res u l t s a re given in Figure 2 . 1 4 , t h e m ost i m port a n t fi n d i ng b e i n g t h a t , w i t h few excepti o n s , Cha nges i n t h c function o f t h e p e l v i s a n d of t h e c ra n i ocervi cal reg i o n re m a i ned const a n t i f not t reated. O n the o t h e r h a n d , t he re were on l y a few re l a ps e s afte r tre a t m e n t . F r o m t h i s i t follows t h a t cha n ges i n t h e functio n i ng o f t h e s p i n a l co l u mn a n d t he l o c o m o t o r system cause s y m p t o m s far more fre q ue n t l y t ha n is ge nera ll y a ss u m e d , even in c h i l d re n . M u c h more freq u e n t l y , however. th ese lesions a re c l i n ic a l l y l a te n t . Pelvic d i stortion p l u s u p p e r cervical lesions a re fou n d in m o re t h a n a t h i rd of all s c h o o l c h i l d re n . M u sc u l a r i m b a l a n ce is eve n m o re freq u e n t , a l t hough less cons t a n t . I t can further be i n fe r red t h a t : 1.

Disturba nce o f fu n c t i o n a p pe a rs Ill uch e a r l i e r i n t h e locomo t o r system t h a n do dege n e ra t i v e m o rp h o l ogica l c h a nges.

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Fi g u re 2.14 Fol low- u p s t u d i e s ov e r 6 y e M s of 72 schoo l c h i l d re n of t h e s a m e age , cov e r i n g i n c i d e n ce of p e l v i c t o rsion , c e r v i c a l b l ockage

sco l i os i s , d i ffe r e n c e i n l e g l e n g t h a n d

Copyrighted Material

23

Theoretical consider(llions 2. T h i s d i stu rba n c e , a lo n e , c a n c a u s e s y m p t o m s w i t h o u t s t r u c t u ra l c h a nge s .

t h e s e q u e l a e of t ra u m a are u s u a l l y more seve re in

s t r u c t u re s with dege n e ra t i v e c h a n ge s . I n d e e d , q u i te freq u e n t l y w h a t a re c a l l ed dege n e ra t i v e c h a n ge s are i n re a l i ty a n a t t e m p t to compe n s a t e d y s fu n ct i o n . Th e y a r e t h e n tes t i m o n y t o p re v i o u s d a m a ge . O n e

Poss i b l e conseq u e n ces of b l o c k a g e in t h e vertebra l m ot o r seg ment

i m po r t a n t c o m p l i c a t i o n o f d eg e n e r a ti o n c a n b e disc pro l a p s e ,

but h e re

again

we

find

a comp licated

r e l a t i o ns h i p betw e e n s t r u c t u r a l c h a nge a n d a l te r e d fu n c t i o n : we k n o w t h a t e v e n d isc p r o l a pse m a y b e

I f b lockage occurs i n t h e s p i n a l col u m n o f a c h i J d o r a n a d o l esce n t , a t fi rst s i g h t t h e c o n se q u e nces m a y seem re l a t i v e l y i n s i g n i fi c a n t : t here m a y b e s o m e tra n s i t o r y p a i n , as i n wry n e c k , b u t i n t h e s p i n e , u n l i ke t h e e x t re m i ty j o i n t s , fu n c t i o n is re a d i l y compe n sa te d b y n e i g h bou r i n g o r e v e n d i s t a n t m o t o r segm e n t s . a n d t h e l e s i o n rem a i n s m a s k e d fo r a v e r y l o n g t i m e . The re i s , howe v e r , a pri ce t o b e p a i d fo r t h a t com p e n sa t i o n : i n c reased d e m a n d s on t h e c o m p e n sa t i n g s tr u c t u r e s , w i t h possi b l e d ysfu n c t io n . A good ex a m p l e is h e a d rota t i o n w b e n t h e re i s

c o m p a t i b l e w i t h a b sence o f s y m ptoms, a n d i t m a y be a d is t u rbance of fu n c t i o n on top of th a t w h i c h m a kes

the

lesion

m a n i fe s t .

On

re s to r i n g correct fu n c t i o n i n

a

the

oth e r h a n d ,

bloc k e d j o i n t , for

e x a m p l e , m a y p r o d u c e com pensa t i o n . T h a t a l tered f u n c t i o n m a y be i m p o r t a n t i n n e rve c o m p ressio n ( e n t r a p me n t s y n d ro m e s ) we have s e e n in

the

c a rpa l

particularly

in

tunnel the

syn d ro m e

initial

stages.

(see On

p.

267 ) ,

thoro u g h

e x a m i n a t i o n we re g u l a rl y fi n d i n creased res i s t a n ce to j o i n t p la y o f t h e carpa l b o n e s . W h e n j o i n t p l a y i s

block age b e t w e e n a t l a s a n d a x i s A l t h o u g h t h e j o i n ts

resto red , t h e s y mp to m s d i s a p p e a r a t t h i s s t a g e . I n

between t h e a t l a s a n d t h e a x i s are a d m i ra b l y s u i ted to ro t a t i o n , t h e rest o f t h e ce r v i c a l s p i n e is not. The refo re head rota t i o n ca r r i e d out w i t h a bJocked a t las-a x i s mov e m e n t c a n be d e e me d a d y s fu n c t i o n , a n d e v e n m o r e so w h e n t h e restricted m o v e m e n t i s n o t sym m e t rica l . Q u i te obv i o u s l y , m ov e m e n t restric tion in o n e se g m e n t p ro d u ces h y p e r mo bi l i ty in a n o t h e r, and i n ge n e r a l , a s we h a v e see n , the conseq u e n ce s of d y s f u n c t i o n w il l b e m os t m a r k e d if fu n c t i o n i s d i s t ur be d in key r e g i on s . O s teop h ytes a re t he typica l c o n se q u e nce of lo ng lasting ove rstra i n , nor i s b l ockage w i t h o u t co n s e q u e nce s , fo r , a s we we l l k n o w , m u c h o f t h e l i t t l e vascu l a r i ze d tissue o f c a r t i l age a n d d i scs d e p e n d s o n move m e n t fo r i t s nu t r i t ion . R a d i o l o g y s u p p l i e s a m p l e e v i d e n ce o f reg u l a r o s te o p h y te fo r m a t i o n i n t h e m o t or seg m e n t adj a ce n t to a c o n ge n i t a l b l o c k . Func t i o n a l b l o c k a ge i n a n te - a n d re t r o fl e x i o n , a s s e e n rad i ogra p h i ca l l y , i s as a r u l e acco m p a n i ed by

o t h e r word s , o n l y i f t h e re i s free m o b i l i t y be tween

.

dege n e ra t i v e c h a n ge s - n a rro w i n g of t h e d i sc - i n the restricted segme n t , a n d by o s t e o p h y tes i n t h e neighbo u r i n g h ype r m o bi l e s e g m e n t ( J i ro u t, 1 956) . M U li e r seg m e n t

( 1 960)

has

eve n t u a l l y

shown

that

becomes

this

hypermobile

blocked,

a nd

the

process spreads t o n e i g h b o u r i n g seg m e n ts . T h i s i s u n d ers t a n d a b l e , f o r osteo p h y t e s a re r i n g s h a pe d a n d have a st a bi l i z i n g func t i o n , as c a n b e s t be s e e n i n

sta b i l ized s po n d y l o l i s t h e s i s . Dege n e r a t i v e c h a n ge s i n t h e m se l ve s n e e d n o t p r o d u c e m a n i fe s t c l i n i c a l s y m p t o m s . The y d o , h o w e v e r , m a k e t h e s p i n a l co l u m n m o re s u sce p t i b l e t o f u r t h e r d a m age. I t i s a g a i n d i s tu rbed fu n c t i o n t h a t esta b l i s h e s i ts e l f more e a s i l y i n a structure a l re a d y ma rked by dege n e ra t ive c h a nges; i n o t h e r w o r d s , i f

t h e bo n e s for mi n g the t u n n e l ca n t h e walls a d a p t t h e mselves to t h e c o n t e nts o f t h e t u n n e l u n d e r v a r y i n g co n d i t i on s of s t r a i n should

not

fo rget

that

part

a n d movem e n t . W e of t h e

wall

of the

i n te v e rtebral c a n a l w h e re r o o t c o m press i o n occu rs is a l so the a po p h y s e a l j o i n t . F i g u re 2 . 1 5 s u m m a rizes t h e m e c h a n i c a l fac t o r s i n t h e p a th oge n e s i s o f bloc k a g e .

T h e s i g n ifica nce of d i stu rbed m ovem ent patter n s (stereotypes) T c o n si d e r d is t u r b e d m o v e m e n t p a t t e rn s a s t h e m o s t i m porta n t s i n g l e c a u s e o f b l oc k a g e , a n d re m e d i a l e x e rcise i s t h e n t h e t h e ra py o f c h o i c e . R e m e d i a l exe rcise is w i d e l y reco m m e n d e d i n p a i n f u l v e r t e b ro genic c o n d i t i o n s , but w h a t is m e a n t by the t e r m i s m u c h l e s s c l e a r , s i nce we a re n o t d e a l i n g h e re w i t h o b v i o u s p a r e s i s , d efo r m i ty o r w e l l - d e fi n e d loco m o to r l e s i on ( w i t h t h e exce p t i o n of blockage, w he re se l f- t r e a t m e n t exercises c a n be t a u g h t to t h e p a t i e n t ) . W e h a ve J a n d a ( 1 97 5 ) t o t h a n k for s h e d d i ng l i g h t o n t h i s p r o b l e m . T h e m a i n obj ect o f re m e d i a l e x e r c i s e i n d i s t u r bed f u n c t i o n o f t h e l ocomotor s y s t e m i s t h e corre c t i o n of fa u l t y p a t te r n i n g ( fa u l ty l o c o m o t o r stereoty p e s ) , i . e . fa ulty coord i n a t i o n o f m u s c l e f u n c t i o n d u e to d i s t u rbed c e n t r a l n e r v o u s c o n t r o l . U n fo r t u n a t e l y fo r t h e sys t e m a tica l l y m i n d e d , m o v e m e n t pa tterns a r e h i g h l y i n d i vi d u a l m o t o r progra m me s , fo r m e d by e a c h s u b j e c t i n t h e course of h i s l i fe o n the basis of c h a i n s o f u n co n d i t i o n e d a n d a c q u i re d (co n d i t i o n e d ) r e fl e x e s . T h e re is t h e re

function re m a i n s c o m p e n s a te d i n a s p i n a l col u m n

fo re gre a t v a r i a b i l i t y , a n d the l i m i ts of t he norm a r e

w i t h dege n e r a t i v e c h a n g e s , a s a r u l e n o s y m p t o m s

v e r y broa d . I n fac t , t h e w a y e a c h i n d i v i d u a l m o v e s

w i l l a r i s e . S u c h a s p i n a l col u mn , h o w e v e r , is m o r e

i s so c h a racte r i s t i c t h a t we c a n recogn i z e h i m b y h i s

l i a b l e t o d e co m pe n s a t i o n . T h a t i s w h y , fo r i n s ta nce ,

ga i t , h i s gestures, t h e way h e writes, a n d so o n .

Copyrighted Material

24

Manipula ti v e Therapy in Rehab ilitation of th e Locomotor System

F a u l ty m u sc l e

Visceral lesion

p a tt e r n

o f co rresp o n d i n g segment \

\

I \ I

'"

\ \

'-

/

B l ockage

I

I

/'

( i f p ri m a ry i n \

k e y re g i o n ) \

\

\

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I

I I t I I I I I

S o ft t i s s u e a n d

C l i n i c a l d e c o m p e nsat i o n

degene rative c h a n g es

( e . g . d i sc p r o l a p s e )

Figure 2.15 P a t h o g e n e s i s : p r o b a b l e c a u s e s a n d cons e q u e n c e s o f b l o c k age

Idea l l y , l o c o m o t o r p a t t e r n s s h o u l d a l low m o v e m e n t

of h i p e x t e n s i o n w i t h t h e a i d o f t h e h a m s t r i ngs a n d

t o b e a s e co n o m i c a l a s poss i b l e , i . e . t o c o n s u m e t h e

t h e e r e c t o r s p i n a e m a y re m a i n n o r m a L w h i l e t h e

s m a ll e s t possible q u a n ti ty o f e n e rgy.

p a t t e r n i s g re a t l y c h a n g e d , w i t h i m po r t a n t conse

H e r e , a s i n m a n y o t h e r s i t u a t i o n s , i t is a b n o r m a lity

q u e nces for l o co m o t o r fu n c t i o n , as we s h a l l see l a te r .

that provides t h e rel e v a n t clues: e v e n a l a y m a n w i l l

Secondl y ,

recog n ize a n a w k w a rd p e r fo r m a n c e , w h i c h m o re

s u rp r i si n g l y

tes t i n g

o f t e n t h a n n o t is ta n t a m o u n t to a n u n e co n o m i c a l

m u s c l e s a lw a y s s h owed a te n d e n cy t o l e s s e r a c t i v i t y

o n e . T h e l a y m a n w i ll o fte n b e a b l e t o correct w h a t

( w e a k n es s ) a n d h y p o to n i a , w h e re a s o t h e rs t e n d e d t o

constan t

these

simple

pattern

m o v e m e n ts ,

e m e rged .

a

C e rt a i n

h e s e e s - fo r insta n c e , s p o r t s t r a i ners d o so d ur i n g

hypera c ti v i ty , i n creased te n s i o n a n d e v e n t a u t n es s ,

their work.

w h i c h ca used a t y p i c a l m o t o r i m b a l a n ce . T h i s i s so

I n p a t i e n ts w i t h c h r o n i c v e r te b r o ge n i c p a i n a n d a w k w a rd move m e n t s , J a n d a

( 1 972)

a p p l ie d t h e c l a s s i c

c h a ra c te r i s t i c t h a t we can now d e te r m i n e s y n d romes t h a t a re o f c l i n i c a l i m p o r t a n ce . T h e y a re c h a racter

m us c l e test to i n d i v i d u a l m us c l e s . T h i s re v e a l e d t w o

istic for i n d i v i d u a l p a t i e n ts : i n s o m e cases t h e re is a

s i gn i fic a n t f a c t s . F i r s t , t h e s i m ple test m o v e m e n ts

pre p o n d e r a n c e of w e a k n es s , fl a b b i n es s g oing h a n d

b e l i e v e d to be c h a ra c t e r i s t i c fo r a s pe c i fic m u scle

i n h a n d w i t h hypermobili t y , w h e reas i n o t h e rs t a u t ness

g r o u p a re m o re often t h a n n o t p a t t e r n s in w h i c h

w i t h i n creased m u s c l e t e n s i o n prev a i l s . It is t h u s

a

is

p o s s i b l e to d r a w u p u s e fu l l i sts o f m uscles ( m uscl e

by

groups) t h a t s h o w a t e n d e ncy to h y p e r a c t i v i t y , a n d

gre a ter n u m be r of m u sc l e s take

co m m o n l y

thought.

Ex a m i n i n g

h ip

part than extension

p o l y e l ec t r o m y ogra p h y , J a n d a s h owed that hip exte n

o f t h o s e t h a t t e n d to i n h i b i t i o n (Ta b l e

2.1).

This d i ffe r e n c e i n t h e be h a v i o u r o f m u s c l e s c a n

s i o n i s n o t o n l y a t e s t fo r t h e gl u t e u s m a xi m u s m uscl e , b u t t h a t t h e p r i m e m o v e rs i n h i p e x t e n s i o n

be s e e n

are t h e h a m s t r i n gs , a n d t h a t i n a d d i t i o n to t h e s e t w o

p a rticu l a rl y c h a r acteristic i n c o m m o n p a i n f u l s t a tes:

u n d e r v a r i o u s c l i n i c a l co n d i t i o n s a n d i s

m uscle g r o u p s t h e l u m b a r ere c t o r s p i n a e a l s o t a k e s

in a p a i nf u l hip i t i s a lw a y s t h e fl e x o rs a n d a d d u c t o rs

p a r t . T h e characteristic d i s turba nce o f h i p exte n s i o n

t h a t a re tense a n d t h e g l u t e i w e a k ; i n s h o u ld e r p a i n

i s d e c r e a s e d a n d b e l a te d a c t i v i t y of t h e g l u t e u s m a x i m u s ( Fi g u r e recogn i ze

2.16).

c l i nically

We h a v e n o w l e a r n e d t o

which

m uscles

take

part

in

s i m ple test move m e n ts , t h u s u s i n g t h e test to assess not

only

m u scle

tight band.

co n s i d e r a b l y

s a m e t y p e o f m u scle w i l l be i n h i bi te d a n d freq u e n t l y s u p e rseded b y m u s c l e s w i t h a t e n d e n c y to h y p e r -

may

be

q u a li t y

a

a l tered w i t h o u t m u c h c h a nge i n fo rce ; t h e s t r e n g t h

q u a l i ty

also

we a k , t h e r e c t u s fe m o ris re m a i n i n g l i k e

Co n d i ti o n s a re v e ry s i m i l a r i n fa t i g u e : aga i n t h e

Th i s

but

c h r o n i c p a i n fu l c o n d i t i o n s o f t h e k nee t h e v a s t i a re

of

pe rfo rm a n c e .

weakness,

t h e p e c to r a l i s a n d s u b sc a p u l a r i s a re t a u t w h e r e a s t h e s u p r a sp i n a ti , i n fra s p i n a t i a n d d e l t o i d s a r e w ea k ; i n

Copyrighted Material

Theoretical considerarions

I NduI

25

8W. .inl

obi ..... .

abel.

cIx

Figure 2. 16 E l e c t r o m y o g r a m o f r i g h t h i p e x t e n s i o n : the r i g h t g l u t e u s maximus i s b r o u g h t i n to a c t ion l a te a n d l i t t l e : m a r k e d a c t i v i t y i n t h e h a m s t r i ngs o n t h e righ t a n d the e re ctores s p i n a e o n b o t h sides: i n h i b i t ion o f t h e r i g h t g l u t e u s maximus ( From V . J a n d a . perso n a l co m m u n ic a t i o n )

a c t i v i t y a n d t a u t ness . O n c l o s e r sc r u t i n y w e fi n d t h a t

a n d t h era py a re d e a l t w i t h in t h e relev a n t c h a p t e r s .

m u scles w i t h a t e n d e n c y t o i n h i b i t i o n a re t h ose t h a t

I t is i m p o r t a n t to p o i n t o u t , h o w e v e r , t h a t t rigge r

a re a lso i n h i b i t e d ( fl a b b y ) i n u p p e r m o t o r n e u ro n lesi o n s , w h i l e t h ose w i t h a t e n d e ncy to h y p e r a c t i v i t y

po i n ts m a y occ u r in b o t h t y p e s of m u s c l e , o n e type being

painfully

tense,

the

other

p a i n fu l l y

flabby

become s p a s t i c . N e u ro logica l l y , the typica l i m b a l a n c e

( i n h i b i t e d ) . I n both, h o w e v e r , these trigger poi n ts

i n fa u l ty moveme n t p a t t e rn s , e n h a nced by p a i n a n d

a re effe c t i v e l y t r e a t e d by post- i s o m e t r i c rela x a t i on .

fa t i g u e , m a y b e i n t e rp reted a s ' m icrosp a s t i ci t y ' .

Ex a m i n a t i o n of s i m ple m o v e m e n ts by a p p ly i n g

Those m u scles w i t h a t e n d e n cy to i n h i b i t i o n a re

t h e m u scle t e s t i s o n ly o u r fi rst s t e p ; o u r h a b i t u a l

ca l l e d by J a n d a ' p redomi n a n t l y p h a s i c ' , w h i le h e

m o ve m e n t s a re i n d i v i d u a l ly a c q u i r e d

ca l l s

h y p e racti v i t y

s t e r e o t y p e s w i t h a degree of p l a s t i c i t y , so t h a t t h e y

' p red o m i n a n t l y pos t u r a l ' . T h e s e t e r m s , w h i c h a re

a re c a p a b l e of be i n g tra i n e d . H o w e v e r , t h i s t r a i n i n g

m u scl e s

with

a

tendency

to

patterns or

s t i l l p ro v i s i o n a l , i n d i c a t e t h a t t h e re a l p h y s i o logical

is v e r y t i r i n g , p a r t i c u l a rl y a t fi r s t , t h e fa t i g u e s e e m i n g

b a s i s for t h e d i ffe r e n c e ,

o u t o f a l l p r o p o r t i o n to t h e e n e rgy re q u i r e d fo r t h e

which

i s c l i n ic a l l y very

st r i k i ng , i s n o t yet known. W i t h o u t going too d e e p l y

move m e n t f o r w h i c h t h e s u b j ect i s b e i n g t ra i n e d .

i n to the q u e s t i o n h e r e , i t s h o u l d b e s t ressed t h a t

Th i s

t h e s e g ro u ps d o n o t c o r r e s p o n d to t h e t y p e s o f

t h e m o re s o for t h e s i c k ; i t i s s o m e t h i n g t h a t m u s t

is

true

even

fo r

h e a l th y

s u b j e cts,

and

all

muscle fi b re d i s t i n g u i s h e d by m o d e r n n e u ro p h y s i

n e v e r be forgo t t e n i n p l a n n i n g re m e d i a l e x e rc i s e

ology, h i s t o l ogy a n d b i oc h e m is t r y . Cl i n i c a l d i a g n os i s

( r e h a b i l i ta t i o n ) .

Copyrighted Material

26

Manipulative Therapy in Rehabilitation of the Locomotor System

Table 2.1 Musc l e groups t hat show a tend ency to

fac i l i t a t e s sto o p i n g , w h i l e l o o k i n g t o t h e s i d e faci l i

hyperacth'ity o r inhibition

t a tes rota t i o n o r i n h i b i ts m o v e m e n t i n t h e opposite d i recti o n . Furth e r m or e , a s s t r a igh t e n i n g o f t h e b o d y

Hyperactivity

is c o n n ected w i th

Inhibition

i n h a l a ti o n ,

and

stooping w i t h

e x h a l a t i o n , i t i s e no u g h fo r t h e p a t i e n t t o l o o k u p to fa c i l i ta t e i n h a l a t i o n a n d i n h i b i t e x h a l a t i o n , and v i ce

On the dorsal aspect of the body Tr iceps su rae

G l u t e a l m uscles

H a ms t r i ngs

Tra pez i u s

L u m b a r s e c t i o n o f t h e e rector

Serratus l a teral i s

spinae

(lower

v e r s a . Th i s , as we s h a l l see, p l a y s a cruci a l pa rt i n part)

t h e m o d e rn n e u ro m u s c u l a r tec h n i q ues most useful fo r m o b i l i z a t i o n .

S u p r a - a n d i n fras p i n a t i

Q ua d ra t u s l u m b o r u m

D e l to i d

R e t u r n i n g t o t h e q u e s t i o n o f i mba l a nce o f muscle groups,

M iddle and upper trapezius

with

the

p re d o m i n a n t l y

p ha s i c

m us c l e s

i n h i b i ted and t h e p r e d o m i n a n t l y post u ra l m u s c l es

Le v a t o r sca p u l a e

o v e r - a c t i v e , i t is e asy to s e e t h a t t h i s m u s t s e r i o u s l y i n te r fe r e w i t h coord i n a te d l ocom o t o r p a t t e r n s . T h i s

On t h e ventral aspect of t h e body

i s p a r t i c u l a r l y so a s i n m a n y i n s t a nces t h e y a re

Ti b i a l i s a nterior

Th igh a d d uctors

a n tagon i s t s , t h e h y p e r a c t i v e m u scle t h e refore h a v i n g

E x t e n sors o f t h e toes

R e c t u s fe m o r i s Te n s o r fas c i a e l a t a e

Pe ro n e i

a n i n h i b i to r y e ffect o n i t s w e a k a n t ago n i s t . Hyper

I l i opsoas

Vast i

a c t i v e l u m b a r erectores s p i n a e w i l l u n fa v o u r a b l y a ffec t w e a k a b d o m i n a l m us c l e s , a n d h y p e r a c t i ve h i p

Pectorales

Rect us a b d o m i n i s

S u bsca p u l a res

D e e p n e c k flexors

Scalenes

D i gastricus

fl e x o rs w i l l i n fl u ence w e a k g l u t e i .

S te r n o e l e i d o m a s t o i ds

The pathoge n ic mechanism of d isturbed movement patterns

M a s t i c a t ory

On tile arms F l e x o rs

E x t e n sors

H a v i n g e x p l a i n e d w h a t m o v e m e n t p a tterns a re a n d h o w t h e y c a n b e d is t u r b e d by i m b a l a n ce o f spec i fi c m u s c l e gro u p s , I n o w t race t h e m ec h a n i s m s b y w h ic h

T h e co n c e p t of p a t t e r n i n g is a v e r y importa n t o n e ,

d i s tu rb a nces o f t h e m o s t i m p o rta n t m u s c l e p a t t e r n s

a n d c a n c h a n ge o u r v i e w o f t h e d i ffe rence b e t w e e n

( s t e r e o types ) w i l l h a v e a d e l e t e r i o u s e ffect o n t h e

ago n i s ts a n d a ntago n i sts q u i t e decisively. For e x a m p l e ,

l o c o m o to r s y s te m .

t h e h a m s tr i ngs a n d t h e q u a d r i c e p s c a n be c o n s i d e re d a s a n tago n i sts

i f we

a r e t h i n k i n g o f the s i m p l e

m o v e m e n t of k n e e fle x i o n . Howeve r , t h e m o v e m e n t

Wa l k i n g a n d sta n d i n g

o f w a l k i ng i s m u c h m o re com p l e x t h a n s i m p l e be n d i n g

H e re t h e m o s t i m po r t a n t i m b a l a nce is between w e a k

a n d s t r e tc h i n g o f t h e k n ee ; d u ri ng w a l k i ng b o t h

gl u t e a l m u scles w i t h h y p e ractive h i p A e x o r s , a n d

t h ese m us c l e s h a v e to c o n t r a c t a n d t o c o o rd i n a te a s

hyperactive

s t a bil i zers o f t h e k n e e . T h i s i s e q u a l l y t r u e o f t h e

a bd o m i n a l muscles. I n s t a n d i n g we see i n creased

a b d o m i n a l a n d b a c k m u s c l e s , a n d o f t h e fl e x o r s a n d

pelvic tilt and

e x te n s o r s o f t h e n e c k . I n fa c t , i n we l l - c o o rd i n a te d

lumbar a

e rectores

spinae

with

weak

protruding a b d o m e n .

The p a t h o g e n i c m e c h a n i s m i s t h i s : s t a n d i n g p l aces

s t r a i g h t e n i n g u p fro m a s t oo p i n g pos i t i o n i t i s t h e

an i ncreased loa d o n the l u m b a r spi n e , a s even w h i l e

a b d o m i n a l m u sc l e s t h a t h a v e t h e d e c i s i v e rol e . I t i s ,

s ta n d i n g a t ease t h e re i s h y pe ractiv i ty o f t h e b a c k

t h e re fo r e , a g r a v e m i s t a ke i n re m e d i a l exercise t o

muscles;

t ra i n t h ese m u scles s i m p l y accord i n g to t h e res u l ts

p e r fo r m e d by t h e i n h i b i te d g l u t e i m a x i m i , b u t b y

o f t h e m u s c l e t e st, a n d n o t w i t h regard to t h e i r

t h e l u m b a r e rectores s p i n a e , c a u s i n g h y p e r l o rd o s i s

fu nct i o n i n t h e v i ta l s t e reotype c o n c e r n e d .

i ns t e a d of e x te n s i o n o f t h e

when

w a l k i ng,

hip

exte n s i o n

is

hip joint - t h a t

not

is,

is

t he r e is i nc r e a s e d s t ra i n o n t h e l u m b a r s p i n e , d u e to

i m p o r ta n t to re m e m b e r t h a t t h e y fu n c t i o n l i k e a

h y pe r m o b i l i ty in the s a g i t t a l p l a n e . T h i s i s gre a t l y

In

t ra i n i ng

correct

movement

pa tterns

it

' p rogra m m e ' t h a t c a n be read i l y fac i l i t a ted o r t r i g

e n h a nced by t h e wea k g l u te i m e d i i ; w h e n t h e pa t i e n t

g er ed if t h e correct a ffe re n t i m p u l se s a re e m p l oye d .

s ta n d s o n o n e l e g these musc l es s ta b i l i ze t h e p e l v i s

F o r e x t r e m ity m o ve m e n ts , m o s t receptors a re o n t h e

i n t h e c o ro n a l p l. a n e ; i f t h e s e m u scles a re w e a k , t h e re

pe r i p h e ry , i . e . t h e fi n gers a n d toes. To fac i l i ta te

is i n c r e a s e d s w a y i n g of the pe l v i s , c a u s i n g l u m b a r

w a l k ing i t is i m p o r t a n t fo r t h e p a tie n t to t h i n k a b o u t

h y pe r m o b i l i ty i n t h e c o r o n a l p l a n e .

l i ft i n g h i s b i g t o e ; h e w i l l t b e n a u t o m a t i c a l l y d o r s i fl e x t h e foot, a n d b e n d t h e k n ee a n d

h i p . S i m i l a rl y ,

fl e x i o n of t h e fi n ge r s w i l l trigge r fl e x i o n i n t h e e l b o w a n d s h o u l de r . W h a t t h e fi n gers a n d t o e s a re fo r t h e

Stra i g hten i n g u p f r o m a stoop i n g posit i o n (wei g ht lifti n g )

e x t re m i ti e s , t h e e y e s a re fo r t h e t r u n k : l o o k i n g u p

I f the tru n k i s i m a g i n e d a s a s t r a i g h t l e v e r d u ri n g

fa c i l i ta te s s t r a i g h t e n i ng of t h e b o d y , l o o k i n g d o w n

w e i g h t l i ft i n g a n d t h e LS-S l d i sc as t h e fulc r u m ,

Copyrighted Material

Theoretical considerations fo rces act i n g on i t of up to a b o u t lOOO k Pa h a v e b e e n c a l c ul a ted ( M a t t h i a s c h , 1 95 6 ; M o r r i s , 1 973 ) . S u c h a force

would

crush

the

d i sc .

Nachemson

( 1 959)

27

The role of respiration in locomoto r d isturbance

m e a s u red i n t r a d i sc a l pressu re in v a r i o u s posi t i o n s of fo u n d t h a t t h e m a x i m u m p r e s s u r e

Th i n k i n g of b r e a t h i n g , o n e n a t u r a lly h a s in m i n d t h e

d u r i ng w e i g h t l i ft i n g was a b o u t 275 % o f t h a t i n t h e

res p i r a to r y s y s te m . Y e t i t i s t h e loco m o t o r s ys t e m

the body and

u p r i g h t posi t i o n , i . e . i t w a s 340 k P a .

that

Th e reason ( a ccord i n g to G racovets k y , 1 988) l i e s

makes

t h e l u ngs

work,

and

the

loco m o t o r

s y s t e m t h a t h a s to coord i n a te t h e specific r e s p i r a t o r y

to w h i c h

m o v e m e n t s w i t h t he rest o f t he b od y ' s locomotor

n o t o n l y t h e b a c k m u s c l e s a t t a c h b u t a l so t h e g l u t e i

a c t i v i t y . This t a s k i s s o c o m p l e x t h a t it would b e a

and

m i r a c l e i f d i s tu rb a n ces d i d n o t o cc u r .

in

t h e r o l e of t h e i n d i re c t l y t h e

w h ich

l u m bodors a l

fasc i a

h a mstrings a s w e ll , a n d fro m

t h e s p i n a l co l u m n

is

' s uspended '

that

I t i s w i d e l y h e l d t h a t m u sc u l a r a c t i v i t y i s fac il i t a te d

fu r t h e r e n

d ur i n g i n h a l a ti o n a nd i n hibited d u r i n g e x h a l a t i o n ,

ha nced by t h e coo rd i n a ted a c t i v i ty o f t h e a b d om i n a l

b u t t h i s i s a n o v e rs i m p l i fi ca t i o n . T h e a b d o m i n al

leve rage i s e l i m i n a te d . T h i s m a y be m u s c l e s w h ich h e l p t h e t h o r a x

so

to a p p ro a c h t h e

m u s c l e s m a y be a c t i v a t e d by ex h a l a t i o n , e s p e c i a l l y e x h a l a t i o n a g a i n s t resis t a n c e . r h a ve a l re a d y m e n

s u p po r t i n g p e l v i s .

tio n e d t h e c l os e c o n n ec t i o n b e t w e e n l oo k i n g u p , i n h a l a ti o n

Lift i n g t h e a r m s

and

s t r a i g h ten i n g

of

the

body,

and

b e t w e e n loo k i n g d o w n , e x h a l a ti o n a n d s t o o p i n g .

H e r e t h e dec i s i v e fa c t o r i s c o r re c t fi x a t i o n o f t h e

Th i s , h o w e v e r , a p p l i e s on l y t o t h e c e rv i c a l

s ho u l d e r g i rd l e ; t h i s i s t h e fu n c t i o n o f t h e u p p e r p a rt

l u m b a r s p i n e ( w h ich a r e decisive i n v i ew o f t h e i r

and

of t h e t r a p ez i u s m u s c l e a n d t h e l e v a t o r sca p u l a e

g r e a t m o b i l i t y ) a n d l e s s to t h e t h o r a c i c s p i n e . H e re

from a bove , a n d o f t he l o w e r p a r t o f t h e t r a p e z i u s

it is m a x i m u m i n h a la t i o n t h a t fac i l i t a tes fl e x i o n i n a

m usc l e a nd t h e s err a t u s l a te r a l i s f r o m b e l o w . t h e fi r s t

k y p hotic posi t i o n

t w o m u scles being a t t a c h e d to t h e c e r v i c a l s p i n e a n d

faci l i t a tes e x te n s i o n in a l o r d o t i c p o s i t i o n , i . e . t h e

t h e l a s t t w o to t h e t h o r a c i c s p i n e .

t h o racic e x t e n s o r s p i n a e contracts, a n d th i s to s u c h

and

maximum

e x h a l a ti o n

that

The m u scu l a r i m b a l a nce fo u n d h e re i s w e a k n e s s

a n e x t e n t t h a t d e e p i n h a l a t i o n i s p ro b a b l y t h e m o s t

o f t h e l o w e r part o f t h e t ra p e zi u s a n d s e r r a t u s

effect i v e m e t h o d o f m o b i l i z i n g t h e t h o ra c i c s p i n e

l a t e ra l i s , w i t h h y p e r a c t i v i t y o f the u p per p a r t o f t h e trapez i u s a n d of t h e l e v a t o r sca p u l a e , res u l t i n g i n

i n to fl e x i o n , a nd m a x i m u m e x h a l a t i o n m o s t effe c t i v e fo r ex ten s i o n .

overstra i n of the c e r v i c a l s p i n e .

The

m o s t s u rp r i s i n g

e ffect

of

i n h a lation

and

e x h a l a ti o n , however, i s t h e a l te r n a t i n g fac i l i t a t i o n a n d i n h i b i t i o n o f i n d ivid u a l segme n t s o f t h e sp i n a l

Wei g ht c a r ryi n g

co l u m n

d u ri n g

s i d e-bendi n g ,

d i sc o v e red

by

H e re t h e posi t i o n o f t h e s h o u l d e r j o i n t i s c r u c i a l : i f

G a y m a n s ( 1 980) . I t c a n b e regul a r l y s ho w n t h a t

t h e s h o u l d e r o f t h e w e igh t- b e a r i n g a r m i s be h i nd t h e

d uring

l i n e o f g r a v i ty o f the b o d y , t h e s h o u l d e r g i rd l e i s

c e r v i c a l as w e J l a s i n t h e t h o r a c i c s p i n e i n t h e e v e n

side-bending

resistance

increases

in

the

fixed i n s u c h a w a y t h a t very l i tt l e or n o w e i g h t i s

segm e n ts ( occi p u t-a t l a s , C 2 , e t c . , a n d a ga i n i n TI ,

b o rn e by t h e u p p e r fi x a t o rs o f t h e s h o u l d e r g i r d l e

T4 , e t c . ) d u ri n g i n h a l a t i o n ; d u r i n g e x h a l a t i o n we

( th e u p p e r p a rt of t h e t r a p e z i u s a n d t h e l e v a t o r

o bt a i n

sca p u l a e ) . I f t h e s h o u l d e r i s d ra w n fo rw a r d , o n t h e

Co n v e rse l y , r e s i s t a n c e i n c r e a s e s i n t h e o d d seg m e n t s

a

m o b i l iz i n g

effect

in

these

s e gm e n t s .

o t h e r h a n d . w e i g h t i s immed i a t e l y t r a n s m i t ted to t h e

( C l , C3 , T 3 , T5 , e t c . ) d u ri n g e x h a l a t i o n , w h i l e w e

upper fi x a to rs a n d t o t h e cervic a l s p i n e , which t h e n

o b t a i n m o b i l i z a t i o n d u r i n g i n h a l a t i o n . T h e re i s a

carries t h e bru n t . T h e m u s c u l a r i m b a la n ce c a u s i ng

' n e u t ra l ' zo n e b e t w e e n C7 a n d T2 . An i m p o r t a n t

this s i t u a t i o n is a h yp e r a c t i v e pectora l i s m us c l e , i n pa rticu l a r i t s s u bc l a v ic u l a r p a rt a n d t h e pectora l i s

i n h a l a t i o n i nc r e a s e s r e s i s t a nce n o t o n l y a g a i n s t s i d e

fe a ture of t h e a t l a s-occ i p u t segm e n t i s t h a t h e re

m i n o r , a n d a w e a k l o w e r t r a pezi u s a nd p e r h a p s t h e

b e n d i n g b u t i n a l l d i re c ti o n s , w h e r e a s e x h a l a t i o n

r h o m bo i d s .

faci l i t a te s m o b i l i t y . Th i s e ffect i s m o s t m a r k e d a t t he

This same

i m ba l a nce

a ls o

c a uses

a

fo rward

c r a n iocervica l j u n c t i o n a n d decreases in a c a u d a l

p a rt i c u l a r ,

d r a w n position o f t h e head, res u l t i n g n o t only in

d i re c t i o n ;

overs t r a i n o f t h e cervica l s p i n e a s a w h o l e , b u t

i n h a l a t i o n ( i n t h e o d d segme n ts ) d i mi n i s h e s i n t h e

even i n c o m p e n s a tory h y p e r l o rd o s i s a t t h e c r a n i o

l o w e r t h o ra c i c regi o n .

cervica l j u n c t i o n , pro d u c i n g re l a p s ing l e s i o n s i n t h a t regi o n .

the

m o b i l izi n g e ffec t

of

A w e l l - k n o w n y e t n o l e s s s t r i k i ng p h e n o me n o n , i s t h a t we b r e a t h e i n a n d h o l d o u r b r e a t h i n s i t u a t i o n s

These a re s o m e o f t h e m o s t o b v i o u s l y pa t h oge n i c examples

in

of

fa u l ty

i n s t a nce when d e l i v e r i n g a b l o w , l i ft i n g a h e a v y

muscu l a r i m b a l a n c e . The most i m po rta n t locomoto r

weight, or sprinti ng; t h a t i s , w h e n oxygen consumption

stereotype

c a n b e e xpected to be v e ry high. If w e h a v e n o t t i m e

t h e re fo re

the

p a t te r n s most

due

i n w h i c h m a x i m u m m uscle a c t i v i ty i s d e s i r e d , for

to

and

move m e n t

p a thoge n i c

d i s t u r b a n ce , h o w e v e r , i s fa u l t y b r e a th i n g .

to t a k e a brea t h , a s w h e n we a r e forced to bra ke

Copyrighted Material

Manipulative Therapy in Reha b ilitation of th e Locomotor System

28

s u d d e n l y w h i l e d ri v i n g we h o l d o u r b r e a t h w i th o u t ,

bre a t h i n g i n .

M o rr i s ef al. ( 1 96 1 ) showed t h a t t h e s pi n a l co l u m n i s s u p p o r t ed b y t h e d i a p h ragm, t h e a b d o m i n a l c a v i ty be i ng

a

A uid - fi l l e d

space

and

therefore

not

c o m p r e ss i b l e s o l o n g a s t h e a b d o m i n a l m u scles a n d

t h e m us c l e s o f t h e peri n e u m a re c o n t r a c te d ; i n fa ct M o r r i s ( 1 97 3 ) s h owed e lec t r o m y o gra p h i c activity of the abd o m i na l m u scles d ur i n g w e i g h t l i ft i n g ( Fi g u re

2.17).

S k l a d a l et al.

( 1 970)

made

the

important

o b s e r v a t i o n t h a t t h e d i a ph ra g m c o n t r a cts w h e n t h e p a t i e n t s t a n d s o n h i s t o e s , a n d r i gh t l y i n te r p reted

t h i s a s a pos t u r a l reac t i o n . I n d e e d , we stand o n our toes as a s t a r t reaction before r u n n i n g , j u mp i n g , etc. H e t h e r e fore r ig h t l y d e s c r i b e d t h e d i a p h ra g m as a ' re s p i ra t o r y m us c l e w i th a p o s t u r a l fu n c t i o n ' a n d t h e abdominal

m u sc l e s

as

' p o st u r a l

muscles

with

a

respira tory funct i o n ' . The s i g n i fi c a n ce of h o l d i n g t h e bre a th d u r i n g m a x i m um m uscle a c t i v i t y ( the V a l s a l va m a n oe u v r e) l i e s in t h e fact t h a t p o s tu r a l s t a bi l i ty i s

ach ieved

at

the

cost

of

the

vital

fu n c t i o n

of

re s p i ra t i o n , w h i c h is ( m o m e n t a r i l y ) s a c r i fi c e d to i t .

A s i g n ifi ca n t b u t freq u e n t l y n e g l e ct e d ro l e i s a l s o p l a y e d by t h e p e l v i c d i a ph ra g m . O b v i o u s l y , t h e po s t u ra l role o f resp i ra t i on is n o t co n fi n e d to Va l s a l v a ' s m a n o e u vre , a n d pe rsist s i n a l l phases o f resp i r a tion s o l o n g a s w e a re i n the v e r t i c a l pos i t i o n . T h i s is m o s t o b v i o u s d u ring e x h a l a t i o n : a l l respi r a t i o n aga i n s t res i s t a n ce a c t i v a tes t h e a b d o m i n a l m uscl e s , a n d t h e s h outs o f j u d o w re s t l e rs a n d s k i j u m p e rs a re e x a m p l e s . The

s i t u a tion

is

m ore

co m p l ic a te d

during

i n h a l a t i o n ; t h e c l u e t o w h a t h a p p e n s m ust be s o u g h t i n t h e fact t h a t the t h o ra x w i d e n s i n t h e h o ri zo n t a l pl a n e as w e b r e a t h e i n . A n a t o m i s t s l i k e to e x p l a i n t h i s phe n o m e n o n by t h e a c t i v i t y of t h e e x te r n a l o b l i q u e i n tercosta l m u s c l e s , b u t

a more

s i gn i fi ca n t

fa ctor i s t h e c o n t r a c t i o n o f t h e m uscu l a r d i a p h r a g m , w h i c h l i fts t h e l ow e r r i b s as l o n g as t h e ce n t ra l t e n d o n is s u p p o rted by co u n te rp r e s s u r e fro m t h e

Figure 2.17 Lo a d i n g o f t h e l u m bosacral j u n c t i o n w i t h o u t (a) a n d w i t h (b) t h e support of t h e abd o m i n a l w a l l ( From Kapa ndj i , 1 974. R e p rod u ced by k i n d p e r m i ssion

of a u t h o r

and

publishers)

a b d o m i n a l m u sdes ( Ca m p b e l l e t at. 1 970; K a p a n dj i , 1 974 ) . T h i s i s borne o u t b y

the

a c t i v i ty o f t h e

a bd o m i n a l m us c l e s d u ri n g i n h a l a t i o n i n t h e e rect p os i t i o n ( C a mp b e l l et aI. , 1 970; B a s m aj i a n , 1 978) . T h i s is t h e o n l y e x p l a n a t i o n of t h e w i de n i ng of t h e thorax

from

b e l o w , a p h e n o me n o n w h i c h

is

an

i m po rt a n t c r i te r i o n o f c o r r e c t res p i r a t i o n ( Pa ro w , 1 9 5 3 ; G a y m a n s , 1 980) .

I t c a n t h e r e fore be c o n c l u d e d t h a t res pi ra t i o n g u a r a n tees po s t u ra l s ta b i l i t y in a l l i ts p h a s e s ; t h i s c a n

be co n s i d e ra b l y e n h a nced b y Va l s a l v a ' s m a n o e u v r e , b u t on l y i f t h e s t e re o type o f resp i r a t i o n i s t h a t

I f, however, th e s u bj e c t i s s u p i n e o r o n a l l fo u rs , no post u ra l reac t i o n i s req u i re d ; p u re a b d o m i n a l resp i ra t i o n is t h e n p h y s i o l ogica l , t h e a bd o m e n b u lg i n g , i ts w a l l c o m p l e t e l y re l a x e d . U n d e r these c o n d i t i o n s the t ho r a x need n o t widen a t a l l ( G a y m a n s type B ) . The c l ose re l a t i o ns h i p b e t w e e n r es p i r a t i o n a n d the m o t o r s y s t e m i s s h o w n i n w h a t m a y be c a l l e d '

re s p i rato r y

synkinesis',

i.e.

a

ce r t a i n

type

of

move m e n t is l i n k e d e i th e r with i n ha l a t i o n o r w i t h

d e s c r i bed by Parow ( 1 953) a n d G ay m a n s ( 1 980) : t h e

e x h a l a t i o n . O n e s u c h e x a m ple is t h e G a y m a n s effect

t h o r a x w i d e n i n g from b e l o w , from t h e wa i s tl i n e ; i t

d ur i ng

m u s t n o t b e l i ft e d . T h e s h o u l d e rs a r e rel a x e d , t h e

e x a m ple is t he close l i n k betwe e n tr u n k a n d h e a d

s i d e - be n d i n g,

described

above.

A n ot h e r

c l a v i c l e s a n d upper r i b s are n o t l i fted b u t r o t a t e

e x t e n s i on a n d i n h a l a t i o n , a n d betwe e n fl e x i o n a n d

s l i g h t l y to a l low w i d e n i n g of t h e t ho r a x . I t i s t h i s

exh a l a t i o n . B e c a u s e , u n d e r p h y s i o l ogica l cond i t i o n s ,

t y p e o f resp i ra t i o n t h a t h a s a stro ng m o b i l i z i n g ef fec t

tru n k ( h e a d ) e x t e n s i o n g o e s h a n d i n

on

t h e sp i n a l co l u m n ( G ay m a ns resp i r a t i o n type A ) .

Copyrighted Material

h a n d wi t h

l oo ki n g u p , a n d fl e x i o n w i t h look i n g dow n , i n i t s e l f

Th eoretical considera tions loo k i n g

up

fac i l i t a t e s

i n ha lation,

looking

down

29

i m porta n t t o be a w a re o f c e r t a i n li m i t a t i o n s (J a n d a , 1 978) .

e x h a l a t i o n , a n d v i c e v e rsa . T r u n k r o t a t i o n i n t h e uprigh t ( s i t t i n g ) p os i t i o n , from n e u t ra l p o s i t i o n to the

side,

is

l i n ked

with

i n h a l a t io n

and

can

be

T h e s i g n ifica n c e of co n stitut i o n a l hyperm o b i l ity

i n h i b i ted by e x h a l a t i o n . R e s i s t a nce a g a i n s t t r a c t i o n of the n e c k i n creases d u ri ng i n h a l a t i o n a n d d i s appears d u ri n g e x h a l a t i o n ; i n t h e l u m b a r s p i n e , o n the o t h e r h a n d , r e s i s t a n c e ( p r o n e ) aga i n s t t r a c t i o n

The i m p o r t a nce of m o v e m e n t r e s t r i c t i o n ( b l o c k a g e )

d u ri n g

a n d o f s h o r t m u s c l e s restri cti ng m o b i l i ty h a s b e e n

i n h a l a t i o n . T h e re i s e v e n a l i n k b e t w e e n i n h a l a t i o n

d e a l t w i t h . The e x p e r i e nced c l i n ic i a n , h o w e ve r , i s

i ncreases

d u ring

e x h a l a ti o n

and

ceases

a n d ope n i n g t h e m o u t h , a n d be t we e n e x h a l a t i o n a n d

we l l a w a re t h a t h y pe r m ob i l i t y i s fre q u e n t l y an e v e n

c lo s i n g t h e m o u t h . I t i s e v i d e n t t h a t t h ese n a t u ra l

m o re d iffic u l t p r o b l e m , w i t h c o n s i d e r a b l e s i g n i ficance

rea c t i o n s

for

ca n

be

v e ry

usefull y

appl ied

for

mobilization . . W h a t a re t h e r e l e v a n t m e c h a n i s m s o f d i s t u rb a n c e

o f t h e d i ap h r a g m .

p r i m a ry

or

seco n d a ry

thorax

vicinity

of

a

inhalation

and,

in

p a r t ic u l a r .

the

the

thorax

even

when

p ro n e ,

a l t hough

con c e r n s

( 1 96 9 ) .

we He

( c o m p e n s a t ory,

restricted

joint) ;

the

in

the

latter

is

pa rti c u l a rly c h a racte r i s t i c of t h e s p i n a l c o l u mn .

pati e n t ' s i n a b i l i t y t o b r e a t h e i n to t h e pos t e r i o r w a ll of

p ro b l e m

l o co m o t o r s y s t e m

L Loca l p a t h o l o g i c a l h y pe r m o b i l i t y , w h i c h m a y b e

The

seco nd mech a n ism is i n s u ffici e n t w i d e n i n g o f t h e during

this

of the

d i s t i n g u i s h e s t h e fo l l o w i n g :

activ i t y i n t h e a b d o m i n a l m us c l e s , t h e spi n a l c o l u m n t h e s u p port

W h e re

fu n c t i o n

owe a m aj o r c o n t r i b u t i o n t o S a c h s e

of res p i r a t i o n p a t te r n s ? The fi rs t i s i n s u ffi c i e n t o r n o t h u s losi n g

p a t h o ge n e s i s .

disturbed

no

2. P a t h o l o g i c a l g e n e r a l iz e d h y p e r m o bi l ity, fre q u e n t

b l ockage h a s b e e n fo u n d i n t h e t h o ra c i c s p i n e . The

i n certa i n c o n g en i t a l a n d n e u r o l o g i c a l c o n d i t i o n s .

3 . Const i t u t i o n a l

thoracic spine s h ows n o re s p i ra tory wave. In s u c h

h y p e r m o b i l i ty ,

which

is

m ost

cases we fi n d r e l a p s i n g move m e n t restr i c t i o n o f t h e

i m p o rta n t from o u r p o i n t of v i e w . In i t se l f it i s a

t h o racic s p i n e olV i n g t o t h e a b s e n ce o f t h e m o b i l i z i n g

v a ri a n t of t h e n o r m , b u t u n d e r c o n d i t i o n s of

effect o f resp i ra t i o n .

m a i n l y sta t i c s t r a i n i ts p a t h og e n i c i m p o r t a nce

T h e m o s t i m p o r t a n t re s p i r a t i o n a l fa u l t i s l i ft i n g

b e c o m e s e v i d e n t . O v e r a l l mob i l i ty is g r e a t e s t i n

the t h o r a x w i t h a u x i l i a ry cerv i c al m u s c l e s i n s t e a d o f

c h i l d h oo d

w i d e n i n g i t i n t h e h o r i z o n t a l p l a n e . Not o n l y i s t h i s

ge n e ra l l y gre a t e r i n w o m e n t h a n i n m e n .

and

decreases

w i th

age ,

being

type o f brea t h i n g i n e ffe c t i v e from t h e p o i n t o f v i e w of v e n t i l a t i o n , b u t i t a lso ove rstra i n s t h e c e r v i c a l

T h e re are co nd i t i o n s i n w h i c h h y p e r m o b i l i t y m a y

muscu l a t u re a n d t h e c e r v ic a l s p i n e ( see F i g u re 4 . 7 6 ) ,

e v e n be a n a d v a n t a g e , f o r i n s t a nce i n certa i n s p o rts.

causi ng rec u r re n t cervical s y n d r o m e s . W h e n t h i s

in

gy m n as t i c s ,

etc.

and

in

employment

w h e re

fa u l t i s s l ig h t . i t i s d e m o ns t r a b l e o n l y i f t h e p a t i e n t

m o b i l i t y is

i s a s k e d t o t a k e a d e e p b rea t h . W h e n i t i s s e v e r e ,

d e c r e a s e d s t a b i l i ty , h owever, a n d as i n m o s t occ u

a req u i re m e n t .

It

is acco m p a n i e d

by

t h e fau l t y p os i t i o n o f t h e t h o r a x d u r i ng i n h a .l a t i o n

pations

and

a re

i n d i v i d u a ls a re l e s s a bl e t o a d a p t to s t a t i c o v e r s t ra i n .

e v i d e n t even at rest i n t h e e re c t p os i t i o n ; i n v e r y

A s liga m e n tous l a x i ty i s u s u a l l y acco m p a n ied by

severe c a s e s i t c a n be s e e n i n

w e a k n ess of the p o s t u r a l m u s c l e s , t h e c o n se q u e n ce

the

a b sence

of

abd o m i n a l a

resp i r a t i o n

supine patient. In

tod a y s t a tic postu re p r ed o m i n a te s , t h e s e

s o m e c a s e s t h e fa u l t i s a s y m m e t r i ca l , o n e s h o u l d e r

is

being raised higher than the other, causing u n i l a te r a l

p a r t i c u l a r l y u n s u i ta b l e fo r s u c h p a t i e n ts : t h e y s h o u l d

o v e rs t r a i n ,

re s u l t i n g

in

pain.

Some

j obs

a re

cerv i c a l l e s i o n s . I n e x t re m e cases t h e a bdomi n a l w a l l

n o t b e d e n t i s t s , f o r i n s t a n c e , o r t e l e p h o n is t s , o r h a v e

protrudes d u r i n g e x h a l a t i o n a n d i s d r a w n i n d u ri n g

t o spe n d l o n g p e r i o d s b e n t o v e r a d e s k o r

i n h a l a ti o n ( , p a r a d o x i c a l r e s p i ra t i o n ' ) .

I n s o m e very pron o u n ce d c a s e s t h ere i s a c o n d i t i o n

T h e i mm e n s e patterns

fo r

i m p o r t a n ce o f fa u l ty

p a t hoge n e s i s

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now be

clear.

Thi ngs a r e a l l t h e m o r e s e r i o u s b e c a u s e m o d e r n

a

m a ch i n e .

o f genera l i n s ta b i l i t y , a l a c k o f coord i n a t i o n w h i c h can be

i n terpreted a s a t y p e of ' m i n i m a l b ra i n

d y s fu n c t i o n ' .

ind u s t r i a l ized c iv i l i z a t i o n e n c o u r a g e s t h is i m b a l a nce

I n t h i s c o n n ec ti o n J a n d a 's observ a t i o n s co n c e r n i n g

betwee n p r e d o mi n a n t l y p h a s ic a n d p r e d o m i n a n t l y

m i n i m a l bra i n d a m ag e s e e m re l e v a n t ( s e e p . 2 1 ) .

postu ra l m u scles i n fav o u r o f t h e l a t te r ; w h i l e m o b i l i ty

is i n creasingly l i m i t e d , t h e l o c o m o t o r s y s t e m

is

overb u rd e n e d by e v e r m o re s t a t i c p e rfo r m a n c e .

A ft e r r e v ie w i ng 1 00 c a s e s h e d i s t i n g u i s h e s t h ree types. The fi r s t i s ' m icrospastic i t y ' , s h o w i n g m i l d s i g n s o f fi r s t m o t o r n e u r o n l e s i on w h i c h c a n be

T h e p ra c t i c a l c o n se q u e n ces o f fa u l ty m o v e m e n t

a s y m me t r i c a l . T h e s e co n d i s c h a ra c t e r i z e d b y h y p o

patterns a re s h o w n i n t h e c h a p t e rs o n d i agn o s i s a n d

t o n i c i t y , a s y m m e tr i c a l t e n d o n r e fl e x e s a n d s i g n s of

t he r a p y , a n d

s uggeste d . T h e

h y p e r m o b i l i ty w i t h a t e n de n cy t o i n s t a b i l i ty a n d

patie n t c a n ofte n be t r a i n e d a d e q u a te l y to c o r re c t

res t l e s s n e s s , c o r r e s po n d i n g to s e v e r e h y pe rm o b i l i ty

t ra i n i n g

tec h n i q u e s

the pre d o m i n a t in g fa u l t i n a re l a ti v e l y s h or t t i m e ,

as d e s c r i b e d by S a c h s e . The t h i rd type is c h a racter

resu l t i n g i n p e r m a n e n t re l ie f. H ow e v e r , i t i s a l s o

ized

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c h a n ge s

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30

Rellilbtfitation of the Locomotor System of awkward-

proprioception, ness w h i c h

can

r e s t o r i n g m ob i l i t y o f the s o ft fo r i ns t a nce c a n i ncrease a ft e r j o i n t m a n i p u l a t i o n .

How can wc

The s i g n ifica nce of soft tissues

s u c h e ffe cts') I t w a s s a i d a t

t h e b e g i n n i ng t h a t a l l m o ve m e n t p e r fo r m e d b y t h e m o t o r s y s t e m i m p l i e s s t re t c h a n cVo r s h i ft o f t h e soft

A n yo n c w h o t r e a t s d y s fu n ct i o n o f t h e m o tor s y s t e m

tissues s u rro u n d i n g it. Y e t soft t i s s u e s , a s the t e r m

a n d h a s l e a r n e d t h e t e c h n i q u e s o f j o i n t m a n i p u l a ti o n

i m p l i e s , a re n o t l i ke a s t r a i g h tj ac k e t a n d w o u l d n o t sim p l y i m pa i r m o t i o n m e ch a n i c a l l y . I t i s certa i nl y a

s h o u l d b y n o w b e fu l l y a w a re o f t h e d e c i s i v e r o l e o f m uscle

fu n c t i o n .

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a w a reness o f the r o l e o f s o f t t i s s u e , i n p a r t i c u l a r o f t h e co n n e c t i v e t i s s u e a n d o f fasci a . T h e p o ss i b l e r o l e

i IH' c o n n e c t i v e t i s s u e is

sca rs c a n p l a y

reflex e ffect d ue to te t h e ri n g , as is most c l e a r l y s h o w n b y t h e effe c t o f ' act i v e ' s c a r s , t h a t i s scars w h i c h d o n o t m o v e free ly , w h i c h s h o w ' a d hesio n s ' , i . e . i ncreased a nd fold i n g ( p i n c h i n g ) .

to l ac k of sci e n t i fic

w i d e l y i g n o re d . k no w l e d g e

e s p ec i a l l y i n t h e s k i n , p r o d u c i n g r e fl e x e ffec t s .

of l a c k o f c l i n ic a l

methods o n palpation which

Cl i n ic a l

o f to n u s we a re

is m o re o ve r l y i n g

i n d i stu rbed

m u sc l e s , a l t h ou g h t he l i s s u e may grea tly

m o d ify i t

11 0

n o r m s n o r s c i e n t i fic

d a t a a v a il a b l e .

I n the p reced i n g paragraphs I have t r i ed to show t h e

I t s e e m s o b v i o u s tha t t h e soft t i s s u e s s u r r o u n d i n g t h e m o t o r s y s t e m m u s t a d a p t t o a ll i t s c h a nges o f

i m po r t a nce of d is t u rbed f u n c t i o n i n t h e l oc o m o t o r s y s t e m a n d t h e s p i n a l co l u m n . Nevert h e l ess, d istu rbed

s h a pe d u ring movem e n t a n d p os t u ra l f u n c ti o n . A l l

fu n c t i o n in i tse l f i s n o t i d e n ti c a l w i t h c l i n ic a l d is e a s e .

i ts l a y e rs i nc l u d i n g t h e s k i n h ave t o s t r e t c h a n d

I n d e e d , t h e pati e n t d o e s n o t a s a r u l e s e e k m e d i c a l

s h o r te n a n d t o s hift o n e a ga i n s t t h e o t h e r , s o a s to

a d v i c e , n o r d o e s h e com p l a i n b e c a u s e of d is t u rbed

a d a p t s m o o t h l y t o every c h a n g e . This i s b y n o m e a n s

m o b il i ty , b u t because h e fee l s pa i n i n t h e back, o r

a n e asy t a s k o r f u n c t i o n a n d i t w o u l d b e a m i r a c l e

i n the h e a d , t h e e x t r e m i t i e s , o r c v e n p e r h a ps t h e

i f d i s t u r b n n c e w o u l fl n o t be comm o n 10 s o v e r y complex n o r m s of s t r e t c h o r s h i ft o f b e e n e s ta b l is h e d n o r

v i s ce r a . O n t h e o t h e r h a n d . t h e re a r e p e o p l e w i t h

These c a n b e

l o c o m o t o r system w h o a re

o f pa i n a n d w h o d o

not

I n fac t , d i s t u r b a nce o f

a re a s o f s k i n fol d i n g , s h i ft i n g s k i n

t h e n o c i c e p tive stim u l u s

against the

a l l t h e so ft t i s s u e s

a ga i n s t W a rd )

n o w p l a ys t h e d e c i s ive a r i se s is: i n w h a t w a y

i m po r t a n t c l i n ic a l

c o ns i d e r a b l e . fo r e x a m p l e

c o m p J e x of

and i t is the reaction part

prod uce

can

n oc i c e p t i v e

stimul ation and pain?

fac t s . N u m e r o u s m e t h o d s o f massage d e a l w i t h soft

B e fo r e p r e s en ti ng a n e x p l a n a t i o n I s h o u l d s t ress

t i s s u e s ; i n d e e d , soft t i s s u e te c h n i q u e s a n d m a ss a g e

t h a t i t is n ot the p u rpose o f t h i s b o o k to d e a l w i t h

a re

t h e t h e o r e t i c a l aspects o f t h e p h y s i o l ogy o f p a i n ;

v e r y o f t e n refe r r e d

to

as

a lmost

identical.

H o w e v e r , t h e re is v e ry l it t l e precise d i ag n o s i s a t t h e

n e v e r t h e le s s , s o m e p e r t i n e n t t h e o re tica l concl u s i o n s

b a s i s o f t h e s e tec h n i q u e s a n d h e nce l i t t l e s p e c i fi c i t y .

s h o u l d be d ra w n f r o m c l i n i ca l obse r v a t i o n . A s I h a v e

The d e c i s i v e step i n

i s the consistent

a l re a d y p o i n te d o u t , observa t i o n b e fo re a n d a fter m a n i p u l a t i o n h a s given u s i m po r t a n t c l ues, fo r n o t

W h e n e v e r we s tretch s k i n o r a n y o t h e r s t r u c t u re ( s t r e t c h or s h i ft )

o n l y fl o e s c l i n ic a l e x a m i n a ti o n s h ow t h a t m o b i l it y i s

u n ti l w e t a k e u p

:l f fc c t e d m u s c l e s , a n d e v e n

t h e s l ack

as in j o i n ts . H e r e ,

I n t e re s t i n g to n o t e t h a t t h e

too, t h e

grad u a l a n d w e l l

b e observed a fte r l o c a l

pathologica l. We il b ru p l p a t h o l og i c a l b a r r i e r , i . e . t h e w h ic h s t r e t c h a n d,

the m us c u l a r t r i gger

this

fi e l d

a p p l i c a t i o n o f t h e barrier phenomen o n . t h e re is a where l ittle

i n particular.

w e t h e n e ng a g e

i t revea l s t h a t te n s i on

etc., if pain has been poinl te n s i o n

c h a r a c t e rized b y i n c r e ased pain.

t h e b a r r ie r , w e w a i t u n t i l w e o b t a i n r e l e a s e a n d t h u s

A p p a r e n t l y p a i n s u b s i d e s i f h a r m f u l fu n c t i o n i n g i s

n o r m a l con d i ti o n s . A s t h i s i s b a s e d o n e x a c t d ia g n o s i s a n d t h e re s u l t i s p r e d i c t a b l e , t h i s could aptJy be c a l le d ' soft t i s s u e m a n i p u l a t i o n ' . I t s c ffects

correct ed . I f w e a re forced t o m a i n ta i n a n u n co m for t a b l e p o s i t i o n f o r l o n g , w e fee l d iscomfor t a t fi rs t , . b u t a ft e r a t i m e we a re forced by p a i n to c h a nge t h a t

Copyrighted Material

31 pos i t i o n . The sa me is I I ha t e x c e e d s o u r s t re ng t h : t h e pa i n di mi nishes a nd w i l l soon d e n o m i n a t o r i n al l t h i s i s t h e c l os e c o r re l a t i o n b e t w e e n t e n s i o n a n d p a in i n t h e l oc o m o t o r s y s t e m . T h I s i s pa rticularly eviden t i n p os t - is o m etr i c muscle re l a x a t i o n w i t h i ts i m m ed i a te a n a l ge s i c e ffe c t n o t o n ly i n th e muscle i tsel f , b u t a l s o i n i ts a t t a c h m e n ts (see Chapter 6 ) . A n y h a r m l u i or d isturbed f u n c t i on i n g i s bo u nd t o cre a te t e n s i o n : b l o c k a g e , w h e n e v e r t h e p a t i e n t t r i e s t o move i n the re s t r i c ted d i re c t i o n ; h y p e r m o b i l i ty d u e to exce s s i v e m ov e men t", l ilb l e res u l t i n g i n s ta t i c overstr al ll Ii sense , and is in ke e p i ng pa i n as a w a r n i ng s i g n wa r nin g o f t h e onset o f I l ill locomotor sy s te m is c o n i t o d a mage as w e wish , and i t s e l f o t h e r t h a n b y ca us i n g t h e con s e q ll e n ce o f m o r p h o l og i c a l c h a ng e i t not hav e t h is sig ni ficant ro le . I n t h i s w a y t h e v o lu nt a ry a c t iv ity o f t he l o c o m o t o r sy stem i s k ep t wi thin due bounds by pain . T h e l o c o m o t o r s y s t e m is , t h u s , b y (ar the m o s t fre q u e n t sou rce o f p a i n i n the h uman o r ga n is m , n o r i s i t m e r e coi n c i d e nce t h a t refe rred p a i n from o t h e r or gans o r s y s t e m s i s , a s a r u le , pe rce i v e d i n p a r t s of t h e l oc o m o t o r s y s t e m . Th e c l ose c o n n e c t i o n b e t w e e n physical a n d m e n ta l fa c t o rs c a n a l so b e a p h y s i cal and a psycho log lc :1 s a m e i s t r u e o f re l a x a t i o n : i ma g i n e psyc h o l o g i c a l m uscle s . Th i s s h o u l d b e w i t h pa t i e n ts s u ffe r i n g II sy ste m . to W h a t is th e r e a c t io n t o d i s t u r b e d fu n c t i o n ? first, w h i c h we h a v e already men tioned . m a y be o f l e s s e r or gre a t e r i n t e n s i t y , w h i c h is o f gre a t c l i n ic a l s i g n I fi c a n c e : i t allows u s t o c o r r e la t e the d eg r e e of c h a nged fu n c t i o n to t h e re flex changes , and i n t h i s w a y to e s t a b l i s h t h e pa t i e n t 's l a b il i t y o r s t a b i l i t y . It is by n o m e a n s o nl y a m a t t e r o f a u t o n o m i c fu n c t i o n s , a s i s fr e q u e n tly t h ou gh t , b u t a l so conce rn s m uscle spas m or m u s c l e i n h ib i tio n , e t c . between The re m a y b e c o n s i d e r ;l b l ci nd iv id ua l pa t i e n ts , b u t c o n s i d e ra b l y i n t h e s a m e a c u t e v e rtebr o ge n ic pa i n dr a ugh t , i t c a nn ot be d u e in s uch p a t i e n ts w e li nd o n e segm e n t , w i t h b l oc k age i s c l i n i ca l l y l a te n t . a lges i c zo ne i n t h e s e g men s t r i k i ng t h i s hy per a l ges ic zone i s s t i m u l us w h i c h in t ens i fi e s the p a t i e n t ' s re a c t i o n a nd ca uses s e v e r e ll1 u s c l e s p a s m w h i c h m a k e s t h e l e s i o n m an i fe s t .

Thus

t h e r e is

m e c h a n i c a l i r r i ta t i o n

p a i n by ces, a s i s

I l ll e nc e o f freq u e n t l y s u gge st ed , t h e root - c o m press i o n mod e l . I t w o u l d , m d e e d , b e a pec u l i a r c o n c e p t o f t h e n e rv o u s system (a s yste m d e a l i n g w i t h in f or mati on ) t h a t w o u l d h a v e i t r ea c t i ng, a s a r u l e , n o t t o s t i m u l a t i o n of i t s r e c ep t o rs but to m e c h a n i c a l d a m a g e t o i ts o w n s t r u c t u re s . R e fe r r e d p a i n from the v iscera and Tr Ps c a n serve as a n e x a mp l e , a s c a n t h e e x p e r i m e n t a l i n fi l tr a t i o n o f hype r t o n i c s a l i n e sol u t io n i n to l ig a m e n t o u s s t r u c t u re s o f t h e spina l c ol u m n , w h i c h was first perfo r m e d by K e ll9. r e n ( .1 Hoc k a d a y and W h iny I ( 1 97 2 ) a n d F e i ns t e in 01. ( 1 J u s t a s i n t hese d e e p s tru c t u res rad i a te s i n t h e c h a nges i n s k i n sometimes with ' p tl Sm , e t c . , th us i m ita t i n g p a m . B r ugge r 1,1 960, 1 962) therefore ca lled it 'pseudoradic ular ' . A s m us cu l a r s p a s m i s a p r o m i n e n t fe a t u re w i th c o n co m i t a n t p a i n i n t e n d o n s a n d i ns e r t i o n s a s w e l l a s i n fasc i a e , t h e t e r m ' my o fa s c i a l p a i n ' ( 't e nd o m y o s i s ' ) i s fre q u e n t l y u s e d . I n t h e G e r m a n li t e r a tu re t h e t e r m ' re fl e x s y n d ro m e ' is p r e f e rr e d a t p r e s e n t . This b r in g s u s t o ' s o ft t i s s u e c h ang e s ' , w h i c h a re t h e ob j ec t of ' s o ft t i s s u e t e c h n i q u es ' or e ven o f ' s oft h a v c' with these t i s s ue m a n i p u l a t i o n ' s k i n or c h a n g e s ( h y p e r a l geSIC ) I!l a i nly i n connective tissue, and a ru le , t e r m s of ' r e fl e x i n t h e a c u t e s t a ge because immedi ate o f m us c l e s p a s m a c h i e v e d a fte r j oi n l l a t e r s t a g e s , c h a nges t h e deep l aye r o f fa s c i a e a nd m uscle s , te nd to become c h ro n i c; s h o r te n e d , t h e se t i s s u e s then cause m o v e m e n t r e s t r i c t i o n . Thi s is w h a t R u ss i a n a u t h o rs m e a n by t h e ' d ys t r o p h i c s tage ' ( V e s el o vs k i a n d Pope l y a n s k i , 1 9 8 2 ; Pop e lya ns k i , 1 9 84 ) . A s i n j o i n t s , w e e nco u nt e r a res t r i c t iv e b a r r i e r w h e n s t re tc h i ng or s h i fti n g these fa s c i a e , a nd c o n s e q u e n t ly h a ve to o v e r c o m e i t in o r d e r t o o b ta i n re l e a s e . W h e n t h i s i s a c h i e v e d , even a t s i dered m orp h ol o g i c a I i.e. functiona l . There under t h e c o n trol 01 so t h a t d y s t r o p h y can I have d w e l t m o s ! th i s can m o s t rea d i l y e v e r , i t s h o u l d n o t be reac t i o n , it is per c e l v c'cI thresh o l d of p a i n pe r c e p t i o n w h ich n e rv o u s c o n trol. On e xa m i n a t i o n , i n d e e d , we v e ry f r e q u e n t ly fi nd c h a n ges i n m a n y s e g m e n ts , of w h i c h pa ti e n ts a re e n t i re l y unaw a re .

Copyrighted Material

32

l\Ilanip u /alive Therapy in Rehabilitation of the L o c o m o t o r System

f u n c t i o n , a s we h a v e se e n , is c l osely

r o o t c o m p ress i o n s u c h a s d i sc p ro l a p s e ? F i r s t , i t

con n ected to t h e reflex c h a nges typica l for nociceptive

s h o u l d b e poi n ted o u t t h a t n e rv e com p ress i o n a l o ne

s t i m u l a t i o n . T h e y t h e refore con s t i t u t e an e n t i ty t h a t

causes p a re s i s and a n a es t h e s i a , b u t no p a i n . W h a t i s

I m p a ired

we p ro p o s e to t e r m 'fu n ct io n a l p a t h o l o gy o f t h e

then

m o t o r syste m ' .

e x a m p l e , d i s c p r o l a pse ca u s e s pa i n ? Q u i t e o b v i o u s l y ,

the

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S u c h i s t h e d i s t r u s t a n d lack o f k n o w l e d g e o f t h e

d i sc p r o l a pse ca n n o t i m p i n ge o n t h e n e rve root

w a y t h e m o t o r s y s t e m fu n c t i o n s , t h a t ' fu n ct i o n a l

b e fore a c t i n g o n t h e d u ra a n d the d u r a l s h e a t h s . It

p a t h o l o g y ' i s v i e w e d a s a s o r t o f s u b t e r fu ge , o r a s

i s p recise l y these s t r u c t u re s t h a t a re r i c h l y s u p p l i e d

a n a t tem pt to ' e x p l a i n a w a y ' c l i n i ca l p h e n o m e n a ,

w i t h pa i n rece p t o r s , a n d we s h o u l d be a w a r e t h a t a t

w h i l e t h e ' tr u e p a t h o l og y ' i s n o t y e t k n o w n . Y e t w h a t o t h e r e x p l a n a t i o n i s t h e re fo r t h e fact t h a t n o t o n l y

s h e a t h s a re

symptoms b u t a lso mobi l ity, m uscle tension and

s h o u ld n o t b e fo rgo t t e n t h a t Laseg u e ' s s ign i n d i c a t e s

a u to n o m i c p h e n o m e n a m a y b e restored to cli n ic a l

m e n i nge a l i nv o l v e m e n t . T h i s i s i n k e e p i n g w i t h t h e

normality

e ffec t o f e p i d u r a l a n a e s t h e s i a i n d i sc l e s i o n s .

i m m e d i a te l y

after

mobil ization

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rubbed o v e r the

p ro l a ps e .

It

restr i c t e d j o i n t , after re l a x a t i o n o f a m u s c l e w i t h a

A n o t h e r c l i n i c a l o bs e rv a t i o n a l so i n d i c a t e s t h a t

t rigge r p o i n t , or a ft e r s t re tc h i n g of a s h o r t e n e d fasc i a ?

p a i n i s p r i m a r i l y d u e t o s t i m u l a tion o f p a i n receptors,

H o w c o u l d s u c h i m m e d i a t e e ffec t b e e x p l a i n e d i f

eve n i f t h e re a r e clear n e u rological s i g n s o f n e rve ro o t i n v o l v e m e n t . Ce r n )1 ( 1 948) registered t h e rad

t h e re w e r e , i n d e e d , m o r p h o l o g i c a l c h a nges? The s i t u a t i o n c a n be compared t o t h e w o r k i n g o f a c a r :

iating pain

t h e e n g i n e m a y n o t w o r k bec a u s e o f

u s i n g a u to d e r m o g r a p h y o f t h e p a i n , a n d fo u n d t h a t

a

fa u l ty b a l l

in

p a t ie n ts w i t h ra d i c u l a r s y n d ro m e s ,

bea r i n g o r a b u rs t c y l i n d e r ( m o r p h o l og i c a l c h a n g e ) ,

t h i s w a s m o re exact a n d

b u t it m a y n o t w o r k b e c a u s e , a l t h o u g h t h e s t r u c t u r e

l o c a l i za t i o n t h a n the t y p i c a l n e u rological sign s , in

i s i n tact, t h e i g n i t i o n i s out o f order, o r the carbur

p a r t ic u l a r

e t t o r n e e d s adj u s t i n g ; a fte r a s i m p l e a d j u s t m e n t , t h e

beca use a nerve root d oe s not conta i n fi b res from

c a r fu n c t i o n s n o r m a l l y a ga i n .

o n e segme n t o n l y , but t r a n s i tory fi b re s from n e i g h

more

so

than

reliable

i n d e r m a t ome

h y po a e s t h es i a .

Th is

is

O n e o f t h e r e a s o n s w h y t h e m e d i ca l profe s s i o n i s

b o u r i n g s e g m e n ts a re u s u a l ly a lso prese n t . T h i s i s

s o s l o w i n rea l i z i n g th a t d y s f u n ction i s t h e m o s t

n o t o n l y a f a c t we l l k n o w n to a n a to m i s ts: i t e x p l a i n s

freq u e n t c a u se o f p a i n i n t h e loco m o t o r s y s t e m i s

t h e over l a p t h a n k s to w h i c h r a d i cotomy i s n o t , a s

t h a t t h e e v i d e nce i s b a s e d o n c l i n i c a l fi n d in g s, a n d

r u l e , fo l lo w e d by h y po a e s t h e s i a i n t h e correspo n d i n g

a

t h is i s rej ec t e d a s ' s u bj e c t i v e ' . T h i s i s a l s o the r e a s o n

segme n ts . T h i s r u l e , h o w e v e r , i s o n l y p a r t i a l l y v a l i d :

w h y c l i n ic a l ex a m i n a t i o n a n d c l i n ic a l sc i e n cc a re

t h e re a re freq u e n t e x c e p t i o n s . H a n ra e t s ( l 95 9 ) e x

i n c r e a s i n g l y u n d e rra t e d . We h a v e a l re a d y s e e n t h a t

pla i n e d i t a s fo l l o w s . D u ri n g o p e r a tion h e freq u e n t l y

t h e ' puzzle o f pa i n ' i n t h e l o c o m o t o r s y s te m , i . e . t h e

fo u n d t h a t n e rv e r o o t s v a ry c o n s i d e ra b l y i n t h i c k n e s s :

fact t h a t p a i n i s c l o s e l y r e l ated to t e n s i o n , w h i l e

if a root i s v e ry t h i c k o n o n e s i d e i t s n e i g h b o u r i s

d ec r e a s e d te n si o n goes a l o n g w i t h re l i e f o f p a i n , i s

l i k e l y to be m u c h t h i n n e r , beca u s e t h e t r a nsitory

u n fo r t u n a te l y b a s e d m a i n l y o n c l i n i c a l e v i d e n c e ; t h e

fi bres be l o n g i n g to t h i s n e i g h bo u r i n g s eg m e n t ca n

a n sw e r t o t h e ' p uzzl e ' l ie s l i t e ra l l y i n o u r ( p a l pa t i n g )

be v e r y n u m e ro u s ; i n t h e t h i n ( ne ig h bo u r i n g segm e n t)

h a n d s . Pa i n rece p t o rs a r e fo u n d p r e c i se l y i n t h ose

root, t r a n s i t o ry fi b re s a re c o n se q u e n t ly v e ry fe w , or

s t r u e t u r e s w h e re te n s i o n i s prod u ce d : in a t t ac h m e n ts

m a y be a b se n t a l t og e t h e r . C o n d i t i o n s on the o t h e r

of t e n d o n s , l i ga m e n ts , i n j o i n t c a ps u le s , m u s c l e s a n d

s i d e m a y be q u i te d i ffere n t : fo r e x a m p l e , i f t h e

m e n i n ge a l s h e a t h s . I n re a l i ty , t h e m o s t fu n d a m e n t a l

root is t h i c k on t h e r i g h t , t h i s n e e d n o t be so on t h e

L5

d i s t i n c t i o n b e t w e e n d i ffe re n t p a i n fu l co n d i t i o n s o f

l e ft . I f

t h e l o c o m o t o r s y s te m i s t h a t between co n d i t i o n s

w i ll be v e r y l i t t l e or no s e n s o ry c h a n ge , b u t if a very

a t tr i b u t a b l e

th i c k

to

p a t h o m o r phological

c h a nges

and

t h o s e c a u s e d by d y s fu n c t i o n , a d i s t i n e t i o n a l re a d y

a

v e ry t h i n root i s c o m p ressed o r c u t , t h e re

root is

i nvolved

t h e re w i l l

be

h a rd l y a n y

t r a n s i t o ry fi b re s i n t h e n e i g h bo u r i n g root o r roots;

d e s c r i b e d a s c o m p a r a b l e to t h a t betwe e n h a rd w a re

hence, t h e re w i l l be m a r k e d h y po a e s t h e s i a a n d some

a n d s oftw are ; h e re d iffe ren t i a l d i a g n o s i s is esse n t i a l .

dysaest hesia

Yet

to

w hi c h w i l l a ffect n e i g h b o u r i n g derma tomes a s we l l

m o rp h o l og i c a l c h a nges, i m prove m e n t ( a n d t h u s a l so

a n d p r o d u ce s o m e c h a n ge s o f s e n s i t i v i ty i n t h e m .

even

in

pain

a nd

disease

a t t ri b u t a b l e

o r i gi n a t i n g

in

the

t ra n s i to ry

fi b res,

d i a g n o s i s ) o f d i s t u rbed f u n c t i o n may be o f great

W h e n H a n r a e t s ( 1 959) s t i m u l a ted s u c h a t h i c k root

c l i n ica l i m po r t a n c e to t h e p a t i e n t a n d i s , i n d e e d , t h e

d u ri n g ope r a t i o n , his p a t i e n ts a lso fe l t dysaesthesia

t y p i c a l o bj e c t of r e h a b i l i t a t i o n m e d i c i n e .

in t h e n e i g h b o u r i n g derma tomes. Hence , a n e rve root is not necess a r i l y m o n o-seg m e n t a l I S t a r y a n d I fo u n d s o m e t h i n g v e r y s i m i l a r ( S t a r )1 a n d

Rad icular pa in

Lew i t ,

1 95 8 ) a fte r r a d i c o t o m y i n p a t i e n t s o p e r a ted o n fo r root s y n d r o m e , i n w h o m no d i s c p r o l a pse w a s fo u n d

A ft e r s h o w i n g t h a t p a i n i n t h e m o t o r s y s te m is d u e

( t h e re w a s a t i m e w h e n r a d i c o t o m y w a s c a r r i e d o u t

to nocice p t i v e s t i m u l a t i o n o f p a i n rece p t o r s , w h a t i s

i n s u c h cases ) . M o s t o f t hese p a t i e n ts h a d few c o m p l a i n ts , if a n y , b u t t h e re were s o m e i n w h o m

o u r explanation of p a i n i n cases of true mechanical

Copyrighted Material

Th eoretical considerations

33

perma n e n t h y p o a e s t h e s i a fo ll o we d , a n d w a s resen t e d .

t a ke n i n t o accou n t i n d i ffere n t i a l d i agnos i s . If t h is i s

H e r e , a p p a re n t l y , a t h ic k root w i t h m os t

c l e a r , t h e t h e r a p e u t i c con s e q u e n c e s s h o u l d n o t c a u s e

of t h e

t r a n s i to ry fi b re s o f t h e n e i g h b o u r i n g s eg m e n ts h a d

much controversy.

been cut.

Y e t , a s w i l l b e s e e n i n f u r t h e r c h a p te rs , v e r t e b ro

R e fe rr e d pa i n com i n g from rece p t o r s , h o w e v e r

v i sc e r a l r e l a t i o n s a re m o re com p l e x , and fo r t h i s

( i . e . from d u r a l s h e a t h s ) , is fe l t in o ne s e g m e n t o n l y

re a s o n s o m e ci rc u m s pe c t i o n i s d e s ira b l e w h e n u s i n g

and

t h e t e rm ' v e r t e b ro ge n i c ' . Th e re a re ma n y d i sorders

t h e re fore

r a d i a tes

only

in

the

d e r m a to m e

corresp o n d i n g e x a c t l y t o t h e c o m p re s s e d roo t . I n

that a re c a u se d b y m o r e t h a n one fa c t o r , and t h e

o t h e r w o r d s , w h a t w e c a l l a r a d i c u l 8 r sy n d ro m e i s a

s p i n a l c o l u m n m a y be o n l y o n e o f s e v e r a l factors

co m b i n a t i o n o f p a i n o r i g i n a t i n g from pa i n re c e p t o r s

causing

w i t h i r ra d i a t i o n i n t h e seg m e n t , a n d o f n e u ro l o gi c a l s i g n s of root co m p ress i o n ( h y po a e s t h e s i a , d ys a e s t h es i a a n d p8res i s ) . The re i s y e t a n o t h e r v e ry i n teres t i n g fe a t u r e t h a t s h o w s t h e role o f t h e fu n c t i o n a l c o m p o n e n t : t h i s i s t h e freq u e n t i m m e d i a te i m prove m e n t o f m us c l e s t re n g t h i n w e a k m u s c l e s a n d even o f t e n d o n r e fl e x e s ( s e e F i g u re s 2 . .1 2 a n d 2 . 1 3 ) a ft e r m a n i p u l a t i o n . This agrees w i th t h e e le c t rom yogra p h i c a l

co u l d b e b e t te r t o s p e a k o f d is e a s e w i t h a v e rt e b ro

s p i n a l c o l u m n ( t h e l o c o m o t o r syste m ) is t h e s o l e o r

fi n d i n gs of D rech s l e r ( 1 970) a n d H a n a k

d is e a s e process, b u t o n c e t h i s h a s s t a rted i t m a y

s h ow i n g

that,

in

true

radicu l a r

el

a l . ( 1 97 0 ) ,

synd romes

with

a

p a t h o l ogica l c o n d i t i o n . In s u c h a case i t

g e n i c fa c t o r , r a t h e r t h a n v e r t e b r o g e n i c d is e a s e . A t y p i c a l i n s ta n c e is m i g r a i n e : we s h o u l d r e s e r v e t h e t e r m v e r t e b roge n i c fo r t h o s e c o n d i t io n s i n w h i c h t h e d e c i s ive fa c t o r , a s i n t h e c e r v i cocra n i a l sy n d r o m e . Howe v e r . a s J u n g h a n n s ( 1 957) h a s p o i n t e d o u t , t h e role o f t h e v e r t e b roge n i c fa c t o r m a y c h a n g e i n t h e c o u rse o f

a

s i n g l e d i s o rd e r . I t m a y t r igge r t h e

d e v e l o p i n d e p e n d e n t l y . G u t ze i t ( 1 95 3 ) v e r y a p t l y

c l i n i ca l s i g n s o f m u sc l e wea k n e s s , n e rv e c o n d u c t i o n

c h a racte rized

v e l oc i ty m a y be n o rm a l . T h i s m a y be i n t e r p r e t e d a s

v a r i o u s roles i n t h e p a t h og e n e s i s o f s o m e d i se a s e s ,

m e re re fl e x i n h i b i t i o n . D rec h s l e r i n s i s t e d t h a t t h e

a s ' i n i t i a t o r , p r o v o k e r , m u l t i p l i e r , l oc a l ize r ' .

c l i n ical

prognosis

was

worse

in

t h os e

t h e s p i n a l co l u m n accord i n g to i ts

ra d i c u l a r

s y n d r o m e s i n w h i c h h e fo u n d d ec r e a sed c o n d u c t i o n v e l oc i t y .

Conclusi ons 1.

The term 'vertebro gen ic'

M orp h o l og i c a l c h a nges c a n n o t e x p l a i n the gre a t m aj o r i t y o f p a i n s a r i s i n g from

the locomotor

syste m . T h e s e c h a nges m a y , h o we v e r , p l a y t h e A f t e r t e r m s s u c h a s ' d e ge n e r a t i v e d i se a s e ' a n d ' d i s copa t h y ' h a d b e e n a b a n d o n e d , t h e n o n -co m m i tta l

p a r t o f a 10ClIS minoris res islen liae.

2.

By

fa r

the

t e r m ' v e r t e b roge n ic ' s e e m e d use fu l a n d h a s b e e n

d i s t u r be d

wi d e l y

mobi lity

adopted .

I

have

a l ready touched

on

i ts

m os t

freq u e n t

cause

of

pain

is

function . This m a y concern passive

U o i n ts ) , m u sc l e

activity (TrPs a nd move

s h o r t co m i n gs : i t i n c l u d e s s t r u c t u ra l d is e a s e of t h e

m e n t p a t te rn s ) , o r

spi n a l co l u m n b u t d oe s n o t c o v e r c h a n ge s i n t h e

t r e a t m e n t i s d i re c t e d t o m o v e m e n t r e s t r i c t i o n o f

fu ncti o n i n g o f t h e l o co m o t o r syste m o u t s i d e t h e

j o i n ts o r m o t o r s e g m e n ts o f t h e s p i n a l co l u m n -

spi n a l co l u m n . H o w e v e r , i n t h e s e n se t h a t t h e s p i n a l col u m n i s u s e d a s

a

pars pro 10/0 , t h e t e r m i s

acce p t a b l e . S o l o n g a s i t i s u s e d fo r b a c k pai n a n d

body sta tics.

Manipulative

b l oc k a g e . 3 . The

most

i m portant

ca u s e

of

b l o c k a ge

is

o v e r s t r a i n c a u s e d b y fa u l t y m o v e m e n t p a t t e rn s or

(closely) re l a t e d d i sorde rs, i t i s h a rd l y c o n t r o v e rs i a l ;

body s t a t i c s , t r a u m a o r v i sce ra l d is e a s e .

i t beca m e , a n d s t i l l i s , c o n trovers i a l w h e n a p p l ied to

fre q u e n t l y fo u n d even in e a r l y chil d hood .

I t is

d i sorders, m a i n l y pai n , us u a l l y a s c r i b e d to i n te r n a l

4. I t s con s e q u e n c e s a r e d i s t u rb e d fu n c ti o n , h y per

o rga n s . Th i s c o n t roversy beca m e p a r t i c u l a r l y h e a ted

m o b i l i t y and a ga i n b l o c k age i n the n e i g h b o u r i n g ,

beca use o f s o m e of t h e t h e r a pe u t i c c o n se q u e n c e s o f

or e v e n i n m ore d i s t a n t , pa rts o f t h e loco m o t o r

m a ni p u l a t i o n .

syst e m .

T h e re is .l i t t l e room

for

c o n t roversy i f o u r p r e s e n t

k n o w l edge a b o u t re fe r r e d a n d ra d i a t i n g p a i n is t a k e n i n to acco u n t . M e l z a c k and W a l l ( 1 96 5 ) a n d M i l n e e l al. ( 1 98 1 ) h a v e show n t h a t n o c i c e p t i v e s t i m u l i fro m a l l s t r u ctu res i n a s e g m e n t c o n v e rge t o c e U s i n t h e l a m i n a V o f t h e b a s a l s p in a l n u c l e u s . Th i s , o f c o u rse , a l s o a p p l i e s t o p a i n c o m i n g from rece ptors

in

the

joint

capsules

of

a po p h y s e a l

U l ti m a t e l y ,

by

d istu rbed

fu n c t i o n

or

c o m p e n s a tory h y p e r m o bil i t y, they c a u s e d e ge n e r a tive c h a nges. 5 . The locomotor system a n d the s p i n a l col u m n act a s a f u n c t i o n a l u n i t w h i c h a d a p t s i ts e l f to a n d c o m p e n s a tes

fo r

distu rbed

functio n ,

so

that

e q u i l i b r i u m i s a l w a y s m a i n ta i n e d . 6 . C h a n g e s o f m e c h a n i c a l fu n c t i o n a l o n e d o n o t cause c l i n ical symptoms (pa i n ) . They const i t u t e ,

i n t e rverte b r a l j o i n ts as w e l l as from i n t e r n a l orga n s .

h owev e r , t h e n o c i c e p t i v e stim u l u s w h i c h prod u c e s

I t i s , t h e re fore , e a s y t o s e e t h a t t h e l o c o m o t o r s y s te m c a n read i l y s i m u l a te v i s ce r a l p a i n , a n d v i ce v e r s a , a n d t h a t t h i s co n s t i t u t es a n i m po rta n t a s p e c t t o b e

r e fl e x c h a n ge s i n t h e s e g m e n t ( m u s c l e s p a s m , h y p e ra l gesic z o n e s , e t c . ) . I f t h ese a re o f s u ffic i e n t i n t e n s i t y t o p a s s t h e p a i n t h resh o l d , p a i n i s fe l t .

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34

Manip,,!ui" !.·

Neflil!n!ilation of the LocomolOr System s i n n u l us i s i n cr e a s e d

f u n c t i o n t h a t i s t h e most

i s t h e r e fo r e a

the most freq u e n t t y p e

w a r n i n g :>ign of h a r m f u l f u n ct i o n i n g w h i c h s h o u l d

o f pa i n w i t h o u t a s pe c i fi c d ia g n osis, a n d t re a t -

T h e m os t t e n s io n .

7 . Pa i n i n

i m p a i r m e n t of m o tor

I

b e c o r r e c t e d i n t i m e b e fore i t c a u ses p e rm a n e n t

m e n t o f t h e p a i n a s s u c h , w i t h ou t a t h o ro u g h

d a m a g e . I t i s p r o b a b l y t h e m o s t freq u e n t t y p e o f

c l i n i c a l u n d e rs t a n d in g o f t h e f u n c t i o n i n g o f t h e locomotor s y s t e m , i s c o u r t i n g fa i l ur e .

p a i n t h ro u g h o u t t h e orga n i s m .

S . I f t h e p a t i e n t i s a b l e to d e s c r i b e a n d l o c a l iz e t he p a i n , a n d we fi nd some c h a n ge s

in

a

9 . T h e complex o f c h a n ge s i n f u n c t i o n o f t he l oco

of t h e t y p i c a l reflex

c orrespo n d i n g

are a

and

h a ve

e x c l u d e d gross p a t h o l o g y , t h e n i t is o u r t a s k t o

Copyrighted Material

motor s y s t e m a n d t h e res u l ti n g r e fl e x c h a nges c o n s t i t ute w h a t may be ca l l e d the ' fu n c t i o n a l p a t h o l ogy of t h e m o t o r syst c m ' .

3 Functional anatomy and radiography of the spinal column

Without a good un dersta nding of fu nctional anatomy as p rese n ted by X-rays, i t is almost impossi ble to u n d e rstand i m p a i red function and t h erefore to i n terpret correctly w hat we have fe lt with our h a n d s d uring examinat i o n . I t is, o f course, not t h e pu rpose of this chapter to dea l with a n a tomy in detai l , but to present those featu res that a re essentia l for a n und e rsta nding bot h o f t he w a y i n w h ich function may be imp a i red, a n d of the mech a n isms involved. Basically X-ray d i agnosis o f the s p i n a l col u m n serves t h ree pu rposes: (1) d i agnosis o f c h a nges i n structure, (2) assessme nt o f locomotor function (ki nema tics) a n d (3) assesme n t of static function (spina l c u rvature, position o f i n d i v i d u a l vertebrae ) .

Diagnosis o f structural changes Classic X-ray d i agnosis is concerned mainly with cha nges in structu re, and this type of d i agnosis is essentia l in ord e r to avoid serious e rror; methods aimed a t correcti n g fu nction are out of p l ace in cases where the u nder l y i n g condition is structura l pathology . Our specia l i n te rest i n t h i s fie ld, however, l i es i n such cha nges of st ruct u re as ma y have a d i rect influence o n fu nction, such as various a n omal ies, i n particular in the shape of j o i n ts, asymme try o f t h e vertebrae, spinal c u rva t u re, etc. Not o n l y is the shape or deformity o f some vertebrae t h e ca use o f asym metrica l function ( e .g. in sco l iosis), but it can itself bc the result of asymme t r ica l function (e.g. rota t i o n of the lower cerv i c a l spine ow ing to dom i n a nce of one h e m isphere a n d asymmetrical loading of the upper extremities, as Jirout (1980) has shown). Diagnosis of structur a l c h an ge can be fou n d i n the classic tex tbooks both o f a n a to m y a n d of radiology, and t h e refore need not be dea l t w i t h i n detail here.

Diagnosis of disturbed function (mobility studies) The X-ray examination of d i sturbed fu nction i n v o l ves exa m i n a tion o f the s p i n al col u m n in vario u s, usu ally extreme, positions such as a n te- and retroflexion (exte n s i o n), side-bend i n g or even rotation. This type of examina t i o n und o u b t e d l y p rovides some d i rect information about mobility; as a routine examination, howeve r, it i s very time consu ming and uneconomica l a nd i ts practical v a l u e is t h u s limited to complicated cases w h e re specia l information is required, o r to cases invol v i n g l i tiga tion. It is advisable to use X-ray exa m ination in cli nica lly re l e v a n t positions, e . g. i n retroflexion in cases o f ve rtigo ca used by ben d i ng the head back. Doctors familia r with manu a l diagnosis of d i s t u rbed funct i o n a re accustomed to assessi ng mobi lity by cli nica l examination; neve r theless X-ray exa m i nati on of mobi l i ty is extre m e l y i mporta n t for res e a rch p u rposes, as i t gives insight into the mechan i s m s u nderlyi ng mobility and i ts d i s turbance, an ins i g h t no othe r m ethod can provide.

Diagnosis of disturbed static function (spinal curvature and 'malalignment') Mobi l i ty is what is usua l l y m e a n t by 'spi n al function', yet static function is no less importa nt, a n d X-rays of the s p i n a l co l u m n with the p a t i ent standing or s i t t i n g (ta ken und e r standard conditio ns) ca n, a n d should, be eva l u a ted f o r static function. As is s h own in more d e t a i l below, spi n a l curva tu re sho uld be such as not to upset b a l a nce. Thi s goes not only for t h e sagittal b u t also for t h e coronal plane, in which every obliq u i t y (e.g. i n w a lki ng) p roduces a scoliotic 35

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Manipulative Therapy in Rehabilitation

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of the Locomotor Systan

c u rva t ure with the correspo n d i ng rotatio n . Curva

posture. To d etermine the p os i tio n of the ce rvical

ture may be smo o t h, or less so; in

segments

spine, the base o f the skull mus t be v i s i b l e , as we l l

kyp h o tic ,

a s the whole o f t h e cervical .

t h e re

may

b e a s harp bend

ce r t ain

(scolio tic ,

l ord otic) or even som e rotatio n or shift ('offset' ) .

The imp orta nce of the se s ig ns of m al a l ignm e n t is highly controversial, es pe cial l y in v i ew of t h e dis c r ed ite d sublu x at i o n tb e ory. The controversy is f u e ll e d by t he d oub t fu l impor ta n ce of asy m m e try, as, in fact, asy mmetry i s t h e rule rat her t h an the exce ptio n . Yet Jir o u t (1978) has shown that alt h oug h

to assess the shape of the l umbar sp i n e we need to se e at le a s t the t h oracolu m b a r j u n ctio n , the ilia, the p u bic sy m physi s and both hip joints on a sin gl e AP picture. This gives a suf fi c i ent n u m ber of l a n dmarks by which to assess correct focusing and t o com p are successive p ictu r e s if a stan dard te c h n iq u e is used .

Th e id e al method f o r X-ray exami n a t io n o f t h e

asymmetry of the positi o n of the atlas in rela t i o n to

sp i n a l column i s t o s h ow the whole column o n a

t h e axis is the rule, i ts i n cidence incre ases with age.

s i n g l e pi cture. An AP a n d

This is e qua lly true for t he a sym m etrical shape of

patie n t st a n ding are required: the on ly condition to

a

l a t e ra l vie w with the

the sp i nous p r o cesses. He conc l u de d that t his is

be obse rved for the AP vi e w is t h a t both feet must

pro b a bly the r e s ult of a s y m m e tr ica l pull due to the

be place d sy m m e t r ic ally in relation to the X-ray

d ominance o f o n e c e r eb ral h e mi sp h e re .

scre e n , and t h at the patie nt be re qu este d to d istri b ute

F r o m this it appears reas o n a b l e to deduce tha t

his weight e q u all y be t w een his t w o feet, keep ing his

asymmetry and irregu l a rity of ' alig n m ent ", while not

legs straig h t . In the lat e ral view, the feet s h o u l d be

in themselves p at h o l og i cal , can be the exp ress i on of

place d so that the ankles are about a fing er' s breadth

example,

. behind the v e r ti ca l to the flo or. from the mid-po i nt

the axis is rotat ed in n eutral posi tion , not only will

of the horizontal edge of the cass ette; the head s h o u ld be n eith e r bent Lo the side no r rotated, the p a tien t fixing s o m e o bj ec t at eye -le v e l in ord er to

asym metry or a n om a l y in fu n c tion.

If, for

it ro tate asym m e t rically d u ring side-bending, b u t the

rest of the cervical spine will follow suit (see p.

65).

retroflexion

Without j u m ping to c o n cl u sio n s , marked asymmetry

avoid a n te tlex i o n or

or 'm alalig nment' in the X-ray pic ture sho uld be

p atie n t holds his arms crossed ove r t h e chest and his

c orrel ated to the c l inical find ings. Marked irregularity

h a n d s on his shoulders.

of t h e head; the

of the r ela t ive p osi tion of vertebrae in the X-ray can be regard ed as a warning signal that there may al.so be some fu n c tio n al anomal y or at least su s cept i b i l i ty to dis t urbe d fun c tio n.

X-ray of the lumbar spine and the pelvis

One obvious ad v a n tage of t h e exam ination of static fun c tion is its e c o n omy: on ly t w o X - rays are

Th e pat i e n t mus t be standi n g if X-ray p i c ture s that

re q ui r e d , t h e anteroposterior (AP) view and the side

can

view. Sta n d a rd c o n d itions must be adh e red to. As

obtained. He is therefore p l ac ed before the X-ray

individual posture is highly characteristic, i.e. constant,

s c re e n as when pictures are take n of the who l e spinal

co m pa r a b l e pi c tures can be e x pe c ted on rep e tition .

column. To acquire in f or m a t i o n about the sta t ics of

be

e v alua t e d

Gutman n a n d Vele (1978) h ave ve ry a ptly s u mmed

the spinal column

up the i m p o r ta n ce of static function: 'The d o minat i ng

Gutman n

fo r sta t ic function are

as

a whole,

a

to be

dev i ce described by

(1970) is used , in which a plumb-line

p rincip le of the sp i nal colu m n is body s t a t i cs '. All

indicates the vertical line from the head. A lin e

ot h e r func tions are subordinate to the requirements

which c o rr es po n d s to the centre of the scre e n is the fl oo r: for the AP vie w the patie n t

of u p right posture on two le gs . Loss of m ob i lity and

draw n on

p a i n ful i m pi nge m e nt of nerve roots is pr e ferred to

places o n e f o o t symmetrically o n each sid e of the

sacrifice of the e re c t p o sture .

line. A movable pl u m b - li n e of m etal wire is attached to the scre e n . The s c re e n is fi r st raise d to t h e l evel of the p a t i e n t ' s oc ci p u t and the metal wire m ove d

Techn i c a l require m e nts The

be

take n

to in

a

posit i o n

a

point

c o r resp o n di n g

to the

o u t er occ ipit a l

that

protuberance. In this way the plumb-line sh ows the

c o rresp o n ds to t h e pa t ie n t ' s natural posture, either

head position. The screen is the n adj ust e d to the

X-ray sh ould

standing or sit ti ng (with the e x c e p t i o n of the AP

he i gh t re quir e d to t ake a picture of the lum bar spine

view o f the cer vical spi n e , which is taken with t h e

and the p e lvis (with the cen tral b eam and the cent r e

p a t ie n t su pi n e ) .

There s h ould ,

therefore, be

no

artificial correction of the patient's p os ture. Distortion must be avoided and f ocusing m ust be s cru pu l ous t o

obtain clear pi c tures t ha t can be used s u c cess i v e l y

of the screen roughly at the h e igh t of the n avel ) . The wire should n ow be taped to the lower edge of t h e

screen a n d th e patie nt l eans aga i n st t h e screen s o as n o t to bl ur the p ict u re (Figure 3.1 ) .

fo r com par i s o n . To ac h i e ve this, some corre c tion is

For t h e lat e ral vie w t h e patie n t p u ts his feet as

u n avoid ab l e , for insta n c e to prevent d i s t o r tion or

desc ribed for t h e X-ray of t h e whole spi ne: the

tilt, b u t t h e nat ural posture must be r e gis t e r ed. It is

scree n with the p l um b -l i ne is raised to the

also esse n t ial to v i sual i z e

suflkiently lo n g section

the h ead in o rder to place the p l u m b - l in e at a point

of the spinal column t o make it p ossible t o assess

correspon ding to the outer meat us acousticus, and

a

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l evel

of

Functional analOmy and

radiography of {he spinal co/ul11n

Figure 3.1 X-ray technique of the lumbar spine with the patient standing. (a) Positioning of the moveable plumb-line: the device prepared For X-ray, AP view: (c) positioning of plumb-line: (d) the device prepared for X-ray, lateral view (After Gutmann, 1970) (b)

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37

38

Manipulative Therapy

in

Rehabiliratioll of rhe Locomoror

Sysrern (Figure

3.2).

lumbar

sp ine is o v er-exposed or the lumbosacral

With

the normal t echniq ue , either the

j unc tion is t ube to

under-exposed. The dis ta n c e of the X-ray the fi l m should be as great as possible,

depending on t he power of the apparatus a n d the corpulenc e of

the

patie nt , the ideal dista n ce b ein g

2 m.

X-ray evaluation of lumbar spinal statics As

we

h a ve al rea d y seen, X-ray examination of t h e

p a t ie n t st a n di n g serves mainly for d ia gnosis o f static fu n c tion and i ts disturbance. It should be borne i n mind tha t clinical examination alone can ascertain the position of the outer occipital prot ub e rance , t h e spinous processes, the intergluteal line and

the

mid

point be tween t he heels in rela ti on to a p lumb-line. In the sagittal plan e , clinic al examination can show the position of the sh oulders, the great troc hante rs and the heels in relation to a plum b -l ine from t h e external aud itory meatus. Clinical exa min a t ion,

ever,

how

cannot provide information about the position

of the sacrum

and L5, i.e. the true base of the s pinal column, information which is essential for the under s tan ding and evalua tio n of spinal statics. This e xplai n s why clinicians in t e r e ste d in body

s t a tics have d e v o t e d t h e i r a t ten tion mainly to the question of bo d y equilibrium as a whole, studyin g d eviation of the head and dev iation from the line of g r a vit y by means of sta tove ctography. Rash an d Burke (1971) p oin te d out that 'in s tationary

the

c e n tre of

g rav i t y

be ver tically above the area of preferably n e ar

Figure 3.2 Lateral view of the lumbar spine using the technique illL:strated in Figure 3.1: perfect visualization of the innominate and the femoral heads, and of the lumbosacral j u nc ti o n. The rest of the lumbar spine is neither over-exposed not distorted

its

posture

of eac h bod y segment sbould

centre.

If

the

supporting base,

persistent gravitation a l

torques are bei ng borne by ligamen ts . or if ex c e s s i ve m uscular c o n traction is r e qui red to m a intai n balance, this p r i nci p l e is being viola ted'. X-ray exa m ina t i o n u n der sta t i c

conditions prov ides pertinent informatio n

on this type of s t a tic disturbance . The me ch a n is m of balance differs a nd the sagitt al p la n es .

This

is

in readily

the coro nal un d erst ood

if the effe ct of a heel-pad is consid ere d. An arti

with the p lumb-lin e in place the screen is t h en

the

ficial difference of m o re t h an 1 cm in leg length

this

the coronal plane ; it is felt and resented by the subject, wh ere as ra isin g (or lowerin g ) both h e els is hardly noticed. T his is because in the coronal plan e the lin e of gra v ity lies between the two hip joints and the heels, guaran t eein g ( r ela t i v ely ) stable equili bri um . Purely mechanical sta t i c chan ges a re t h e re for e much more readi l y felt in the coro n al than in th e sagittal plane . In the l a tter the tru n k is in a state of labile equilibrium above th e two perfectl y round sur faces

tec h nique is that it giv e s an u n disrort e d view of the

of the hip joi n ts. Ba l a n ce in this pla n e canno t be

pelvis and the hip j oin ts and correct exposure of

maintained by static forces alone ; dyna m i c m uscul ar

bo t h t h e lumbar s pin e and the l umb osa cra l junc tio n,

forces mus t be brought i n t o pla y , but should be kept

and yet there is no disto r t ion of the lumbar spine

at

lowered to

level requ i red for t h e latera l v i e w of

the lumbar spine (the centre of the screen at the level of the

navel

or slight ly above ) . The p l umb- line

must a g ain be ta ped to

the lower edge

of

the screen

and the p a t i e n t must le a n aga inst the screen to avoid blurring. In the la t e ral view it is an adva n tage not to focus t h e central beam o n th e mid dle of the pic tur e but eccentric ally mi d way between the i l i a c

cre s t a nd th e greater t ro chan te r , i. e. level of

the sa cral

roughly

a t t he

promontory. The advantage of

changes t he balanc e in

i m med iat ely

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a

minimum.

FunClionai analomy and radiography of the

Lumbar spinal statics i n the coronal pla ne

Under 'ideal' cond i tions the pelvis a n d sacrum in the AP view a re s t r a ight and a l l vertebrae a re symmetrical: the outer occi pi ta l protru berance is i n the mid-line a n d s o are all the spinous processes down to the sacrum, as well as the coccyx and the p u b ic s ym ph ysi s. Not only is such a s p i n a l colu m n the exception but it is o f l ittle i n te rest. N o bod y ever sta nds n atu ra l l y sy m metrica l l y o n both feet. a n d du r i ng move m e n t the p e l vi s con s t a n t ly s w i n g s f r o m one side t o the oth e r. The pro b l e m is thus not obliquity in i tse l f b ut correct or fa u l ty reactio n to obliquity, and the crite ria by which this reaction c a n b e j udged. This can be stud ied physiologically i f one creates obliquity of the base i n a he a lt h y s u bject b y lengthe n i ng one le g (Figure 3.3). The pe lv is shifts to the h igh e r side while the lumbar s pi n e bends to the same s i d e , if bo t h l egs are stra ig ht and the p a t i e n t re l a x e s. Tn X-rays the same shift to the side. sco li o si s a n d rotation to t h e lower s i d e can b e observed. The summit of th e scoliotic curve i s us ua l ly at the mi d lumbar reg i o n , so that the tho racol u m b a r junctio n comes to stand above the sacrum. The d egree o f rotation i n l u m b a r scoliosis d e p e n d s on lordosis: if this is prese nt, rotation is norma l l y fo und. If th e r e is no lordosis - as in acute l u m bago or sci a tica, for example - there is a l so no rotation; if t here is kyphosis there may even be rotation to the o p po s i t e side. The c rit e r ion of norma l stat i c function of the lumbar spine mllst therefore be its reactio n to obliquity at the base - this base not necessari l y being only the sacrum but also the l ower l umbar vertebrae up to U. If the ob liq u ity is not due to a sho rt l e g (pelvic i n cl i n a t i o n ) but o n l y to inclinati o n of the base of the s pi n e . i t will persist w h e n the p a tie nt is seated, and therefore correction of the sitting pos it i on should be cons i d e red . Reaction to o b l iquity at the base is normal if (1) t h e r e is s co l io s is to t h e lower s id e; (2) there is rotation to the same s i de , p rov ided th at lordosis is present; (3) t he th oracol umbar junction stands vertically above the sacrum; and (4) the pelv i s shifts to t h e higher side . Tho racic scoliosis is always in the opposite d i r e c t io n to l u m b a r scol i osis (Figu re 3.4). These facts reflect the physiology of bala nce a n d

Figure 3.3 Body statics with the subject standing: with his weight equally on both feet. the body axis corresponds to the plumb-line between the heels: (b) with a heel-pad, the weight again equally on both feet. the pelvis shifts to the higher side; (c) w i t h the weight on the right foot the whole body deviates to the right. the head deviating furthest (a)

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spinal

column

39

40

Manipulative Therapy

in

Rehabilitation of the

Locomotor System

Figure 3.4 Normal reaction of the lumbar spine and pelvis to a short right leg (pelvic obliquity): static dextroscoliosis with dextrorotation of the lumbar spine, deviation of the pelvis to the left from the mid-line (arrow)

affect the whole question of difference in leg length.

that while clinically we determine pelvic tilt,

This in itself is of no significance if it does not cause

cannot determine the position of tbe

sacrum

we

nor that

obliquity of the base of the spinal column. There

of the lumbar vertebrae that constitute the base of

fore, the age-old dispute over how to measure this

the spinal column, as the pelvis may be straight while

difference is beside the point. What is important is

the sacrum is tilted, and vice versa. Only by X-ray

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Functionrd anatomy

and radiography of the spina! column

41

Figure 3.5 Pelvic obliquity. (a) Pelvis lower on the right (short right leg) with a horizontal sacrum, the lumbar spine with a right heel-pad the pelvis is horizontal, but sacral obliquity appears, with deviation or the lumbar spine to the left and slight dextroscoliosis

straight: (b)

examination can the true b a s e of the s pinal col umn and the reaction of the s p i n a l col u mn to incl i n ati on b e determined (Figure 3.5). The principa l pathological fi nd i n g s a r e : 1. Obliquity

without scol iosis or w ith insu ffic i e n t scoliosis, so that the thoracolumbar j uncti o n is n o t above the lumbosacral. 2. No pelvic shift to t h e hi g he r side. 3. No rotation whe n there is sco l iosis and lordosis or ro t a t i o n i n the opposite d irectio n from t h e scoliosis, or even sco l i osis to t h e h igh er s ide . Co rre ct i n g disturbance of st a t ics by me a n s of a heel - p ad is the pra c t i ca l a pplica tion of these cr ite r i a . This is, of cou rse, always a c l i n i cal q uestion whi c h can ne v er be decided b y X-ray alone. Neve rtheless, it is X -ra y examination that prov id e s the m ost i m p or t a n t information. What do we expect to a ch ieve by usi ng a hee l-pad to reduce obliqu ity? 1. If

scol iosi s is

sufficient to bring t h e above the lumbosacral, or if sc o li o s i s is abse n t , the th oracolumbar j unc tion will be b ro ugh t to stand above the lu mb o sac r a l , or to a ppro a c h t h is p os i t i o n . 2. If the pelvis is shifted, usually to t h e h i g he r side, it wil l return to the mid-line. not

thoracolumbar j unct i o n

3.

Even if the scoliosis (scoliotic c urv e ) has been b a l a nced, it will decrease a fter o n e h e e l h a s b e en r a is e d .

All this m u s t be c h ec k e d again b y X-ray. With each of these p ossi bi l i ti es we obse rve a p os i t i v e or a negative r e a c t i on , t h e spi nal column e i ther ' a cce pt ing' or ' rej e c t ing' the c o rrection . In cases of 'rejection' i t would b e wro n g t o 'force' c o rrec t i o n upon the patient, be c a us e t h is wo uld only in cre ase the s t r a i n a t t h e b a s e (F i g ure s 3.6 and 3.7). D e v i a ti on fr om t he p l u m b - li ne c a n us u a l l y be i n te rpr e t ed as a s i gn t h a t the p a t i e n t p u t s m o re weight on the leg towards w h ic h the plumb-line i s s h i fted . The tra d i t i o n a l reacti o n t o o b l iqu i t y has been studied by Ill i (1954) a nd Biederma n n and Edi n ge r (1957), w i th t h e s ubj ect ma r ki ng time i n fro n t of a n X -r a y screen . A t every step ob l iqu i ty appeared a t t he b a s e and with i t sco l iosis to th e lower side; the s u mmi t of the scol i o tic cu rv e ap p e a r ed at L3 a nd the thoracolumbar junction was b ro u g ht above the s acrum. A bove T12 the thoracic s p i ne made a (co m pe nsatory) scoliosis to the opp o site side, but it was le ss marked, like a d a m ped w a v e . A cc o rding to Biedermann and E di ng e r (1957), the thoracolumbar jun ct i o n forms a k i nd of fixed p o i nt which s h o u l d n o t swing more than 4 c m fr o m o ne s id e to t h e o t h e r.

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Manipulalive Therapy

in

Rehabililation of the Locomotor

System

Figure 3.6 Pelvic aDd sacral obliquity due to a short left leg. (a) Left scoliosis with eleviation of the thoracolumbar the right; (b) normal l um ba r statics after application of a left heel-pael

junction to

Figure 3.7 Pelvic and sacral obliquity elue to a short left leg. (a) Left scoliosis with deviation of the thoracolumbilr (b) l e s s pelvic obliquity after application of a left heel-pad, but 110 improvement in lumbar statics

jun ction to the le ft :

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rudiographr

FllncJjoJloi [!i1alorny The relation of scoliosis to rotation under the influence of lordosis has been studied by Lovett ;!ccording

whom the

spine'

ares

is lordosis, but direction oC scoliosis if lhe opposite side in kyphosis. This call be

43

'iff! spinal

there is an increased difference between L5 and T 12, the latter being more than 4 cm dorsal to L5 (Figure

1 is

l'labby' llnualance

the

lypical

to

reaction

the rnuscles conlrolling poslure of the

explained by the relative mobility of the vertebral

lumbar spine and pelvis; it may be the result of weak

bodies and the arches during side-bending. If there

abdominal and gluteal muscles, but equally well of

is

the

in

sagittal

proeesse" which an, ?lre locked

therefore rccsist

side-bending; the vertebral bodies, however, arc lice

4).

hack

hip

muscles

Lumbar splltal curvature

J�

(see

clearly dependent

to bend sideways. Hence, there will be more lateral

on pelvic tilt which, in turn, varies according to

flexion of the vertebral bodies than of the arches,

the 'type' of pelvis, as is shown in the following

"Ide of scoil()slS will resuit, the and ro(;ltion to spinolls processes rnnaining in mid-line

IO!1. can, therefore\ be concluded that

spinal

On the other hand, if there IS kyphosis the joints

curvature is adequate if in the sagitta! plane the

are much freer to move, as the joint facets are in

thoracolumbar junction is behind the lumbosacral

loose apposition. The vertebral bodies, however, are

junction and there is no excessive anteposition of

pre,;scd against antt:nor edge, and as

other, pcnticularly therefore

as free

tbeir bend

lordosis. Side-bending of the arches will tllus

sdcral promolltory, and L5 (not

T12 is

far

the most important

coronal

average). In

100

which is double the

than

be the same as, or even exceed, lateral flexion of

criterion is also that the thoracolumbar junction

the vertebral bodies. The result will be either no rotation at all, or rotation in opposite direction from scoliosIs. can be in X-ray

should be vertically above the lumbosacral. If there

of (Figure

3.8).

with acute lumbago, taken slandll1g

obliquity

base

normal redetion is

scoliOSIS and rotal!on shift of

pelvis to

lordosis

present)

higher side.

This can also be ascertained clinically

If curvature of the spinal column subserves these

if a subject with a marked lumbar kyphosis when

rules, i,e. the rules of body statics, then it is physio-

sitting relaxed is told to side-bend: while in lordosis his in

spinous processe:; Ime, in

the,

remain airnost form a

; I am not 8ware of any other criteria of spinal be infern:cI that the

curvature. Furthermore, it column

scoliotic arch.

only helps

maintain equilibrium

the whole body but also determines the relation ship between the various parts of the body under

Lumbar spinal statics in plane

the influence of gravity. Wc

sagittal

therefore speak of

equilihnum' subservcd accordance

38).

the spimil column

the criteria of Rash

Burke

In the sagittal plane we are concerned with what are

(1971) (see p.

called 'normal' curvatures, generally held to comprise cervical lordosis, thor8cic kyphosis, lumbar lordosis

recumbent or if the position of the pelvis and the

and sacral kyphosIs. (1961

have the

Sollmann and Breitenbach for clisproving this

Curvature cannot be evaluated if the patient is spine

to at

cannot

seen on

the thoracolumbar single radIOgraph.

accepted view, on the basis of 1000 X-rays of the entire spinal column. They came to the conclusion

'flat' spine) goes hand in hand with hypermobility

that there is only an 'individual norm': they do not,

anrllack of stahilitv, while greater curvature (in both

however lay down thai

is a con,llInt correlation between the ti It of L5 and that of T12, and more important still, that the T12 vertebra lies 4 cm behind L5 (150 measurements were taken). I in 200 mysI'lf ccmfirmecl ,ewit,l lind also showed that plumb-Ililc from the external acoustic meatus passes exactly through the scaphOlds at its base. The sacral promontory lies 4 mm behind and the axis of the hip joints 12 mm in front of this changed in distllrb plumb-11IIe. These cI1I1ditions anct' dynamics, of muscular function. IS wrote

most eVident in muscle spasm due to acute sCl3tica

It is important to realize that a slight curvature (a

sagittal and and

coronal

corrcsponds to

rnobility.

The pelvis pelvis

the spinal column constitute a

functIOnal entity, the pelVIS being the base of the column and the point of connection with the lower extremities. The pelvis transfers motion from the extremitit" [he ilia,

and acts

a shock absorber.

muscles dnd Iigarllcills attach

themselves to the spine as though to a mast. The

or lumbago in disc lesions, when there is a forward

sacroiliac joints and the pubic symphysis allow

thrust posture (Figure

for some mobility (springing) while guaranteeing

whieh

3.9)

or in flabby posture in

he sacral promontory

forwa

and

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44

Manipulalive Therapy in Rehabiliralion of lhe LocomOlOr System

Figure 3.8 Typical posture in acute disc lesions with deviation of the plumb-line and the (straight!) pelvis 10 the side: 'paradoxical' scoliosis vith slight rotation to the opposite side: lumbar kyphosis can be deduced from the shape of the pelvis

Pelvic types

There are frequent anomalies of the lumbosacral

The function of the pelvis and its influence on body

region: the last lumbar vertebra is a 'transitional'

statics depend largely on its type. We owe this

vertebra and shows by definition that there is harclly

concept to Erdmann (1956) and Gutmann (1965).

any 'norm' and that variation is the rule. ff the

Copyrighted Material

Functional anatomy

and radiography

of Ihe spillal column

45

forward thrust posture, in an acute radicular syndrome

Figure 3.10 Lateral view of the lumbar spine in 'flabby' posture - a fo rw a rd shift of tbe pelvic promontory - in this case due to a shortened iliopsoas muscle

variations are asymmetrical, the result may be obli

pe l v ic gird l e, the sacroiliac j oin ts having the d ec isi v e

quity of the sacrum, c a us in g the c hanges in statics

role.

Figure 3.9 Lateral view of the lumbar spine with

a

d ist ing u is h

The sacr u m is wedge shaped in two directions: (1) the w h ole structure tapers like a p y ra m id in the caudal direction; and (2) the upper part (S1-S2) t apers in a d orsa l d i r e c ti o n ( accord ing to Solonen, 1957), while the lower p art may taper in either

three p elvic types with far-reaching d ifferences in

direct i o n . There is a tuberosity on the i nn om inate

already dealt with. If, h oweve r , there is symm etric a l variation,

the

most important

con s eq uence is a

change in the length of the sa cru m , a ffec t ing the postion of the sacral promontory. Gutmann (1965) and E r d m a n n

(1956)

fun c t i on and possible pathology. The first pr es ents a

bone

long s a crum and high sacral p romon tor y , the second

su r fa c e,

the average or intermediate ty p e , and the third

a

low

p elvic inclination,

a pp r ox i m ately

in

t he

mid d le

of the joint

fitting into an impression on the joint surface of the sacrum at the lev e l of S2, but there is

For greater cl arity the d iffe re nt criteria are s h ow n

grea t variability and this is not the only t u be r os i t y . In the AP X-ray there is a d o u bl e contour owing to the wedge sha p e described above, but this varies from case to case and is frequently asymmetrical. It

in Tabl e 3.1 and F i gure 3.11.

is of some i m p or tance that the greater the distance

promontory

and

considerable

which the authors call Hohes Assimiliationsbecken, Normal Becken and Uberlastungsbecken, respectively .

when

between the two contou rs of the j o i nt , the greater

evaluating X-ray findings: the type of pel vis will

the d iv erg ence (or convergence) a n d the na rr ower

All

of

this

sh o ul d

be

b or n e

in

mind

determine the d egre e of lordosis to be expe cte d ,

the joint space appears. C o n ve rsel y , if th e r e is no

while the height of the last intervertebral disc will

con verge n ce and we see only o ne contour, the j oint

de termin e the mobility of the se g men t.

space appears to be wide.

Greater c o nv ergence

(wedge sh ap e) g i v es more stabi li t y , whereas little convergence accom p a ni e s hypermobility.

The sacroiliac joints

It is

impor ta n t to poin t out that, d espite its

Thanks to the s acroilia c joints an d the p u bi c sym

unusual shape and the fact that t h e r e are no muscles

phy s is there is some m obili t y of the otherwise firm

moving

the

Copyrighted Material

sacrum against

the innominate,

t he

46

Manipllimnc

Rehllhiillalion of Ihe Locomotor Syslem vertical from the promontory

the outer and to the

(b) vertical from

(a)

Figure 3.11 Pelvic types. (a) High promontory: (b) average type: (c) increased pelvic (sacral) inclination (After Gutmann, 1965)

Copyrighted Material

(c)

vertical from the outer meatus

Fun Clional

analOmy

radiography of the

and

spinal column

47

Table 3.1 Pelvic ty pes Crilerion

Typ e

High I n c l i n a t i o n of s acr u m

Interm ediate

Low

50-70

35-50

1 5-35

\ 5 -30

3 0- 50

50-70

p rom ontory

prom o n t o ry

( degrees) I nc l i n a t i o n of u p p e r

s u r fa ce of S l (degrees) Pos i t i o n o f L4 disc

Above t h e l i n e of t h e i l iac

cres t s

At the

h e i g h t o f the

l i n e o f the i l i a c d iscs Posi t i o n of the .

At

Ecce n t ric ( d orsa l )

pro m o n t o r y i n t h e pe l v i c

t h e c e n tre

At t h e ce n t re o r eve n

r i ng

Rec t a n g u l a r

Wedge s h a pe d

S h a p e of L5 d i sc

R e c t a n g u l a r a n d h ig h e r t h a n L4

Wedge shaped a n d l owe r t h a n

W e d ge s h a p e d

L4

LS-S I

L4-- L 5

L i t t l e fi x a t i o n of L5

G ood fi x a t i o n of

m o b i li t y R o l e of i l i o l u m b a r

Wed ge s h a pe d a n d lower than

L4

L4-- L S L5

l i ga m e n t W e i g h t - b e a r i n g s t ru c t u re

l i n e of t h e

v e n t ra l

S h a p e of L5 v e r te b r a

Level o f m a x i m u m

B e l ow the i l iac c r e s t s

G oo d

fi x a t i o n o f LS

a n d e v e n o f L4

End p l at e of L5

E n d p l a te of L5

A poph ysea l j oi n t s u r face of

SI , s a c ro i l i a c

j oi n t Spi n a l c u r v a t u re

Flat

Average

I nc r e a s e d

X-ray statics

H i p j o i n ts in fro n t o f p r o m o n t o ry : t h e p l u m b - l i ne from t h e o u te r acoustic m e a t u s coi ncides w i th the ve r t i c a l

A s fo r h ig h

The p l u m b - l i n e from

p ro mo n t or y t y pe

f r o m the os n a v icu l a r e a n d l i e s b e h i n d t h e h ip j o i n t , sl i gh t l y b e h i n d

the

lies

i n fro n t o f t h e h i p

j o int

H y p e r m ob i l i t y , d e ge n e ra t i o n o r pro l a p s e o f

fro n t o f

the pro m o n t o ry , w h i c h

p romo n tory Clinical c o n s e q u e n c e s

the o u t e r aco u stic mea t us l ies i n

B lo c k a g e , d i s c l e s i o n

LS d isc: l i g a m e n t p a i n

sacroi l i ac joint is a true dia rthrosis w ith its own mobility ( M e n neIJ, 1 952; Weisl, 1 954; Co lachis el al., 1 96 3 ; Duckworth, 1 970) . A ccord i n g to Duckworth, ' the normal movemen t that occurs is rota tion of the sacrum a ro u n d the s h ortest and strongest part of the i n terosseus sacro i liac l i game nts, w h i ch run from t he i l iac tube rosities to the transverse tu bercles of the second sacra l vertebra ' . Th is move m e n t can be described as nutation, a n d the weight o f the spinal col umn d u r i n g walki ng w i l l le nd to rotate the sacr u m forward w i t h each step, t h e sacroi l i a c j o i n ts p l a y i n g t h e part of spri nging shock-absorbers. This rotational move ment o f the sacrum against the ilium ca n be palpated and is fa m i l i a r to gy naecologists i n the manageme n t of labour. However important i t i s that there should be some mobi l i t y o f the sacro i l i a c j o i n t , it should b e very lim ited a n d l ax i ty is u n d esirable. A t t h e e n d of t h i s section on t h e function a l anatomy o f the p e l v i s some re m a r k s a re re q u i red

o f L 4 disc

A rt h ro s i s : l u m b o s a c r a l,

s a cro i l ia c and

o f the h i p

about a cli n ically very stri king p h e n o m e n o n w h ich m a y be called ' pelvic d istorti o n ' . I f the most promi nent points of t h e bony pelvis are palpate d , a peculi a r a pparent d iscrepa ncy e merges: whereas the posterior spi n a il iaca superior (PSIS) i s higher on one side, us u a l ly t h e right, the reve rse is fou n d on palpating the a n terior s p i n a i l i aca superior ( A S I S ) . T h e i l i a c crest may be l a tera l l y a t t h e same level, o r t h e r e may be a slight d iffe re nce. O n p a l p a t i o n o f t h e posterior part o f the i l iac crest a s i m i l a r d i ffe rence will be fel t to t h a t observed o n the posterior spinae i l i a cae, confirm ing the fi n d i ngs. This might give the i m pressio n t h a t one i nn o m i n a te was rota ting against the oth e r o n a horizo n t a l axis. This cannot be so beca use we should then find a considera b l e s h i ft of the pubic bones a t the symphysis. These c l i n ica l facts may best be i ll u strated a n a tomically by Cra m e r 's d i agram (Figure 3 . 1 2 ) . This s h ows a one-sided n u tation a n d there fore a l so sl ight

Copyrighted Material

48

Manip u lative Therapy ill Rehab ilitation

of the

Locomotor System

has been foun d t h a t p a l p a t i o n fi n d ings of a in the l e v e l of the p u b i c b o n e s a t t h e s y m p h y s i s a n d a t t h e ischia l tube ros i ties do not co r r e s p o n d to X-ray fi n d i ngs (see Chapter 4 , p a l p a tory i l l u s i on , p . 1 00 ) . It

d i ffe r e n c e

The lumbar spine A l t h o u g h o n l y a l i t t l e s h orter t h a n t h e t h o ra c i c spine, t h e l u m b a r sp i n e i s u s u a l l y fo r m e d o f fi ve vertebrae. H ow e ve r , m o b i l i t y i n a n t e - a n d retro fle x i o n as well a s i n l a te r a l be n d ing e ns u r e s most o f the m o bi l i t y of the t r u n k . In a d d i t i on t o t h i s i m po rt a n t

a spect, the lumbar s p i n e h a s t o c a r r y m o s t t h e trunk. The vertebral bod ies as w e l l a s the a r ch e s a re t h ere fore m o re r o b u s t . The a p o p h y s e a l j oi n t s give b o t h m o b i l i t y a n d s t a b i l i t y . They a re v e r t i c a l , t h e ( l a r g e r ) l a te r a l p a r t

of

FiglJfe

3.12 The

mechan ism

of pelvic distortion ( A fte r

Cra m e r , ( 965)

the

w e i g h t of

i n the s a g i ttal pla ne a n d t h e ( s m a l le r ) m edia l p a r t i n

the

coro n a l p l a n e . T h e two p a rt s m a y t h u s t y p i ca l l y

form a n a n g l e : howe v e r ,

t h e sacrum between the i Ji a , p ro d uc i n g r o t a t i o n o f o n e i n no m i n a t e rou n d a horizo n t a l a x is a n d o f t h e ot h e r roun d t h e ve r t ic a l . A l t h o u g h m a n y a t t e m p ts h a v e b e e n m a d e to v i s u a l i z e by X - r a y so m e of the a s y m m e tr ica l ch a n g es to be ex p e c t e d . X - r a y d i a g nos i s of t h i s co n d i tion rema i ns unsat isfactory . T h e re is one c h a n ge , however. that do es a p pe a r in the X - ra y p i c t u r e , and that i s a ch a ng e in the statics of t h e l u m b a r spi n e , co n si s t i n g c l i n i ca l l y i n a s h i f t of t h e p e l v i s to t h e s i d e o f t h e h i g h e r pos te r i o r i l iac s p i n e , w h i c h m a y p rod u ce static decompe nsa t i o n of the l um b a r s p i n e , v is i b l e i n t h e X - r a y p i ct u re t a k e n s t a n d i n g ( F i g u re 3 . 1 3 ) . ro t a t i o n of

( a)

a n a rc h ,

the

freq u e n t ly

t h e y o n l y form

l a te r a l part po i n t i n g i n to ( h e s ag i t t a l a n d

i n t o t h e c o ro n a l p l a n e . I f there is the joi n t is e a s i l y v i s u a l ized by X - r a y , b u t t h i s is not t h e c a s e i f i t is a rch e d . The l u m b o sa c ral j o i n t , h o w e v e r . i s m a i n l y i n t h e coro n a l p l a n e . As t h e fi n a l s h a p e of the j o i n t is formed d u r i n g o n to g e n e s i s , a nom a lies a n d a s y m m e t ry a r e v e ry fre q u e n t . T h e s h a pe o f the a r t i c u l a t i o n determ i n es t h e f u n c tion o f the lum b a r s p i n e ; i t a l l o w s f o r m uch a n t e a n d r e t ro fl e x i o n a n d p r a c t i c a l l y e xc l u d e s a n y a x i a l rota t i o n as l o n g a s t h e l u m b a r s p i n e is e re c t . I t l i m i t s .l a tera l fl e x i o n as l o n g a s l o r d os i s i s p rese n t , a s h as a l re a d y b e e n e x p l a i ne d (see p p . 42 a n d 43). It the

medial

a n g u la rity

( b)

( c)

Figure 3.13 D i s t u r bed sta t ics i n p e l v i c d i s t o r t i o n . (a) Pelvis s t r a i g h t . o b l i q u i t y at L4 w i t h d e v i a t i o n of t h e l u m b a r s p i n e t o t h e l e f t a n d s l i g h t s i n i s t rosco l i o s i s . ( b ) N o i m p ro v e m e n t a ft e r a p p l y i ng a l e ft h e e l - p a d . ( c ) A ft e r trea t m e n t o f a b l oc k e d a t l a n t o - o c c i p i t a l ( ! ) j o i n t . n o r m a l s t a t i c s a o d no p e l v ic d i s t o r t i on

Copyrighted Material

( ollimn

Functional ana /amy and shou l d , however, be

v e r t e b r a e . A l t h o lJ {' h

caps u l es a re v e r y w i d e

i n t e rv e r t e b r a l fora m e n

a p p o s i t i o n o n l y i n l or d o s i s

the rest o f t h e l u m b a r

i n n e u t r a l a n d k y p h o t i c pos i t i o n s .

im p or t a n t

T h e i n te rv e r t e b r a l d i scs a re t h ic k e s t i n t h e l u m bil r

to bear

49

t h ick, tbe n a rrower t h a n fo r a m i n a . I t i s

in

m i nd

that

the

i liolumbar

m ob i l i ty . T h e i r t h i c k n e ss

l ig a m e n t i s a t t a c h e d t o t h e t r a n s v e rs e p ro c e s s o f L5 s o t h a t the fift h l um b a r v e r te b r a t r a n s m i ts i m p u l s e s

i nc r e a s e s from Ll down t o L4; h e n c e , m a x i m u m

t o t h e l u m b a r s p i n e b o t h f r o m t h e s a c r u m a n d from

mob i l i t y i s u s u a l l y fou n d a t t h e L4/5 s e g m e n t . O n l y

the i l i a , p l ay i n g the r o l. e of a s h oc k - a b s o r b e r as w e l l . ;\ s t h e u p p e r s u r f a c e o f t h e s a c r u m i s u s u a l l y con

spine

a n d a l l ow g r e a t

i n t h e p e l v i c t y p e w i t h a h i g h s a c r a l p r o m o n to r y i s m a x i m u m t h i c k n e s s a n d m o b i l i t y fo u n d b e t w e e n L5

s i d e r a b l y i n c l i n e d , t he p os i t i o n o f the l u m bo s a c r a l

and S 1 .

a p o p h y s e a l j o i n ts i n a m a i n l y c o ro n a l p l a n e m a y a c t fo rw a r d g l i d in g

as a preven t i o n Some of the

X-ray a nato m y T h e w h o l e o f t h e v e rt e b r a l

h a v e a l re a d y b e e n cases o f transi t i o n a l

in Figure

d i ffi c u l t t o dete r m lll c

3. I 4 ;

the oval

e n c o u nt e r e d types. I n i t may be vertebra

( r a d i x a rc u s ) a re m o s t p r oj ects o n t o t h e u p p e r

i s a l u m ba r i z e d

t h e fi ft h v e r t e b r a a n d

i liac crests: i f an

most p r o b ab l y a t t r i b u t a b l e [ 0 l

t h e vertebra beJo\\

of t h e v e rt e b r a l c a n a l i n t h e l o w e s t p a r t

l i n e passes t h rough t h e m i d d l e o f a verte bral body,

I

The m o s t

r e l i a b l e r e fe r e n c e

l u m b a r s p i n e From the p e d i c l e w e may fo l l o w t h e b r o a d s h a d o w o f t h e l a m i n a i n t h e d i re c t i on o f t h e .

the two t h a t l i ne

,

however, t h i s

i t m a y b e i m poss i b l e t o d e t e r m i n e t h e t ra n s i t i o n a l

s p i n o u s p r o c e s s . La t e r a l t o a n d a b o v e t h e p e d i c l e

v e r t e b r a , i n p a r t i c u l a r i f t h e re a p p e a r to be s i x l u m b a r v e r t e b r a e , w i t h o u t t a k i n g a n X - r a y of t h e

we c a n fi n d t h e u p p e r a r t i c u l a r p ro c e s s ; f r o m t h e

t h orac i c s p i n e . I n s t e a d o f a t r a n sv e r s e p ro c e s s , a

l a m i n a downwards and below the ped icl e , t h e l o w e r

t r a n s i ti o n a l l u m b o s a c r a l v e r t e b r a m a y h a v e a m a s s a

a r t ic u l a r p rocess c a n be t r a c e d i n a c a u d a l a n d l a t e r a l

l a te ra l i s w h i c h ( o nu s a

d i rectio n towards t h e p e d i c l e ( a n d t h e u p p e r a rt i c u l a r

m a s s a l a t e r a l i s o f t h e s a c ru m , a n d m a y e v e n c a u s e

process) o f t h e n e x t ( c a u d a l ) v e r t e b r a . B e t w e e n t h e

s y m p to m s

a rc h for m e d b y b o t h l o w e r

and

.

T h e m ost i m por t a n t

t h e s p i n o u s process 01

a b l y a n a rr o w s p i n a l

v e r t e b r a it i s poss i b l e t o

n a rrowe r a s a res u l t

i . e . t h e c a n a l i s n o t coveTed

e a s i l y recog n ized

i n d i c a to r o f t h e e ffe c t i v e

p ro p o r t i o n b e twe c: 11 s h o r t t h i c k p e d ick"

i n t h e A P proj e c t i o n . W h e re

m i n a a n d the s t e e p

m e e t ( c l os e a bo v e t h e space ( i f p a r t o f t h e

pse u d o a rt h ro s i s w i t h t h e

, i s probbecome e v e n r e l a t i ve l y t h e d i s body a n d I m e rv e r t ebra l

fo r a -

A P v i e w , a l th o u g h IS

I n t he s a g i t t a l p l a n e ) .

th i s co n d i t i o n s h o u l d n e v e r b e a s s e s s e d a c c o r d i ng

T h e re i s s l igh t d i v e rgence o f t h e a p o p h ys e a l j o i n t i n

to t h e i n te rpe d ic u l a r d i sta n c e , b u t by t h e d i s t a n c e

a c ra n i a l d i rect i o n .

b e t w e e n t h e t w o l o w e r a rt i c u l a r proces s e s , i . e . t h e

T h e l a t e r a l v i c w (Figure 3 . 1 5 ) a ls o s h o w s t h e t h i c k

w i d t h of t h e t ra ns l u c e n c y corres po n d i n g t o t h e s p i n a l

p e d i cl e s , from w h i c h t h e a r t i c u l a r p r o c e s s e s a ri s e .

c a n a l . I n s u c h c a s e s t h e a rt i c u l a r processes p rese n t a

H e r e , t o o , we m a y s e e t h e j o i n t s p a c e i f p a r t o f t h e j o i nt i s i n t h e coro n a l p l a n e . B e t w e e n t h e u pp e r a n d

s w a l l o w - t a i l s h a p e on X-ray T h e a r t i c u l a r processes

l o w e r a r t i c u l a r p r o c e s s e s l ie s t h e p a rs i s t h m i c a , t h e s i te w h e re s po n d y l o l y s i s m a y b e s o u g h t . B e l o w t h e

p i ct u r e i s s e e n i n b o t h v i e w s we m a y in fe r t h a t t he s p i n a l ca n a l i s trefoi l i n h o r i z o n ta l section. ( Ho w e v e r

ped i c l e s w e s e e t h e i O lc n e rt e h r a l l ie a l m o s t e x a c t l y i n t h e

sca n n i n g v i s u a lizes

\\ h i c h

.

a r e v e ry t h ic k and the j o i nts c l e a r l y v i s i b l e . If a t y p i c a l

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zon t a l d i a m e t e r a l m o s t post e r i o r w i d t h o f t h e

criteria for a s s e ss i n g

c ov e re d b y t h e a r t ic u l a r

d i s c ; i t s h o u l d be b o r n e

t h e se p rocesses o n ly t h e

h y po p l a s i a i s a c o m n l O l 1

p rocess ca n be see n . T h e I

w i t h d is c d e ge n e r: 1 1

sound

I

on to t h e a r t i c u l a r p rocess

fou n d p a r t i c u l a rl y

sm a l l t h i c k s h a d o w .

( w h e r e a n o m a l ie s m o s t o fl e n occ u r ) . T h e r e fo r e i f

T h e l a s t l u m b a r v e r t e b r a d i ffers fro m t h e r e s t i n many ways: i n t h e side view i t i s wedge shaped a n d

t h e l a s t v e r t e bra s h o w s m a r k e d s i g n s o f be i ng a t ra ns i t i o n a l v e r t e b r a a n d t h e r e are n o s i g n s o f

w i t h powerfu ll y d e v e l oped t r a n sv e r s e processes i t

m a rg i n a l s cl e ro s i s , b o n e s p u rs o r i nc r e a s e d l a x i ty

s ho w s a t r a n s i t i o n a l s h a pe i n r e l a t i o n t o t h e s a c r a l

( s h i ft ) a d i a g n o s i s of d e ge n e ra t i o n i s u nfo u n d e d . A ,

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Manip u lative Therapy in

Rehabilitation of the Locomotor System

10

2

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3 4 5 6 7

13

8 9 14

(a) (b)

( i)

( ii )

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Figure 3.14 Com p a r i s o n of t h e a n a to m i c a l s t r u c t u r e s i n t h e d o rs a l a s p e c t of t h e l u m b a r s p i n e a nd t h e s a c r u m (a) w i t h t h e a n t e ro poste r i o r X - r a y ( b ) a n d t h e v e n t r a l a s p e c t ( e ) . 1 , S p i n o u s process; 2 , u p p e r a r t i c u l a r process; J , l a m i n a ; 4 , p a r s i n t e r a r t i c u l a r i s ; 5 , j o i n t s p a c e ; 6 . low e r a r t i cu l a r process; 7 . s p i n a l ca n a l ; 8 , posterior s p i n a i l iaca supe rior: 9 , dorsal p a r t o f t h e s a c ro i l i a c j o i n t; 1 0 , disc: 1 L t r a n s v e rse p rocess: 1 2 , v e r t e b r a l bod y ; 1 3 , p e d i c l e ; 1 4 , v e n t r a l p a r t o f t h e s a c ro i l i a c j o i n t . ( d ) D e Seze ' s d i a g r a m v i s u a l i z i n g t h e A P X - r a y o f l u m b a r ve rtebrae: ( i ) t h e v e r te b r a l bod y , (Ii) t h e v e r t e b ra l a r c h , ( iii) t h e p e d i c l e s , ( i v ) t h e e n t i re v e r t e b r a

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Functio l / a l a l / atomy a n d radiography of th e sp inal

column

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7 6 5 Ij. 7 2 3

Figure 3.15 Co m pa ri s o n of t h e a n a tomical s t ru c t u re s in the l a te r a l v i e w of t h e l u m b a r spine (model) a n d t h e X-ray. 1. Ped icle: 2, p a rs i n t e ra r l i cu l a r i s ; 3 , lowe r a rt i cu l a r p rocess; 4 , up p er a r t i c u l a r p roce s s : 5 , joint space ; 6 , i n te rverte b r a l fora m e n : 7 , t ra n s verse p r ocess

v a l u a b l e s ig n of d i sc h y p o p l a s i a i s r e d u c e d wi d t h o f bot h v e r te b r a l margins a dj a c en t to th e h y p o p l a s t i c disc . A l t h o ug h w e u s u a l l y r e l y o n la teral v i e ws fo r

t i o n s h o u l d be p rop o r t i on a t e to scoli o s i s a n d c a n be modi fi e d by t he degree of lordosis ; if rota tion is d is proportiona te, o r l i m i ted to one or two i n terverte b r a l

t h e assess m e n t of d i sc s , marke d asy m metry in t h e

segmen ts o n l y , i t c a n be a s ign o f d istu rbed fun c t i o n .

AP v i e w m a y be o f s o m e i m por t a n c e , p a rti c u l a rl y at the LS-S 1 i n ters p ac e , as here assess m en t may be d i ffi c u l t in view o f t h e fre q uen c y of a n oma l i es . A

process a n d the ped i c l es i n t h e d ir e c t i o n opp o s i t e to

marked nar rowing on one s i de m a y t h e n poin t t o

becomes w i d e r a n d t h e ar t i c u l a t ion is better vis u a l

d isc d e gen e ra t ion ( Fig u r e

ize d ; t he t r a n s v e rse p rocess i s sh o r t er ( F i g u re 3 . 1 7 ) .

3 . 1 6) .

R o t a t i o n is recognized

by

a

s h i f t of th e s p in o us

t h a t of rot a t ion . On t h e sid e of ro tation t h e p e d i c l e

Rotati on sho u l d never b e eval u a t e d o n t h e basis o f o n e s i n g l e sign

E v a l ua t i o n o f fu nct i o n F o r eval uation o f fu n c tion and

(such

a s devia tion o f t h e s p i n ou s

p roces s ) . T h e a s s ess m e n t of lateral fl e x i o n ( scolios i s )

its

possible d i s

t u r b a n c e s , p ictures m u s t b e ta k e n u n d e r standa rd

cond itions (see pp. 36-3 8 ) . A ssessment of r o t a t i o n is of value, because rota-

i s ca r r i e d out a c cord in g t o the p rin c i p l e s o f bod y sta tics .

In the lat e ral v iew we assess lord osis or k y p h o sis a forwa rd or bac kward s h i ft . A l oca l

a s wel l as

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Manip uia live Therapy in

RehaiJililGlion of Ihe LocomOlor System

Figure 3.16 The a n t e rior lower edge o f the verte b r a l b o d y o f L5 i s lower on the l e ft s i d e (artTow) in re l a t i o n t o t h e s a cr u m , h e n ce t h e L 5 d i s c is n a rrowe r on t h e l e ft : com p e n s a t o ry l u m b a r sco l i osis w i t h l e ft ro t a t i o n

i n te r r u p t i o n o f t h e l o rd o t i c l i n e

or of kyphosis,

b e t w e e n t w o v e r t e b ra e , c a n be a s i g n

of

d i s c l e s ion .

A s h i ft ( f o r w a r d s or b a c k w a r d s ) m a y be a s i g n o f i n c r e a s e d m o b i l it y - l a x i t y . T h i s m a y be p a r t i c u l a r l y c o n s p i c u o u s d u ring a n t e - o r r etr o fl e x i o n . V e ry s l i g h t p r op o r t i o n a l s h i fts in a n te- o r r etr o fl e x i o n i n youn g p a t i e n t s , see n a t X - ray e x a m in a t i o n , c a n be rega rded a s n o rm a l . Tw o d i a g n o s t i c p itfa lls must b e s t r e s s e d . The fi r s t i s t h e i n c o n gru o u s s u rfa ces o f two a dj a ce n t v e r te b r a e , o cc u r ri n g m o s t fr e q u e n t l y betwe e n L5 a n d t h e sacru m ; th e u p per s u r f a ce of S l in such c a s e s i s u s u a l l y s l i g h t l y l o nger t h a n the l o w e r s u rface o f

L 5 , a n d look i n g

at the

edge of t h e adj a c e n t o f a n a n t e r i o r s h i ft the a n t e r i o r e d ge) of a posterior pos terio r

ve r t e b ra e o n e gets t h e i m pre s sion

o f L 5 , or ( l oo k i n g at s h i ft of L5 . The second p i t f a l l i s s l ig h t rota ti o n : h e re the p os t e r i o r a n d a n t e r i o r m a rg i n s of the v e r t e b ra e fo rm a d o u b l e co n t o u r w h i ch c a n be m i s t a k e n for a s h i ft .

to h y p e r m o b i l i ty m u s t , o f c o urs e , from true spo n d y l o l isthe s i s ( w i t h s p o n d y l o l ys i s ) a n d fro m degenerative spon d y l o l i s t h e s is ( t he p s e ud o s p o ndy l o l i s t h e s i s o f J u ngha n n s , 1 930) d u e to d e fo r m i ty . t h e b e n d i n g fo rwa rd o f a n These s h i fts

due

be d i s ti n g u i s h ed

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Func/ional a n a /amy

and ra diography of (he sp inal co/limn

53

Figure 3.17 R o t a t i o n o f l u m b a r v e r t e b r a e with l a t e r a l s h i ft o f t h e s p i n o u s processes a n d p e d i c l e s i n re l a ti o n t o the v e rte b r a l bodies

u p p e r a r t ic u l a r p rocess ( m ost freq u e n t l y w h i c h t h e v e rt ebra a b o v e gl i d es fo r w a rd

L5 )

over

m a y be d e s c r i b e d a s a s o r t of l e v e r a ge (J i r o u t , 1 95 6 ) .

N a r rowing o f a n i n te rv e r t e b r a l d i sc, c a u s e d b y

.

d egeneration , m a y some t i m e s be v i s i b l e o n l y i n a n t e or re trofle x i o n . I n s u c h c a s e s we see exagge ra ted

X - ray studies of move m e n t X - r a y p i c t u re s

in

the

upright

posi t i o n

a n te r i o r n a rrow i n g of the d i s c ( w i t h o u t compe n s a t o r y may

not

p os t e r i o r w i d e n i ng) i n a n t e fl e x i o n a n d e x a gge r a t e d

provide a n y c l u e s t o d i s t u rbed f u n c ti o n ; t h ose t a k e n

poste r i o r n a r r o w i n g ( wi t h o u t c o m pe n s a t o r y a n te r i o r

i n a n te- o r retrofle x i o n o r l a t e r a l fl e x i o n m a y t h e n

w i d e n i ng ) i n retrofle x i o n .

reve a l s o m e i r re g u l a ri t y . W e m a y d i s t i n g u i s h seg

M o b i l i ty s t u d i e s a r e u s u a l l y m a d e w h e re t h e re i s

m e n t s o f i n c re a s e d o r l ow e r e d m o b i l i t y . In a n te - a n d

a c l i n i c a l rea s o n f o r d o i n g s o , i . e . i f move m e n t i n

retrofle x i o n i ncreased m o b i l i t y m a y t a k e t h e fo r m o f

some speci fic d i recti o n c a uses s y m p t o m s . A cond i t i o n

v e n t r a l o r d o rs a l s h i ft , respect i ve l y ( ' d isc r o l l i n g ' ) .

i n w h ic h t h is t y p e o f e x a mi n a t i o n i s p a r ti c u l a rly

A s has a l re a d y b e e n p o i n te d o u t , v e r y s l ig h t pro

i m po r t a n t i s s p o n d y l o l is t h e s i s , beca u s e i t i s a d v i s a b l e

port i o n a l s h i ft i n g m o v e m e n t s in all se g m e n ts may b e

to asce r t a i n w h e t h e r t h e s p o n d y l o l i s t h e s i s is fi x e d o r

cons i d e red n o r m a l , p a r t i c u l a r l y i n y o u n g s u bj e c t s

m o b i l e ; i t i s t h e l a t t e r t h a t c a uses s y m p t o m s a n d h a s

(J i r o u t , 1 95 6 ) . The re is o n e i n te r e s t i n g exce p t io n : i n

a te n d e n cy to d e t e r i o r a t e .

t h e l u m b osacra l segm e n t t h e re s o m e t i m e s o c c u r s

a

I n l a t e r a l fl e x i o n i t i s m o s t i m p o r t a n t to corre l a t e

' p a ra d o x i c a l ' s h i ft , i . e . a d o r s a l s h i ft d u r i n g a n te

t h e d e g re e o f fl e x i o n a n d rota t i o n w i t h rega rd t o t h e

fl e x i o n a n d a v e n t r a l s h i ft d u r i n g r e t r ofl e x i o n . w h i c h

degree o f lordosis (see p.

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54

Manip uialive Therapy in Rehab ililOlioll of !he Locomo!or Syslem

The thoracic spine

coro na I p l a n e as if o n the p e r i p h e r y of a cylinder w hose cen tre is i n front of t he ve rtebral b o d y T h i s s h ape would a l low for considera b le r o ta t i on w e re it n o t fo r the r i bs and the i n terve rtebral d iscs. S i d e a n d fo rward-bendi ng, too, a re l i m i te d m a i n l y by rh e ribs, a l t h oug h t h e l a tter movem e n t is a l s o h e l d i n check b y t h e i n te r- a n d s u p r a s p i n a l l iga m e n ts. B ack bending i s l i m i ted m a i nly by a p p o s i t i o n locking of the articular a n d t h e s p i nous processes. Because of t his relativel y l i m i ted m o b i lity, t ru n k r o t a ti o n was ,

.

Fun ctional a n atomy

The thoracic s p i n e (Fig u re s 3 . 1 9 a n d 3 . 20) is the long est part of the s p i n a l col u m n a n d that which e n j o ys the least m o b i l i t y The main reason for th i s i s i ts c l ose re l a t i on s h i p to the thorax but i t is a lso related to t h e t h i n ness o f th e i n te rve rtebra l d iscs. Th e apophyse a l j o i n ts a re a l m ost ve rtical a n d s h o w a s l i g h t t i l t i n the .

Figure 3.18 The t h o ra co l u m b a r ( sJde �exion) begi nning a t LS

spi n e d uri n g t r u n k ro t a t i o n with the pe l v i s fixe d : t h e re is both rot a t i o n a n d s c o l iosis

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FlinCl iulla! anatumy and be l i eved

to take

p l a ce m a i n l y i n t h e l o w e s t t h or a c i c

55

the

l o west p a rt o f t h e t h o r a ci c spi n e ( l h e t h o ra co l u m b a r j u n c t i o n ) w a s refu t e d by S i n g e r a n d G i l e s ( 1 9 90 ) .

Fu n c t i o n a n d i ts d i st u r ba nces a re of p a r t i c u l a r

thoraco l u m b a r j u n c t i o n . T h is m a y b e b e c a u s e i n t h i s re g i o n moveme n t c h a nges fro m o n e l y p e 1 0 a n ot h e r w i t h i n a s ing l e s e gm e n t . as c a n b e d e d u c e d fro m t h e s h a pe o f t h e a p o p h ys e a l j o i n ts : on a s i n g l e vertebra t h e u p p e r a r t i c u l a r pr oc e s s e s m a y be i n t h e co r o n a l p l a n e a n d t h e l o w e r m os t l y i n t h e s a g i t t a l p l a n e ( Fi g u re 3 . 1 9 ) . As we h a v e a l re a d y s e e n (see p . 4 3 ) , w i t h t h e p a t i e n t m a r k i n g t i m e t h e t h o ra co l u m b a r j u n c t i o n fo rms a re l a t i ve l y f ix e d poi n t w h e re l u m ba r sco l iosis to o n e s i d e cba nges to thoracic s c o l i os i s to t h e o p p o s i t e s i d e . T h e t h o raco l u m ba r j u n c t i o n i s a l s o t h e o n l y tra n s i t i o n a l regi o n w here t w o v e ry m o b i l e s e c t i o n s of t h e s p i n a l c o l u m n m e e t : d y s f u n c t i o n i n t h i s r e g i o n t h e refore re s u l t s in w i d e s p r e a d s p a s m .

coil l m n

T h a t t r u n k ro t a t i o n ta k e s p l a c e m a i n l y i n

segm e n t s , t h o s e l e a s t fixed b y t h e r i b s . s i g n i fi c a nce a t t h e

radiog raphy oj Ihe spinal

Th e y de m o nstra t e d

by

s o m e ro t a t i o n o f

fe w d e g r e e s t a k e s p l a ce

a

CT d u r i n g t r u n k r o t a t i o n t h a t

both i n thro u g h o u t a l l t h e seg m e n ts To e x p l a i n the poss i b l e m e c h

t h e l ower t h o r a c i c a n d

of t h e l u m b a r sp i n e . a n i s m , I e x a m i n e d t ru n k r o ta t i o n by X - r a y ( L e w i t ,

1996) a n d d e m o n s t ra t e d th a t s i d e fl e x i o n d o e s i n deed t a k e p l a c e d u r i n g t r u n k r o t a t i o n , i . e . t h ere i s a c o u p l e d m o v e m e n t w h i c h i s v e ry s i m i l a r to w h a t w e see d u ri ng s i d e - b e n d i ng ( Figure 3 . 1 8 ) . A n o t h e r re g i o n o f t ra n s i t i o n a n d i n c r e a s e d v u l n e ra b i l i t y is t h e c e r v i c o th o r a c i c j u n ct i o n d o w n to T3-4 , b e c a u s e i t is h e re t h a t m o v e m e n t s of t h e h e a d a n d n e c k e n d , a s a r e m o s t c l e a r l y s e e n i n ma x i m u m a n t e - a n d re t r o fl e x i o n . T h e s a m e i s t r u e fo r s i d e be n d i n g a n d r o t a t i o n i f t h e c e rv i c o t h o r a ci c j un c t i o n

Figure 3.19 C o m p a r i s o n of t he a n a t o l1l i c a l s t ru c t u res in t h e d o rs a l v i e w of t h e t h o r a c i c s p i n e ( s k e l e t o n ) w i t h t h e a n l c ropos t e r i o r X - r a y . I , S p i n o u s p rocess: 2, p c cl i c l e s : 3 , r i b s ; 4 , t ra n sve rse process: S , t r a n s v e rsocos t a l j o i n t

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Manipulative Therapy

56

is held

upright

.

ill

Rehabili llltion of the

Function is partic u l a r l y

Locom otor System

v u l n e ra b l e

h e r e , beca u s e t h e v e ry m o b i l e c e r v i ca l s p i n e m e e t s

the m uc h less with i ts

g i rd l e

,

mob

ile

t h oracic s p i n e . T h e s h o u l d e r

p o w e r fu l m u sc l e s , i s

a lso

a ttached

to

t h is j u n c t i o n .

A l l t r a n s i ti o n a l

r e g i o n s a re r i c h i n a n o m a l i e s . m a y be a r u d i m e n t a r y t w e l ft h r i b or a ( r u d i m e n tary) l u m ba r L 1 ; r e ma r k a b l y , a c e rv i c a l r i b (C7) i s q u i t e com m o n , w h e r e a s w e r a re l y fi n d a r u d i m e n ta ry fi r s t r i b .

T h e re

The ribs

r i b s a re attached t o t h e vertebrae a t t h e tra nsversocost a l a n d costoverte b r a l j o i n t s . The h e a d of the r i b a r t i c u l a te s w i t h t h e u p p e r m a rgin o f t h e b o d y of t h e corresp o n d i n g v e r t e b ra a n d w i t h t h e

The

l ower m a rg i n o f

t h e n e x t v e r t e b ra l boel y a b o v e . T h e of t he h e a d o f t h e ri b (crista capitu l i ) i s a t t a c h e d to the i n te rverte b ra l el i s e b y l iga m e n ts. The firs t rib is a n exce p t i o n in t h a t i t a r t ic u l a t e s e x c l u s i v e l y w i t h t h e b o d y o f t h e fi rs t thoracic verteb r a . The n e c k o f the r i b fi xeel b e t w e e n the costove r t e b r a l and costotra n s v e rs a l a rticu lation fo r m s a n a x i s f o r r i b m o v e m e n t . Th i s a x i s i s h o r i z o n t a l i n t h e t ru e ( v e r t e b roste r n a l ) r i bs and p rod uces a m o v e m e n t by w h i c h t h e s t e r n u m is l i fteel a n d at the same ti me t h e thorax broa d e n s . In the fa lse ( v e r t e b roc h o n d ra l ) r i b s the a x i s is o b l i q u e , l a terodo rso ca u d a l , a nd p ro d u c e s a w i n g- l i k e move m e n t . T h e l a st two r i bs ( free r i b s ) a re a t t a c h e d t o r u d i m e n ta ry c e n tre

t r a n s v e rse processes by c o n n e c t i v e t i s s u e o n l y ( s y n d e s m os i s ) .

Co n se q u e n t l y ,

t h e re

n o j o i n t move m e n t re s t r ic t i o n

is no j o i n t a nd can a r ise h e r e .

h e nce

Figure 3.20 C o m p a rison o f t h e a n a t o m ica l s t ructu res i n t h e l a t e r a l v i e w o f t h e s k e l e t o n o f t h e t h o r a c i c s p i n e w i t h t he X - ra y . I , L o w e r a r t i c u la r p rocess; 2, j o i n t space; 3. u p p e r a rt i c u l a r p rocess: 4. i n t e rverte bral fo r a m e n : 5, pe d i c l c s : 6. ri b : 7 , t ra n sve rse process

Copyrighted Material

Fl lnctional anatomy alld d e fo r m i t y ,

The X-ray picture

coillmn

w hi c h

I

the

the

1 11

osteo-

t ho r a c i c spine a s

I n t h e A P v i e w , v i s u a l izm l () o

57

v e r t e b r a l a rc h is m u c h l ess d e t a i l e d t h a n i n t h e

c h o n d ro s i s . In a s y m m e t r i c a l move m e n t r e s tr i c t i o n of the ribs

l u m b a r s p i n e . I n a d d i t i o n t o t h e v e r t e b ra l bod i e s a n d

t h e re may b e a s y m m e t ry of the d i s ta n c e be tw e e n the

i n t e r v e r t e b r a l d i sc s , w e s e e t h e s p i n o u s processes

a rc h e s o f the r i b s .

a n d t h e p e d i c l e s (see F i g u re

3. 19).

It s h o u l d be b o r n e

i n m i n d t h a t fro m a b o u t T 4 t o T l O t h e t i p o f t h e s p i n o u s p rocess i s s e e n a t t h e l e v e l o f t h e b o d y o f

The cerv i c a l sp i n e

t h e n e x t v e r t e b ra b e l o w . T h e c h a ra c te r i s t i c fe a t u re is the c o s t o v e r t e b r a l j u nc t i o n , the h e a d of t h e r i b agaJ llst t he i n te rv e rt e b ra l d is c a n d t h e o v e rl a p p i ng s h a d o w o f t h e costa l cess. A s t h e facets o f t h c

I

pro

t i l t e d from d o rsoe r a n i ,l l

T h e c e r v i c a l s p i n e i s th e m o s t m o b i l e s ec t i o n o f t h e w h o l e s p i n a l c o l u m n . T h e c r a n i oc e r v i c a l j u n c t i o n i n pa rticu l a r is the their repercussi o n s

t h e vertica l p l ane) t h e

m u s c u l a t u r e ; d i st a re , t h e refore,

ized i n t h e A P v i e w

a d e q u a te t re a t m e n t

rc ll e x e s w i t h 1f1

pos t u ra l t h i s region and

t he i r

t h oracic r i b s , i f t h i s t i l l I n t h e l a te r a l v i e w

v c rte b r a l

a r c h e s a re p a r t l y o ve r l a p pe. d

X -ray tech n i q u e I n o r d e r to o b ta i n p i c t u re s t h a t c a n b e e v a l u a t e d fo r

t h e p i c t u res a re c l e a r , w e g e t a g o o d v i e w o f t h e i n t e rv e r t e b r a l fo r a m e n a n d e v e n o f t h e j o i n t f a c e t s

f u n c t i o n , a d e q u a t e s ta n d a rd

( a r t i c u l a r process e s ) . T h e t h o r a c i c s p i n e a bo v e T 3

a d h e re d to. The u s u a l t e c h n i q u e , w h i c h v i s u a l izes

i s u n fo r t u n a t e l y h i d d e n b y t h e s t r u c t u re s o f t h e s h o u l d e r g i r d l e a n d m us t be v i s u a l i z e d e i t h e r b y o b l i q u e v i ews o r b y t o mogra p h y . I t m a y b e d i ft1 c u l t t o n u m be r t h e v e r t e b r a e i n t h e

t e c h ni q u e s m us t

be

the cra n i o ce r v i c a l j un c t i o n p oo r l y in t h e s i d e v i e w a n d n o t a l a l l i n t h e A P v i e w , i s n o t e v e n a d e q u a te to s h o w t h e a n a to m i c a l d e t a i l s p ro p e rl y a n d i s c o m p l e tely u s e l e s s for t h e e v a l u a t i o n o f fu n c t io n .

l a te r a l v i e w , a s T l c a n n o t b e s e e n a n d i t i s h a rd t o

I n t h e A P v i ew t h e e n ti re c e rv i c a l s p i n e s h o u l d b e

re cog n i ze T 1 2 . I t i s t h e refore usefu l t o r e m e m b e r

v i s i b l e , from t h e c ra n i oc e rv i c a l j u n c t i o n ( fora m e n

t h a t t h e lowe r a n g l e o f

m a g n u m w i th t r h '

u s u a l ly

at t h e h e i g h t o f T7 , t h e

the

t h o ra c i c v e r te b r a e .

fo r k o f t h e t r a c h e a

the

s u ffic i e n t , b u t 1 5

d i a p h ra g m a t T91 1 0 .

1 t o t h e fi r s t

the upper thoracic p a ti e n t i s p l a ce d a s ro l 1 95 6 ) : fi r s t he i s t h e e x t e n d e d l eg :,

Eva l uating X - r a ys As i n a l l pa r t s o f t h e

li re i s

i m p orta n t h e re from t h e p o m ! o f v i e w o f fU li c t i o n , the

m o s t s i g n i fi c a n t c h a n g e s b e i n g sco l i os i s a n d i n c re a s e d k y p h o s i s . H e re a ga i n i t m u s t b e p o i n t e d o u t t h a t i t i s esse n t i a l for u s t o k n ow w h e th e r t h e

each side of the

one on a s ke d t o

l i e d o w n , w i t h o u t u s i n g h is a rm s , i n t h e p os i t i o n t h a t i s m o s t n a t u r a l t o h i m ( t h e pos i t io n m a y b e c h e c k e d b y r e pe a t i n g t h e p ro ce d u r e ) . I f t h e h e a d r eg u l a r l y

yet

d e v i a te s f r o m t h e m i d - l i n e t h i s m us t n o t be c o r r e c t e d , b e c a u s e t o d o s o w o u l d e i t h e r correct o r

a n o t h e r I m p o r t a n t a s p e c t o f c u r v a t u r e : t h e m o re

p ro d u c e c e r v i c a l sco l i o s i s a nd a t t h e s a me t i m e

m a r k e d it i s , t b e l e s s m o b i l e t h a t s e c t i o n of t h e s p i n a l

i n d uce a x i s r o t a t i o n a n d l a tera l d e v i a t i o n of t h e a t l a s .

c u rv a t u re

is

in

s t a t i c e q u i l i b ri u m .

T h e re

is

co l u m n w i l l b e , a n d c o n v e rs e l y , a fl a t t h o r a c i c s p i n e

I t i s t h e r e fo r e n e c e s s a ry to s h i ft t h e fi l m a n d t he

i s accom p a n i e d b y h y p e r m ob i l i ty , w h i c h i s o f c o n s i d e r a b l e c l i n ic a l s i g n i fi c a n c e

X - r a y t u b e a c c o rd i n g l y . The p a ti e n t n o w o p e n s h i s mout h as wide is placed 1 0 u n ti l t h e between his teet h ,

seen i n t h e u p p e r t h or a C i C

g l a be l l a a nd t h e 1 1

C h a nges i n f u nc t i o n

h o r i zo n t a l h e a d i s o ft e n

s i g n s of s u d d e n r o t a t i o n

plane. For this a

or w i t h a s u d d e n d e v i a t i o n

n e ce ss a r y .

toge t h e r w i t h s i g n s o f d i a g n ose d b y a s h i ft o f

W e a re n o w ce n t r a l r a y m us t

o n e fi n ge r

a nd t h e p e d i c l e s i n t h e

b e l o w t h e upp e r

a b ove t h e

o f rota t i o n .

poster i o r m a rg i n o f t h t: oCCi p i t a l lor a m t: n ( F i g u re

S h i fts a re h a r d l y e v e r s e e n i n t h e l a te r a l v i e w o f the t h o r a c i c s p i n e , n o r i s k y p h o t i c a ng u l a t i o n b e t w e e n

3.21 ) .

tube. The

I f t he pa t i e n t h a s no t e e t h t h e c e n t ra l r a y

p a s s e s t h ro u g h a p o i n t o n e fi n g e r b e l o w t he u p p e r

t w o v e r t e b r a e t h a t i s s i mp l y a tt r i b u t a b l e t o c h a n ge s

g u m s to t h e pos t e r i o r ma rgi n o f the foram e n m a g n u m .

i n fu n c t i o n . A n g u l a t i o n m a y , h o w e v e r , b e d u e t o

T h e d is t a n c e fro m foc u s t o fi l m s h o u l d b e 1 m .

Copyrighted Material

58

Manipulative Therapy in

Rehabilitation of the Loconwlor

Syslem

Figure 3.21 X-ray tech n i q u e of the ce rvica l spine accord i n g to S a nd b e rg ( 1 955). (a) F oc u s i n g the ce n t r a l r a y in t h e a n t e ropos t e r i o r v i e w w i t h t h e aid of a s t r i n g , the h e a d in a horizon ta l p o s i t i o n ; (b) foc u s i n g t h e X - r a y t u be i n the l a t e r a l v i e w a t t h e m a s to i d process

F i n a l l y , we correct a n y rotatio n o f the pati e n t ' s

e y e s o n s o m e obj e c t at eye- l e v e l , to kee p the h e a d

h ead , b eari n g in m i n d t h e possib i lity o f as y m m e try

in a

(th e u p p e r tee t h are a u s e f u l l a n d m ark) .

fl e xion m us t be c o r r e c te d .

I t is poss.ib l.e to proceed in an a nal ogo u s m a n n e r

s ta n d ard

position; h ead

rotation

o r l a te ra l

T h e ce n tra l ray i s foc used not a t t h e m i d - cervical (c e n tre

of

t he

fil m )

but

at

wit h t h e patie n t s e a te d , w h i c h is m ore di fficu l t b u t

region

has t h e a d v a n tage of being perfor m e d u n d e r t h e

proc e s s . Th is yields an u n d is t orted view o f th e base

the

mastoid

i n fl u e nce o f bod y s tatics . N e v e rt h e l ess, t h e re can b e

o f the sku l l a n d y e t ca uses no d i s t o r t i o n of the l o wer

diag n o s tic advan tage if t h e sid e view, which m ust

cervica l spine ( b ecause the base o f the skull is w ide,

a l ways be take n w i t h the patie n t seate d , reve a l s

w hi l e t h e cervical v e r te b r a e are n a rrow) . In additi o n

d i screp a n cies w h e n c o m p ared with t h e

AP

v i ew

take n w i t h the patie n t s u pin e . In s u c h cases t h e

AP

we ac h ie v e correct e x posure of b o t h t h e base o f t h e sku l l a n d t h e cranioce rvical j u nctio n a n d

of the

v i ew c a n a l w a y s be repe a t e d in t h e si t ting pos i t i o n .

c e rv ic a l v e rte brae . The distance from foc u s to fi l m

S o m e a ut h ors d is l i k e t h e o p e n - m o u t h t ec h n i q u e

s h o u l d b e .1 5 0 c m o r more . W i t h t his tech n i q u e

because t h e man d i b l e overlaps t h e mid-cerv i cal s pin e ,

pict ures o f t h e cra n i o cervical j u n c t i on are so cl ear

a n d prefer to t a k e t h e picture w h i l e t h e patie n t

th a t tomogra p h y is s e l d o m n e ce ssary.

r h y t h m ic a l ly o p e n s a n d s h u t s h i s m o u t h ; i n t h is w a y t h e shadow o f t h e m a ndib l e is bl u rred. The tec hniq u e , h owever, pres e n ts t h e danger of a s l i g h t s haki n g o f t h e h ead , w h i c h w i l l cau s e bl urrin g o f t h e image o f t h e a p o p hyseal j oi n t s o f t h e cranioce rvical j u n c t io n . I n t h e l atera l view t h e patient i s s eated re l ax e d i n

Asses s m e n t of the q u a l ity of X - r a y p i ctu res B e fore e v a l u a t i n g an X -ray o f t h e c e rvica l spin e , partic u l a r l y w h e re fun ctio n i s co n c e r n e d , we m us t

cm or

3.22 ) . I n t h e A P v i e w we fi r s t m a k e sure that we c a n s e e b o th

2 4 x 30 c m , a n d m u s t be p lace d s o t h at t h e X -ray

occipital c o n d y l e s , t h e a t las a n d t h e ax i s with both

fro n t o f a vertic a l X -ray casse t te ; n o Potte r - B u c k y d iaph r a g m i s n e e d e d . T h e fi l m may be

1 8 x 24

assess i t s q u a lity a s a p i c t u r e (Fig u re

s h ows t h e base of the sku l l wit h t h e s e l l a turcica , t h e

tra n s versocostal fo ramina (fora m i n a o f the verte bra l

h a r d p a l a te a n d t h e cervical s p i n e d own to C7 , if

artery) , a n d at t h e c a u d a l e n d , t h e (irst t h o r a c i c

possib l e with t h e first two th ora cic v e r t e b ra e . T h is ,

v ertebra. I f t h e v i e w i s co rrec t we see t h e c l e f t

howev e r , i s poss i b l e o n l y i n s u bj ects ( u s u a l l y w o m e n )

b e tw e e n t h e u p p e r and l o w e r fro n t te eth in mid - l ine ,

with v e r y tapering s h o u l d e rs . The patie n t nxes h i s

toge t h e r w i th t h e ce n tre of t h e o d o n toid p rocess and

Copyrighted Material

Functional anatomy

and

radiography of the

59

spinal colLlmn

Figure 3.22 A n a t o m i c a l s t r uctures o f the c r a n i o c e r v i c a l j u n c t i o n , a n t e ropos t e r i o r v i e w . 1, L o w e r edge o f the c l i v u s ; 2, fo ra m e n m a g n u m ; 3 , occi p i t a l co n d y l e : 4 , l o w e r e d g e o f t h e a n t e r i o r a r c h of t h e a t l a s ; 5 , l a t e r a l t r i a n g l e ; 6 , fo r a m e n t r 3 1l s v e rsa r i u m of t h e a x is: 7 . l o w e r con t o u r o f t h e s q u a m a occipi t a l i s ; 8 , m e d i a l t ra n s l u ce ncy o f t h e a t l a s ; 9 , t r a n s v e rse p rocess o f t h e a t l a s : 1 0 , l o w e r e d ge o f the p o s t e r i o r a rc h o f the a t l a s : 1 1 , ped i c l e of the axis: 1 2 , l a m i n a of the a x i s

o f t h e ch in. T h e cervica l spi n e as a w h o l e must lie be t w e e n the two halves of th e man d ibu l a . E v e n i f each of these structures is asym metrical there a re suffi cient la ndm a r ks by w h ich to recogni ze dis tor tion. A pict ure without the cra nio ce rvical j u ncti on and the fi rst thoracic verte b r a with the thoracic outlet is insuffici ent fo r o u r purpose .

s y m metr ica l l y

T n the l ate r a l view w e need t o see the base of t h e s k ull w i th the sella turcica , the c l i vus d o w n to the ba si on , t h e

p o st e rio r

margin of the

fora men

magnum, the hard p a l ate , the odontoid process and

If po s s i b l e even the fi rst thoracic verteb ra s hou ld be see n, but in heavily

the cervical spin e down to

C7 .

bui l t pati ents it m a y be impossible

to

vi suali ze

C7

in the l a teral vie w . It is imp o rta nt tha t the hard palate

should be

lordos i s

horizontal

or kyphosis)

(fo r

assess m e n t

and tha t the two halves

of

of the

m a ndibula should be e x actly ove rlaid, showing tha t

( Figure

there is neither side -be nding nor rot a tion

3 .23 ) .

Fine m a n et al.

of only

( 1 963 )

show ed that

10 degrees in incli na tion

of

a

d i fference

the

head

is

su fficien t to c h ange lordotic to linear posture, and vice versa.

T h e o b l iqu e view serves m a i nly to show

the

intervertebral fora min a , wh i ch in the ce rvical s p i ne

a re not visualize d at al l in the side vie w a nd

Copyrighted Material

poorly

60

Manipulative Therapy in Rehabilitation of the Locomotor System

Figure 3.23 La t e ra ] X-ray o f t h e e e l'viea l p l a n e of t h e fora m e n magnum. t h e a t l a s a n d the a x i s i n d ica ted : t h e c l i v u s a n d t h e pos t e ri o r e d g e o f t h e v e r t e b r a l c a n a l a r e a ls o shown s p i n e with t h e

i n the A P view. I t should be t a ken with the p a t i e n t s i t ti ng o n a c h a ir t u r n e d a t 45 degrees to the casse tte ; the p a t i e n t u s u a l l y sits with h i s back to i t , b u t l i ke G u t m a n n I p r e fer t h e p a t i e n t to face the cassette a n d t o h o l d the h e a d in retrofle x i o n , because if t h e patie n t faces t h e cassette i t i s t h e fo r a m e n n e a r e r t o i t t h a t is visualize d , a n d na rrowing o f t h e fora men is o fte n v i s i b l e o n l y i n re t ro fl e x i o n ( Figure 3 .24) . O b l i que views a re p a r t i c u l a r l y i m po r t a n t i n cervical radic u l a r synd romes a n d i n cases of the v e rtebra l artery syndrome. because of the close re l a t i o n s h i p betwee n the i n terve rtebra l fo rame n , the n e rve roots and the verte b r a l artery. F u n ct i o n a l a n atomy of t h e cervi ca l spi n e

The cervical s p i n e h a s two very disti n ct sect ions: the cra n i ocervica l j u nction between the occi p u t and C2. and the section from C2 to C7. Most of the move m e n t s i t pe rforms start a t t h e cra niocervica l j unction,

and the mov e m e n ts of the head a n d neck a re u s u a l ly i n i tiated by eye moveme n ts . I therefo re b e g i n w i t h a s h o r t a na t o m i c a l descri ption i n w h i c h t h e t w o pa rts a re t re a te d separa t e l y , w h i le t h e fu nction of t h e ce rvical s p i ne is dea l t w i t h a s a w h o l e . F u n ct i o n a l a n ato m y

C2-C7

As in o t h e r pa rts o f the spi n a l co l u m n , the cl egree o f move m e m t i n the cervic a l s p i n e is d e t e r m i n e d m a i n l y by t h e th ick ness o f the i n terverte b r a l d isc; t h i s is usua l l y greatest in the segme n ts C4/5 a n d C5/6 , w h e re mobi l i t y i s a lso greatest. T h e c h a r acteristic fe a t u r e o f t h e ce rv ica l verte b r a l bodies is a latera l ridge the u n ci fo r m process . Its sign i ficance fo r cervica l fu nctio n is t h a t the s h a pe of the vertebral body l i mits l a te r a l fl e x i o n while encouraging a n t e a nd la tera l fl e x i o n . T h e a po ph y se a l j o i n ts a re al most p a ra l l e l o n b o t h sid es and a re t i lted f r o m v e n t rocra n ia l to

Copyrighted Material

,

Fun Cliona/ aJ1a lOmy and radiography of

Ihe sp inal co/u /1 / 11

ol

a d u l t s , a r e l e s s m a r k e d i n h i g h e r a g e g ro u ps . I t i s i m p orta n t to r e a l i ze t h a t t h e y a r e p h y s i o l o g i c a l i f th e y a re p roportion a te . a n d t h a t t h e sh i ft i s grea test a t t b e C2/3 s e g m e n t ( s e e F i g u re 3 . 30) It m u s t be a l so b o r n e in m i n d t h a t d u ri n g a n te fl e x i o n t b e ce r v i c a l v e r t e b ra l ca n a l l e n g t h e n s c o n s i d er a b l y . shorte n i n g d u r i ng retrofl e x i o n . T h i s p rod uces a s i g n i fi ca n t m o v e m e n t of t h e m e n i nges w i t h t h e i r root s l e e v e s , a n d a l s o o f t h e s p i n a l cord , wh i c h c a n be s e e n i n p n e u m o m y e lographs to g e t l o n g e r a n d t h i n n e r i n a n t e fl e x i o n a n d s h o r t e r a n d t h ic k e r i n re t r o fl e x i o n . A n o t h e r h i g h l y s i g n i fi c a n t fe a t ure i s the cou rse o f t h e v e r te b r a l a rtery, w h i c h e n te rs t h e b o n y c a n a l a t t h e tra n sv e rsoco s t a l fora m e n of

C6

a nd r u n s

u pw a rd s , cro s s i n g t h e i n te rv e r t e b ral c a n a l s i n c l ose c o n t a c t w i t h the a r t i c u l a r p rocesses a l m o s t at ri g h t a n g l e s to t h e cou rse o f t h e n e r v e r o o t s . T h e r e fo re , a s the i n te rv e r t e b r a l fo ra m e n ( c a n a l ) n a rrows i n retrofl e x i o n , t h i s m a y a ffec t the n e rv e r o o t a n d t h e ve rte bra l a r tery.

F u n cti o n a l a n atomy of the cra n i ocervica l j u n ction S t u d y o f t h i s m o s t i m porta n t j u n c t i o n i s co n ce r n e d w i t h t h e m o b i l ity o f e ac h o f i ts j o i n ts a nd t h e b o n y s t r u c t u res a n d l i g a m e n t s t h a t l i m i t i t . T h e r e a re n o i n te rv e r t e b r a l d i scs. T h e upper a rt i c u l ar fa cets o f t h e a t l a s are o v a l wi t h t h e l o n g a x i s r u n n i n g o b l i q u e l y , c o n v e rg i n g p o s t e r i o r l y a n d m e d i a l l y l i k e a sect i o n o f t h e s u rface

Figure 3.24 O b l i q u e v i e w

of

of a sphere w i t h t h e c e n tre loc a t e d above

lhe cerv i c a l s p i n e i n

both

a r t ic u l a r s u rfaces . The m a i n m o b i l i ty i n t h e a t l a n to

ret ro A e x i o n s h ow i ng a n a r ro w e d i n t e rv e r t e b r a l fo r a m e n

occi p i t a l

of C213 on t h e r i g h t

j o i n ts

d e g re e s ( Fi g u r e

i s a n t e - a n d r e t r o fl e x i o n , a b o u t 15

3.25).

There is poste r i o r gli d i n g o f

t h e occ i p i t a l c o n d y l e s d u r i n g a n te fl e x i o n a n d a n te r i o r d o rsoca u d a l . Th i s t i l t v a r i e s co n s i d e r a b l y ( a b o u t 4 5

gl id i ng d u r i n g retro fle x i o n . S l i g h t rota t i o n i s poss i b le .

d egrees ) . b e i n g g r e a t e s t a t C2/3 a s a r u l e . A t t h i s

w h ich J i r o u t ( 1 98 1 a ) h a s s h o w n to be a v e r y l i m ited

l e v e l t h e j o i n ts a re freq u e n t l y n o t p a ra l l e l b u t a s i f

l a t e ra l fl e x i o n , rota t i o n b e i n g c o u p l e d w i t h s i d e

o n t h e s u rface o f a cy l i n d e r w i t h i ts c e n tre b e h i n d

be n d i n g to t h e o p p o s i t e s i d e .

the s p i n a l c o l u m n ; i t i s t h e refore n o t p a t h o l o gical i f t h e a r t i c u l a t i o n C213 i s n o t we l l v i s u a l i zed i n t h e s i d e v i ew ( u n l i ke t h e o t h e r cerv i c a l a po p h y se a l j o i n ts) . The s h a p e o f t h e cerv ica l a p o p h y s e a l j o i n ts is best s u i t e d t o a n te - and re t r o fl e x i o n . O n l a t e r a l flex i o n t h e t i l t o f t h e j o i n ts produces rota t i o n t o t h e s i d e o f in c l i n a ti o n a n d d u r i n g h e a d ro t a t i o n i n c l i n a ti o n

The

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o d o n to i d a s w e ll a s the j o i n ts b e t w e e n t h e m as s a e l a t e r a l e s a n d t h e a x i s , a n d th e i r m a i n f u n c t i o n i s a x i a l r o ta t i o n . T h e j o i n t fa cets r u n a n te roposte r i o r l y a n d a re concave on t h e m a ss a l a tera l i s of t h e a t l a s a n d convex o n t h e a x i s . I n a d d i t i o n , t h e re i s t h e a t l a n t o -

re s u l ts fo r t h e s a m e reaso n . D u ri ng a n te fl e x i o n t h e re is freq u e n t l y a s l i g h t s h i ft of t h e c ra n i a l v e r t e b r a , a n d i n r e t r o fl exi o n a sl i g h t b a c k w a rd s h i ft w h ich is a lso i n a c c o r d a n c e w i th t h e t i l t o f t h e a r t i cu l a r face t s . Accord i n g to Pe n n i ng

( 1 968)

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at the d o rs a l part of the l ow e r verte b r a l bod y . It s h o u l d be po i n te d o u t t h a t t h e se s h i ft i n g m o v e

Figure 3.25 A n t e - and retrofle x i o n bet w e e n occi p u t a n d

m e n t s . w h i c h a re t h e r u l e i n c h i l d r e n a n d yo u n g

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Manip uialive Therapy in

RchabililaliOI1 of the

Locomotor

o d o n t o id j o i n t between t h e a n terior a rc h of t h e a tl.a s a n d t h e odon toid process a n t e r i o r l y . w h i l e t h e p o s t e r i o r s u rface of t h e od o n t oi d p rocess is l i n e d by c a r ti l a g e and in c o n t a c t w i t h t h e t r a n sv e r s e l i g a m e n t . T he p ossi b l e movements a re a n te- and retro flexion and r ot a t i o n . D u r i n g a n te - and r e t r o fl e x ion t h e a n terior arch of t h e a t l a s g l i d e s u p a n d down o n t h e odon toid a n d i f t h e t r a n s v e rs e l i ga m e n t i s fi r m t h e space between t h e s e t w o structures d o e s n o t w i d e n . The range o f m ovm e n t h ere is a g a i n a bo u t 1 5 degrees.

The m ost i m p o rta n t m o v e m e n t , h o w e v e r , i s r o t a t i o n , i n w h i c h a l l j o i n ts t a ke p a r t ; w h i l e t h e re i s rota tion rou n d t h e o d o n t o i d , the m assa l a t e r a l i s of t h e a t l a s g l i d es on t h e axis p os te ri o r l y o n the side of rota t i on a n d a n t e ri o r l y o n t h e o pp o s i t e s i d e . Rotation i s l i m i te d b y th e j o i n t c a p s u l e a n d the p o w e r f u l alar l iga m e n ts w hi c h are a t tached t o t h e m a rgins o f t h e forame n m a gn u m a n d t o t h e atlas. R o t a t i on a m o u nts o n ave rage to 2 5 d e g rees to e a c h side, the m a x i m u m b e i n g 40 d e g r e es ( F i g u re s 3.26 and 3 .27) . D v o r a k ( 1 988) h a s sh o w n b y a xi a l c o m p u t e d tomo gr a p h y that the ra nge o f mo v e m e n t between a t l a s a n d a x i s m a y b e e v e n gre a t e r : h e fo u n d ave rages o f 4 1 . 5 d e g r e e s t o t h e r i g h t and 44 d e g r e es to t h e l e ft w i t h a m ax i m u m o f 50 d e g re e s ( ' ) to o n e s i d e , a nd i n a d d i t i o n a n a v e r a g e of 4 . 5 d e g r e e s be t w e e n o c c i pu t a nd a t l a s to t h e r i g h t , a n d 4 . 1 d e g r e e s to t h e l e ft . H ug u e n in a n d H o p f ( 1 993 ) u s i n g m a g n e t i c reson a n ce, on t h e o t h e r h a n d , fo u n d t h a t t h e ra nge o f motion c o r r e s p o n d s m u c h m o r e to o u r e a r l i e r fi n d i n g s .

K i n e s i o l o g y of t h e cerv i c a l spi n e as a whole Rota tion

D u ri n g ro t a t i o n , m ov e m e n t sta rts b e tw e e n the a tlas a n d the axis a n d t a k es p l ace m a i n l y t h e re until the range of motion is e x h a u s te d , i . e . to about 25 d e g rees to e ac h side, o n a ve r a ge . U p to t h i s p o i n t the re i s pure a x i a l rotat ion i n t h e hor i zon t a l p l a n e . From this p o i n t o n w a rd s rotation t a kes place fro m C3 to C7 in s u cc e s s i o n j f there i s fl e x i o n a t t h e c e r v i c o t h o r a c i c j u n ct i o n , a n d as fa r as T3 if t h e cervicothoracic j u n c t i o n i s s t r a i g h t e n e d up. Th ere i s sti I I s o m e a d d i t i o n a l pa s s i v e r o t a tion be t w e e n t he o c c i p u t a n d t h e at l a s . T h e m o m e n t rotation t a k e s p lace i n t h e c e rv i c a l s p i n e b e low t h e a x i s ; s i d e - b e n d i n g a u t om a t i c a l l y occurs a t t h e s a m e t i m e , u n less d e l i be r a t e l y a v o i d e d . Side-bending

System

u p p e r cervica l a rea (Figu re 3 .28). T h i s shows t h a t l a t e r a l fl e x i o n sta rts w i t h rota t i o n of t h e a x i s i n t h e d i re c t i o n o f s i d e - b e n d i n g a n d a t t h e s a m e t i me t h e re is sy n k i n e s i s o f t h e a t las, s h i ft i n g re lative to the o cc i p i t a l c o n d y l es and to t h e a x i s , i n the d i rection o f s id e - b e n d i n g . O n l a t e r a l flexion of t h e w h o l e of t h e c e rv i ca l s p i n e we see s i d e - b en d i n g a n d r o t a t i o n i n t h e d i r e c t i o n o f l a te r a l flex i o n , b e i n g g r e a t e s t a t t h e a x i s . As J i rout ( 1 968) h a s s h ow n , t h i s rota t i o n usua l l y e nd s i n t h e l ow e r c e r v ica l s p i n e d u r i n g s i d e - b e n d i n g to the r i g h t . b u t d u r i n g l a te ra l !kx ion to t h e l e ft ca n be fo l lowed d o w n i n t o t h e u pper t h o r ac i c re g i o n . (This he e x p l a i ns as t h e result of s t ro nger p u l l o f the m u s c l e s o f the shou l d e r g i rd l e a t t a c h e d t o t h e s p i n ou s processes on t h e r i g h t s i d e . ) T h i s co m b i n a ti o n o f s i d e - be n d i n g a n d rotati on is, o f cours e . i n ac c o rd a n c e wi t h the t i l t o f t h e c e r v i c a l a po p h y s e a l j oi n ts b u t n o t a d i rect c o n s e q u e n c e o f the t i l t , as i s u s u a l l y t h o u g h t , as t h e movem e n t sta rts a t t h e c r a n i o c e r v i ca l j u nction a n d rot a t ion o f t h e a x is c o m e s fi rs t , fol lowed by r o t a tio n of t h e l o w e r c e r v i c a l v e rte b r a e in success ion . A s i s s h ow n i n d e ta i l l a te r , i f ro t a t io n o f t h e a x i s does not t a k e p l a c e , t h e re i s n o ro t a t i o n o f t h e rest o f t h e c e r v i c a l s p i ne . J i rollt ( 1 97 1 ) h a s d e p i c t e d t h e force c a u s i n g rot a ti o n d u r i n g s i d e - b e n d i n g (Figure 3 .29) . I t c a n eas i ly be seen t h a t s o m e a n te fl e x i o n m i g h t t a k e p l a ce w i th r o t a t i o n d u r i n g s i d e - be n d i n g , and these s y n k i n es e s in the sagi t t a l p l a n e h a v e , i n fa c t , been co n fi r m e d b y J i ro u t ; t h e y const i t u t e j o i n t p l a y i n t h e c e rv i c a l s p i n e ( see F i g u re 3 . 4 6 ) . H o w e v e r , the exact m e c h a n i s m t h a t fo rces t h e a x i s to rotate , t h e moment t h a t l a t e r a l fl e x i o n s t a rts ( w h i c h c a n e a s i l y b e p a l pa te d ) , re m a i n s u n k now n . A n te flexion a n d retro flexion A n te fl e x i o n can be carried out i n d i ffe re n t ways: w e can e i t h e r draw the c h i n i n , or l e t t h e h e a d d ro p fo r w a r d , o r b r i n g t h e c h i n to t h e chest. which is a c o m b i n a t i o n of t h e fi rst two m ov e m e n t s . In r e t rofl e x i on t h ere a re no s u c h d i ffere nces. T h e two m e c h a n i s m s o f a n t e fl e x i o n a re s o m e w h a t ;r. com pe t i t i o n : u n l ess there i s h y p e r m o b i l i t y , if w e d r a w t h e ch i n i n w e c a n not d ro p t h e h e ad fa r f o rw a r d a n d if we d r o p i t fo rw a rd , we c a n not d raw t h e ch i n i n . Th e e xp l a n a t i o n l i e s i n t h e m e c h a n i s m o f a t l as ti l t , w h ich must b e u n d e rs tood i n order to assess c e r v i c a l a n te- and retro fl e x i o n . T h e fo l l ow i n g c h a n g e s c a n b e o bs e rved i n X - r a y s t u d i e s i n t h e s a g i t t a l p l a n e ( s e e F i g u r e s 3 . 30 a n d 3.3 1 ). 1.

S i d e - b e n d i n g can be studied o n l y by X-ray, a n d t h e re fore i s d e a l t w i t h u n d e r X-ray m o b i l i t y s t u d ies. Like rota t i o n , i t b e g i n s a t the cra n i ocervical j u n c t i o n . T h i s c a n b e s t be s t u d i e d d uring p a ssiv e s i d e - t i l t i n g m o v e m e n t l o ca l i zi n g l a t e ra l fl e x i o n m a i n l y i n t h e

Wi t h t h e p a t i e n t i n t h e e r e c t p o si t i o n t h e p l a n e s of t h e fora m e n m a g n u m and the a x i s r u n a l m o s t p a r a l l e l . t h e atlas b e i ng t i l t e d b a c k w a rd s a t a n a v e r a g e a ngle of about 6 degrees. 2 . W h e n t h e p a t i e n t draws i n t h e c h i n , a n t e fl exi on b e t w e e n occi p u t a n d atlas i n c rease s o n l y s l i g h t l y :

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Figure 3.27 R o t a t i o n o f the a x i s i n rela t ion t o t h e a t l a s ( h e a d ) : t h e h e a d i s fi x e d i n n e u t r a l pos i t i o n , th e b o d y i n m a x i m u m rota tion ( h e re a t 4 0 degrees axis r o t a t i o n : cf. Figure 3 . 26 (h))

t h e m a i n m o v e m e n t i s a n t e fle x i o n b e t we e n a t las and a x i s , t h e fo r m e r b e i n g now t i l t e d fo r w a rd w h i l e t h e rest of t h e c e r v i c a l s p i n e re m a i n s a l m o s t s t ra i g h t . 3 . In m a x i m u m a n le ll e x i o n t h e c e r v ic a l s p i n e i s a l m o s t h o r i zo n t a l : t h e re i s p ro p o r t i o n a te v e n t r a l

s h ift of the ce rvical v e r t e b r a e u p t o C2/3; there is m a x i m u m a n tefle x i o n between Cl/2 b u t , c o n t r a ry to pos i t i o n s ( I ) a n d (2) ,

a n t e fl e x i o n

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Figure 3.28 A n te r o p o s t e r i o r X - r a y of t h e c e r v i c a l spine of a h e a l t h y s u bj e c t . i n n e u t r a l posi t ion . d u r i n g a c t i ve l a t e r a l fl e x i o n . and p a s s i v e l a t e r a l Ikx i o n l i m i t e d to the upper c e r v ica l re g i o n . ( a ) In n e u t ra l pos i t i o n the a t l a s is t o the r igh t i n r e la t i o n to the co n d y l e s. a n d t h e p l a n e of the c o n d y l e s a n d the axis c o n v e rge o n t h e righ t . t h e a x is be i n g ro t a te d a b o u t 5 d e grees to t h e l e f t . (b) At a c t i v e l a t e ra l fl e x i o n t o t h e l e ft t h e a t l a s i s s t i l l t o t h e r i g h t o f t h e c o n d y l e s a n d the p l a n e o f t h e cond y l e s a n d t h e a x i s con verge a l i t t l e t o t h e r i g h t . t h e a x i s n o w b e i n g ro t a te d about l O degr e e s to t h e l eft . (c) Passive l a t e ra l fl e x ion o f t h e upper c e r v i c a l s p i n e t o t h e l e f t : t h e a t l a s i s n o w c l e a r l y t o t h e le ft o f t h e c o n d y l e s il n d the p l a n e o f t h e co n d y l es i s para l l e l t o t h e a x i s w h i c h is ro t a t e d a b o u t 1 0 d e g rees

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Figure 3.29 M e c h a n ism or l a t e ra l rl e x i o n o f the cerv i c 8 1 s p i n e ll Ccord i n g J i r o u t ( I (7 1 ) . D u r i n g s i d e - b e n d i n g the h e a d tO ta tes a sag" a xi s ( x ') s i l uated a n t e r i o r c r a n i a l fos s a . The diagram s h o w s h o w the base of the s k u l l . w i t h t h e c o n d y l e s , s h i ft s in the o p p o s i t e d i re c ' l o TI o f l a r c r 2 1 fl e x i o n " c a i n s t t h e 2 t l a 5 . a n d h o w t h e axis w i t h t h e ce rv i c a l v e r t e b r D e b r o u g h l mto rO l a t i o n a n d t h e ,pi n o Ll s process o f the a x i s i s l i l t e d for w a rd by c r a n i a l p u l l

b e t w e e n t h " c l i v u c; a n d t h e o d o n t o i d ,

l.G.

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re m a i n s [ h (� s a m (' 8 S w i t h t h e h e a d

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g re a t e s t w h e n t h e c h i n is J w w n i n .

rhe re is s o m e degree of fo rward s h i fr o f t h e b a s i o n agai n s t t h e t i p o f t h e od o n t o i d .

4.

r e t ro f\: x i o n w i t ' l nEI ,( l m u m

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m a s s e s o f t h e a t l a s a n d we l l b e l o w t h e b o r d e r o f t h e fo r a m e n m a g n u m . C l o s e b e n e a t h t h e l a t e r a l t i p o f the

we

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t h e fo ra m e n costl! t ra ns-

fo r a m e n llxis. Medial to see t h e p e d i c l e s . w h i l e b e t w e e n t h e p e d i c l c s we s e e t h e v e rs a n u m o f

a r ch of t h e a x i s w i t h t h e s p i n o lI s p rocess i n m i d - l i n e . to the H t h ere I S m a r k e d l o rd O S I S i t i s t r a n s l uccncy o f t he s p i m l l c a n al at t ll .! t l e ve l . B e l ow C2 t h e ce rvical v e r te b r a e a re c h a ra c t e rized by the u n c i fo r m p roces<; o n b o t h <; i d e s ; t h e i n t e r v e r t e b r a l d isc t h e r e fore m u ch h ig h e r m e d i a l l y t h a n l a t e ra l l y . T h e n a r r o w s h a d o w o f t h e p e d i c l e s l i es b e t we e n t h e u n c i form process, a n d t h e s p i n o u s processes a re m i d - l i n c . Lateral t h e u n c i fo r m p roC,ISS t h e i n te rv e rt e b r a l fo r a m e n C;1Il be The l a te r a l c o n t o u r i s for m e d b y t h e t r a n sve rsocos t a l process, a n d s o m e t i m e s t h e i n t e r v e r t e b ra l j o i n t c a n be see n .

odon to i d .

5 . I n r e t ro fl e x i o n w h i l e l y i n g o n t h e s i d e t h e re i s n o w m a x i m u m re t ro fl t: x i o n of the occi p u t il ga i n s i' atlas atlas much re t r o fle x i o n o f a g a Jl1 s t t h e Cl x i s . T h e re is no s h i ft of t h e b a s i o n b a c k w a r d s ( t h e s u bj e c t m u s t n o t fo rce h i s h e a d (sec Figure 3 . .\ 1 ) .

Side vie w (Figure 3. 34) In the; s i d e v i e w a n u n d l s t o r t e d

re of

base

o f t h e � k u l l w i t h I ls r e l a t l O n � h i p to t h e u p p e r c e r vi c a l spi n e i s o b ta i n e d . I n p a r t i c u l a r , t h e c l i v u s c a n b e fo l l o w e d d o w n

where

for m s t h e: a n te r i or m a rg i n

o f t h e fora m e n m a gn u rn ( b a s i o n ) w h i c h is u s u a l l y

Th e m e c h a n i s m u n d e r l y i n g t h e s e p h e n o m e n a , i n p a r t i c u l a r m o ve m e n t o f the a t l a s , i s i l l u s t r a t e d i n F i p ll f C 3 . 3 1

which

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seen

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t h e s k u l l . I f n o t , t h e p o s t e r i o r m a rg i n of

t h e c � r v i ca l s p i n (l l c a n a l i s fo l lo w e d a n d w h e r e i ts

of the occ i p i ta l c o n d y l e s

p r o l o n ga t i o n m e e t s t h e

o f t h e s k u U t h e pOS i t i o n

o f t h e o p i s t i o n i s u e t e rm lllcd ( s e e Fig u r e

X-ray a n atomy of the cervical spi n e AP

the

process. T h e p os i t i o n o f t h e poste r i o r m a r g i n o f t h e

3.23).

T h e m a s t o i d p r o c e s s freq u e n t l y o v e rs h a d o w s p a r t o f t h e m a ss a l a te r a l i s o f t h e a t l a s

vie w (Fig ures 3.32 and 3. 33)

a t l a ll t o occi p i t a l j o i n t i ,

I n t h e AP v i e w we s e e t h e a r c h to r m e d by b o t h

in the SIde view;

occi p i t a l c o n d y l e s a n d t b e a n te r i o r m a r g i n o f t h e

seen v e r y w e l l (Figure

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3.35).

116

Manipulalive Therapy

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Rehabilillllion of the LOCOmOI()r

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Figure 3.30 Mobil i ty of the c e r v i c a l s p i n e d u ri n g a n t e - a n d r e t ro fl e x i o n . ( a ) N e u t r a l pos i t i o n w i t h the p a t i e n t e re c t : the atlas is i n r e t r o fle x i o n with r e l a tion t o t h e axis a n d t h e h e a d in a n t e fl e x i o n in r e l a t i o n to t h e a t l a s . (b) With the c h i n d r a w n i n , a n t e fl e x i o n o f t h e occi p u t with relation t o t h e a t l a s i n cr e a s e s o n l y v e r y l i t t l e , w h e r e a s t h e re i s n o w m a r k e d a n t e fl e x i o n o f t h e a t l a s i n r e l a t i o n t o t h e a x i s . ( e ) A n teflex i o n : w h i l e a n t dl e x i o n o f t h e a t las i s n o w a t m a x i m u m ( a n te ri o r t i l t of t h e a t l a s ) t h e h e a d h a s m o v e d i n t o re t ro fl e x i o n s o t h a t t h e pl a n e o f t h e fora m e n m agn u m a n d of t h e a t l a s n o w l i e a l m o s t p a ra l le l . (d) R e t r o fl e x i o n s i tting : t h e r e is b o t h r e t r o fl e x i o n of t h e h e a d a g a i n s t the a t l a s a n d o f t h e a t l a s aga i n s t the axis, t h e fo rm e r b e i n g l e s s o w i n g t o t h e t i l t i n g o f t h e a t l a s : a s i n a n t e fl e x i o n , t h e plane o f the fo r a m e n m a g n u m l i es p a r a l l e l t o t h e p l a n e o f the a t l a s . ( e ) R e t r o fl e x i o n w i t h t h e p a t i e n t o n h e r s i d e : as t h e w e i g h t o f t h e h e a d n o l o nger plays a p a r t , t h ere i s n o back w a r d t i l t o f t h e a t la s a n d t h e re i s m a x i m u m retrofle x i o n o f the h e a d a ga i n s t t h e a t l as a n d fa r l e s s r e t r o fl e x i o n o f t h e a t l a s a g a i n s t t h e a x is . N o t e a l so t h e s h i ft o f t h e b a s i o n fo rward d u ring h e a d a n t e fl e x i o n a n d b a c k w a r d s d u r i n g re t ro fl e x i o n ( s i tt i n g )

Copyrighted Material

Funclional

Figure 3.30

of Ih e spinal CDllimn

67

(con t i n u e d )

Figure 3.31 T h e m e c h a n i s m o f a t l a s t i l t

T o d e t e rm i n e the p l ane of t h e fo r a m e n m a g n u m l i n e i s d rawn from the b a s i o n t o t he posterior m a r g i n of t h e fora m e n magn u m . The p l a n c of t he a tl a s corresponds to a l i n e co n n e c t i n g the ce n t re o f the an terior a n d the posterior a rches: the p l a n e of the axis corresponds to a l i n e from t h e lowest poi n t o f t h e transve rsocos t a l p rocess t o t h e lower margin o f the arch o f t h e axis. This a l lows rel a t i v e a n te - o r retrofl exion t o be assessed (see Figure 3 .23 ) . The sha dow o f the o d o n to i d process i s j ust b e h i n d t h e a n t e r i o r a rch o f l h e a t l as, the t i p o f the odontoid a

analOmy lint! radiography

being usually about the s a m e level as the upper m a rg i n of t h e a n t e rior a rch . I t s h o u l d n o t be m u c h a bove t h e pala to-occi pital line; t h i s i s t h e c a s e i n basi l a r i m p ressio n . U n l i k e t h e res t o f t h e s p i n a l col u m n , t h e tra ns ve rsocostal p rocesses w i t h the pedicles project on to the vert e b r a l bod ies i n the si de view. Th e u p p e r m a rg i n of t h e t r a n sversocost a l process is e v e n slightly a bove t h e upper m a rgi n of t he verte b r a l bod ies, somew h a t bl urri n g t h e l ow e r contour of t h e i n ter ve rtebra l d iscs. The s hadows o f t h e articu l a r p rocesses and the tra n s l ucency of t h e j o i n ts p rojecting into t h e spi n a l ca n a l ca n b e s e e n be h i n d t h e v ertebra l bodies. I f t h e s i d e v i e w has b e e n t a k e n correctly, o n l y o n e l i ne can be see n , showing t h a t the j o i nts a re p a ra l l e l . The posterior m a rg i n o f the spin a l ca n a l is i n d icated b y a s h adow a t the b a s e of the s p i n o u s processes w h e re t h e l a m i n a e m e e t . The shadow is u s u a l ly also clearly v is i b l e a t t h e l e v e l o f the atlas; i ts absence i s a clear sign of spina b i fi d a , a fre q u e n t a n o m a ly o f t he a t l as a rc h . X-ray eva l u at i o n o f fu n ct i o n

The most c h a racteristic d isturbance of s t a t ics i n the cervica l reg i o n i s the fo rward drawn position (Figure 3 . 3 6 ) . Th is is so because even when sta tics a re n o r m a l the centre o f gra v i ty of the head is slightly i n fron t o f its s u pport a nd the refore there i s a lways some m us c u l a r activ i ty in the neck m u sc u l a t u re in the e rect

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Manipulative Therapy in Rehab ilita tion

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Figure 3.32 S k e l e t o n of the ce rvical s p i ne ( v e n t r a l aspect) compared w i t h t h e a n t e ro p os t e r i o r X - ra y . I . A n t e r i o r e d g e t h e fo ra m e n m a g n u m : 2 , l ow e r edge o f t h e a n t erior a r c h o f the atlas: 3 . fo ramen cos l o t ra n s v e rs a r i u m o f t h e a x i s : 4 . fo ra m e n i n te rv e r t e b r a l e : 5 . c o u rse o f t h e v e r te b r a l a r t e r y ; 6 . u nc i fo r m process: 7 . ped i c le of

Figure 3.33 S k e l e to n of t he c e rv i c a l s p i n e ( d o r s a l a s p e c t ) c o m pa re d w i t h the a n t e ro p os t e r i o r X - r a y . I . Fo r a m e n 2 . l o w e r e d g e o f t h e poste r i o r a rc h o f t h e a t la s : 3 . r n a s s a l a t e r a l i s o f t h e a t b s w i t h 4 . t h e l a te r a l t ri a n g l e : 5 . j o i n t s p a c e : 6 . s p i n o u s p r o c e ss cos t o t r a n s v e r s a r i u m o f t h e a x i s ;

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Figure 3.34 S k e l e t o n o r t h e c e rv i c a l s p i n e ( l a t e r a l a s p e c t ) c o m p a red w i t h the l a tera l X - ra y . 1 . Transve rse process: 2 , w i d t h or t h e s p i n a l c a n a l : 3 , j o i n t space: 4. lower a r t i c u l a r p roce s s : 5 , ro ra m e n i n t e r v e r t e b r a l e : 6 . u p p e r a r t i c u l a l process

Figure 3.35 A t l a n to-occi p i t a l j o i n t . l a t e r a l view

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70

Manip l l iative Therapy in Rehabiliwlion of the Locomotor Sys/al1

Figure 3.36 Fo rwa r d - d r a w n posi t i o n of the head : t h e e x t e rn a l a u d i t ory c a n a l a n d t h e o d o n toid p rocess l i e fa r a n t e r i or to t h e u p p e r a n d a n t e r i o r e d ge of C2: t h e c r a n iocerv i c a l j u n c t i o n i s i n a pos i t i o n o f c o m p e n s a t o r y h y p e r l o rdosis

Figure 3.37

view of the c e r v i c a l s p i n e w i t h t h e e re c t : t h e e x t e rn a l a u d i t o ry c a n a l ( ce n t re of g r a v i t y of t h e h e a d ) a n d t h e o cl o n t o i d process l i e above t h e a n t e ri o r a n d u p per e d ge o f t h e v e r t e b r a l b o d y of C 7 . I n t h i s c a s e k y p h o s i s o f t h e m i d -cerv i c a l s p i n e i s i n k e e p i n g w i t h a n o rm a l s t a t i c f u n c t i o n , ow i n g t o a fl a t bac k , C 7 be i n g a l m os t h o r i z o n t a l L a te r a l

pat i e n t si tting

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Figllre 3.38 Late ral view of t h e c e rv i ca l s p i n e w i t h t h e a t l a s i n a n t elk x i o n ( rela tive t o t h e axis)

posi t i o n . O b v i o u s l y . i n t h e forw a rd d r a wn p os i t i o n

t h i s i m b a l a n c e is gre a t l y e n h a n ce d . p ro d u c i n g i n

creased

aci ti v i t y

i n the neck

m u sc l e s

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( b y co u n

kyphosis.

m a y be i n

A s G a i z l e r ( 1 974 ) h a s s h ow n , i n ord e r t o ge t a

t r u e p i c t ure it is v e r y i m p o rt a n t to t a k e the l a t e r a l v i e w i n a re l a x e d p o s i t i o n . t h e s u bj e c t s i t ti n g w i t h o u t s u pport. or fa u l t y p os t u re m a y be o v e r l oo k e d . It i s ne c e ssa r y . how e v e r . t o i n s is t o n t h e p a t i e n t r e l a x i n g

a

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e r e c t , s t a n d i n g a n d s i t t i n g re l a x e d .

Whereas with the

inc rea sed

cra n i o c e r v i c a l j u n c t i o n t h e a t l a s

k e e p i n g h i s gaze on a n o bj e c t

at e y e l e v e l . to a v o i d h e a d a n t e[-l e x i on . In

p a t i e n ts s i t t i n g

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w h i l e c o ns t a n t l y

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3.37)

a u d i to r y m e a t u s w a s a l m o s t e x a c t l y a b o v e

t h e a n te r i o r u p p e r e d g e o f t h e C7 v e r te b ra ( o n m m be h i n d ) , i n s t a n d i n g p a t i e n t s i t w a s 7 m m i n fro n t o r t h i s e d ge . a n d i n t h e re l a x e d s i t t i ng pos i t i on ( i . e . i n t h e h a b i t u a l w o r k i n g pos t u re ) i t was 1 6 mm in fro n t. I n i n d i v i d u a l c a ses t h ere w e r e d i ffe rences of u p to 5 cm ' Th i s is p a r t i c u l a r l y s o if t h e re i s m a r k e d l u m b a r k y p h o s i s i n s i t t i n g , ca u s e d average 1 . 9

by

l umbar

h y per mobil i t y .

c h a n ge s i n s ta t ics co n c e r n i n g t h e w h o l e c e rv ic a l spine. t h e re ca n be re l a t i v e fo rwa rd In addition

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Figure 3.39 A s y m m e t r i c a l posi t i on of t h e a t las re l a t i v e to the co n d y l e s a n d the axis ( t h e dotted l i n e s represe n t t h e p l a n e s o f t h e co n d y l es a n d t h e a x i s . conve rg i n g to t h e s i d e of t h e re l a t iv e a t l a s s h i ft )

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Man ipulative Th erapy

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Figure 3.41 D e x t r o r o t a t i o n of t h e a t l a s . ( a ) A n te ro X - ra y . ( b ) D i a g r a m

poste r i o r

I n a d d i t i o n to r o ta t i o n i n i n d i v i d ua l segme n t s t he re is fre q u e n t a s y m m e t ry o f t h e a t l as i n re l a t i o n t o t h e a x i s , a s though t h e a t l a s w e re s h i ft e d to one s i d e . A t t h e same t i m e the c o n d y l e s a re s h i f te d re l a t i v e to t h e a t l a s i n the o pp o si t e d i recti o n . T h i s i s fre q u e n t l y descri bed a s a s h i f t o f t h e a t l a s re l a tive to t h e a x i s and the condyles i n t h e s a m e d i re c t i o n , b u t t h i s i s n o t q u ite cons iste n t . a s m o v e m e n t i n t h e s p i n a l colu m n s h o u l d a l w a y s be d e s c r i b e d in re l a t i o n to t h e l ow e r ele m e n t (Figu res 3 . 3 9 a n d 3 . 40) . I s o l a t ed r o t a t i o n o f t h e a t l a s in r e l a t i o n to both t h e a x i s a n d t h e occi p u t i s u n c o m m o n . O n t h e s i d e o f ro t a t i o n there i s a n a rrow a rtic u l a r c l eft b e t we e n a t las a n d a x i s a n d a l a rge r l a t e r a l t r i a n g l e o f the a tl as , t h e cen tre o f the poste r i o r a t las a rc h b e i n g s h i ft e d i n t h e o p p o s i t e d i re c t i o n a n d t h e m a s s a l a t e r a l i s b e i n g l a rg e r o n t he s i d e o p p o s i t e t o ro t a t i o n ( F i g u r e 3 .4 1 ) . M u c h more fre q u e n t l y t h a n rota t i o n o f t h e a t l a s i s a x i s r o t a t i o n i n t h e n e u t r a l p os i t i o n o f t h e h e a d a n d n e c k ( s e e F i g u r e s 3 . 2 6 a n d 3 . 2 7 ) . In fact, r o t a t i o n of t h e order of 5 d e g re e s is q u i t e common a n d eve n of t h e order of t o degrees i s n o t u n u s u a l . I n t e rest i n g l y , ro t a t i o n ( a n d eq u a l ly a sy m m e t ry of the sp i n o u s process) of t h e a x i s is acco m p a n i e d by rota t i o n of the ce rvica l verte b rae be l o w the a x i s , q u i te fr e ,

Ib) Figure 3.40 ( a ) A n t e ro p o s t e r i o r X - r a y s h o w i ng the a t l a s a ga i n s t the occi p i t a l c o n d y l e s t o t h e l e ft . ( b ) A ft e r t r e a t m e n t t h e pos i t i o n i s a s y m m e t r i c a l pos i t io n of

s y m m e t rica l

a n teAex io n a n d re tro A e x i o n s i t t i n g (see Figure 3 . 30 ) , t h e a t l a s is u s u a l l y i n a s l i g h t l y retroAexed p o s i t i o n if t h e r e is c e rv ica l l o r d os i s , the h e a d b e i n g conse q u e n t l y i n a n teAe x i o n ; c o n v e r s e l y i n a k y ph o ti c forw a rd - d r a w n p o s i ti on the a t l a s t e n d s to b e i n a n te Aexion a n d t h e h e a d i n r e t r o A e x i o n i n re l a t i o n to t h e a t l a s (Fig u re 3 . 3 8 ) .

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Figure 3.42 Rot a t i o n of t h e cerv i c a l sp i n e i n t h e l a t e r a l v i e w : t h e t r a n s ve r s e a n d a rt i c u l a r p rocesses a s w e l l a s t h e j o i n t s p a ces a re v i s u a l ized s e p a r a t e l y , o w i n g to r o t a tory d istortion

que n t l y down to C7 , p a r ticula r l y when r o t a t i o n is to

h y p e r mobi lit y ; rota tion t e l l s u s m u c h l e s s because it

t h e l e ft. The mecha n i sm is p roba b l y that d es c ribe d

i s di f A c u l t to a s se s s .

duri n g sid e-bending ( see Mob i l i ty s t u dies , below) . T h e c h a racte r i s t i c fe a t u r es of a x is rota t i o n i n t h e A P v i e w a re a s fo l l o w s : t h e s p i nous process a n d t h e ped icles s h i ft t o t h e oppos i te dire c t ion to tha t of

The physiologi c a l

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ped icles. I n t h e s i d e v i ew o f rot a t i o n o f t h e cerv i c a l

b e n d i ng, t h e re wil l be n o n e i n the lowe r cervic a l

s p i n e , t h e s t r u ctures t h a t u sual l y overla p a re separ

s p i n e (Figure 3 . 43 ) . O n the ot h e r hand , l a c k of

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ro t a t i o n i n t h e lower c e r v ic a l s p i n e w i l l not have a n y

t r a n sverse p rocesses . I n fa c t , t h e t r ansve rse p roce s s

e ffec t o n rota tion i n t h e u p p e r c e rv ic a l spi ne. This

o f t h e a x i s i s proj ected i n fro n t o f t h e bod y of t h e

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l owe r cerv i c a l ve rtebrae by m eans of t h e s pinous

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this v e r te b ra wi l l not rota te , just as t h ough rota tion

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Figure 3.44 T h e e ffe ct o f a sy m m e t ri c a l po s i t i o n o f a process on r o t a t i o n of t h e ca u d a l cerv i c a l ve rte b r a e a t s i d e - b e n d i n g . ( a ) A t n e u t r a l p o s i t i o n t h e s p i n o u s p r oc ess o f C 2 d e v i a t e s t o t h e r i g h t . ( b ) S i d e be n d i n g t o t h e r i g h t c a ll s e s d e x t roro t a t i o n of t h e a x i s . t h e s p i n o u s process o f t h e a x i s rOUl t i n g o n l y i n t o m i d l i n e , however: t h e ca u d a l c e rv i c a l v e re t e b r a e re m a i n unrotated ( A fter J i ro u t . 1 970) s p i n o ll s

h a n d . if th e axis d o e s n o t r o t a t e t h e re i s n o s i d e

b e nd i n g a t t h e c ra n i oc e r v i c a l j u n ct i o n ( F i g u re This i s i n k e e p i n g w i t h t h e fa c t t h a t i n

3 .45 ) . cases o f

a t l a s a ss i m i l a t i o n to t h e occ i p u t , s i d e - b e n d i n g a t t h e

j u nc t i o n

may be n o rm a l .

T h e q u e s t i o n n o w a rises w h e t h e r m o v e m e n t re s t ri c t i o n b e t w e e n a t l as a n d occi p u t o n s i d e -b e n d i ng c a n be v i s u a l i z e d by X - r a y . We h a v e s h o w n t h i s to b e po s s i b l e

( Le w i t and K r a u s o v
w i t h the h e a d r o t a t e d .

Figllre 3.43

(a)

B l o c ked rot a t i o n o f t h e

a x i s il t t h e r i g h t : n o ro ta t i o n o f t h e ce rv i c a l s p i n e be l ow C 2 . ( b ) A ft e r t r e a t m e n t : norm a l d e x t ro ro t a t i o n from t h e a x i s d o w n t o C.'i . l a t e r a l flex ion o f the e n t i re sp i n e i n creased c o m p a red w i th (a) l a t e ro fl e x i o n t o

A l t h o u g h s i de -s h i ft i ng o f t h e a t l a s i s the r u l e i n l a t e r a l fl e x i o n . a t t i m e s i t d o e s n o t t a k e p l a c e w i t h o u t m o ve me n t r e s t r i c t i o n . i n p a r t i c u l a r i f t h e re i s m a r k e d

a s y m m e t ry : e v e n m ore i m porta n t . e v e n i n c a se s o f cl i n i c a l l y s e v e re m o v e m e n t re s tr i c t i o n b e t w e e n a t l a s

a n d occ i p u t , t h i s s i d e - s h i ft m a y be see n . On t h e o t h e r

It is u s u al l y e a s y to s e e m o v e m e n t re s t ri c t i o n between t h e a t l as a n d a x i s o n side-be n d i ng: the a x i s d o e s n o t r o t a t e ( Fi g u re 3 . 45 ) . I n t h e r e s t o f t h e c e r v i c a l s p i n e t h i s i s m uc h l e s s e a s y t o v i s u a l i ze by X - r a y , e v e n w h e r e it c a n be c l e a rl y d i a g n os e d c l i n i c a l l y . A cco r d i n g to J i ro u t ( 1 970) s m a l l t i l t i n g m o v e m e n ts i n t h e s a g i t t a l p l a n e t a ke p l ace on s i d e b e n d i n g a n cl c a n be r e c o g n i z e d b y a c h a n ge i n t h e p o s i t i o n o f t h e s p i n o u s p ro c e s s . T h e s e sy n k i n e s e s i n t h e s a gi t t a l p l a n e c o r r e s p o n d t o j o i n t p l a y o f t h e ce r v i c a l s p i n e a n d a re m o re p r o n e to m ov e m e n t r e s t r i c t i o n th a n i s l a t e r a l b e n d i n g ( a s c a n be s e e n from c o m p a r i s o n o f X - ra y s taken b e fore a n d a fte r m a n i p u l a t i o n ) . Mo r e o ve r . t h e c h a n g e d posi t i o n o f t h e s p i n o us process, i . e . t h e t i l t i n t h e sagi t t a l p l a n e , d o e s n o t n eces s a r i l y d i s a p p e a r a ft e r t h e ce rv ic a l s p i n e re t u r n s to n e u t ra l po s i t i o n : i t m a y n o t r e a c h t h e s a m e po s i t i o n , b u t m a y e v e n o v e r r e ac h i t .

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Figure 3.45 B l o c k e d pass i v e l a t e ra l fl e x i o n a t t h e I n t h e n e u t r a l p os i t i o n t h e

c r a n ioce r v i c a l j u n ct i o n . ( a )

a t l a s i s s l i gh t ly a s y m m e t r i ca l , to t h e r i g h t o f t h e c o n d y l e s

a n d t h e a x i s . ( b ) A t t e m p t e d p a s s i v e l e ft l a te r a l fl e x i o n a t fa i l e d ; t h e re i s n o a x i s rota t i o n , y e t t h e a t l a s h a s m o v e d t o t h e I d t ( I ) . ( c ) A ft e r t rea t m en t , n o rm a l l a terai ll e xi o n o f t h e u p p er cervica l s p i ne is r e s t o re cl , wi t h n o rm a l ( sl i g h t ) ro t a t i o n of t h e a x i s a n d s h i fr o f t h e a t l a s t o t h e l e ft t h e u p p e r ce r v i ca l s p i ne h a s

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76

Manipulative Th erapy in Rehabilitation of rhe Locomotor System

Figure 3.46 AP p i c t u res of the c e r v ica l s p i n e : l e l t in n e u t r a l pos i t i o n , right s i d e be n t to the l e ft . Co m p a r e t he pos i t i o n o r t h e s p i n o u s process i n r e l a t i o n to t h e v e r t e b r a l b o d y a t C 7 a n d C 6 ( r e p r o d u c e d b y k i n d p e r m i s s i o n o f Pro fessor -

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t h e h e a d a ga i n s t t h e c e r v i c a l s p i n e i n t h e c o ro n a l

p l a n e is m a i n l y t h e res ult o f a x i s rota t i o n ; c o n v e rs e l y , i f we res to re blo c k e d s i d e - be n d i n g a t t h e

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the atlas a n d axis.

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a n d a x i s a re l o c k e d , i . e . i f t h e h e a d is r o ta t e d Move m e n t restr i c t i o n of t h e o c c i p u t on t h e a t l a s

a n te A e x i o n of t h e whole of t h e c e r v i c a l sp i n e

not o n l y when t h e chin i s h e l d i n , but a l so d u r i n g

.

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o p i st h i o n i n re l a t i o n to t h e a t l a s , w i t h o u t l a x i ty of t h e t r a n s v e rse l i game n t ( F i g u r e

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the

m ov e m e n ts m o s t

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3.48) .

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Figure 3.47 H y p e r m o b i l i t y at head a n te fl e x i o n w i t h l a x i t y o f t he t r a n s v e rse l i ga m e n ts o f t h e a t l a s . (a) In the n e u t r a l pos i t i o n the a n t e r i o r fa c e t of the a n t e ri o r a rc h of the a t l a s is p a r a l l e l to t h e o d o n t o i d p rocess. ( b ) L i g h t a n d (e) m a x i m u m a n tefl e x i o n : t h e re is i n cre a s i n g a n gu l a t i o n b e t w e e n t h e a r t i c u l a r fa c e t s o f t h e a n t e ri o r a rch o f t h e a t l a s a n d t he o d o n t o i d ; n o t e t h e c h a n g e i n t h e a n g l e b e t ween t h e c li v u s a n d t h e a x i s a n d t h e a n t e r i o r s h i ft of the b a s i o n

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at

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Figure 3.49 I n c o m p l e t e c o n g e n i t a l c o a le s e n ce o f C5 a n d C6 w i t h a h y p o p l a s t i c i nt e l've r t e b r a l d i sc a n d a s h o rt a n t e ro poste r i o r d i a m e t e r of bot h a d j a c e n t verte b r a l

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Figure 3.52 Os o d o n t o i d e s , side view ( a r r o w s ) ( R e prod u c e d by k i n d p e r m i s s i o n o f D r E . G.

Metz)

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( a) Figure 3.53 Spo n d y l a rth ros i s w i t h a h orizo n t a l C O llrse of t h e i n tervertebral apophyseal j o i nts. (a) In the A P ; ( b ) ( opposite) i n the s i d e view

A n o m a l i es

A n o m a l ies m a y be i m p o r ta n t b e c a u s e tbey fre q uently imply some degree of c h a n ge i n funct i o n . T h i s is pa rticu l a r l y o b v i o u s i n coa l esce nce o f vertebra l bod i es a n d/or a r c h e s . These m a y be o n l y parti a l . a n d i n s u c h c a s e s w e s e e a hypop l astic i n te rverte b r a l d i sc, the verte b r a l bodies adjace n t to tha t d isc being n a rrower (Figure 3.49). The a n o m a l y i m p l i e s red u c e d or n o m o b i l i ty i n a segm e n t a n d prod uces (compensa t ory) hypermobili ty i n t h e neigh bouring segm e n t ( u s u a l l y cran i a l ) res u l ting u l t i mately

i n degenerative cha nges. A fre q u e n t anoma l y is a transitio n a l cerv i cot horacic ve r t e b r a C7 w i t h l a r ge tra n sverse p rocesses a nd/or cervical ribs and w i thou t unciform processes; it is often asymmetrical. Cl i n ic a l l y the most i m porta n t anomaly is a na rrow s p i n a l ca n a l , because it m a y cause cervica l myelo p a t h y . A more usefu l method t h a n measuring the w i d t h o f t h e a n te r i o r-posterior d i a m e t e r is t o ob serve t h e a l t e red proport ions visible a t firs t glance: n o r m a l l y the s p i n a l c a n a l is wider t h a n the vertebra l body i n the cerv i c a l spine; i n t he n a rrow s p i n a l ca na l it is na rrowe r a n d t h e s h a d ow of the a r ticu l a r

Copyrighted Material

FI I I I Uiol7 (1 /

(JIl(l l O m V

(I n r i

radiography of fhe spinal

cO/limn

8l

( b) Figure 3.53

(co n t i n ued )

processes cover m o s t of t h e b r e a d t h o f t h e s p i n a l

a b o v e t h e b i m a s t o i d a n d b i d i ga s t r i c a l l i n e s ( Fi g u re

ca n a l

3.5 1). At the

( Figu re 3 . 50 ) .

The

c ra n i oc e r v i c a l

j u n ct i o n .

as

a

region

of

t r a n s i t i o n . i s the s i t e o f freq u e n t a n o m a l i e s . The

most i m p o r t a n t o f t h e s e is b a s i l a r i m press i o n d u e t o hypop l a s i a o f t h e b a s e o f t h e occ i p i t a l b o n e . I n t h i s co n d i t i o n t h e o c c i p i ta l p a r t o f t h e cl i v u s i s s h o r t e n e d a n d t h e r e f o re t h e o d o n t o i d process i s d r a w n u p i n to t h e fo ra m e n m a g n u m a n d is s i t u a te d c o n s i d e ra b l y above t h e p a l a t o -occ i p i ta l l i n e i n t h e l a t e r a l v i e w ; i n t h e A P v i e w i t c a n r e a c h t ile u p p e r b o r d e r o f t h e fora m e n m a g n u m betwe e n t h e c o n d y l e s , a n d b e h igh

s a m e t i m e t h e fo ra m e n m a g n u m m a y be n a rrow e r t h a n us u a l , u n l e ss t he r e i s a l so a n A rno l d -Ch i ari d e form i t y . T h e c h a n g e s m a y c a u se c o m p re s s i o n of t h e nervo u s tiss u e n o t u n l i k e t h a t w h i c h oc c urs w i t h a n a rrow s p i n a l ca n a l f u r t h e r

d o w n ( F i g u re 3 . 5 1 ) .

I n a d d i t i o n t h e re i s o f t e n h y p o p l as i a o r a s s i m i l a t i o n of t h e a t l a s to t h e occ i p i t a l c o n d y l e s . Less i s c o a l e s c e n c e o f t h e m a s s a l a t e ra l i s o n e - s i d e d ) w i t h t h e a x i s . A ll t h e a n o m a l i e s m o re oft e n th a n n o t a s y m m e t r i ca l : t h is

common

(u s u a l ly are

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82

lv/an ip l l iative Therapy in Rehabilitation of the

Locomotor System

O n e i m porta n t a n o m a l y ( m a lfo r m a t i o n ) is hypo plasia of the odontoid and the os odo n t o ides, which i m p l i e s p a t h o logica l hypermob i l i ty (Figure 3 . 5 2 ) . A n o t h e r s i g n i fi ca n t a n o m a l y o f t h e odontoid is i n creased rec l i n a tion ( G u t m a n n , 1 98 1 ) , wh ich forces the atlas i n t o a position of retroflexion a n d the refore p l aces i ncreased s tra i n on t h e transverse liga m e n t of t h e a t l a s d u ring head a n teflex i o n , a n d m a y cause l a x i ty of that ligame n t . D e g e n erative c h a n g e s

Degenerative c h a nges in t h e cerv ica l sp i ne a re o f speci a l c l i n i c a l i n terest w h e n t h e y i mpi nge on t h e i n te rve rte bral fora m i n a a n d m a y therefore i n terfe re w i t h b o t h t h e sp i n a l roo t a n d the vertebral artery. For t h is reason oblique views are useful (see Figu re 3.24). These cha nges m a i n l y conce r n the u n c i form processes ( n e u rocent ral j o i n t s ) i n pa rticular t h e i r poster i o r parts . They a re close l y corre l a ted to d isc dege n eratio n , as n a rrowi n g of the d isc b r i ngs t h e u n ciform p rocess o f t h e lower vertebra into close c o n tact with the lower la tera l m a rgin of the vertebra a bove. S i m i larly, deform i t y o f t h e articu l a r processes m a y i m p i nge o n t h e i n te rve rtebral fora m e n . This i s fou n d i n a rth rosis o f the apophyse a l j o i nts, w h i c h u s u a l l y goes h a n d i n h a n d w i t h a h o r i z o n t a l posi tion ; i n such cases t h e a pophyse a l j o i n ts beco m e the weight bearing structures (Figure 3 . 5 3 ) . They a r e the refore seen very w e l l in the A P v i e w . Fi n a l l y , I m ust poi n t o u t t h e great sign i ficance o f a c h a nge i n the p a ra l l e l course of both apophyse a l j oi n ts i n o n e segm e n t , seen i n a n und isto rted l a t e ra l v iew T h is i m p l ies fo rced rotation o f the ce rvica l spi n e d u ri n g retro fl e x ion , p rod ucing na rrow i n g o f t h e i n tervertebra l foramen o n one s i d e ( Fi g u r e 3.54). ,

Figure 3.54 D i ffe rence in the o b l i q ue co u rse of t h e C3 a n d C 4 i n t h e l a t e r a l v i e w

a p o p h y s e a l j o i n ts b e t we e n ( a rrow)

asy m me t ry concerns t h e w h o l e of the cra n iocervical j u nction a n d m a y p rod uce side-s h i ft of the atlas and e v e n m a r ked rotation of the axis in n e u t r a l posi t i o n , w h i c h n ecessa rily prod uces asymmetrica l mechanisms of s i d e - b e n d i n g a n d rotati o n .

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.

4 Examination of locomotor function and its disturbance

Case history

heart, or in

times and As in oth er fields of medicine, examination sta rts with the anamnesis. B ec a u se v erte b ro genic disorders represent the m ost im portant grou p, they will serve as the pr in cipa l e x a m pl e. I t i s i m p ort a nt to stre ss from the outset that diagnosis of disturbed f u nctio n as the cause of d is ease should not be ma de per exclusion em - i.e . o n ly if other ( organ ic) causes are ru led out - but principa lly on po siti v e evidence, of which a cha ra ct e ri stic history is sig n ifi c a nt. We owe the main c r ite r ia t o G u tze i t (1956). Chronic i ntermittent course Unless we see a n acute condition in a young patien t , we can us u a l ly ascertain by q u es tion ing that t h e re have been p reviou s a ttacks, perh aps going a s fa r back as ad o l e sce nce (e.g. low - b ac k pain d urin g menstrua tion i n y o u ng girls). There are pe ri od s o f com p l e t e recovery i n b etwe en, a n d w e sho u l d try t o ascert ai n the frequency a nd d u ration of the a t tacks ( and the free inte r v a l s ) , and the t i me of onset of t h e l a test attack, providing ev i d ence for the ge neral tre nd of the p at i en t ' s condi tion.

Involve ment of the locom otor system function o f t h e l ocomo to r system a n d its d ist u rbance can never be l im i ted only to one structure, and therefore sym p toms occur in various more d istant parts of the system in t h e co urse of time, the vari o u s l y l ocated c om p laints ha ving, perh aps, a comm o n denominator - the vertebral colu mn. This, too, has t o be elicited by c a re ful questioning; the patient will pr ob a bly be una wa re of the pos si ble connection between, for exa m pl e, h eada c he , sh o u l der pa in , pain in the reg io n of the The

the

hip or knee, ex p e r ie nced

at

different

pe rh a ps after considerable intervals.

S u sceptibi l ity to strain a n d sustained posture

Fun ction and

its

disturba nces i n the locomotor

syste m are ob v i ou s ly

influe n ced by stra in imp ose d by e n fo rced movement or sustained posture. O ne of the most important poin ts in recording the case h is to ry is to det ermine u n der wha t condi tions the a t ta c ks occur; this is n ot on l y of d ia gnostic va l u e, bu t a l so im po r tan t for t h e ra p y a nd pre v en t ion . This is the m ost crucial but also the most diffic u l t inform a t i on to extract from the p a tient. It does little good to a sk him after what his sy m ptoms started, for he is likely to provi d e all the theories he has h e ard or formed for himself. Wha t we need to know a re the imm edia t e circumstances i n which p a i n was fe l t . Thi s pa t i e nt s are often rel uc t a n t t o tell, either beca use they cannot reme m be r or bec a u se t h e y find it i rrele vant o r unim p o rt a nt ; such s ta t e ment s a s 'I was s itt i n g, a n d w h e n I got u p from my ch ai r ... ', 'I was shaving a nd when I looked in to the mirror . .. ', ' . . . when wak i n g up i n the m orning o r turn ing round in bed . ..', 'when 1 st oo p ed to p ick up this bit of pa per from the floor . . . ', a re sign ifican t details. It is also important to learn which po sition or movement giv es rel i e f. I t is i mportant to .k provo k ed b y a si ng l e br u sq ue movement, by stre n uous effort of so m e d u ra t ion, or by an e n for ced l), rigid pos i ti on . S l ight d etails m a y be i m p ort a n t : the u nderlying calise of p a in may be very differe nt if it occurs d u ri ng fo r w a r d b e nding, while stooping (e.g. o ver a work bench ) , in maximum flexion ( e.g. s t oo ping to wipe a floor ), or while straightening u p from a sto oping posi tion. Also pain m a y occur o n co u g hin g , sneezing, even la u gh i ng. 83

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H4

Manipu/otil'I.."

/?ciluhrlirarion of rhe Locomotor S),SI"lIl Even if the patient

or

Trauma

further questioning

desCi

Trauma is

of

causes of disturbed

paroxysmally.

revea

function alltl pnlvldllS e'lgnifICi\f11 corroboration, even ii' structural damage is also present. We must insist on the fact that any external force applied to the body affects the locomotor system and the spinal column. This is particularly the case in head injury.

Asymmetrical localization Vertebrogenic pain is rarely sYlllmetricaL and IS often one-sided. This holds for radicular and pseudo

Unfortunately the patient often forgets a minor

radicular syndromes of the extremitics as well as for

trauma (such as an awkwardly performed somer

headache, shoulder pain and pain in the chest.

saUlt) and it is therefore advisable to ask what sports he indulges in. To give a typical example

Cl

patient

who 'never suffered am' trilumil' silid that hiS hobbies

The role of age For

were boxing

tlecolCiing to the age of the

the

patienl

We In vertebrog,"rJlc

t is important to bear in pathological conditions

osteochonclrosis in adol-

mechanical factor

in young patients and

rCJC!ions of the nervous

middle-aged adults; after

II bll account. These include undue susceptibility to changes in the weathcr, particularly to cold and to high humidity; infectiOUs

(osteoporosis) may occur, the ilGt especially in women; progressive (destructive) osteo arthrosis, especially of the hip and knee JOJlll. can

is not the system mthl

Olle'.

diseases causing high temperatures; hormonal diS'

be found in older men and women and so, too, can

turbances (more apparent in women because of the

malignant disease. For this reason a history of pain

menstrual cycle); pain of locomotor origin which is

in the locomotor system that b eg ins after the age of

heightened during menstruation; even allergy may

about 50 and takes a progressive course mLlst be

be involved.

treated with great circumspection.

The

Exa

As the

instrument of our !.lent symptom of

expected I present

in

it is only to be

by clinical examination. of medicine in which

!llctor is frequently

decisive a role, and is so

The

Psychological

of locomotor function.

excludes, but rather

moment the patient enters

I clr:;lUrbed function of the motor system. It must be stressed that adequate

down, undresses, etc. The patient must always un

treatment of the locomotor disturbance usually deals

dress for the first examination (to bra and briefs);

involvemellt corroboral

he or she moves, sits

most effectively with the pain, giving the phYSician

natural movement is essential. Whatever the site of

a much better chance to deal with the psychological

the trouble, important if not vital information may

problems, having understood the patient's main

be missed if the patient remains fully dressed.

trouble. The course of treatment reveals the import ance of the psychological factor as such and finally shows whether the patient recovers psychologically when relieved of pain. or whether the psychological relapse through conditions muscular masked

Examination of posture (inspection)

for example, in

with the rear view; the

pain is not

the heels. This is

is capabJe of

observing the patient

I. without frequent

fronl of tIle'

final.ly by examination be followed by examin-

atiol! We

Paroxysmal

looking at the shape

(roundness) of the heel and its deviation; the shape

Those complaints in which autonomic nervous symp toms are prominent follow a typical paroxysmal course, e.g. vertebrogenic headache, vertIgo, cardiac

and thickness of the Achilles tendon and the calves; the lateral deviation of the knees; the shape and thickness of the thighs; the height of the gluteal lines;

Copyrighted Material

Examination of /ocorl1otOf

t he posi tio n a n d symme t r y of t he h ips; t h e c o u rse of the i n te r glu tea l l i n e a n d t he sh ape of t he b u ttoc k s; the wa ist bet wee n t h e pe nd a n t arms forming t r i angles whi c h may o r m a y n o t b e symm e t r i ca l ; the rhom boid of Michae l i s between the d i mples si t u a ted at the p o ste r i o r iliac spines and t h e upper en d of the i n terglute a l l i n e and the culm i n a t i n g p o i n t of l u m bar lordosis and i ts t ra nsi t i o n i n t o t h orac i c kyp h osis. The t h i c k ness and prom i n e n ce o f t h e erector spi n a e muscles are compared o n each sid e , as is the groove between these muscles w here t h e sp i n ous processes are s i t u a te d , and a sco l i o tic c u rve m a y b e detected . Above the wa i st the posi t i o n of t h e s h o u l d e r b l ades is c ompa red , toge t h e r w i t h t h e i r rel a ti v e he ig h t and dist a n ce from t he m i d -line: then the h ei ght and course o f the shou l d e rs is compa red . The l a t e r a l contour o f t h e b a c k i s fo rmed by t h e qu a d r a tus lumborum muscle at the w a i s t a n d the l a tissimus dorsi above, u p to t h e a x i l l a . The upper margi n of the shoul ders is fo rmed by t h e m uscu l us trape z i u s l atera l l y , a n d b y t h e leva tor scapu lae m o r e med i a l ly . The neck s h o u l d be in mid-line, b u t may devia t e t o one s i d e o r t h e oth e r; fi n a l l y , t h e h e ad may be in m i d - l i n e . or i n c l i n e d i n line w i t h t he neck , or form i n g a n ang l e w i t h the nec k . T h e n eck c a n be s l im o r thick, and the h a i r l i n e may b e h i g her o r lowe r o n t h e n ape o f t h e n ec k . J n t h e side v i e w i t is advisa b l e t o consid e r the pos t u re as a w h ole: n o r m a l l y , t h e h e a d s h o u l d be vert i c a l above the s h o u l d e rs w h i c h a re vertical a b ove the hips a n d the f e e t , so t h a t t h e o u t e r me a t us acous t i cus is vertica l l y above t h e clavi c u l a r b o n e a n d slightly i n f ront o f t h e a n k les. I t is extreme l y important to regi s te r a fo rw a rd - d ra w n pos i t i o n w h e r e the head a n d n eck a re i n fro n t of t h e s h oulder g i r d l e and t h i s is i n f ront of the hips , so t h at the buttocks stick out b e h i n d t h e a rms, w h i c h h a n g l oo s e l y o n e i t h e r sid e . Ag a i n t h e e x a m i n e r looks from t h e feet up w a r d s , no ting t he sh ape of the fee t, t he cou rse of t h e l e gs, in pa r tic u l a r wheth e r the knees a re bent bac k w a rds or eve n slightly fo rward, and the convexi ty of the buttocks. Then he fol l o ws t h e ( us u al l y lordotic) curve of t h e l umba r spi ne; i t is importa n t to note whether lordosis is m ost accentua ted a t the l um b o sacra l or i n t h e m i d o r upper l u mbar region. In cases of i n c re ase d l o rdosis (Aa b b y posture) the a bdomen pr o tr u de s (even if the pati e n t is s l i m ) a n d aga i n this protrusion may be acce n t u ated at the l e v e l of the na v e l o r above t h e pe lvis, accord i n g to w here t he muscu l a t u re is wea kest . In the thoracic regio n ( w h i c h is u s u a l ly k yp h o t i c ) it is i mportant to note w h e t h e r t he back is Aat or not, w h e t h e r k yphosis is exagge rated a n d also if kyphosis is mainly in t h e uppe r or lower t h o racic regio n . A Aa t back freque n tly accompa n ies i ncreased kyp hosis at the cervicothoracic j u n c ti o n . In a d dition to kyph osi s it is i mpo rtant to n o t e w h e t h er t h e shoulders a re d rawn fo r w a rd . Ce rvic a l lo r d osi s

d e pe nd s on

junctioll

and ils disturbance

85

the s hape of t h e t h o raci c spine, a n d in fla t backs (frequen t ly in a thl etic y o u n g s te rs ) t h ere is no lo rdos i s . If t h ere is i n creased l or d o s i s, typical in Aabby posture , the t rache a a n d t h e t h yr o i d c a rt i l a g e may p r o t r u d e , at first g l a nce giv i n g t h e impression of an e nl a rg e d t h y r o i d gland w h ic h , however, dis a pp e a rs in the supine pos i t i o n . Fi n a lly , in a forw a rd drawn position t h e re is fre que n t ly h ype rl o r d o s i s a t t h e cran.iocervical junc ti o n . I n t h e f r o n t v i e w, the e x a m i n e r may begin w i th t h e posi t i o n of the toes a n d the a rc h o f t h e fee t . followed b y the legs; a t t h e knee we note v a lg osi t y o r v arosity and poss ible l a te ra l d evia tion of t he p a t e l l a . We then foHow the con t o u rs of the t h ighs a n d o f t h e lowe r a b d o m e n between t h e i l i a and t h e nave l , wh ich m a y be s h i fted t o t h e s i d e , m a y b e o n t h e su r f a c e , or m a y be e n gu l fed. The Aa n ks ma y be d ra w n in at the w a i s tl i n e , or m a y bul g e . I f muscles are wea k, the abdomen p rot rude s w i th the n avel on i ts s u r face and the tlanks are bulg i n g. The lower e d g e of t h e t h or a x m a y be p r o m i n e n t, o r m a y be h i d d e n b y a p rot r u d i n g a b d omen; t h e e pi gastric a ngle may be obtuse o r a cute . It is only po ss i b l e to assess the sternum and its p os i t ion relative to the p ect o r a l m usc l e s in men. The l a ter a l portion of t he p ector a l i s fo rms t he anteri o r bord er of t h e axilla: the subclavic u l a r porti o n o f the p e cto r a lis can be a ssessed even i n w ome n who a re not obese, a n d the upper r i b s may be visi ble . Above the in frac l avic u l a r f os sa a re the col l ar bo n e s on both s i d es, and it is part i cula rly impo rtant to note to wha t e x te n t they m ove d ur i n g r espi r a tio n . The d e pt h of t h e s upr acl avicu l a r fossa m a y be i m p o r ta n t ( t h e i nsp i ra t o ry p osit i on of t h e t h ora x ); above th is there is t h e contour of t h e trapezius a n d the le v a t o r sca p u l a e, w h i c h i s n o r m a l l y concave p ro v i d e d that there is no h yperton u s . The s h o u l d ers are late r a l l y a b ove t h e a x i l l a, often unequal i n h e i ght. The m o s t pro m i n e n t feature of t h e n e c k is the j ug u l a r fossa and t h e two ste roocleid o m astoi d s; the a t ta c h m e n t po i n t at the sternum is m ore n o t iceable than o n the cla v i cle . B e tw e en the steroomastoids a n d t h e tr a p e z ius some b un d l e s of t h e scaleni may be v isib l e . In mid-line a b o v e the fossa j ugu laris t h e re is t he p romin e n ce of t h e thyroid carti lage; it is very i m po rt a n t to n o te wheth er it is e x ac tl y in mi d - lin e . or p e r h a ps is slig h t l y shifted to o n e side (diffe re nce in te nsion in the d i gastric musc les). If this is the case, there m a y be noticeable asy m m e try of t h e subma n d i b u l a r reg i o n , a s far as to the angl e o f the man dible. Hype rton us a n d h y peractivity of the mast i c a tory musc l es is ofte n seen, a n d w e sho u l d note h o w far the patient opens h is mouth d u r i ng spee c h . Facial asymme t ry is very frequent a n d can be comb i n e d w i t h a symmetry o f both the tee t h and t he skull as we l l as w it h sco l i osis. From both t h e r e a r and front view it is possible to d i a gnose rel a tive weakness of o n e sid e ( h e m i h ypo ge ne sis); d o m inance of o n e cere b r a l hem isp here can

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86

Manipulative Therapy in Rehabilitation of the Locomotor System

freque n t l y be recognized by the d iffere nce i n m uscula t u re o f the upper e xtremi ties . In the lower l i mbs, the s u pporti n g leg is u su a l l y the l eft ( n o n d om i n a n t), w h i c h is t h e r e fore m ore powe rfu l . Inspecti o n d u ri n g a n te flexion o f t h e trunk IS i m p o r t a n t; rotation of t h e v e r t e b r a l co l u m n i n sco l i os i s pat i e n ts t h u s becomes m o re a pp ar ent in bot h t h e lu m b a r a n d t h e t h o racic region, w i t h t h e r i b s beco m i n g even m o re prominent o n the con vexi ty. There is often l i t tle or no kyphosis in t h e l owes t t h o ra c i c are a, o r i n t h e l ow l u m bar re g i o n , whereas k y ph os i s m a y be exaggerated in the upper thoracic region . I nspection from above may reveal rot a t i o n o f the s h o uld er gird le i n relatio n to the pel v i c girdle a n d t h e hee l s . Inspec ti on o f t h e seated patient when relaxed may s h o w m a r k e d c h a n ges i n posture, p a r t i cul a r l y i n h y p e r m o b i l e s ubjects, i n w h o m m arked l u m b a r l or dosis s ta n d i n g becomes sign ifica n t l u m bar kyphosis w h e n seate d . T h i s resul ts i n a n i m p O t1a nt c h a nge in h e a d positi on, which m a y be norm a l w h e n t h e patient s t a n d s but dra w n forward w h e n h e s i t s i n a re l a xe d posi t i on. T h i s i s p a r t i c u l a rl y i m po r t a n t In s u bj ects whose profe s s i o n is mainly s e d e nta ry .

Pa l pati o n (soft tiss u e l e s i o n s) P a l p a tion is e ssen t ial, both for d i a g n o si s of p ainful c han g e s in t h e tis s ues in general and in the loco m o t o r system in p a r t icular, and also for a ll m a n i p u l a tive tec h n iques. 1t is t hus l ogical to proce ed to palpation and soft tissue d i ag n osis a t t h is point. T h e first step in p a l p a t io n, afte r to u ch i n g the surface of the pa tie n t s body, is to c o n cen trate on o u r goal: tes t i n g resistance, m o b i l i ty, shape, te m per a t u re, moisture and roug h n e ss, or provoki ng pa in. As palpation is related to touch, a n d to uch receptors to press ure it is freq u entJ y a ss u m ed that pa l patio n is pr i m a r i l y t h e registr a t i o n of pressure, and t h a t a pressu re-registeri n g d e v ice could make p a l pa t i o n m o r e objecti v e. Un fo r t u n a tely, t h i s i s r a re l y t h e c a s e , fo r d u r ing palpation our fingers ( hands) d o n o t exert static pressure, bu t pe rform s u b t l e a n d j u d i c i o u s move m e n ts. Therefore we engage n o t o n l y tacti l e but a lso p r o pri oce p ti v e receptors a n d in t e gra te i n fo rma tio n from b o t h . T h e b a r ri e r p h e n ome n o n common to mos t soft t issu e s h a s already bee n discussed (Cha pter 2, p. II); whether soft t i s s u e is stretched, or s o ft tissue layers a re sh i fted, we fi rst meet very l i tt l e res ista n ce u nti l we re a c h a n e a s i l y spru n g b a r r i e r . In h ype ra l ge s i c zon e s (HAZ) s t r e t c h or mobility i s l i m i ted; t h e b a rr ie r i s sti f f a n d d oe s no t g i ve . T h e b a r r i e r p h e n o m e n on ena b l e s us e v e n t o differen tiate the s u p erficia l from the u n d e r l y ing tissue l a y e rs by s h ifting one a g a i nst the oth er: shifting t h e m o s t supe rficia l l a y e r by m i n i m a l force '

,

,

we a t first meet n o resistance until t h e ba rri e r is reached. At t h i s moment the next underlying t is s ue layer s t a rts m o v i ng and so on. T h i s is particularly i m p o r ta n t in movement p a lp a ti on of bon y structures

co v e red by soft tissues: th e soft tissues move first

and bone will not move until we have reached the

b ar ri er (e.g. in sacroili a c m otio n pa l p a ti on ) T h e s i m p l e st w a y to tind a hyperalgesic skin zone (HAZ) is to r un one's ri ngers very ligh t ly over the surface of the skin: increased skin drag re ve al s he i gh tene d fri cti o n due to moister s k in a t the s ite of an HAZ. This is m o re re a di l y recognized, the lighter the touch. For further ex a m i n a t i on of t he superlkial layer of the s kin it is best to stretch the a re a of increase d ski n d rag, if s m all between the tinger tips, a larger area between the thumb a n d the thenar, while a c onsi d erable patch of skin is b e st ex a m i ne d between the crossed hands. T h e barrier is reached w it h a s l i g h t pull ( ta k i n g up the s l ack ), w h ile another slight tug (witho u t moving a wa y from the barrier) should s p r i n g it. A symmetrical skin patch on the other s i de of the body must be stretched in t h e same direction for compa rison (see F igure 6.72). This technique is pa rt i cularl y valuable a t the skin fo l d between t oes and fi ng e rs which is the s i t e of cl inica l l y i m po r t a n t HAZs in root sy n d r o mes . A n ot he r ( for the patient more p a i n ful) t e c h ni q ue is to create a skin fold : it is t h icke r at the s i te of t he HAZ in comparison w ith a s y mm e tri ca l ly localized normal area. To examine connective tissue ( i e subcutaneous tissue, s c a r tissue, muscles w i t h th ei r fas c i a ) it is best t o fo r m a fo l d (see Fi gure 6.74) and to stretch (not s q uee ze) i t u nt i l a bar r ie r is reached; t h i s should spring, but will be stiff if there is an HAZ. If soft tissue cann o t be fol d e d, m o derate pressure may be a p plie d ; t h e pressing finger s i n k s into the tissue until the barrier is engaged. The diagnosis of a n o rma l or a pa t h o l o gi c al ba r r i e r c a n t h us be made (see Figur e .

.

.

6.75.).

In d ia gn os in g c h a nge s in the fascia, i t is useful to tissue r e l ati v e to b o n y structures: sh i ft i ng the lumbodorsal fasc ia towards the b uttocks or the shoulders. with the pa t ient prone; moving the bu ttocks up or down; shifting ( a nd s tre tch i n g) the deep tissue layers on both s i des of t h e trunk, with t h e patient seated (see Figu re s 6.77-6.79). The sca l p can re ad ily be s h i fted in all directions a gai n s t t h e skul l , and restrict i v e 'ad h e si ons' noted. The mobility o f soft tissues against bone can be ex a m in e d at the hee l, by ro t a t o ry moveme n t a t the n ec k and the extremities, and resistance can be felt. At pe r i os t a l p ain po ints we regularly tind shift deep l a y er s of soft

('adhesions') of subperiostal tissue in one direction, unl ike the other si de fOLlnd

pathological barriers

,

ty pically at spi n o us pro ce sse s e pico nd y les iliac spines etc. T h e re are specific disturbances o f mobility where movement of a d j a c en t bones depe n ds on soft tissue

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,

.

Examina/ion Taut (palpable) bands in muscle

of locom%

r IttnClion

and

ils disflIrbance

87

Local twitch response

Taut bands

Relaxed

Local

muscle

t==:::=:::==�� of

twitch

fibres

band

A

A

Figure 4.1 Snapping palpation according to Travell and Simons (l983)

resistance; this is particularly the case between the

pointing to the affected root. At the same time we

metacarpal and metatarsal bones. This resistance is

also usually find an HAZ b e twe e n the fingers or toes.

often

increased

in

root

radiates to the toes, and is

syndromes a

where

A very characteristic soft tissue lesion presents as

pain

valuable diagnostic sign

a

myofascial

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trigger

poin t

(TrP);

this

widely

88

Manipulative Therapy in Rehabilitation of the Locomotor Systern

Table 4.1 Important muscular trigger points Muscle

Clinical significance

Soleus

Pain at the Achilles tendon

Quadriceps femoris, tensor fasciae latae

Pain at the upper edge of

Thigh adductors

Lesion of the hip joint

the patella

Iliacus

Lesion of segment

LS/SI (coccy x)

Piriformis

Lesion of segment

LAI5 (coccyx)

L3/4

Rectus femoris

Lesion of segment

Hamstrings

Lesion of segments LS-Sl. pain at the tuberosity of the ischium

Levator ani (per rectum)

Coccyx

M. coccygeus (Jig. sacrotuberale)

'S'-reflex - pe lvic dysfunction (Silverstolpe) pelvic diaphragm

and fibular

(hip)

head

Psoas and quadratus lumborum

Lesion of thoracolumbar junction (TIO-Ll)

Erector spinae

Lesion of segment at the corresponding level

Rectus abdominis

Tenderness of xiphoid,

Pectoralis major

a bd o m in al viscera Thoracic viscera, upper ribs

symphysis,

low-back pain at back-

bending,

t he upper thoracic ouLiet of upper extremity

Pectoralis minor

Tender proc. coracoideus, syndrome of

Middle part of trapezius

Cervicobrachial and radicular syndromes

Subscapularis

Frozen shoulder. scapular pain

Supinator, finger extensors. biceps, brachioradialis

Radial epicondylalgia

Finger flexors

Ulnar epicondylalgia

Triceps brachii

Pain at the dorsal aspect of the axilla

Upper part of trapezius

Any

Sternocleidomastoid

Lesion of segment

Short extensors of the occiput (overlying the

Lesion of the atlanto-occipital. segment

cervical lesion

COil and e2/3, pain referred to skull and face

posterior arch of the atlas) Masticatory muscles Digastricus

Temporomandibular Joint, h eadache, facial pain

Pain at the h yoid dys p h agi a .

acce pted term has been d efined best by Travell and Simons (1983): A h y per-irritable spot, usually within a ta u t band of s k e l e t a l muscle or in the m u scle's fascia, tha t is pa i nful on com pression and can give rise to ch aracte ristic referred pain, t e n derness a n d auton o mic phenome n a'. If such a m uscu lar ba nd i s rolled under the fingers, a l oca l twi tch ca n be felt a n d can be registe red by EMG, whi l e the patient fee l s a sha r p pain (Figure 4.1), The trigger p oint appears to be a band of m u scul ar tissue which is in a state of contraction while the rest of the m u scle is quiesce n t; com p l ete relief ca n be obtained by d econ traction (e,g. by the spray and st retch method, or by post-isome tric relaxatio n); i.e. what we have h ere is a reversible cha nge of fu nction, s i m i l a r to reversible jo i n t moveme nt restriction. In 1993 Hubbard showed that spontaneous EMG activi t y can be registered in TrPs with the a i d of monopo l ar e lectrod es. Myo fascia l TrPs are not the onl y tend er points (TePs); these ca n be fo u n d a t perioste a l poi nts, on joints (j oin t ca p s u l e s ) , and at attachment poi nts of m uscles. I n deed. a muscle with a TrP p rod ucing te nsio n is u sua l l y con nected with a TeP at the m uscle a ttachment. Eve n in m uscles there may be tender poi n ts which a re not taut bands, e.g. in 'tibromyalgia' w here we can p a l pate a painfu l 'pasty (i,e, dough'

like) hypo tonus'. Such TePs may even prod uce re ferred pain, but no twitch sign can be elicited nor does re lax atio n prod uce any re sults . Eliciting the twitch sign i n a TrP i l l ustrates another very important fea ture of palpa tion: it provokes a reaction of the patie n t's tissues, add itional d i agn ostic informa tio n esta blis h i n g a u n ique feed back relationship between two highly com plex se l f regula ting systems, examiner and patie nt. which can be matched by no other instrument. This would satisfy any criteria of mod ern inform atio n t heory, if it were reprod ucible and scie ntificaJly verifiable. We are thus faced with a parad oxical situation: the clinical method that p rovides the richest and most diffe re n tiated i n form ation is stigm atized as 'sub j ective' a n d the refore n o n-scientific. compared with sophisticated apparatus which at best is but a poor copy of the nervous system. w h ereas pal pation uses the h um a n bra i n itself. and the sensing hands. Tab le 4.1 lists some importa n t muscle trigger points. Reflex c h a nges on the perioste u m - p a i n p o i nts

There a re n u m erous pain points on the periosteum in patie nts with disturbed fu nction of the loco motor

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Examinalion of 10comOIOr J�lnclion and ilS dislurbance

89

Table 4.2 Important periosteal points Peri os leal poilll

Clinical significance

Calcaneal spur

Tension in pla n t ar a po n e u rosis

Pes anserinus (tubercle of tibia)

fibular head

Tension in long adductors. hip l es ion Tension in biceps femoris, block a ge

Upper margin of pa te ll a

Tension in quadriceps or tensor fasciae latae

P oste r ior su p erior iliac spine

Frequent but not speci fi c

Tuberosity of the ischium

Tension in hamstrings

Lateral aspe ct of the p u bi c symphysis

Tension in the adductors. s ac roi liac b l o ck age hip l es i o n

Uppe r margin of the sy m p h y sis

Tension in the rectus abdomi n is

Coccy x

Tension in the gluteus maxim us, levator ani, pi riformis

Iliac crest

Lesion of thoracolumbar junction. tension in q uadra tus and gluteus medius

Greater trochanter

.

Tension in abductors. hip lesi on

Spinous process (most frequently LS) Spinous process Th5, 6 (Maigne's 'dorsalgie')

Tension in deep paraspinal muscles

Spinous process of C2

Lesion of segments Cl/2 C2/3. t e nsi o n in levator sca p u Jae

Xiphoid process

Tension in rectus abdominis

On rib s in the mammary and axillary line At sternocostal ju n ct io n of upper ribs

Tension in pectoralis and serratus atta c h ed here. visceral pain

Angulus costae

Sternum just

be low clavicle

Low cervical lesion, th or acolumbar le sion

Tension in the scaJenus Movement restrict ion of ribs Lesion of fi rst rib

Medial end of clavicle

Tension in sternocleidomastoid

Erb's point Transverse p ro cess of atlas

Lesion of atlas/occiput segment, tension in sternocleidomastoid and

On the oc ci put (Iinae nuchae) Styloid proc ess of radius Epicondyles

Upper limb root syndromes. te nsion in the scaJenes recti capit is lat er aJe s Referred from the pos t e r ior arch of the a t la s and l a te ral aspect of spi no us process C2 Lesion at the elbow joint Lesion of the elbow joints. tension of mus cles attached at epi con dyJe s .

Attachment of deltoid

Lesion of scapulohumeral j oin t

Condyle of mandible

Lesion of t empor o ma ndi bu lar joint. tension in mas t i ca tory muscles

Cornua of hyoid bone

Tension of the digastricus. dysphagia

system. Frequently. like trigger points in muscles,

joint which is palpated in the groin, of the acromio

pain points are highly characteristic of certain lesions

clavicular and sternoclavicular j oints palpated at the

and therefore have high diagnostic value (Table 4.2).

lateral and medial end of the clavicle, and of the

Their disappearance (improvement) also serves as a

temporomandibular joint palpated before the tragus.

valuable test of the efficacy of treatment. Frequently the tender periosteum is changed on palpation, offering increased resistance to shift. Many periosteal

Root syndromes

pain points are sites of attachment of tendons or ligaments

(enthesopathy). and the

tenderness is

I have repeatedly stressed that mere reflex changes

apparently related to increased muscular tension,

in a single segment, including radiating pain, hyper

e.g. the greater trochanter, fibular head. Achilles

algesia and even dysaesthesia, do not constitute

tendon and attachments. If spinous processes are

sufficient grounds for a diagnosis of root syndrome.

tender on one side. this correlates with the side of

Conclusive evidence of a root lesion is provided

muscle spasm and with restricted rotation to that

by neurological deficit: hypoaesthesia. hypoalgesia.

side.

muscular weakness with hypotonia and/or atrophy,

Where joints can be palpated directly they are

increased idiomuscular excitability and decreased

tender on palpation if there is any lesion. This is true

tendon reflexes. Unless these signs are present we

for the intervertebral joints. which can be particu

may suspect root lesion but require further proof.

larly well palpated in the cervical region with the

There are two signs. however, which strongly suggest

patient supine; for the rest of the spinal column deep

a root syndrome: pain and/or dysaesthesia radiating

paraspinous palpation is required, with the patient

as far as the toes or fingers. the impression that the

prone. All extremity joints are accessible to palpation.

entire leg is painful and that the bone hurts; and the

and this is very important in affections of the hip

straight leg raising test below 4S degrees.

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90

Manipulative Therapy in Rehabilitation of the Locomotor System

(a) Figure 4.2 The dermatome chart given by Hansen and Schliack

(f):

(1962)

the leg and foot; (f) on the outer aspect

of

the leg;

(g)

at the

perineum

Copyrighted Material

by Keegan (1944) (d) on the inner and (e) outer

(a-e and g) and

dermatomes on the (a) ventral. (b) dorsal, (c) lateral aspects of the trunk;

aspect of

Examination

Figure 4.2

of 10COnW!iH

(continued)

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di.l!urbance

91

92

Manipulative Therapy

in Rehabilitation of the LocanlOtor System

(e)

(e)

(d) (f)

Figure 4.2 (con li n ued)

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Examination oj locomotor junction and its disturbance

93

E xa m i nati o n of m o b i l ity

Only certain g e n e r a l p r i nciples a re d e a l t with here. should examine a c t i v e m o b i l i t y , p a ssiv e mob i l i t y a n d move m e n t a gai n s t resis t a n c e . A c t i v e m o b il it y shows bot h muscula r activ i t y a n d j o i n t m o b i l i ty u n i n fl u ence d by t h e exa m i ne r . Any force a p p l i e d by t h e exa m i n e r may be less tha n , equal to or gre a t e r t h a n t h a t used by t h e p a t i e n t ; we t h e n h a ve c o n We

centric ( resisted) m o v e m e n t , isometr i c resista nce, or ecc e n t r ic m o v e m e n t . Each t e c h n i q ue e x a m i n es m u scul a r function ( t h e s t r e n gth of m u scle, reaction to p a i n provoked i n t h e muscles, e v e n coord i n a tion ) . Pass i ve move m e n t shows the d egree o f m o b i l i ty of j o ints a n d m a y at the s a m e t i m e reveal musc u lar t e n s i o n or s p a s m . E x a m i nation o f a p a r t i c u l a r j o i n t m a y d i sclose norma l , i nc reased, o r restricted m o b i l i t y . T h i s m a y affect functio n a l m o v e m e nt as wel l a s j o i n t play (see Chapter 2) . Th e fol l ow i n g c h a nges s h o u l d be looked fo r d u ring exami nat ion:

Fi g ure 4.2 (con t i n u e d )

The i n d i v i d u a l root s y n d romes are dealt with i n Chapter 7 . T h e dermatome c h a r t o f H a n s e n a n d Sch l i ack ( 1 962 ) is rep rod uced here ( Figure 4.2a-e and g) toget her w i th t h a t of Keegan ( 1 944 ) (F i g u r e 4.2f) for the l eg. I t s h o u l d be poi n t e d o u t t h a t to t h is day there is no g e n e r a l l y a cce p t e d d e rma to m e chart, w h ich m a y per h a ps be e x p l ai n ed by the fact t h a t d e r m at o m e s v a ry from o n e s u bj e c t t o the n e x t . A n i m po r ta n t poi n t i n t h e H a n se n a n d S c h l i a c k ( 1 9 6 2 ) cha rt is the i r 'cerv icothoracic a nd lum bosacra l h ia t u s ' : segm e n ts C5-T I a n d L2-S2 d o n o t a p pear o n t h e tr u n k , b u t o n l y o n t h e extrem ities. O n t h e s c a p u l a r line on the ba c k t h e re is a 'step' which these a u th o rs consider to be t h e r e g i o n w h e re the dors a l a n d v e n t r a l rami m e e t . I n conclusion, i t can be s a i d that t h e re is a w e a l t h o f de tecta b l e s i g n s o f re fl e x c h a nges d u e t o p a i nfu l ( n ociceptive) s t i m u l a t ion i n t he s k i n a n d u n d e r l y i n g t i ss u e s , i n m u s c l e s , pe r i o st e u m , te n d o n s a n d l igame n ts , a l l o f w hic h ca n be d i agnosed c l i n i ca l l y and some of which c a n be regi stered ( s k i n tempe ra t u re . ele ctrical resistance, e tc . ) . These signs enable us t o m a k e a c l i n ica l d i agnosis a n d to locate those changes t h a t can be the o b j ec t of s pec ific and a d e q u a t e t h e ra py .

7,?00

1.

Limi ted range o f movement com pared with the sym m e t r ical joint o r a neighbo u ri n g s p i n a l motor segme n t , the ' p a t h o l ogical b a r r i e r ' of A m e r i c a n os t e o p a t h s ; this h a s been regi s t e re d r e m a r k a b l y s u cc e s s fu l l y by a de v i c e constructed by Berger ( 1 982 ) , wh i c h i s l i ke l y to prove very i m p o r t a n t fo r acc u r a t e a n a lysis o f i m pa i red mob i l i t y (see Fi g u r e 4.32b, c , p. 1 1 2 ) . 2 . R e s i s t a n ce d u r i n g m o t i o n , particu l a r l y d u ring t h e exa m i n a tion of joint p l a y . 3 . R e s i s t a n ce or s p ri n gi n g i n t h e e n d - posi t i o n . T h e p a t h o l o gi c a l barr i e r , i f e n ga g e d , d o e s n o t s p r i n g . H e re i t is e s sent i a l to t a k e up the s l ack of both functi o n a l move m e n t and j o i n t p l a y . This resist a nce in e n d-position has been r e g i s t e red by F i gar and Kra usova ( 1 975) u s i ng a re s i s t a n c e transducer, i n a b l ocked ce rvical seg m e n t before tre a t m e n t , d u r i n g a h i g h - v e l o c i t y thrust a n d a Eter treatm e n t ( Fi g u re 4 . 3 ) . A d i agnosis o f move m e n t res tricti on ( b l o c k a g e ) i s u s u a l l y fol l owed by e x a m i n at i o n for the directi o n o f

Kraft in N (9) 77,3 (7730) 7c,3 (7230)

12,00

O ��AL------��--�-�-(a)

(b)

(c)

Fi g ure 4.3 Record i n g re s is t a n c e i n t h e e n d - po s i t i o n by t h e m e t hod o f Figa r a n d K ra u sova (1 9 7 5 ) . (a) I n c r e a s e d in t h e block e d seg m e n t . ( b ) The fo rce req u i red fo r thrust m a n i p u l a t i o n i n t h e blocked se g m e n t . (c) E q u a l res i s t a n c e i n all seg m e n t s a ft e r m a n i p u l a t i o n . A w e i g h t o f 4 0 0 g w a s u s e d a s a g a u ge re s i sta n c e

Copyrighted Material

94

Manipuiariv(! Therapy in Relwb ilira riol7

Figure 4.4 The

m e c h a n i s m o f l a t e ra l fl e x i o n

of rhe

Lacamaror Sysrem

in t h e

Figure 4.5 Co m p a rison o f t h e l e v e l o t h e r s y m m e t ri c a l s t r u c t u re s . usi n g

the i l i a c c r e s t s o r spirit level

of a

l u m ba r s p i n e

rest r i c t i on ; t h e ra pe u tic tec h n i q ues a re concerned m a i n l y w i t h m o b i l izati o n i n a specific d i rect i o n . W i t h

move m e n t res t r i c t i o n i n t h e s p i n a l co l u m n , howev e r , it is someti m e s o f i n terest to n o te n o t o n ly t h e d i re c t i o n of restriction but a l so w h i c h o f t h e two i n te rv e r te b r a l apophyse a l j o i n ts is i n v o l ve d . H o w e v e r , t h i s is not a lways easy to d e te r m i n e a n d , i n f act , m o s t tech n i q u e s a re e ffecti v e i f a p p l i e d i n t h e correct d i re c t i o n , w h i c h e v e r j o i n t i s a ffected . The q ue s t i o n o f w h ich s i d e is a ffected is most r e a d i J y solved in t h e lumbar region by s i m p l e c l i n i cal e x a m i n a t i o n , beca use h ere axial rota tion is not po s s i b l e and t h e refore a c o m b i n a t i o n o f restri c t i o n in t h e sagi t t a l a n d coro n a l p l a n e s s h ows c l e a r l y w h ich s i d e i s i n volved . It can b e e a s i l y u n d e rstood that o n a n te fl e x i o n t h e a r t icu l a r s u r faces a re i n e n d to-end position , w h e r e a s i n retrofl e x i o n t h e y a r e i n fu l l c o n t a c t . D u r i n g s id e - b e n d i ng, h owever, t h e artic u l a tion o n t h e c o n v e x s i d e i s i n a n e n d - t o - e n d pos ition as d u r i ng a n te fl e x i o n , w h e re a s t h a t on the c o n c a ve side i s in fu l l c o n t a c t as d ur i n g re tro fl e x i o n ( F i g u re 4 . 4 ) . T h e re fore, rest ricted retroflex i o n a n d s i d e - b e nd i n g to o n e s i d e s h o w s t h a t the j oi n t o n t h e s i d e o f restricted l a te rofl e xion i s a t fa u l t , w h e re a s restricted a n te fl e x i o n a n d s i d e - b en d i n g i n d icates t h a t t h e j o i n t o n the s i d e o p p o s i t e to restricted l a terofl e x i o n i s l es i o n e d . I n t h e r e s t o f t h e s p i n a l col u m n , i n p a r t i c u l a r i n t h e cerv ica l region, a comb i n a tion o f la t e r o fl ex i on a n d a n te - or r e t ro fl e x i o n m a y be h e l p f u l : if l a tero fle x i o n i s restricted ( m a i n ly ) in re troflexion i t is t h e j o i n t o n t h e s i d e to w h i c h we s i d e - b e n d t h a t i s a ffec t e d ; i f i t i s m o re rest ricted i n a n t e fl e x i o n t h e j o i n t o n t h e o p p o s i te s i d e is b l ocked .

E x a m i n ati o n of t h e l ower extrem ities a n d t h e pelvis is n o n e e d to repeat h e re w h a t f h a v e a l re a d y s a i d a b o u t t h e gene ra l e x a m i n a t i o n o f p os t u re . f t is

T h e re

i m portant t o a ssess t h e a rch o f t h e fo o t i n both p l a n e s . To c o m p a re t h e fee t it is useful to pla ce one fi n ge r under t h e a rc h of each, from the medial a s p e c t : w h e re t here i s a fl a t foo t , t h e fi n ge r m e e ts resist a n c e . [t m a y be even m ore revea l i n g to exa m i n e t h e arch as i t fu n c t i o n s ( i n w a l k i n g ) : from t he m ed i a l aspec t we c a n s e e w he t h e r t h e a rc h sags (decom pen sation of fl a t foo t ) . F o r the fu n c t i o n o f t h e whole l i m b i t i s v e ry i m p o r t a n t t o note va lgosity o f t he heel a n d t h e d egree of e x te r n a l rola t i o n o f the foot ( i . e . of t h e h i p ) . Exa m i n i ng t h e k n e e , we a r e interested b o t h i n va rosi t y a nd i n v algosity, a n d i n t h e ge n u rec u rv a t u m . Flexion i n the h ip j o i n t w h i l e s ta n d i n g i s c h a ract e r i s t i c of h i p j o i n t i n v o l v e me n t : i t prese n ts itself, h o w e v e r , by i n c rea s e d l o rd os i s ( u n l i k e l u m b a g o ) a n d by k n e e fl ex i o n . For more d e t a i l ed e x a m i n a t i o n o f t h e pe l v i s , p a l p a t i o n is n e e d e d . Fi rst t h e i l i ac cres t s s h o u l d be p a l p a t e d . T h i s i s m o r e d i fficu l t t h a n i s us u a l ly t ho u g h t : i t m u s t be done from above, fro m t h e r i bs d o w n - t h e crests ca n be m uch h i g h e r t h a n one w o u l d e x pect from the s h ape o f t h e b u t toc k s , i . e . close b e l o w t h e lowest r i b . I f t h e h i p s d ev i a te to o n e s i d e t h e i l iac crests a l s o dev i a t e , a n d t h e r e fore i t i s n o t d i ffi c u l t to p a l p a t e t h e crest on t h e s i d e to which t h e p e lv i s d e v i a t e s , b u t g r e a t e r p r ess ur e is need e d t o g e t o n t o p o f t h e i l iac crest o n t h e o t h e r s i d e . T h e i l i a c cre s t t h u s a p pea rs h i g h e r on t he s i d e to w h i c h t h e p e l v i s s h i fts, u n l e s s g r e a t ca re i s exercised . To be s u re th a t the i l i a c cre s t s a re at t h e s a m e h e i g h t i t i s w i s e to c h e c k w i t h a s pi r i t leve l (Figu r e

4 . 5) .

The i l i a c crests s h o u l d be p a l p a ted l a t e r a l l y ( a t t h e h ighest poi n t ) a n d fo l lowed towa rds b o t h posterior s u pe r i o r i l i a c s p i n e s , and note t a k e n w h e t h e r the two p a l p a t i n g h a n d s c o n v e rge. Both t h e p o s t e r i o r a n d t h e a n t e ri o r i l i a c s p i n e s po i n t d o w n w a rd s a n d s i d e w a y s a n d h a v e therefore t o be p a l pated f ro m be l ow a n d from t h e s i d e in order to fi n d the correspo n d i n g poi n ts .

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At t h e s a m e tim e w ei g h t dis tri b u t ion c a n be e x a m ined on t wo sca les ( F i g u r e 4 . 6 ) , w i t h a nd w i t h o u t a heel - p a d o n t h e lower s i d e , t o see w h e t h e r the p a t i e n t i s b e tter a b le to a s s e s s e q u i l i b r i u m w i t h or w i t h o u t the p a d . The s u bj e cti v e react ion i s test e d by as k i n g t h e p a ti e n t w h e t h e r he fee l s h a pp i e r w i t h a h e e l - p a d , or w he t h e r it m a kes no d i fference. ( J n view o f static c o r rec t i o n an X- ray c heck is nec e s s a ry : see pp. 39-43 . ) If w e co nclude t h a t t here i s a d i ffe r e nce i n l e g le n g t h we a g a i n c h ec k w hether t h i s i s d ue to a s y m m e t ri c a l d e f o r m i ty a t t h e k n e e (va lgosity o r varos i ty ) or to a one-sided fl a t foot, i n w h ich case a n a rc h s uppo r t is more app r o p r i a te th a n a he e l -p Cl d . Bes ides o b l i q u i t y , t he p e l v i s m ay be r o ta t e d a s a w h o le in rela t i o n to the s h o u l d e r g i rdle a nd the fe e t . I ncl i na t ion (rec l i n a t ion) of the pe l v i s is assessed by c o m p a r i n g the h e i g h t of the a n te r i o r a n d p o s t e r i o r u ppe r iliac s p i n e s . Pe lvic distortio n

Fig u re 4.6 Ex a m i n a t ion of s y m m e t r i c a l s t a nce scales in fro n t 0 1 a p l u m b - l i n e

a ll

two

I f both i l i a c c r e s t s a re a t t h e s a me h e i g h t - a n d t h is is a lso t r u e o f t h e a n t e ri o r a n d p o st e r i o r i l i a c spines - t h e p e l v i s i s h o r i z o n t a l and t h e legs a r e p ro b a b l y o f e q u a l l e n gt h : i f t h e i l i ac cr e s t i s h ig h e r on o n e s i d e - a n d the s a m e is t r u e o f both a n terior

a n d pos t e r i o r s u perior i l i ac s p i n e s - and if the A n g e rs pa l p a t i ng t h e crests t o w a r d s t h e pos ter io r spines meet, t h e re i s pe l v i c o b l i q u i t y and t h e m o s t p r o b a b l e re ason i s d i ffe rence i n l eg l e n g t h . Pelvic o b l i q u ity Me a s ur e m e n t of leg l e n g t h i s m o re d i fAcu l t th a n might be t h o u g h t , beca u se t h e fe m o r a l h e a d s a n d n ec k s a re h i d d e n . Pe l v i c o b l i q u i ty i s t h us t h e m o s t re l i a b l e c l i n i c a l s i g n of d i f fe r c nce in le g l e n gt h , u n l ess t h i s i s c a u s e d by a d i tle re n ce in the l e n g t h of the le g s below t h e k n e e , a c o n d i t i o n w h i c h ca n be rea d i l y H ss e s se d , e . g. w i t h t h e pHtient s u p i n e , w i t h k n ees fl e xe d . T h e e x a m i nat i o n o f a p a t i e n t s t a n d i ng, w i t h b o t h l e g s s t r a i g h t , u s u a l l y d e tects d e v i a t i o n o f the p e l v i s towa rds the h i gher side; in t y p ica l cases the s h ou l d e r i s l o w e r on t h e side w h e re the p e l v i s is h i g h e r . The (cl i nica l ) e ffect of a h e e l p a d shou l d t h e n b e t e s ted : i f t h e pe l v i s i s leve l a fter the heel has been ra ised on t h e l ow e r side, t h e re s h o u l d be n o s i d e-s h i ft a n d t h e s h o u l ders s h o u l d h a v e l e v e l l e d o u t . Howe ver, t h i s te s t i s usefu l only i f there is n o maj or move m e n t r e s t r i c t i o n a nyw h e r e i n the spine.

T h is is a curious p he n o m e n o n w h i c h m us t be d i s t i n gu i s he d fro m p e l v ic o b l i q u i t y a nd i s a lways s e c ond a ry to some othe r lesion which s h ou l d be fo u n d a nd t re a ted. In the r e a r view t h e pelvi s devi a tes s l i ghtly to one s i d e ( u s u a l l y to t h e r i g h t ) a n d is s l i gh t ly rot a ted ( u s u a l l y to t h e l e ft) . P a l p a t i n g of t h e i l i ac c r e s ts s h ows that t h e y a re more or less o n the s a me leve l l a t e r a l l y , but as the A n g e r s p a l pate towa rds t h e posterior s u p e r i o r s p i n e s t h e y do not meet: o n e s u p e r i o r p o s t e r i o r s p i n e (usu a l ly t h e righ t ) l i e s h i g her t h a n t h e o t h e r . T h i s c a n be confi rmed by d i rect p a l p a t i o n of t he spi ne s . In the fro n t view the converse i s fou nd : here the r i g h t a n t e r i o r su p e r io r i l i a c s p i n e is usu a l l y lower a nd t he l e ft h i g h e r . The two i l i a seem to be d istorted one a g a i ns t t h e o t he r . Thus t h ere is a l ways a d i sc r ep a n cy i f t h e i l i ac c r e s t s , a nd t h e a nt e rior a nd p os te r i o r superior i l i a c sp i n e s , are c o m pa re d , b u t re l a t i o n s vary s o m u c h here th a t t h e differ e nce a t t h e a n terior o r pos terior sp i n es m a y b e g re a te r o r sm a l le r , a n d t h e crests a cc o rd i ng l y level o r no t ; confus ion w i t h pelvic o b l iqu i ty c a n e a s i ly occur ( Figure 4 .7 ) .

F o r t h i s reaso n, i f e x a m i na t io n s h o w s s i g ns o f p e l v ic ob l i q u i ty w ith some d i s c re p a ncy o n p a l p a t i o n of t h e most i m port a n t p oin t s on t h e pe l v i s , t h e best a p p roach is to t r e a t the pe l v ic d i stortion il rst, a n d t he n to re -exa m i n e fo r pe l v i c o b l i q u i ty , A n o t he r fe a t u re of pelvic d i s to rt i o n is i m po r t a n t because i t po i n ts to d i s t urbance of fu n c t i o n : th e ' o v e r t a k e ' p h e n o m e n on , in whi c h on s ta n d i n g or s i t tin g t h e l e ft su per i o r poste rior i l i a c s p i n e i s Ll s u a l l y t h e lower, b u t ov e rt a k es t he r i g h t on s to o p i n g , b e c o m i n g t h e more cra n i a l of t h e two fo r a s h o r t t i m e (less th a n 20 s ) , a fter which t h e t w o spi ne s a re leve l a nd re t u r n t o a s y m m et r ic a l posi t i o n . If t h er e is n o overta ke p h e n om e n o n o n s t a n d i ng we s h o u ld ex a m i n e it w i t h the p a t i e n t s e a t e d o r w i t h both

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96

M a n ip u la t i v e Therapy

ill Rehab ilitalion or Ihe LocomolOl" Syslem

figure 4.7 Pe l v i c d i s t o r t i o n i n a c h i l d . N o t e t h e typica l p e l v i c a sy m m e t ry

knees s l i g h l ty b e n t so as to e x c l u d e t h e p u l l o f t h e h a m stri ngs. F i g u r e 3 . 1 2 ( see p . 48 ) s hows t h a t the s a c r u m m u s t l i e a sy m m e t ri c a l l y b e tw e e n t h e i l i a i n s u c h a w a y a s to c r e a t e m o re t e n s i o n o n t h e s i d e o f t h e l o w e r p o s t e ri o r s u pe ri o r i li a c spine; as a r e s u l t i t fol lows the s a c r u m mo re p ro m p t l y in stoopi n g . ca u s i n g t h e ' o v e r ta k e ' . T h e fi g u re s h ow s clea rly t h a t i n t h e s u p i n e posi t i o n t h e r e i s grea t e r e x t e r n a l r o t a t i o n o f t h e le g o n t h e s i d e o f t h e l o w e r p o s t e r i o r spin e , a n d t h ere m a y be w h a t D e r b o l o w s k i ( 1 956) h a s ca l l e d a

' v a ri a b l e d iffe ren c e ' i n l e g l e n g t h - i . e . o n e l e g m a y be a p p a r e ntly s h o r t e r i n t h e s u p i n e p o s i t i on . whe re as on s i t t i n g t h i s is r e v e rsed . M ore s i gnific a n tl y , i n t h i s co n d i t i o n th ere i s u s u a l l y musc u l a r i m b a l a n ce i n t h e p e l v i c re g i o n : s p a s m of t h e i l i a c u s is freq u e n t on t h e s i d e o f t h e l o w e r p o s t e r i o r s p i n e a n d t h e fu n c t i o n o f t h e g l u te a l m u sc u l a t u re is f re q ue n t l y a s y m m etrical. but m u c h d e p e n ds o n the ca use of the p e l v i c d i s t o r t i o n , w h i c h , as I h a v e s t resse d , is always sec o n d a ry .

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Exam ination of /ocomolOr function and its disturbance

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ex a m i n e . The p a t i e n t i s t h e n t o l d e i t h e r t o r a i s e t h e

p e r fo r m i n cases where p a l pa t i o n o f t h e P S I S a n d

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i s aga i n s u p i n e

a n d t h e e x a m i n e r aga i n

grasps t h e k n e e a n d a d d u c ts t h e th igh a c r oss t h e p a ti e n t ' s p e l v i s , b u t w i t h o u t fi x i n g i t wi t h t h e o t h e r h a n d . I n s t e a d h e conti o u e s a d d uc t i o n u n t i l t h e p e l v i s begi n s t o rotate , i . e . t h e poste r i o r s p i n e b e g i n s to l i ft fro m the ta b l e . A t t h i s p o i n t t h e s l a ck is t a k e n u p at the sacro i l i a c j o i n t a n d the ex a m i ne r pl aces a fi n ge r o f h i s free h a n d betwe e n t h e poste r i o r s u p e r i o r s p i n e a n d t h e s a c r u m , s o a s to p a l p a te move m e n t ( s p r i ng i n g ) . W i t h o u t i n c reasing a d d u c t i o n he n o w e x e rts

s l i g h t pressure a ga i n s t the p a t i e n t ' s k n ee in t h e d i rection o f t h e a x is o f t h e t h i g h ( t a k i n g u p t h e s l a c k ) a n d f r o m t h i s p o s i t i o n s p r i n gs t h e j o i n t b y a g e n t l e p ush i n t h e s a m e d i re c t i o n ( Fig u re 4 . 9 ) . The force w i t h which t h e sacr o i l i a c j o i n t is s p r u n g i n t h i s tech n i q u e p r o d u c e s a dorsa l s h i ft o f t h e i l i u m aga i n s t t h e sacr u m , i . e . a m o v e m e n t m a i n l y i n t h e sagi t t a l p l a n e . T h i s t e c h n i q u e i s very p o p u l a r b u t d i ffi c u l t beca use w e h a v e t o e n gage t h e barri e r twice : fi rs t

Figure 4 . 8 T h e ' s p i n e sign ' : c o m p a ri s o n o f t h e d i s t a n c e between t h e t w o t h u mbs pl aced o n t h e s p i n o u s process of LS a n d t h e PS I S , r e s pe c t i ve l y . when the p a t i e n t s t a n d s w i t h b o t h l e gs s t ra i g h t . t h e n w i t h o n e leg b e n t a n d t h e h i p d ro p p e d

w h e n we t u rn t h e p a ti e n t t o t h e po i n t w h e n t h e PSIS begi n s t o be l i ft e d . a n d t h e n when a p p l y i ng a x i a l press u r e o n t h e p a t i e n t ' s k n e e . T h e re i s a n o t h e r v e r y usefu l m e t h o d fo r s p r i n g i n g t h e s a c ro i l i a c j o i n t . The p a ti e n t l i es o n h e r s i d e , a n d

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98

Manipulative Therapy in Rehabilitation of the L ocomotor System

Figure 4.9

S p r i n g i n g the sacro i l i ac j o i n t : w i t h t h e p a t i e n t

s u p i n e , o n e leg flexed a t the h i p a n d k n e e

a n d add ucted on the

across t h e p e l v i s , t h e t h e r a p i s t e x e r t s press u re pat i e n t ' s k n e e

t o stabil ize the pelvis it is best i f t h e lower leg is extended a n d the upper fl exed, with t h e knee on the ta ble. The operat or p u ts his forearm (soft muscles) o b l i q u e l y over the patient's i l i ac crest, so as to p rod uce gapping between t h e poste rior superior iliac spine a n d t h e sacr u m . This is achieved by slight pressure i n a ventromediocran i a l d i recti o n , b u t great ca re m ust be taken not to rotate t h e pelvis. Gapping is fe lt with t h e thumb o f t h e other hand, between the posterior su perior i l iac s p i n e and t h e sacrum ( Figure 4 . 1 0 ) . This techn i q u e t h u s prod uces a movement o f the i l i u m against the sacrum io the horizo n t a l p l a ne , and i t is importa n t to point o u t t h a t i t ca n revea l bl ockage even i f the tech n i q ues d escribed a bove show normal mobility. R hythmic repe tition of this m a n oe u vre evokes excell e n t mobil ization, a n d i t ca n be used as a high-velocity t h rust a fter ta k i n g u p t h e s l ack (see p . 179) . S p r i nging of the sacroiliac j o i n t c a n o n l y be examined a t the upper or lower end; fre q u e n tl y o n l y

Figure 4. 11

P a l p a t i o n o f m o b i l i t y a t t h e uppe r p a r t o f

the

s a c ro i l i a c j o i n t w i t h t h e p a t i e n t p ro n e

one part o f the j o i n t is blocke d . I f restriction is fou n d at t h e u pper end t he exa miner p laces his t h u m b o r fi n g e r on t h e upper end of the s a c r u m , w h i l e the other hand grasps the a n terior s p i n a ( A S IS) from below, t h e patient ly i n g pro n e , and l i fts i t rhythmically i n a vertical d i recti o n . I f t h e re is no restriction t h i s l i fting move m e n t should ha rdly be fel t a t all a t t he base of the sacru m . I n blockage, however, i t is clearly fel t by the p a l pating t h u m b (Figure 4 . 1 1 ) . A t t he lower e n d o f t h e sacrum t h e exa m i n e r d i rectly springs the end of the s a c r u m o n the r i g h t a n d on t h e l eft w i t h h i s t h u m b , from above, and com p a res the degree of resistance o n e i th e r s i d e . T h e m ob i l ization tec h n iques shown i n C h a p t e r 6 can be used for d i agn osis. The re are typica l pain points a t t he upper and lower e d ge of the sacroi l iac joint on the sacrum where increased resista nce to spri nging may be fe l t, a n d a tender a t t achment p o i n t of the add uctors a t the symphysis. We fi n d a s l ightly posi tive Patrick's sign w i t h the straight leg raisi n g test, but n o pain is felt i f the patie n t is s itting u p w i th l egs o u ts tretched ' There is some back-be n d i ng a n d/or stooping restric t i o n , and p a i n rad i a tes in the SI dermatome.

Sym p hysea l s h ift

Figure 4.10 Wit h t he p a t ient lying o n h e r si d e the therapist i l i u m in an o b l i q u e ventromed iocra n i a l d i rect i o n , w i t h h i s fore a r m , to produce ga p p i n g between

spr ings the

t he pos t e r i o r sacro i l i a c spine a n d the sacru m , w h i c h h e pa l pa t e s w i t h t h e

t h u m b of t h e o t h e r h a n d

A n o t h e r c l i n ic a l l y importa n t lesion ca n be described as 'symphysea l s h ift ' , the n a t u re o f w h ich is d i scus sed below. O n palpa tion with the patient supine we fi n d t h a t t he pubic bones close to the sym physis are not leve l ; i n most cases (83 o u t of 92 examined) the right was lower than the left. I n a l l these cases there was also a s h i ft at the isch i a l tuberosity i n the prone pos i t i o n . In 3 9 cases the t u b e rosity was lower on the side where the pubic bone was lower; in 53 cases it was lower on the opposite s i d e . The symp hysis a n d a djacent parts o f t h e p u b i c b o n e m u s t b e p a l pa ted from above, t h e fingers p a lpating t h e upper edge of the symph ysis t h rough t h e a b d o m i n a l wa l l , then

Copyrighted Material

Exan-zinalion of locopnortH of

m o v i n g from s i d e t o t h e b o n y s t r u c t u re s . p a l p a te d from below ,

from

diSlurbance

p os i t i o n , o n e

99

A S I S ro ta te d

w i th t h e whereas t h e

other is m o r e p r o m ll1 e n t a n ci

i n w a rd s ('in-

t h e gl u te a l l i n e . O n l y a d i ffere nc e of a p p r ox i m a t e l y

fl a re ' ) . H e n ce the t ri a ng l e for m e d b y b o t h A S rS a n d

2 c m is s i g n i fi c a n t . W he re t h is c h a n ge i s c l i n ic a l l y rel e v a n t we fi n d

t h e n a v e l i s distorted. If t h i s i s n o t m e r e a s y m m e tr y , w e fi n d r e l a t i v e hy perto nus a t t h e l ower a b d o m e n

te n d e r n ess a t t h e symphysis with c o rresp o n d i n g TrPs

o n t h e s i d e o f i n fla r e a n d de creased t o n u s o n t b e

in the s t r a i g h t a b d o m i n a l m usc l es a n d h y per t o nus i n

s i d e o f o u t fl a re . ( F o r m o re a b o u t t h i s l e s i o n see

o n e b u t toc k , n o t n ec e ssa ril y accomp a n i ed b y p a i n .

C h a pter 8, p. 257)

,

Com p a r i n g res i s t a nce o f d e e p fas c i a s w h i l e s h i fti ng e a c h o f the but t o ck s i n a c r a n i a l d i re c t i o n , t h e r e i s i n c reased r e s i s t a n c e o n the side of t h e h y p er to n us , w he re the tuberosi t y

pa l pati o n sacroi l iac .

Th i s sh i ft i s p robil b i y b l o c k age; i t was n o t '

cases a n d speci fi c treal nlCllt h a d no effect o n t h e ,

of o ur

The 'S'-reflex ( S ilverstol pe-S ko g l u n d ) S i l ve rstol p e c l i n i ca l l y freq u e II I c a l l ' p e l v i c d ysfu nc ti on

thrust ! )

t h ro ug h ou t t h e

that on

s t e p i s t o fin d a

ex a m i n a t i o n i n t h e

could

b e de te c t e d e i t h e r a t I

t uber

-

osities. However, whc

'

section of t h e exam-

l e ft s i d e where i n a ti o n , p ro v o k m g

we p r o d u ce

te n d er n ess of t h e sy m p h y s i s w i t h t r i gg e r p o i n ts a n d h y p e r t o n us

c o n t r a c t i o n o f t he low lumbar p a r t o f t h e e r e c t o r

o f the a b d o m i n a l m us c l e s , t h e pat i e nt s h o w s forw a rd

s p i n a e w i t h d o rs i fle x i o n o f t h e p e l vi s . If t hjs i s t h e

d r a w n pos t ure . T h i s c a n be c o r rected b y s pec i fic

c a s e w e usua l l y find a v e r y t e n d e r poi n t i n t h e l a te r a l

,

t h e r a p y . I t i s p r e c i s e l y t h i s forward-drawn p osi t i on ca used m a i n l y by i ncre a s e d te n s i o n o f t h e a b d o m i n a l

,

m u s c l e s , w h ic h i s the most rele v a n t l e s i o n a n d s h o u l d be rout i ne l y l oo k e d for .

I

region o f t h e b u t to c k o f t h e s a m e s i d e a t t h e lev e l o f t h e tip o f t h e cocc y x . F r o m t hese fi n d i ngs

we

can

that

fo re te l l

at

h and w i t h

p a lpa ti o n of t h e sacro t u bero us l i g a m e n t w e w i l l fi n d a h ar d a n d e xtreme l y t e n d e r p o int Th i s i s

i n creased t e n s i o n o t t h e m use-I e s o f t h e h a e- k a n d

rea c h e d b y t h e fi n ger a t I'he side o f t h e coccyx

I n t y p ica l c a s e s t h is g o e s hand i n

th is

.

p o i n t i n g i n a c l:t n i a l

i n cre ased te n s i o n V ery fre que n t l y we a lso

fi n ger fe e ls

t h e l o w e r e x t rem i ty

e re c t o r sp i nae

,

s h a r p p a i n At t h e .

I

t h e fi b u l a r h e ad w i t h Origi n a l l y

we

b u t ! ock d i s a p pe a r

e ffect is p ro d u c ed

use d X - r a y , th e

isc h i a l t u b e ros i t i e s and the symphysi s did n o t cha nge po sitio n e v e n if at p a l p a t i o n the d i ffere n c e s w e re ,

consi d e ra b l e . W h a t , h ow ev e r , d i d c h a n ge was the p os i t i o n of our pal p a t i n g fi n ge rs . T h e i m p ort a n t c o n c l us i o n is t h a t i f we p a l p a te b o n e t h r o u g h s o ft t i s s u e of u n eq u a l tension we m u st be p r e p a re d for 'palpa/ory { llusion ' , a p h e n o men o n w h i c h is m ost i m port a n t i n the i l1 terpre ta t i on of fi n d i n gs by p a l p a t i o n ( Fi g u re 4 . 1 2 ). More about t h i s

It is much mOle u n de rly i n g m. d i a phragm

which

by

our

A ten der coccyx A t e n der coccyx s h o u l d n e v e r b e m issed a t e x a m i n a ti o n o f t h e p e l v i s ; i t i s fa r more fre que n t l y a s ig n o f l ow - b a c k p a i n t h a n o f coccvgod y n i a (a m u c h l e ss

as simp l e as i t is a t t h e ve n t ra l

.

reac hed

.

pa i nfu l t e n s i o n t h ro u g h O il I I

coccyx, a n d i t

l i te ra t u r e a l so

lig a m e n t . fro m t h e t h e p elvic

p a l p a t i ng fi nge r. (For m o re abo u t t h is s y n d ro m e s e e C h a p t e r 8, p p 259-260)

common condition Co rr e ct p a l p a l

the

p art be

esse nce o f t h i s c h a ng e toms are very va r ied

.

t h i s s t ri k i n g

It seems u n li k e l y

manoeuvres' for t r e a l e v e r , w h e n t h e e ffe c t

moment the

b u t not o f tenderness t i p of t h e coccyx t h a t

dow nsl i p or

p res e n ts th is

Figu re 7 . 2).

more difficult by

Innominate shear dysfunction

p o ss i b l e e v e n t o r e a c h t h e t i p of t he coccyx , i n w h i c h c a s e a n e x t r e m e l y t e n d e r coccyx mu s t be

A cl i n i c a l l y i m po r t a nt c h a nge desc ribed by Gre e nma n

assumed.

'

made even gl u tei present may

not

be

(1 986) as i n n o m i n a t e s h e a r d y s fu n c t i o n ' is o c ca s i o n

I n a d d i t i o n to t h i s m ost imp or t a n t s i g n there c a n

a l l y fou n d , ma i n l y aft e r a fa l l (t r a u m a) ; i n t h e su p i n e

b e a v i s i b l e h y pe ralges i c z o n e o n t he s a c r u m , l o o k i ng

'

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1 00

Manip ula ti ve Therapy in Rehab ilitation of the Locom o t o r System

( a)

( b) Figure 4.12 Pa l pa t o r y i l l u s i o n : p e l v i c X - r a y s h o w i n g s y m m e t rica l p o s i t i o n o f i s ch i a l t u b eros i t i es t re a t m e n t . W h a t h a s c h a n ge d i s t ile p os i t i o n o f t h e e x a m i n e r ' s fi n ge rs

l i k e a c u s h i o n o f fa t covered by very s m o o t h ( t a u t ) s k i n ; P a t r i c k ' s s i gn m a y b e s l i g h t l y p o si t i v e on b o t h s i d e s , a n d t h e s a m e i s t r u e o f t h e s t r a i g h t l e g ra i s i n g t e s t , as w e l l as of s p a sm of t h e i l i a c u s .

(II) be fore a n d ( iJ )

a ft e r

L i g a m ent p a i n Close l y re l a t e d to b o t h s a c ro i l i a c les i o n s a n d t o t h e te n d e r coccyx t h e re i s t h e c o n d i t i o n k n o w n a s

Copyrighted Material

Examination of /OCDI110rOr function an d irs disturbance 'liga m e n t p a i n ' ( H a c ke t t , 1 95 6 ; B a r bor, 1 964) . I t i s exami ned a n d e l icited b y tec h n iques t h a t a r e t hought to prod uce tension i n the liga m e n ts. Accord i n g to Hackett ( 1 956) and B a r bor ( 1 964) three l i gaments are conce r n e d : these a re the sacroiliac, t h e i l io l u m bar and t h e sacrotub e r o u s ligaments. The first two appear to be of consi d e ra b l e cli nical i mportance. The fo l lowing te chn ique is used to p rovoke the p a i n . The p a t i e n t l i e s s u p i n e on t h e t a b l e , a n d the examiner (standing by t h e table) grasps the further knee, flexes the patie n t ' s h ip and a d d ucts t h e k nee; at about 90 degrees o f h i p flexion and add uction the i l i olumbar l iga m e n t is tested ; if fl e x i o n goes fu rther (7 0-60 d egrees) the sacroi l i ac l i ga m e n t s are tested. I f the operator fee l s resistance to i n crease o n furt h e r add uction he h o l d s t he pressure aga i ns t t he k n e e i n t h e d i rection o f t h e a x i s o f t h e thig h . th us prod ucing a ga pping e ffec t a t the site of t h e l iga m e n ts, and m a i n ta i ns t h i s p ress u re for several second s . I f the iliolumbar l i ga m e n t is te n d e r , t h e p a t i e n t fee ls p a in in the gro i n ; i f t h e sacroi l i ac l i ga m e n t is t e n d e r , the p a i n rad i a tes down t h e leg i n t h e S l d e r m a t o m e ( F i g u r e 4. 1 3) . B e fore testing the l i ga m e n ts t he exa m i n e r m ust be s u re t h e sacro i l i a c j oi nts a re not bl ocked in e i t h e r t h e sagi t t a l o r t h e horizo n t a l planes. On c l os e r scruti n y , however, i n t h e l a rge m aj o r i t y of c a s e s w i t h a positive l i ga m e n t tes t, res i s t a nce t o add uction is i ncreased o n t h e pai n fu l side, so t h a t th e d i s t a n c e betwee n t h e a d d ucted k n e e a n d the table i s considerably greate r on the pa i n ful s i d e .

Figure 4 . 1 3 Te s t i n g l i g a m e n t pa i n : t h e l eg i s flexed a t t h e h i p a n d k n e e : ta k i n g u p the s l a c k i n t o a d d u c t i o n ( a rrow 2) and m a i n t a i n i n g press u re a l o n g t h e axis o f the thigh ( a rrow I ) . the t h e ra p i s t prod u ce s a gapping e ffec t b e t w e e n the i l i u m a n d t he s a c r u m ( LS ) . p r o d u c i n g t e n s i o n in t h e s a c ro i l i il c ( i l i o l u m b a r ) l i ga m e n t

[OJ

Obviously, l iga m e n ts c a n not b e t h e sou rce of t h is increased resis t a n ce and m uscu l a r spasm m u s t be looked for and trea ted . T h i s type o f p a i n is fo u n d p a r t i c u l a rl y i n hypermobile p a t i e n ts suffe r i n g fro m static p a i n .

Ex a m i n at i o n o f t h e l u m b a r s p i n e Some criteria o f pelvic exa m i n a t i o n , particu l a r l y w i t h t h e p a t i e n t standing, a r e a l s o va l i d fo r t h e l u m b a r spi n e . E x a m i na tion of m o b i li t y s ho u ld s t a r t w i t h a c t i v e move m e n t , a n d I reco m m e n d back be n d i ng. He re we a re n o t o n l y concerned with the total ra nge of move me n t , but can fol l ow i t from the t h o racol u m b a r region to the sacru m, n o t i n g reg u l a r i ty o r loca l hypo- or hypermobi l i ty . N o r m a l l y i t s h o u l d b e poss i b l e t o fo l l ow the movem e n t down t o t h e sacru m , a s t h e re is co n s i d e ra b l e mobi l i ty between L5 a nd S l i n retroflex i o n . If mobi l i ty ceases a bove S I , there is m ove m e n t restriction in the seg m e n ts above and e v e n a t the sacro i l i ac j o i n ts . I n hypermob i l i t y , on t he othe r h a n d , t h e re may be a s h a r p b e n d at t h e t horaco l u mbar or a t the l u m bo sacral j u n c t i o n . T h i s i s a freq u e n t fi n d i ng, a nd of i mportance; i f back-be n d i n g is n o t res t ricted b u t is p a i n fu l , t h i s m a y be a s i g n of ten d e r spi n o u s p rocesses. When e x a m i n i n g side-bending, care s h o u l d be t a k e n to see t h a t the p a t i e n t is i n n e i t h e r a forward n o r a backwa rd-be n t posi t i o n , t h a t t h e hands a n d a rms slide sideways dow n the legs, a n d t h a t t h e l egs a re s t r a i g h t . The patient bends a s fa r sideways as s h e c a n , a nd we n o te ( 1 ) how fa r d o w n t h e fi n ge rtips reach; (2) w h e t h e r the sp i n o u s processes a rch s y mmetrically and regu l a rly to both sides; and (3) wheth e r t h e re is rotation s y n k inesis: o n s ide-be n d i n g i t is norm a l fo r the p e l v i s to rotate towards the convexity of the c u r v a t u re , i.e . to the right w h e n b e n d i n g to the l e ft. Loss o f t h i s sy n k i nesis is often the fi rs t sign o f movement restrict i o n i n the l u m b a r spi n e a n d/or i n the sacroiliac j o i n ts. O n a nte flexion w i th t b e k n ee s h e l d stra i g h t , w e n o te h o w close to t h e floor t h e fingertips re a c h , a n d a t the s a m e t i m e note t h e a rc h o f the l u m b a r s p i n e a n d t h e p o s i t i o n o f the p e l v i s , f o r i t is import a n t to d isti nguish w h e t h e r the pelvis is m u c h bent forward w h i l e the l u m b a r spi n e rema i ns a lmost stra ig h t , o r w h e t h e r , on t h e contrary, t h e l u m ba r s p i n e a rc hes fo rwa rd w h i le the pelvis is o n ly s l ig h t l y flexed with regard to the legs. We then fol l o w the arch o f t h e spi n e , n o t i n g w h e r e i t is exagge rated a n d w h ere i t i s fl a t t e n e d . T h e r e i s freq u e n t l y a fl a t te n i ng a t t h e t h o raco l u m b a r j u nction w h i c h s h o u l d be rega rded a s physi ologica l, a n d l i t t le o r n o k y p h os i s a t t h e l u m bo sacral j u n ct i o n , with exagge rated k y phosis o f the t h o racic spine ( w h ich i s not co nsi dered n o r m a l ) . Obse rving t h e patie n t from t h e r e a r w e n o t e w h e t h e r t h e transverse processes a n d the e rector s p i nae

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Manip u lative Therapy ;n Rehllbililation of the L o comotor System

m usc l e s a r e n o t m o re pro m i n e n t on o n e s i d e t h a n o n the o t h e r , i n a n t efle x i o n . T h i s is a s i g n o f rotation usually fo u n d i n sco l i osis. In t h e t h o racic regio n t h e c o r r e s p o n d i n g p h e n o m e n o n i s p ro m i n en c e o f t h e a rc h fo r m e d by t h e r i bs. I n a d d i t i o n to r o t a t i o n t here can a l s o be tru n k d e v i a t i o n t o t h e side w h i c h i s p a r t i c u l a r l y c h a racteristic i n root synd romes. W e s h o u l d n o te n o t o n l y h o w fa r t h e fi ngert i p s a re from the floor, but a l so the opposi t e - a pa t i e n t who c a n l a y h e r h a n d s fl a t o n t h e floo r w h i l e b e n d i n g fo rward wi t h knees s t r a i g h t ; hyper m obi l i t y i s as s i gn i fic a n t a s re s t r i c t e d movem e n t . T h e p ropo r t i on s o f t h e p a t i e n t - a r m , l e g a n d t r u n k l e ngt h - m u s t of c o u rse be t a k e n i n to acco u n t . Fo rwa rd - be n d i ng w h i l e s t a n d i n g m ay be p a i n fu l a n d y e t n o t restricte d ; one reason i s the pa i n fu l a re ' d e s c r i b e d b y C y r i a x ( 1 97 7 ) . A l m o s t a t t h e begi n n i ng of fo r ward-ben d i n g t h e p a t i e n t fee l s a s h a r p pa i n , a n d a s l i g h t e v a sive re a c t i o n c a n often b e s e e n i n t he s p i n a l c o l u m n ; fo r w a r d b e n d i n g m a y t h e n p rocee d w i t h o u t d i fficu l t y b u t o n s t r a ighte n i ng u p p a i n i s a ga i n fe l t j us t b e fore t h e e r ect pos i t i o n i s reach e d . Th i s p h e n o m e n o n i s n e v e r s e e n i n a n te fl e x i o n fro m t h e s u p i n e p o s i t i o n a n d is d u e to con t r a c t i o n of t h e e re c t o r s p i n a e m uscle o n stooping; i t is a n i m p o r t a n t s i g n o f t r u e d isc l es i o n . I f, h o w e v e r the p a t i e n t fee ls p a i n o n l y as s h e s t r a i g h t e n s u p , t h i s is a sign of a rt i c u l a r b l o c k a ge ; i n s u c h c a s e s b a c k b e n d i n g i s a l so r e s tricted I f a n t e fl e x i o n is res t r i c t e d w h i l e s t a n d i n g w i t h k n e es s traig h t , i t s h o u l d a l w a y s be e x a m i ne d w i t h t h e p a t i e n t s i t t i n g o n a c h a i e t h is loca l i z e s t h e m ov e m e n t restriction i n to t h e l u m b a r s p i n e . I f t h e re is n o s u c h restrict i o n , t h e s t r ai g h t l e g r a i s i n g test i s use d , w h ic h w i l l s h o w res t r i c t i o n d u e to te n s i o n i n t h e h a m s t r i ngs B e fore e x a m i n i n g move m e n t restrict i o n i n i nd i v i d u a l segm e n ts o f t h e l u m b a r s p i n e i t is a d v i sa b l e to e x a m i n e t e n s ion ( trigger p o i n t s ) i n certa i n musc l e s co r res p o n d i n g to t h o s e s e g m e n t s . Th i s h a s a l re a d y been d e il l t w i t h (see T a b l e 4 . 1 ) . .

'

-

,

,

Figure 4.14 E x a m i n a t i o n of s p r i n g i n g of t he l u m b a r a n u t h o r a c i c s p i n e . us i n g h e e l of t il e h a n c1 coll t a c t w i t h t he a r m o u ts t re t c h e d

,

-

.

.

p rocess, i . e . o n t he tra n s v e rs e p rocesses o r o n e v e rte b r a ; t h e h y p o t h e n a r o f t h e e x t e n d e d ot h e r a r m i s the n p l ac e d across t hese fi nger t i p s , s p r i ng i n g t h e v e r tebra a fte r ta k i n g u p t h e s l a c k i n t h e s a m e w a y a s befo r e , aga i n t a k i n g ca r e t o a v o i d i r r i t a t i n g t h e spi n o u s processes ( Figure 4. 1 5 ) . I f i n cre a sed resista nce ca n b e fe l t a n d t h e pa t i e n t fee l s p a i n , t h i s i s p ro b a b l y d u e t o a rt i c u l a r b l ockage . I f, h o w e v e r , there is n o i nc r e a s e d resistance a n d y e t t h e p a t i e n t fee l s pa i n , t h ere i s l i k e l y to b e a d i sc lesi o n . T h e s p r i n g i n g tes t , howe v e r , ca n n o t l oca l ize m o v e m e n t res tr ic t i o n o r h y p e r m ob i l i ty in a singl e m otor segm ent p r eci s e l y To a c h i e v e t h is , s pe c i 6 c m o b i l i ty t e s t s m u s t b e used . .

To test re tro flexion (extension)

Exa m i nation of i n divid u a l seg m e nts i n the l umbar spine Te n d e rn ess is fi rst e x a m i n e d by p a l p il t i n g t h e s p i n o u s p rocesses w i t h t h e fi n ge r ti p s ; te n d e rn e ss i s u s u a l l y not q u i te s y m m e trica l , b u t m o r e p r o n o u nced o n o n e side or t h e o t h e r Then the s p r i n g i n g test i s a p p l i e d : th i s e x a m i n e s both res i s t a n c e a n d te n d e r n e s s o f d e e p s t r u c t u re s ( m a i n l y t h e d i scs a n d apo p h y s e a l j o i n t s) a n d a v o i d s i rr i ta t i o n of the s p i n o us proce s s e s The t h e n a r e m i n e nce of one h a n d is p l a ced o n one transverse p r oce ss and the hypot h e n a r on t h e o t h e r ; v e r y s l ight p ressure is exerted by t h e e x t e n d e d a r m t o t a k e u p t h e s l a c k , a n d t h e n to s p r i n g the v e r t e b r a by a s l i g h t ex t r a p u s h ( F i g u r e 4 . 1 4) . A n o th e r m e t h o d i s to u s e t w o fi ngerti ps o f one h a n d , p l a c i n g o n e on e i th e r s i d e of the s p i n o u s .

.

T h e p a t i e n t lies o n her side w i t h both h i ps and k nees fle x e d . T h e h i p should b e I-l e x e d t o a b o u t 1 00 deg rees. The e x a m i n e r l e a n s a ga i n s t t h e p a t i e n t ' s k n e e s w i t h h i s t h i g h s fi x i ng t h e s p i n o u s p rocess o f t h e u p p e r v e r t e b r a 0 1' t h e e x a m i n e d se gm e n t w i t h o n e fi nge r, rei n fo r ced by t h e fi n gers o r t h e o t h e r h a n d p lac ed over i t . He n o w e x e r t s s l i g h t p r e s s u r e aga i n st the p a t i e n t s knees in the p r e s u m e d d i re c t i o n o f t h e i n te rv e r tebra l disc o f t h a t se g m e n t so as t o ta ke u p t h e s l a c k , il n d t h e n s p ri n gs t h e segm e n t b y a s l i g h t a d d i t i o n a l p u s h w i t h h i s t h i g h s : h e fee l s a s l i g h t s h i ft of t h e p e l v i s a n d t h e l owe r v e r t e b r a a g a i n s t t h e o n e t h a t is fi x e d . I n c a s e s o f b l ock a ge n o m o v e m e n t i s fe l t i f th e sla c k h a s b e e n p r o p e r l y t a k e n u p . I f n o r m a l s p r i n g i ng i s fe l t , d o r s i fl e x i o n til kes pl a ce be t w e e n t w o a d j a ce n t v e rt e b rae as can be see n i n a n i m age

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Examination of locomotor .lill1etion and its disturbance

1 03

Figure 4.16 Te s t i n g r e t ro A e x i o n i n o n e l u m b a r segme n t : t h e pa t i e n t l i es on h e r s i d e , the t h e r a p ist exert i n g springing p ressLl re o n b o t h k n ees a n d fi x i n g t h e u p p e r s pi n o us process w i t h b o t h h a nd s .

i n t e n s i fi e r. I f t h ere i s h y p e r m o b i l i t y t h e r e m a y b e s o m e a d d i t i o n a l s h ift

( Fi g u re 4 . 1 6 ) ,

R e t ro fl e x i o n c a n a l so b e e x a m i n e d b y g r a s p i n g b o t h t h e p a t i e n t s fe e t a b o v e the h e e l s w i t h o n e '

h a n d , The p a t i e n t l i e s o n h e r s i d e w i t h s l i g h t l y be n t k n ees a n d h i ps a n d t h e ex a m i n e r p u ts o n e fi nger o f

h i s o th e r

h a n d be twe e n t h e s p i n o us proce sses o f t h e

m o t o r segm e n t

he

i n te n d s

to

examine.

In

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posi t i o n t he exa m i n e r s h i fts b o t h legs horizon t a l l y i n a d o r s a l d i re c t i o n p r o d u c i n g re tro fl e x i o n of t h e l u m b a r s p i n e , W i t h t h e fi n ge r o f t h e h a n d p a l pa t i n g

t h e s p i n o u s p rocesses h e

feels t h a t t h e adjace n t

s p i n o u s processes a p p ro a c h o n e anothe r . W h e n t h e

u p h e s p r i ngs t h e segm e n t i n t o t h e re i s m o v e m e n t r e s t r i c t i o n res i s t a n c e i s i n c re a s e d a n cl t h e seg m e n t d o e s n o t s p r i n g ( F i gu r e 4 . 1 7 ) .

slack

is

ta ken

re t r o fl e x i o n .

If

Exam i n a tion of an te flexio n T h e p a t i e n t aga i n l ie s on h e r s i d e w i th fl e x e d h i p s a n d k n e e s . With o n e e l b ow t h e e x a m i n e r fixes t h e u p p e r t h o r a c i c r e gio n w h i l e p us h i n g b o t h

fl e x e d

k n ees a ga i n s t t h e p a t i e n t ' s a b d o m e n , u s i n g h i s be l l y and

t h i g h s ; t h i s p r od uc e s m a x i m u m

a n te fl e x i o n .

W i t h t h e i n d ex fi n g e r o f t h e h a n d fi xi n g t h e u p p e r

t h o r a ci c s p i n e he p a l p a t e s b e t w e e n t h e two s p i n o u s p rocesses of t h e m o t o r segme n t , s e n s i n g mov e m e n t ( se p a r a t i o n o f t h e s p i n o u s p r o c e sses) a n d t e n s i o n ( a t

Figure 4.15 E x a m i n a t i o n of springing (as in Figure 4. ( 4 ) . ( a ) T o a v o i d p re s s u r e o n t h e s p i n o Ll s process, t w o fi nge rs of t h e h a n d com i n g fr o m b e l ow a re p l aced on t h e t r a n s ve rse p rocesses o n e i t h e r s i d e . ( b ) O n t h e s ke l e ton . (c) W i t h the u l na r e d ge o f t h e e x t e n ci e d a r m over b o t h fi n g e r t i p s o n t h e t r a n s ve rse p rocesses, t h e t h e r a p ist s p r i ngs a l u m b a r ( t h o r il c i c ) v e r t e b ra

m a x i m u m fl e x i o n ) . W i t h h i s o t h e r h a n d over t h e p a t i e n t s b u t t o c k s h e re i n forces flex i o n o f t h e h i ps '

( this

h a n d m a y a l so be used fo r p a l p a t i o n i f t h e

p a t i e n t i s v e ry t a l l a n d the o p e r a t o r c a n n o t reach t h e rele v a n t segment w i th t h e upper h a n d ) . The most i m porta n t tech n i ca l d e t a i l i n t h i s m a n oe u vre i s t h e

fi x a t i o n o f t h e u p p e r t h o r a c i c s p i n e w i t h t h e e l b ow

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Man ip ulative

Figure 4.17

Therapy in Rehabililalion of Ihe Locomotor

E x a m i n a t i o n of l u m b a r

Syslem

s p i n e retro fl ex i o n by

m o v i n g b o t h legs i n a dorsa l d i r e c t i o n

Fi g ure 4.19

L a t e r o li e x i o n o f

the l umbar spine

the l u mbar s p i n e . Wit h the fi n gers of t h e other hand he se nses move m e n t a n d , fi n a l ly, res i s t a n ce ( Figure 4 . 1 9) . Fi g ure 4.18 Te s t i n g a n te fl e x i o n in o n e l u m b a r segm e n t : t h e p a t i e n t l ie s o n h e r s i d e , t h e t h e r a p i s t p u s h i n g t h e p a t i e n t ' s k n e e s a ga i n s t t h e c h e s t , e x e rt ing c o u n t e r press u r e w i t h h i s e l b o w . The h a n d on t h e p a t i e n t ' s b u t tock i n c re a s e s a n te fl e x i o n o f t h e p e l v i s , w h i l e t h e fo re fi nger o f t h e o t h e r h a n d pa l p a te s m ov e m e n t ( t e n s i o n ) b e tw e e n t h e s p i no u s processes

w h i le the k nee i s p u s h e d towa rds the a b d o m e n , i . e . i n t h e d i rection o f the e l b o w ( Figure 4 . 1 8) . Exam in a tion o f side-be n ding

The patient is in the s a m e posi t i o n as in t h e last sect i o n b u t the lower leg is b e n t a t right a ngles to the hip, the knee protrud i n g s l i g h t l y over the edge o f the table; the upper leg is flexed even m ore so t ha t the foo t lies be h i n d the thigh o f the lower leg. The operator stands by the t a b l e , facing t he patient, a n d grasps the hee l o f the lower l e g w i th one h a n d . W i t h t h e other h a n d he fixes the p a t i e n t ' s fl a n k , t h e h e e l o f t h e h a n d crea t i n g a fulcrum a t t h e l e v e l o f the motor segm e n t be i ng e x a m i n e d , w h i l e he pa l p a tes between t h e s p i nous processes with one fi nger, from above. The h a nd hold i n g the patient's h e e l l i fts the lower leg, prod u c i n g l a t e ro flexion o f

Exa m i n atio n o f t h e t h o racic spi ne and t h e r i bs Active m o b i l i t y is first e x a m i n e d , w i t h the patient seated astr i d e t h e t a b l e a n d p e r forming a n te- a n d re tro fl e x i o n , side-be n d i ng a n d rotation . I n rotation symme trica l move m e n t ca n be assessed by sight by traci n g the l i n e formed by the spinous processes, especially i n a slightly kyphotic position , a n d by not i n g the a ngle formed between the patient's shou lders a n d the table. As i n the l u m bar spine, t h e s pi nous processes a re palpated for te nderness; t h i s is b e st done in a kyph otic p osition ( Figure 4.20). Spri n gi n g is performed by the same tech n i q u e as t h a t d escribed fo r the l u mb a r s p i n e . Fo r the e x a m i n a t i o n o f passive move m e n t the p a t i e n t sits o n t h e t a b l e with hands c l asped b e h i n d her bead a n d t h e e l bows b rough t toge t h e r i n fron t of t h e face . T o t e s t bac k-bend i n g t h e exami ner stands by t h e side of t h e p a t i e n t , grasping both e l bows from below, so a s to extend her t r u n k a n d p a l p a te w i t h one finger o f the o t h e r h a n d between t h e spi nous processes of the segme n t b e i ng ex a m i ned , sensi ng move m e n t a n d t h e n resista nce i n t h e e n d pos i t i o n ( Figure 4 . 2 1 ) .

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Examination oj locomotor jun ction and its distu rbance

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Figure 4.21 E x a m i n a t i o n of retrofl e x i o n of t h e t h o racic

spine

Fi gu r e 4.20 (a) Palpating t e n de rn e ss

of the tip o f t h e the t h o r a c i c s p i n e , s e p a rated b y a n t e fl e x i o n . ( b ) S k e l e t a l d i agra m

s p i n o u s processes of

To e xa m i n e

forwa rd-be n d i n g th e o p e r a tor grasps

t h e p a tie n t ' s e l b ows from above i n o r d e r to a n te flex

the t r u n k , a ga i n pa l p a t i n g b e t we e n

the s p i n ou s

processes w i t h o n e fi n g e r o f t h e o t h e r h a n d , fo r m o v e m e n t a n d for t e n s i o n i n t h e e n d - p os i t i o n . I n both t h e s e ex a m i n a t i o n s i t i s i m p o r t a n t t o m o v e t h e patie n t so

as t o p r o v i d e m a x i m u m a n te- o r retro

Figure 4.22 Exa m i n a t ion o f a n te fl e x i o n o f t h e t h o r a c i c

spine

fl e x i o n a t the s i te o f p a l pa t i o n ( Fig u r e 4 . 2 2 ) . I t i s a lso po s s i b l e t o e x a m i n e

a n t e - a n d retrofle x i o n i n a l y i n g on h e r s i d e ; t h i s

s i m i l a r way w i t h t h e patient

w i t h t h e l a t te r h a n d w h i l e h is o t h e r fo r m s

po s i t i o n i s u s e d f o r m o b i l iza t i o n in to r e t r o fle x i o n

a ga i n s t t h e r i b s , t he th u m b p a l p a ting t h e m o v e m e n t

( s e e Figure 6 . 3 5 , p .

o f t h e s p i n o u s processes a n d re s i s t a nce i n t h e e n d p os i ti o n . T h e b e n d i n g m o v e m e n t m a y be p e r fo r m e d a t t h e l e v e l of t h e p a t i e n t ' s s h o u l d e r ; if t h e u p p er t h o ra c i c s p i n e i s b e i n g ex a m i n e d, t h i s h a n d may be

1 8] ). To ex a m i n e s i d e - be n d i n g t h e o p e r a t o r s t a n d s

b e h i n d t h e p a t i e n t w i th o n e h a n d ro u n d t h e p a t i e n t ' s r i b s a t t h e l e v e l of t h e s e gm e n t bei n g e x a m i n e d , t h e t h u m b ag a i n s t t h e i n terspace b e twee n t h e s p i n o u s processes o f t h e s e gm e n t a n d t h e o t h e r h a n d a ga i ns t t h e p a t i e n t ' s s h o u l d e r . He s i d e- b e n d s t h e p a t i e n t

a fulcrum

a ga i n s t t h e p a t i e n t 's n e c k ; d u ri n g e x a m i n a t i o n o f t h e

t h oraco l u m bar s p i n e i t m a y be b e l ow the s h o u l d e r . T h e o t h e r h a n d m u s t a l w a y s s t a b i l i ze t h e c h est fro m

Copyrighted Material

JIi/anipuia t i v e Therapy

1 06

in

Reh a b ilitation

of the L ocomotor System

figme 4.23 E x am i n a t i o n of l a t e r a l flexion of t h e thoracic sp i n e , s ta n d i n g b e hi n d t h e p a t i e n t

c r e a t i n g a s o l i d fulcr u m , eve n i f t h e a p pears to be fa r from t h e s pi n o u s p ro c e ss es when the patient is e re c t . D u ri n g s ide b e n d i n g the t hu m b u s u a l ly reaches t h e s pi n o u s processes, ow i n g to r o t a t i o n c o u p l e d w i t h s i de b e n d i n g (F i g u re 4.23 ) . I f, h o w e v e r t h e p a t ie n t has a very b r o a d b a c k a n d t h e exa m in e r has a v e ry s m a l l h a n d the fo l l o w i n g tech n i q u e is more a p p ro p ri a te : t h e e x a m i n e r s t a n d s a t t h e p a t i e n t s s i d e sl i g h t l y b eh i n d h e r , a n d grasps the fu rth e r e l b ow rais i n g i t a bove h e r head . T h e e x a m i n e r places h i s t h e n a r e m i n e n c e with t h e t h u m b p a ra l l e l to the s p i n o us p ro c e s s e s o n t h e s i d e t o w h ic h s i d e b e n d i n g is b e i n g e x a m i n e d . W i t h t h e t i p o f h i s t h u m b h e fi x e s t he s p i n o u s process of t h e l ow e r v e r t e b r a of t h e m o t o r s e g me n t . He now p ro d u ces la tero flexion o f the tru n k by p ulling the p a t i e n t s e lbow tow a rd s h i m s e l f, t h e the n a r a n d the th u m b c r e a t i n g a fu lcrum loca l izing l a t e r ofl e x i on t o t he t i p of t h e t h u m b (Figu re 4 . 24) . To e x a m i n e rota t i o n t h e o p e r a t o r s i ts the p a t i e n t a s t ri d e t h e t a b l e a n d g r a s p s o n e s h o ulder, p a s s i n g h i s fore a rm u n d e r h e r a x i l l a o n t h e o t he r s i d e . He fi rs t c a rri e s o u t ma x i m u m rota t i o n to o n e s id e , r e pe a t i n g t h e m a n o e u vre o n t h e o t h e r s i d e to c o m p a re t h e two . For e x a m i n a t i on o f i n d i v i d ua l seg m e n ts a s l i gh t l y k y p h o ti c p o s i t i o n i s reco m m e n d e d , m a k i n g t h e s pino u s p rocesses m o re accessible b o t h t o i n s pe c t i o n a n d t o p a l p a t i o n . I f t h e r e i s move m e n t r e st r ic t i o n t h e b l oc k e d segment i s o ft e n v i s ib l e : t here is very l i t t l e r o t a t i o n i f we fo l lo w fro m t h e l u m b a r s p i n e i n t o t h e th or a c i c u p to the b l o c k e d segment, w h e r e a s t h e re i s hypermob i l i ty above i t so t h a t the l i n e of t he s p i n o us p r oc e ss e s a n g u l a te s O n the s ide w h e re rotation is free we see the u n b r o k e n l i n e o f the s p i n o u s p r oce s s e s fro m t h e l u m b a r u p to the t h o ra c i c r e g i o n . Pa l pa ting the s p i n o u s p rocesses o f the si d e

,

palpating thu mb

Figure 4.24 E x a m i nation o f l a tera l flex i on o f t h e t h o racic sp i n e , s t a n d i ng a t the side o f the p a t i e n t

,

'

,

-

'

,

.

Figure 4.25 Exa m i n a t ion o f r o t a t i o n o f t h e t h o racic spi ne

the

segm e n t w i t h t w o fi n g e rs we fe e l mobil ity, w h e re as o n t h e n o r ma l side ro t a t i o n w i l l be felt fi r s t a t t h e u p p e r a n d a l i t t l e later a t the l ow e r sp i n o u s p rocess ( Figure 4.25 ) . I t is most i m p o r ta n t for the e x a m i n e r to ro t a t e the p a ti e n t exact l y r o u n d h e r b o d y a x i s , a n d t o p a l p a t e w i th r e l axed fingers w h i ch c a n fo llow t h e m o v e m e n t of b lo c k e d

no re l a t i v e

Copyrighted Material

,

Examination of locom otor fUlI ction and i t s dis/I.Irban ce

1 07

the s p i n o u s p rocesse s . T h i s is n o t e a s y , a nd it is there fo re a grea t a d v a n tage t o form a d i a g n o s i s b y i n spec t i on; t h i s i s u s u a l l y poss i b l e i n k y p h o s i s u n less t h e pa t i e n t is too obese . Rota t i o n r e s t r i c t i o n is m o s t s i g n i fi c a n t in t h e l o w e s t t h o racic s p i n e a n d a t the t h oraco l u m b a r j u n c t i on, and l e s s s o i n t h e m i d d l e or upper t h o ra c i c regi o n s . (Rece n t i nvestig a t i o n s have shown t h a t w h a t w e see and p a l p a te i n this case conce r n s i n t h e fi rs t p l ace the s p i n o u s processes a n d n o t necess a r i l y t h e e n t i re m o t o r segm e n t ; s e e p . 5 4 Figure 3 . 1 8 . ) M o b i l i ty o f t h e t h o r a c i c s p i n e c a n b e e x a m i n ed w i t h t h e p a t i e n t pro n e , b r e a t h i n g s l o w l y i n and o u t : n o t o n l y c a n w e s e e h o w t h e w h o l e of t h e t h o ra x l i fts b u t t h e s p i n o u s p rocesses c a n b e see n s pre a d i n g l i k e a fa n . This fa n - l i k e move m e n t c a n be fo l l owed

from t h e l u m b a r s p i n e u p to the ce rvico t h o racic j u nc t i o n . T o a c h i e v e t h is we reco m m e n d i n s t r u ct i n g t h e p a t i e n t fi rst t o b r e a t h e i n to h i s a b d o m e n ( l u m b a r spine) a n d t h e n i n to h i s c h est, a n d as fa r u p a s h e ca n . A s a

rule,

a t the

poi n t w b e re t h e re i s a n

i n te r r u p t i o n t h e re i s b l ock a g e ; a f t e r t re a t me n t w e see t h e n o rm a l m o b i l i ty restored d u r i n g b re a t h i n g . T h e exce p t i o n t o t h i s r u l e i s p a t i e nts w i t h a fau lty resp i ra t i o n tec h n i q u e w h o a re u n a b l e to b r e a t h e i n to t h e posterior w a l l of t h e t h o r a x e v e n w h e n pro n e .

Ribs We n o w p roceed to examine t h e t h o r a x , p a r ti c u l a r l y t h e ri b s . For scree n i n g i t i s usefu l t o move t h e fla t h a n d s o v e r the r i b c a ge , n o t i n g a n y a sy m m e t ry , a n d particula rly w h e t h e r a n y ri b i s p ro m i n e n t . J u s t a s we

Figure 4.26 P a l pa t i o n of resi sta nce at the (upper) ribs a t retro A e x ion o f the t h o r a x . accord i ng t o K u b i s ( person a l

com m u nication)

pa l p a te t h e s p i n o u s p rocess fo r te n d e r n e s s , so we p a l p a te the most p r o m i n e n t part o f t h e rib, the c o s t a l a n g l e ; i n t h e region 0 1' t he u p p e r r i b s we h a v e first to a b d uct the s h o u l d e r - b l a d e , by m o v i n g t h e e l b ow

th a t o n t h e o t h e r s i d e , i . e . i t h a s ' o ve r t a k e n ' t h e o t h e r

tow a rd s t h e s h o u l d e r of t he opposite s i d e .

r i b . The s i d e o f lesser m o b i l i ty i s u s u a l l y t h e s i d e o f

In t heory , a

rib can

be

b l oc k e d

both

in

the

m o b i l i ty r e s trictio n .

E . K u b i s ( u n p u b l is h e d o b s e rv a t i o n s ) h a s d e s c r i b e d

e x p i ra t o r y a n d the i n s p i r a tory posi t io n ; from t h i s i t fo llows t h a t i t i s m o re

pro m i n e n t i f b l ocked

in

t h e b e s t m e t h o d o f d i a g n o s i n g blockage by i n c r e a s e d

i n h a l a t i o n , a n d l e s s s o i f b l o c k e d i n e x h a l a t i o n . Aga i n

re sista nce t o ( p a s s i v e ) m o b i l i ty d u ri n g back-be n d i ng :

i t i s w i s e r t o rely o n exa m i n a t i o n a n d com p a ri s o n of

t h e p a t i e n t s i t s o n t h e edge o f the t a b l e w i th t h e

m o bi l i ty ra t h e r t h a n on posi tio n ; t h i s m e a n s t h a t

h a n d o f t h e s i d e to be e x a m i n e d b e h i n d h e r h e a d ,

w e e x a m in e r i b m o ve m e n t o n b o t h s i d e s d u r i n g

so

b re a t h i n g i n a n d o u t , e x a m i n i n g b o t h by i n s pec t i o n

s t a n d s o n the o t h e r sid e , g r a s p i n g t h e e l b o w from i n

tha t

the e l b o w p o i n t s u p w a rd s . T h e e x a m i n e r

a n d palp a ti o n . It i s part icularly usefu l to i n s i s t o n

fro n t a n d prov o k i n g b a c k - be n d i ng . W i t h t h e fi n ge rs

d e e p in h a l a t i o n a n d ex h a l a t i o n : i n t h e fo rmer, t h e

o f t h e o t h e r h a n d at t h e costa l a ng l e of t h e r i b u n de r

restricted s i d e w i ll s t o p b re a t h i n g i n s o o n e r t h a n t h e

e x a m i n a t i o n h e crea tes a f u l c r u m a n d se n s es re s i s t

h e a l t h y s i d e ; d u r i n g e x h a l a t i o n t h e s a m e w i l l h a p pe n .

a nce to b a c k - be n d i n g, resis t a n c e t h a t i n cre a s e s i f

I t i s c l e a r l y recog n iz a b l e t h a t m o ve m e n t c o n ti n ues

t h e re i s b l o c k a ge ( F i g u r e 4 . 2 6 ) .

on one side but i s a rr e s t e d o n t h e o t h e r. A p a r t i c u

I t is i m porta n t t h a t t h e fi ngers fi x i n g t h e r i b s h o u l d

l a rl y s t r i k i n g phe n o m e n o n is t h e ' overt a k e ' p h e n o

b e l e v e l o n t h e cos t a l a n gl e ; c u ri o u s l y e n o u g h , t h e

m e n o n , fo u n d c h a racte r i s t ica l l y i n t h e regi o n of t h e

s h o u ld e r - b l a de i s n o o b s t a c l e to effe c t i ve p a l p a t i o n .

upper r i b s : p a l pa t i o n a p p r o x i ma tely i n t h e n i p p le

Resistance is

l i n e , or e v e n c l o s e r to the ste r n u m , ofte n s h o w s t h a t

b l ockage o f t h e seco nd t o fifth r i bs , i . e . t h e r eg i o n

t h e ribs a re n o t q u i te on t h e same l e v e l o n t h e two

w h e r e r i b b l ockage occurs m o s t freq u e n t l y . Care

t he p a t ient i s asked t o t a k e a deep brea t h ,

s ho u l d be taken t h a t o n ly b a c k - b e n ding t a k e s p l ace

sides.

If

t h e r i b t h a t stood lower w i ll u s u a l l y be h i g h e r t h a n

fel t t h ro u g h t h e s h o u l d e r- b l a d e

and no r o t a t i o n of t h e p a t i e n t ' s trunk.

Copyrighted Material

in

1 08

Man ip u lati v e Th erapy in Rehabilitation of

th e Locomotor System

( a)

Figure 4.27 E xa m i n a t i o n of a b l o c k e d first ri b b y fo rw a rd of t h e head ro t a t e d to t h e o p p os i t e s i d e

be n d i n g

(

E xa m i n ation of the fi rst rib I n d e ra n ge m e n t of t h i s r i b , p a i n i s fel t m a i n l y in t he s h o u l d e r a n d i n the c e rv i c a l regio n : t h e re is a t y pic a l tender spo t , w h ich can be p a l p a ted b e n e a t h the clavicle towards t h e m a n u bri u m s t e r n i . The t y pic a l re striction of moveme n t is i m p a i r e d a n teflexion of t h e rotated h e a d : t h e e x a m i n e r s t a n d s b e h i n d the s e a t e d p a ti e nt a nd r o t a t e s her head away from the a ffec t e d r i b . W i th the rad i a l aspect o f t h e f o r e ll n g e r of the o t h e r h a n d he c r e a te s a fu lcrum p a r a l l e l to a n d a b o v e the c l a v i c l e , over which t h e r o t a t e d h e a d a n d n e c k are b e n t fo rward ( Fi g u r e 4 . 27 ) . T h e re s u l t o f t h i s ma n o eu v re i s c o m p a re d for b o t h sides. I n cr ea s e d resis t a n c e a n d e v e n te n d e r n e ss m a y b e fe l t o n s p r i n g i n g t h e first r i b from a b o v e ( see F i g u re 6.50, p . 1 88 ) . D i r e c t m o v e m e n t p a l p a ti o n of t h e fi r s t r i b i s pe r fo r m e d b y inse r t in g t h e fo re fi n ger be h i nd the clav icle, with the patient s u pin e and fol l o w i n g t h e move ment of t h e r i b d u r i n g i n h a la ti o n and exha l a t io n .

,

E x a m i n at i o n o f t h e cerv i c a l sp i n e A fter genera l i n s p e c t i on o f the head a nd nec k posi t i o n we test a c t i v e m o b i l i ty - ante- a n d re troflexio n , s i de b e n d i n g a n d rotation. W h e n d e a l i n g with the ce rvica l spine it is i m p o r t a nt not t o o m i t e x a m i n a t i o n of res i s ted i s o m e t r i c m o b i lity w h i c h r e l i a b l y rev e a l s pa i n d u e to m u s c u l a r l e s i o n s : t h i s i s fre q u e n tl y si g n i fi c a n t i n a c u te trau m a . T h e best p o s i t i o n fo r t h e p a t ie n t d u r i n g p a l pa t i o n is s u p i n e t h e h e a d resting a ga i n s t t h e exa m i n e r ' s t h igh o r be l l y a n d s l i gh tl y rai s e d . I n t h i s po s i t i o n t h e

.

, ,

� ( b) Figure 4.28 Palpa t i o n of t h e t r a n sv e r s e p rocesses of t h e a t l a s ( a ) with t h e p a t i e n t s e a t e d : ( h ) cerv i c a l s p i n e . s u p i n e

m u scles are re laxed a n d w e can p a l p a t e n o t o n l y t h e processes b u t a l so t h e t r a n s v e r se and a rtic u lar p ro ce s s e s , w h i l e if the head is sl i g h t l y raised we can p a l p a t e the p o s t e r ior a rch of the a t l a s . In order to p a l p a t e the l a tera l il s pe c t of the s p i n o u s p rocess of C2, w h ich i s one of t h e p r i n ci p a l p a i n p o i n t s the h e a d m u s t be b e n t to t h e o p p o s i te side. The tra ns v e rse processes of t h e a t l a s a re fe l t between the mastoid p rocesses and t h e r a m u s of the mand ible. but t h e y should be p a l p a t e d from b e l o w , w i t h t h e p a t ie n t s e a t e d , because t h e y a re m o re p r o m i n e n t t h a n t h e tra nsverse processes o f t he l ow e r ce r v i c a l v e rtebrae ( Fig u re 4 . 28 ) . For e x a c t o r i e n til t i o n i t i s i m p o rt a n t to l o cal iz e cor r e c t l y t h e s p i n o u s p rocesses of C7 : t h i s is done d u r i n g re t rofle x i o n o f t h e c e r v ic a l s p i n e . P l a ci n g one fi n g e r on C7 a n d t h e n e x t o n C6, we will n o t e t h a t w h i le C 7 re m a i n s in p l a c e . C6 m o v e s forw a rd a n d is d i ffic u l t to p a l p a te in r e t r o fl e x i o n . ( N B : One s h o u l d n o t rely o n the vertebra p ro mine n s b e i ng i n e V i ta b l y spi n o u s

.

C7 .) Exa m i n a ti o n of p Cl s s i v e m o b i l i ty m u s t begin w i t h of t h e w h o l e o f t h e ce rv i ca l s p i n e . The p a t ie n t i s s e a t e d a n d t h e e x a m i n e r m u s t fi x t h e m o bi l i ty

Copyrighted Material

Examinatio/l ( i m m o b i l i z e ) t h e s h o u l d e r g i rd l e . passive

of 10("01ll01Or f1ll1C1ion anrl ils dis/llrbana

1 09

He be g i n s w i t h of t h e

r e t r o fl e x i o n : s t a n d i n g b y t h e s i d e

p a t i e n t h e moves h e r h e a d i n to r e t r o fl e x i o n w i t h o n e hand

w h ile

the

other

fi x e s

the

cervicoth oracic

j u nc t i o n . In p a s s i v e a n te fl e x i o n t h e p a t i e n t ' s ch i n is drawn to t h e

stern u m ;

t h i s i s a m o v e m e n t th a t is

o ft e n r e s t r i c t ed beca use o f s h o r t e n e d neck m u scles.

If m a x i m u m a n t e fl e x i o n is i m m e d i a te l y p a i n f u l , and t h e r e i s n o m e n i n g i t i s o r a c u te rad i c u l a r p a i n , the p a i n fe l t b y t h e p a t ie n t is us u a l l y d u e to r es t r i c t e d a n t e fl e x i o n of t h e occi p u t aga i n st t h e a t l a s ; i f, how

e v e r , pain i s fe l t a fte r l ig a m e n t

pain

(see

1 5-20 pp.

s , this i s most p r o b a b ly

270-27 1 ) ,

A n te fl e x i o n

head a c h e ) . I n o r d e r to e x a m i n e s i d e - b e n d i n g o f t h e

cervica l s p i n e . t h e o p e r a t o r m u s t fi x t h e s h o u l d e r o f th e s i d e towa rds w h i c h t h e h e a d is b e n t a n d c o m p a re mo b i l i t y in b o t h d i re ct i o n s .

( I f he fi x e d

the shoulder

a w a y from w h i c h t h e h e a d is b e n t he w o u l d t h e n b e e x a m i n i n g t h e s t r e tc h i ng o f t h e tra p e z i u s m u s c l e o r e v e n o f t h e sc a l e n i . )

( a)

Rotation With th e pa tien t 's h e a d a n d n eck e rect The e x a m i n e r e i t h e r fixes the s h o u l d e r away from w h i c h the h e a d is

tu r n e d ,

w i th one e l b o w , o b s e r v i n g

how c l ose he can b r i n g t h e c h i n to t h e s h o u l d e r o n one

s i d e o r t h e o t h e r ; or h e cro s s e s b o t h h a n d s a n d ,

w i t h h i s fo re a r m , h e fi x e s fr o m b e h i n d t h e s h o u l d e r towa r d s

w h i ch

the

head

is

t u r ne d ,

m o v i ng t h e

occ i p u t . H i s o t h e r h a n d m o v e s t h e c h i n . C a r e m u st be t a k e n to p e r form r o t a t i on of t h e head and n e c k

ro u n d a v e r t i ca l a x i s

(Figu re

4.29).

With t h e head i n maxim um a n te flexion The

examiner

s t a n d s be h i n d t h e p a t i e n t ; w i t h o n e

h a n d on t h e occ i p u t h e m ov e s t h e h e a d a n d n eck i n to

maxi m u m

a n te fl e x i o n , w h i le

his o t h e r h a n d

h o l d s t h e p a t i e n t ' s ch i n . T h e ro t a t i o n h e n o w e ffec t s

is m a i nl y b e t w e e n t h e occ i p u t a n d C2, i . e . betwe e n a t l a s a n d a x i s . Aga i n . c a re m u s t be t a k e n t o rota te ro u n d t h e axis o f the head and the ce r v i c a l s p i n e , i . e . t h e o p e ra t o r m o v e s t h e occ i p u t f r o m o n e s i d e t o

t h e o t h e r . w h i l e t h e c h i n re m a i n s a l mo s t fi x e d . A word of c a u t i o n : b e c a u s e t h e e x a m i ner is s t a n d i n g b e h i n d t he p a t i e n t , i t i s t h e occ i p u t b e s e e s , a n d h e

( b) Figure 4.29 Exa m i n a t i o n of ro t a t i o n of t h e e n t i re ce r v i c a l h a n d s m o v i n g i n t h e s a m e d i re c t i o n :

spi n e : (a) b o t h ( b ) bot h hands

a n d a rm s m o v i n g i n oppo s i t e d i re c t i o n s .

l a t t e r i s p a r t i c u l a rl y u s e f u l fo r e x a m i n a t i o n o f ro t a t i on i n r e t r o l1 e x i o n

The

is t h e r e fo re t e m p ted t o m o v e t h e c h i n l t h e h a n d on t h e occi p u t t h a t ro t a t e s t h e h e a d , t h e

a x i s o f r o t a t i o n b e i n g c l o s e b e h i n d t h e fo r e h e a d . A t

With the pa tie n t 's c h in dra wn towa rds the neck

t h e s a m e time s o m e degree o f t r a c t i o n i s a p p l i e d to the h e a d .

A s l i ro u t ( 1 97 9 ) h a s s h o w n , move m e n t rest r i c t i o n o f t h e ( '2/3 segme n t ca n b e sele c t i v e l y s h o w n b y t h is mov e m e n t . A g a i n t h e ex a m i n e r s t a n d s be h i n d the p a ti e n t , rota t i n g the head w i t h o n e h a n d o n the occ i p u t and one o n the c h i n . The l a t t e r i s n e c e s s a ry m a i n l y to fix t h e c h i n a ga i n s t the n e c k , w h i l e it i s

I n retro flexion This rev e a ls bloc kage below C3 ; the grea ter t h e r e t r o A e x i o n , t h e m o r e c a u d a l t h e seg m e n t c a u s i n g i t . H e r e . t o o , t h e c h i n s h o u l d b e a l m o s t fi x e d w h i l e t h e

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Munip u la/ive Th erapy

in Rehab ili/O Iiol1 of the L o c o m %

r

Systel ll

h a n d on the occi p u t p r o d u c e s rotati o n . To fix the p a t i e n t s s h o u l d e rs , t h e e x a m i ne r ' s a r m s s h o u l.d move in opp o s i t e d i r e ct i o n s , i . e . rot a t i ng t h e p a t i e n t s head to t h e l e f t h e grasps t h e c h i n w i t h h i s righ t h a n d ( p u s h i n g th e c h i n s l i g h t l y to t h e l e f t ) a n d t h e occi put w i t h h i s l eft , p u s h i n g towards t h e r i g h t and re si s t i n g rotation of t h e s h o u l d e r w i t h h i s l e ft fore a r m ( F i g u re '

'

4.29b).

Afte r these more o r l e s s scree n i n g te c h n i q u e s w e t o t h e mos t i m po r t a n t s p ec i fic tech

m u s t p roc e e d n i q ues.

S i de-be n d i ng T h i s c a n be p e rfo r m e d wi t h t h e p a t i e n t s e a t e d

or

su p i n e ; i n e a c h c a se t h e e x a m i ne r b e n d s t h e p a t i e n t 's h e a d s i d e w a y s w i t h o ne h a nd w h i l e t h e o t h e r crea tes

fu lcrum wit h t h e aid of t h e m e d i a l a s p e c t o f t h e fo re fi n ge r a ga i n s t t h e tra nsverse p rocess of t h e lowe r v e r t e b ra o f t h e s eg m e n t u n d e r e x a m i n a tio n . B o t h the r a n g e o f m o v e m e n t and the res i s t a n c e i n e n d po s i ti o n m u s t b e no te d . I n t h e s u p i ne p o s i t i o n the p a t i e n t ' s head i s pr oj ec te d over the end of t h e t a b l e a n d cr a d le d i n t h e exa m i n e r' s h a n d . I t is a d v i s a b le to rot a t e th e h e a d s l i g h t ly i n t h e o pp o s i te d i re c t i o n to t h a t of s i d e - b e n d i n g , a n d to l i f t i t (F i g u r e 4 . 30a) . T h i s technique is a p p l i ca b l e from C 1I 2 to C5/6 a n d a

( a)

e v e n C617 .

To e x a m i n e s i d e - be n d i n g a t C 1 I2 , the ce r v i c a l s p i n e s h o u l d be k e p t s tra ig ht up to C2 w h i l e t h e op e r a t o r rota tes the h e a d ro u nd a n axis t h r oug h t h e b r i d ge of t h e n ose ( F i g u re 4 . 3 0 b ) . So as to d e t e r m i n e on which s i d e th e a p o p h y s e a l j o i n t is r e s t r i c t e d , s i d e - be n d i n g c a n be e x a m i n e d w i t h t h e cerv i c a l s p i n e i n a n t e - o r i n r e t ro A e x i on , b y r a i s i n g t h e h e a d i n t h e fo r me r c a s e , o r l o w e r i ng i t i n

t h e l a t te r. I f r est r i c t i o n i s fe l t i n a n tefl e x i o n t h e j o i n t o n t h e o p po s i t e side is restricted in s id e -ben d i n g a nd in a n t e A exi o n , if in r e t r o fl e x i o n , t h e j o i n t on t h e s i d e to w h i c h l a teroflex i o n i s c a r r i e d o u t i s r es t ri c te d in re t r o fl e x i o n a n d s i d e - be n d i ng . Dealing w i t h t h e ce rvico thoracic j u n c t i o n , w i t h t h e p a t i e n t seated t h e exa miner must ta k e care to m a i n t a i n t h e w h o le of the cervicotho racic s p i n e e r e c t , a n d t h e n e c k e v e n i n s l i g h t r e t ro fl e x i o n , w h i l e the h e a d m u st b e s l i g h t l y ro t a t e d i n t h e d i rect ion o p po s i t e to t h a t of the s i d e - b e n d i n g . With t h e t h u mb of the o t h e r h a n d h e c re a t e s a f u l c r u m a g a i n s t t h e sp i n ous processes o f t h e l o w e r v e rtebra o f the ex a m i n e d s e g m e n t

( F ig u r e

4.31).

T h e s a m e e ffe ct c a n be a ch i e ve d w i t h t h e p a t i e n t l y i n g o n h e r s i d e : t h e e x a m i n e r sta n d s i n fr o n t of t h e pa t i e n t , cr a d l i n g h e r h e a d a n d ne ck i n h i s fore a r m a n d t h u s p ro d u c i n g a s i d e - be n d i n g m o v e me n t , wh i le t h e t h u mb of h i s o th e r h a n d fi x e s t h e spi n o u s p ro cesses fro m above ( f r om t h e s i d e ; s e e F i g u re 4.34). I n b o th cases t h e hand that side-bends the c e rv i c a l s p i n e a l s o fi xes ( p u s h e s ) t h e s p i n o u s process o f t h e u p pe r vertebra, with the thenar (hypo t h e n a r ) .

( b) Figure 4.30 E x a m i n a t i o n o f p a s s i ve l a t e r a l nex i o n o f i n d i v i d u a l s eg m e n t s o f t h e cerv i c a l s p i n e w i t h t h e p a t i e n t s u pi n e : (0) i n t h e l o w e r c e r v i c a l spi n e : (iJ) he t ween the a tlas a n d axis

Rotat i o n T h e pa ti e n t i s s e a ted w h i l e t h e e x a m i n e r s t a n d s b e h i n d h e r a n d fi x e s betwee n t hum b il n d fore fi n ge r of o n e h a n d t h e verte b ra l a rc h of t h e lower ver t e b ra of t h e r e l e v a n t segm e n t , from o ne t r a n s v e rse p r o c e s s to the o t h e r . The e x a m i ner n o w ro t a t e s t he p a t i e n t ' s head ( usu a l l y w i t h h i s o t h e r h a nd on t h e ch i n ) u n t i l h e fe e l s t h a t t h e t r a n s v e rs e process is e n g ag e d a g a i n s t h i s t h umb or forefi nger. He begins w i t h t h e a x i s , establish i ng t h e ra nge o f m o ve m e n t be tween a tl a s a n d a x i s . proceed i n g from one v e r t e b ra l a rc h

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Examination of /ocomOlOr function and its disturbance

111

o f s i n g l e m o b i l e segme n t s , a n d e q u a l l y s u i t a b l e for optical r e g i s tr atio n . B e r g e r ( 1 984) has const ructed a dev ice (cervicomotogra ph ) w h i c h is a h e l m e t fixed t o the cei l i n g b y j o i n ts and r o d s . The p a t i e n t is seated, l oo k i n g a t a fix e d poi n t in or de r to d e te r m i n e t h e n e u t ra l po s i ti o n o f t h e h e a d . U s i n g t h e tec h n i q u e desc r i b e d h e re t h e opera t o r fi rs t e x a m i n e s t h e seg

m e n t C1/2 by fix a t io n of C2, t he n C2/3 by fixation o f C3, a nd so o n down to C5/6; c a p a c i t y t r a n s d ucers i n the rod j o i n ts m a k e e l e c t r o n i c r e co r d i ngs o f the range o f m o v e m e n t p o s s i b l e . T h e r es u l t i n g gra p h is a ' c e rv i c o m o to gr a m ' (Fi gu r e 4.32b, c) . T h e r e a re two i m p or t a n t tech n i ca l d e t a i l s to be noted i n this rotation tech n i q u e : ( 1 ) i f t h e e x a m i n e r fi x e s t h e a r c h o f a v e r t e b r a h e m u s t do s o e x a c t l y i n t h e n e u t r a l p o s i t i o n , i . e . h e m u s t sen se t h e co rr e c t pos i t i o n ; (2) he m u s t n o t use fo rce to fix t h e verte b r a l arc h : t h e p a t i e n t s i m p l y stops t u r n i ng t h e h e a d a t t h e m o m e n t when h e s e n ses t h e e x a m i n e r ' s fi ngers c om i n g i n to contact w i th t h e artic u l a r p rocess from b e h i n d b y s o m e retlex a c t i o n . R o t a t i o n c a n a l so b e exami n ed i n t h e ce r v i co aga i n s t t h e e x a m i n e r ' s s h o u l d e r ( by t h e fo re a r m ) , n o s e a n d c h i n t u r n e d towa rds h e r e l bow; t h e h e a d a n d n e c k a re t h u s t u r n e d to the s i d e . The e x a m i n e r ' s hy po t h e n ar a n d l i t t l e fi n ger a re at t h e c e r v i c o t h o r a c i c j u n c t i o n from a bov e , the l i t t l e fi n ge r r o u n d t h e s pi n o us process of C7 or Th l . The t h u m b of h is o t h e r t h o ra c i c j u nc t i o n ; t h e p a t i e n t ' s h e a d i s h e l d

( a)

h a n d e x e r ts sp r i n g i ng p r ess u r e

p rocess, opposing

a ga i n s t

the spinous

f u r t h e r r o t a t i o n a f t e r t h e s l ack h a s

b e e n ta k e n u p (Fi g u re

4 . 32d) .

A s i m pl e s c r ee n i n g t e c h n iq u e is to h o l d t he s p i n o u s p rocess be t wee n both t h u m b s , from C 7 d o w n t o Th3

i n s u c c ess i o n , as t h e p a t i e n t rota tes t h e n e c k as fa r a s p o ssi b l e w h i l e m a i n t a i n i n g n ec k a n d t h o rax e r e c t . T h e e x a m i n e r s e n s e s t h e m o v e m e n t of t h e s p i n o u s process h e fi x e s be twee n h i s t h u m b s from s i d e t o s i d e .

S h ifting tech n iques These a re u s e d

to

e x a m i n e j o i n t pl ay i n t h e ce r v i c a l

a n a n t e ro p o s t e rio r i n a l a t e r o l a t e r a l d i rection . The e x a m i n e r s t a n d s a t t h e s i d e of t h e s e a ted p a t i e n t a n d p u ts his a r m ro u n d h e r h e a d i n s u c h a w a y t h a t h i s e l bo w i s i n front of h e r fa ce or fo r e h e a d , w h i l e h i s l i t t l e fi n ge r grasps t h e ve r te b r a l a rch o f the u p p e r v e r t e b r a o f t he segm e n t to be teste d . W i t h t h e o t h e r h a n d he fi x e s t h e v e r t e b r a l a rch o f the l o w e r v e r t e b r a b e t w e e n th u m b a n d fore fi n g e r from b e h i n d . W i t h h i s a r m on the p a t i e n t ' s h e a d h e now ( 1 ) p u s h e s t h e h e a d a n d t h e u p p e r v e r t e b r a b a c k w a rd s , t a k i n g u p t h e slack a n d fi n a l l y s p r i n g i n g t h e e n d - p o s i t i o n a g a i n s t t h e t h u m b a n d fi ng e r of t h e fix i n g hand; o r (2) h e s i d e - s h i ft s t h e p a t i e n t ' s h e a d a n d u p p e r v e r t e b r a a g a i n s t e i t h e r t h e t h u m b or the fo r e fi n ge r o f the fixing h a n d , fi rs t t a k i n g u p t h e s l a c k and t h e n s p r i n g i n g t h e e n d - po si t i o n ( F i g u re 4.33a). I n t h i s w a y s p i n e a n d c a n be c a r ri e d o u t i n and

( b) Figure 4.31 Exa m i n a t ion of l a t e ra l s p r i nging a t t he ce rvico t h o ra c i c j u n c t i o n s . by a p u s h w i t h t h e t h u m b aga i n s t t h e l a t e r a l a s p e c t o f t h e lower s p i n o u s process t h e segm e n t ex a m i n ed

of

to t h e n e x t . The r a n g e of m o v em e n t s h o u l d i n c r e a s e from one segm e n t to t h e n e x t . If t h e re is bl o c ka ge i n a m o b i l e seg m e n t , the a b s e nce o f th i s i ncrease i n one or both d i re c t i o n s s ho u l d b e n o te d ( Fi g u r e 4 . 32a). T h i s t ec h n i q u e i s p a r t i c u l a r l y s u ita b l e fo r d e m o n s t r a t i o n i n t h e l e c t ure h a l l of movement r e s tr i c tio n ste p - w i s e

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1 12

Manip u lalive Therapy in

Rehabililalion of Ihe Locomotor Syslem

100 80 60

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L

R ( b)

100 80 60

( a)

�I

--

--

R

2

3

( c)

Figure 4.32 (a)

E x a mination ( m o b i l i za t i o n )

of res t r i c t e d

r o t a t i o n i n t il e cerv i c a l s p i n e w i t h t h e p a t i e n t

( a rrow:

fi x a t i o n

by

the

thumb

seated

from behi nd ) .

( b ) ' Cervico m o togra m ' ( from M . B e rg e r . perso n a l

com m u n ic a t i o n ) s h o w s o n e x a m i n a t i o n o f r i g h t rota t i o n

("2/3 , and C3/4 . rota t i o n to t h e l e ft ( t h i n l i n e s ) bei n g n o r m a l . (e) The s a m e case: ( 1 ) right ro t a ti o n on l y : ( t h i c k l i n es ) m o ve m e n t restrict i o n a t C 1 /2 a n d h y p e r m o b i l i ty at

( 2 ) a ft e r t r e a t m e n t o f C l /2 ;

(d)

(3)

Examination (mobilization)

a f t e r t re a t m e n t o f C2/3 .

of ro t a t i o n at t h e

cervicothoracic j u nction

c a n e x a m i n e the c e rv i c a l segme n ts fro m C2!3 to C5/6 and a lso in t h e a n teroposterior d irectio n , the occ i p u t a g a i n s t t he a t las - h e re I reco m m e n d s l i g h t a n te fl e x i o n of t h e h e a d . T h e fi x i n g h a n d sta b i l izes t h e a r c h o f the a x i s , b u t s h i ft i n g occ u rs e x c l u s i v e l y between o cc i p u t a n d a t las b e c a u s e no s h i ft i n g m o v e m e n t c a n occ u r between the a n terior a rch of t h e atlas a nd the odontoid pro c e ss (Figure 4.33a) . From C617 to T I /2 o r e v e n TI/3 i t i s a g a i n o n l y p o ssi b l e to ca rry o u t a n t e ropos terior s h i fts. w i t h t h e p a t i e n t s e a te d . The exam i n e r a p plies h i s h a n d to t h e m a ss of the p a t i e n t ' s upp e r trapez i u s m u sc l e . from a bove, producing a b a c k w a rd s h i ft . w h i l e h e fi x es t h e

he

down

( d)

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Exarn inotiol1

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I 13

Figure 4.34 E x a m i n a t i o n o f t h e c e r v i c o t h o r acic j u n c t i o n the patient lying on her side

with

may now push the

patient's head backwards or

u p w a r d s , i . e . J a te ral l.y i n t h e d i re ct i o n o f t h e fix i n g t h u m b ; d o w nw a rd s t h e m o v e m e n t is l e s s e ffe c t i v e . I n t h e cerv i c o t horacic re gi o n the h a n d c o m i n g from a b ove again p u s h e s a ga i n s t t h e mass o f

the upper m u s c l e t o p r o d u c e a backward s h i ft; i t m a y a l s o p u s h u pwa rds, p r o d u c i ng a l a t e ral s h i ft a g a i n s t t h e spi nous process of the u p p e r vertebra, i n the d i r e c t i o n of t h e thu m b of t h e o t h e r ha n d fi x i n g t h e s p i n o u s p r o c ess of t h e l ower v e r t e b r a from a b o v e ( Fi g u r e 4 . 3 4 ) . I t i s i m p o r t a n t that the p u s h fro m be low should a l w ays be d e l iv e red a t t h e l ev e l o f th e upper verte bra of t h e s e g m e n t , so t h a t t h e re a re n o trapezius

Figure 4.33 E x a m i n a t i o n of dorsal shift (springi ng) of t h e cra n i a l a ga i n s t t h e ca u d a l a dj a ce n t v e r t e b ra (a) in t h e cervical s p i n e a n d ( b ) i n t h e c e rv i co t h o racic j u n c t i o n : t h e h e a d a n d cra n ia l ve r t e b r a o f t h e e x a m i n e d segme n t a re s h i fted (backwa rds), w h i l e m o b i l i t y ( re s i s t a nce) is fe lt a t t h e spinous p rocess o r verte b r a l a rc h o f t h e l owe r v e r t e b r a

s e g m e n ts

separating

taking

the

the

e x a m i n i ng h a n d s !

Both

be carried out w i t h m i n im u m force . To s i d e - b e n d t h e e l bow of t h e a rm pe r f o r m i n g the move m e n t s h o u l d s h ift on t h e e x a m i n a t i o n t a bl e a n d n o t be r a i s e d , the h a n d rotating a n d side-be n d i n g t h e p a t i e n t ' s h e a d a u t om a t i c a l l y . T h e s e tec h n i q u e s fo r ex a m i n i n g s h i ft (j oi nt p l a y ) a re a m o n g t h e m o s t s e n s i t i v e , r e v e a l i n g bl o c k a ge i n t h e c e rv i c a l a n d cerv i co t h o r a c i c s p i n e t h a t is a s y e t u n exposed by a n y o t h e r t e ch n i q u e . up

slack and

s p r i n g i n g s h o u ld

M ov e m e nt between a t l a s a n d occiput 1.

e x a m i n er sta n d s pa t i e n t w i t h h i s fi n gers o n h e r face and c h i n a n d b r i n gs t h e h e a d i n t o m a x i m u m r o t a tion , s t a bi l i z i n g i t a g a i ns t h i s c hes t a n d ta k i n g c a re to s e e t h a t t h e h e a d i s ere c t , ro t a t i ng c o r rect Without

u si n g

a n y fo rce , the

b e h i n d t h e s e a te d

sp i n ous

p rocess of the lower ve rtebra of the s e g m e n t fi n g e r o r t h e th u m b o f t h e o t h e r h a n d a n d h a n d be twee n h i s fo rea rm a n d c h e s t w h i l e

w i t h on e the

m o v i n g h i s t r u n k b a c k w a r d s ( Fi g u r e 4 . 3 3 b ) .

ly round a v e r t ica l a x i s . Af t e r t a k in g u p the s l a c k

S h i ft c a n a l s o b e ex a m i n e d w i t h t h e p a t ie n t lyi n g on h e r s i d e ; t h e e x a m i n e r s t a n d s i n f r o n t o f h e r , g r a sp i n g h e r h e a d i n h i s a r m a n d s t a b i lizing i t again s t h i s c h e s t , w h i l e h i s l i t tle fi n g e r cl a s p s the verte bra l arch of t h e u p p e r v e rt e b ra o f t he segme n t be i n g e x a m i n e d . T h e o t h e r h a n d fi x e s t h e s p i n o u s process of t h e l ower ve rtebra w i t h h i s t h u m b . The exa m i n e r

h e s p r i n gs maxi m u m r o t a t i o n w i th t h e m i n i m u m

F ig u re 4 .29a) . W i t h a fi n g e rtip of o t h e r h a n d h e s e n s e s s p r i n g i n g a t the tra ns ve r s e process of the a t l a s . An a lte r n a tive m e t h o d is to .fix the a t l a s w i th the t h u m b a n d fo re fi n g e r a g a i n s t t h e t r a n sverse p rocess o n e a c h s i d e from beh i n d , ( s e e F i g u re 4.28a, p. 1 08) a n d to g r a s p

of

force ( see

the

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1 14

Manipulalive Therapy in Rehabilitation of the Locomotor System

Figure 4.37

Exam i n a t i o n of a n te fl e x i o n b e t w e e n occi p u t

a t las w i t h fi x a t ion o f t h e tra n sve rse p rocesses o f t h e a t las

and

Figure 4.35 E x a m i n a tion and atlas

2.

with the

of

l a t e ra l

Aexion

bet wee n

occ i p u t

b e a d r o t a t e d to t h e o p p os i t e s i d e

the p a t i en t ' s head w i th the other arm in order to produce a very sma l l rot a tory move m e n t w h i l e sl ightly side-bending the head i n the opposite d i recti o n . In order to reach t h ose transverse processes from beh ind the d i vergi ng t h u m b a n d fore fi nger m u s t be i ncli n e d , poi n t i n g upwards beneath the occ i p u t . S ide-bending - The p a t i e n t lies s u p i n e w i t h her h e a d over the edge of t h e t a b l e ; t h e e x a m i n e r rot a t es t h e h e a d so as t o l o c k C 1 I2, i . e . a t l e a s t a b o u t 50 degrees. H e n ow side-be nds the head aga i ns t the cervic a l spi n e (which is erect). Head rotation need not exceed 50 d egrees, an i m porta n t

poi n t t o re m e m b e r w i t h elderly patients ( Figu re 4.35 ) . 3 . Retroflexion - The p a t i e n t is s u p i n e w i t h her head ove r t h e e n d of the ta ble ; the exa m i ne r pl aces o n e h a n d on the c h i n a n d the o t h e r on t h e occiput, rota ting i t to lock the atlas/axis, a n d bend ing i t back against the cervical s p i n e . Ca re must be t a ke n n o t to grasp the occipu t too close to the a tlas, so that th e fingers meet n o obs t ruction befo re full back-be n d i ng is achieved (Figure 4.36) . 4. A nteflexion - The patient is supine on the table; the exa m i ne r places h i s hand under h e r occiput from o n e side so that h i s t h u m b is resting against o n e transverse process o f the a t l as a n d h i s i ndex finger against the o t her, p roduci ng fi x a t ion of t he
Exa m i nation o f t h e extrem ity j o i nts

Figure 4.36

Exa m i n a t i o n o f r e t ro A e x i o n

a n d occ i p u t w i t h

the

h e a d ro t a t e d

between a t l a s

B e fore goi ng i n to d e t a i l r m us t st ress o nce again that correct o r d istu rbed fu nction of the locomotor system concerns both the s p i n a l co l u m n and the extre m ities, and t h a t if p a i n is due to such a d isturb a nce, fu nction m ust be norm a l ized , w h a tever i ts loca l iza t io n . I t is often taken for gra n ted by neurolo gists, as well as m a n i p u lators, t h a t the s p i n a l column has the ' d o m i n a n t role ' a n d that pain al most n e cessa r i l y rad i a tes from the spine to the extremi ties, i n a somew h a t hiera rch ica l manner. This i s to neglect the fact that n e rvous con trol is the res u l t o f processed i nfo r m a tion from rece ptors, a n d t h a t t h ese are most n u merous a t t h e periphery of t h e b o d y , i . e . a t the h ands a n d fee t ; a ffere n t i n put is of paramo u n t importa nce. [ t c a n be disastrous for t h e p hysici a n to neglect distu rbance o f the e x t re m i t y

Copyrighted Material

Examination of iocomotor function and its dislLLrhance

joints or o f the temporom a n d i b u l a r joints (m asticat ory dysfunction ) . The exam i n a ti o n o f i n d iv i d u a l j o i n ts fol l ows the pattern a lready esta blished: active movement, resis ted or isome tric move m e n t to show wh ether m uscles a re at fa u lt, and passive mobi l i t y i n c l u d i n g j o i n t p la y . I [ passive m o b i l i ty i n a j o i n t i s i m p a i red , there is a 'capsular p a ttern ' ( Cy r i a x , 1 977) for e ach j o i n t , i . e . i f there i s move m e n t restrictio n i n several d i rections it shows characteristic proportions, or a patte r n . I f i m p a i r m e n t d o e s not fol l ow t h i s p a t t e r n w e m a y conclude t h a t t h e lesion is n o t i n t h e j oi n t b u t a ffe c t i n g i t from w i t h o u t . T h e signi fica nce of joi n t p l a y l i e s i n t h e fact t h a t i ts d i s t u rb a n ce i s the first sign of a lesi on. The tec h n i q u e o f exa m i n a tion of j o i n t play i s descri bed in Cha pte r 6 , as i t is i d e n tical to that of j o i n t m obi lization . The s h o u l d e r

Active m o b i l ity i n c l udes abduction and elevation o f the a r m , rota tion, a n teflexion and re troflexion. The most stri k i ng d i s t u rbance is the ' p a i n fu l arc' of Cy ri a x ( 1 977 ) d ur i ng abducti o n : the patie n t may feel sharp p a i n d u ri n g abduction to even less than 90 degrees, but when she passes this point s h e c a n t h e n raise her arm t o a ful l 1 80 degrees. Th is phenom e n on is d u e to d isturba nce o f the subacrom i a l b u rsa which faci l i ta tes the g l i d i n g motion o f t h e head o f the h u m e rus, with t h e ro tator cu ff under the coraco acromia l l ig a m e n t . I sometric resis t a nce m ay s h o w tend erness of some muscle i nsertions: against abd ucti o n , the supra spinatus ten d o n ; aga i ns t ex ternal rota tion , the i nfra spi n a t us ; a n d aga i nst r a i s i n g the se m i - flexed a r m ( l i ke a wa i te r carr y ing a tray, Figure 4 . 38c), the long biceps tendon . Te nderness i n t h e s u bsca p u l a ris m ust

1 15

be d iagnosed by d i rect palpation, as described i n Chapter 6 , p. 225 . If passive m o b i l i t y is i m p a i red a n d t h e character istic capsu l a r pa ttern of the shou l d e r j o i n t is prese n t , t h e lesion is in t h e capsule of t h e g le n o h u me r a l j o i n t , as is t h e case i n 'frozen shou lder ' . I f we exa m i ne from the n e u tra l pos i t i o n , i . e. w i th the a r m i n a d d uction , t h e el bow i n righ t-a ngle flexion a n d the forea r m faci ng forw a rd , we find accord i n g to Cyriax m a x i m u m restriction of exte r n a l rotation fo l l owed by abd uction and internal rota tion. Rece n tly, how ever, Sachse (1 995) u s i ng the tech nique shown in Figure 4.63 showed that i t i s abduct i o n w h i c h a s a rule is restricted fi rst a n d most. I t is therefore i m porta n t to exa m ine abd uction fi x i n g the sh oulde r blade from above; e x t e rn a l rotation s h o u l d be exam i ned by the exam iner s t a n d i n g be h i nd the seated patient and grasping t h e forearms c l ose to t h e e l bow, k e ep i n g the e l bows c losel y a d d ucted agai nst the patie n t ' s tru n k a n d using the forearm as a lever to produce extern a l rotation (Figure 4.39). B y drawing the p a ti e n t ' s t h u mbs u p her back, o n both sides, w e examine mainly i n te r n a l rota t i o n coupled with extension a n d adduct i o n . I f i t is o n l y abduction t h a t is restricted, a n d ro tation is free , t h e l e s i o n is i n the subacro m i a l b u rsa, whether th ere is a p a i n fu l arc o r n o t . I n this case there i s often i m pa i red j o i n t p l a y . The e xa m i n e r s t a n d s behind t he sea ted patie n t a n d a bducts h e r a r m to 9 0 d egrees, t e l l i n g h e r t o re lax. W i t h h i s other h a nd on t h e head of t h e h u m e r u s h e exerts v e ry sligh t pressure from above i n order to take up the slack, and then springs t h e j o i n t in the s a m e d i re c t i o n . I n teresti ng l y , if t here i s a t r u e caps u l a r p a ttern a nd yet i t is possible t o a b d u c t the a r m to the horizontal, we fi n d normal j o i n t play, which aga i n shows that the 'frozen s h o u lder' i s n o t d u e to

Figure 4.38 E x a m i n a tion aga i n s t iso m e t r i c res i s t a n ce o f t h e m u s c l e s o f t h e r o t a t o r c u ff a t t h e s h o u l d e r : ( a ) a g a i n s t a d d u c t ed u pper a r m (supraspinat us): (b) against external rota t i o n ( i n f r a s pi n a t us); ( c ) aga i nst r a i s i n g of t h e se m i - fl e x e d arm (long biceps t e n d o n ) a b d u c t io n o f the

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116

Man ip ulative Therapy

in Rehabilitation of the L o c o m o t o r System

Pa i n d u e to blockage of t h e sternoclavicular j o i n t is a m uch less common con d i t i o n , u n less t h e re is rhe u m a toid arthri tis. The patient experiences pa i n w h e n m o v i n g t h e s h o u l d e r-blades (sh rugging the s h o uld ers) ; p a ss i v e rotation of t h e should e r i s restricted a n d direct pa lpation rev e a l s tenderness. There is one d i agnostic p i t fa l l to b e avoided , however: t e n d e rness of the m e d i a l e n d of the clavicle c a n be due to tension a t the a ttac h m e n t poi n t o f the sternocle idomastoid m uscle.

The e l bow j o i nt

Figure

4.39 E x a mi n a t i o n

t h e shoulder w i t h t h e Aexed a t r ig h t a n g l e s

of

a rms

p a s s i v e e x te rn a l r o t a t i o n o f i n a d d u c t i o n a n d e l bows

I m p a i r m e n t h e re concerns m a i n l y fl e x i o n and ex tension , the former s u fferi n g more (capsular pattern ) . I n addition t h e re is pronation a n d s u pi n a t i o n betwe e n t h e ra d i u s a n d t h e u l n a . A s t h ere a r e t h re e bones a r t i c u l a t i n g at the e l bow, however, j o i n t p l a y i s c o m p l e x , and i n c l udes move m e n t between rad i u s a n d u l n a . The most i m porta n t c l i n i c a l c o n d i t i o n i s p a i n a t the e p ico n dyles, w h e re we fi n d i n a d d i tion to loca l tende rness a t the e p i co n d y l e s , i m pa ired l a t e r a l s p r i n g i ng, and typical m uscle s p a s m s which wi l l be dea l t with e l sewhere.

T h e wrist j o i nt

of joint p l a y ( ca u d a l shi ft) with arm i n 9 0 d e g r e e a b d u c t i o n ; sp r i n g i n g p re s s u re i s a p p l i e d from a b o v e , o n t h e head o f t h e hume rus Figure

4.40 E x a m i n a t i o n

the patient

sea ted, her

b l oc kage. Joi n t p l ay, however, i s certai n ly impaired if o n l y a b d u c t i o n is i n volve d , i.e. i n w h a t m i ght be called ' periarthr i t i s ' i.f i t were not prefera b l e to d rop this m i s l e a d i n g term and ca l l it ' a bd uction lesion ' ( Figure 4.40) . Care m u s t be ta ken to place the h a n d o n the h e a d o f t h e h u m e ru s a n d not on t h e labr u m g l e n o i d a l e o f the sca p u l a . Two more joints may c a u s e s h o u l d e r p a i n : the acromioc l a v i c u l a r a n d the sternoclavicu l a r . I nv o lve m e n t o f t h e forme r is a very frequent b u t r a r e l y d iagnosed cond i t i o n , yet d iagnosis is not d i fficu l t : i f we pus h t h e elbow of the affected s i d e aga i n s t t h e opposi te s h o u l d e r . t h e p a ti e n t fe els pa i n and t h e move m e n t is restricted compared w i t h t h e h e a l th y s i d e . D i rect p a l p a t i o n o f t h e j o i n t i s a lso pa i n fu l .

This is a complex j o i n t c o n s i s t i n g of the r a d i u s a n d u ln a , t h e ca rpa l b o n e s a n d t h e j o i n ts of t h e d ista l. carpa l bones a n d t h e me taca rpals. For c l i n ical loca l i za t i o n it is use fu l to k n ow that the proxi m a l s kin fo ld o n the d orsa l aspect o f the w r i s t in dors i flexion co rresponds to t h e radiocarpal j o i n t , w h ereas the fold o n t h e p a l m a r as pect i n p al m a r flexion corresponds to the carpom etacarpal j o i n ts . Active move m e n t consists o f d o rsal a n d pa l m a r flexion and ra d i a l a n d ulnar flexion. For correct t r e a t m e n t each o f the movem e n ts m u s t be fu l l y u n d e rstood . Dorsal fle x i o n takes p l a ce more i n the m i d -carpal joint, the d i s t a l row o f the carpal bones gliding i n a p a l m a r d i rection . I f this m o v e m e n t is i mp a i red , p a l m a r g l i d i n g (jo i n t play) m u s t be restore d . Palma r fl e x i o n t a k e s p lace m a i n l y i n t h e rad io c a r p a l j o i n t , the prox i m a l row of the carpa l bones g l i d i n g i n a d o rs a l d i rection (j o i n t play) . I f p a l m a r flexion is i mp a i re d , dorsal g l i d i n g m u s t b e restore d . U l n a r flex i o n co n s ists of a r a d i a l gl iding move ment o f t h e ovoid o f the wrist in re l a t i o n to the rad i us ( a nd u l n a ) , by w h i c h t h e hand rotates i n to u i n a r fl e x i o n . Th i s g l i d i n g move m e n t of t h e prox i m a l row against t h e radius m u s t b e restored i f u l n a r fl e x i o n is i m paired. Th e most com p l ex o f t hese move m e n t s is rad i a l A e x i o n . T h i s moveme n t is achieved b y a p p roa c h i ng t h e base o f t h e first me taca rpal to t he sty l oid p rocess of the ra d i u s . T h i s i s m a d e poss i b l e by a l oca lized dorsi flexion b e t w e e n the sca phoid and the trapez i u m , w h i ch c a n b e palpated a s a p a l m a r pro t u b e ra nce i n the prox i m i ty o f t h e styloid process d u r i n g rad i a l

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Examinalion oj locomotor Junc/ion and its distllrbance

1 17

flex i o n , T h u s radial fl e x i o n cannot be carried out i f the h a n d i s i n p a l m ar flex i o n , w h e re a s i t i s fac i l i tated by dors i fl e x i o n , T o res t o re t h i s mov e m e n t we m u s t therefore res tore j o i nt play between the t r ap e zi u m a n d t h e sca phoid , mov i ng t h e for m e r i n a palmar d i rect i o n , E ve n more f r e q u e n t l y , h owever, radial fl e x ion is re st r i c te d by yet a n o t h e r m ech a n i s m : impa i re d p ro n a ti o n o f t h e radius aga i nst the u l n a . O n m o v i n g the h a n d i n t o ra d i a l a n d u l n a r fl e x i o n on a h o r i z o n tal board we can e a s i l y see that t h e forearm m a k e s a pro n a to ry s y n k i n e s i s d u r i n g radial fl e x i o n a n d a s up i n a t o r y s y n k i n e s i s d ur i ng u l n a r flexion . Hi nd e r i n g this s yn k i ne s i s by placing a t h u m b u n d e r t h e s t y l o i d process of t h e radius w i l l prev e n t r ad i a l flex i o n , T h e same holds - i n t h e opposite d i rection - for u l na r flexion. We m u s t th e re fo r e exa m i n e a n d restore j o i n t p l a y i n t h e e lbow j o i n t a s w e l l : fo r i m p a i r e d rad i a l fl e x i o n , l a t e r a l s pr i n g i n g of the e l bow joint s h o u l d be use d , and fo r u l n a r flexio n , m e d i a l springing, This i s a l s o t h e mech a n i s m u nd e rl y i n g s ty l o i d p r o c es s pa i n , I n a d d i t i o n to m o v e me n t t h a t ca n be ca rried o u t a c t i v e l y t h e re i s , o f cou rse , j o i n t p l a y betw e e n e ach of the c a rp a l b o n e s a n d b e t w e e n t h e c a r p a l bones and the fo re a r m , a n d also between t he c a r p a l a n d t he metaca rpal bones. a n d even between t h e bases o f the me tacarpa l s , T h i s has b e e n s h own to b e of considerable cl i n i c a l i mpo r t a n c e i n v i ew of t h e freq u e n t occ u r re n ce o f t h e c a r p a l -tu n n el s y n d r o m e W hereas t h e g l i d i n g move m e n ts of j o i n t p l a y c a n normal ly be b ro u g ht about w i t h the m i n i m u m o f force (i ndeed, i t i s d i fficu l t to e x e r t s o l i t tle force as not to m ov e th e s e b o ne s ) in the c a r p a l - t u n n e l syndrome there is i ncreased resista nce to j o i n t p l a y , I t c a n o n ly be d i agnose d , however, by exami n i ng w i t h t h e m i n i m u m of fo rce , Th e c l i n i c a l co nseque nce is clear: we t r ea t the carpal-t u n n e l syndrome by remov i ng its m a i n cause, d i s t u r b e d j o i n t p l a y of the bones t h a t fo r m the w a l l s of the carp a l t u n n e l , b e a r i n g i n m i n d th a t t h i s functi o n , t o o , i s i n fl u e n c e d by move m e n t p a tt e rn s c o n t r o l l i ng t h e upper ,

Figure 4.41

Exa m i nation

of t h e

hip

joi n t for Patrick's sign

.

,

extremity. T h e fi n g e r j o i n ts

a re d e a l t with i n Chapter 6 ( p . 1 6 1 ) .

The h i p joint

Alth ough t h e h i p i s a n e x t re m i t y j o i n t c l i n i c a l l y i t o f the pe l v i s a n d fr e q ue n t l y the fi r s t sym ptom i n lesions of t h e h i p joint is low-back p a i n The most c on s t a n t s igns to be looked fo r are P a t r ick's sign (Fi g u r e 4 . 4 1 ) , a tender fe m o r a l head in the g r o i n , restriction and tenderness on i n te rn a l ro tation ( Figure 4.42), a n d p a i n on m a xi m u m ac t i ve a b d u c ti o n w i t h th e p a t i e n t ly i ng o n h e r s i d e . The re i s t e n de r n es s o f t h e grea ter t r oc h a n te r a n d , i f t h e p a t i e n t a l s o c o m p l a i n s of p a i n i n the k n ee s , tendern ess o f t h e pes a n s e r i n u s on the t i b i a . The t y pi ca l ca p s ul a r pattern is m a x i m u m d i s t u rba nce of i n tern a l ro t a t i o n ,

is pa rt

,

.

Figure 4.42 I n t ern a l

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rotarian of t h e hip joint

Copyrighted Material

EXlim inmioll

of lacoma/or fl lllClio/1 (Ind i/s di,\"IIIriJmICf

1 19

b r u x i s m , w i t h r e s u l t i n g, c h a n ge s i n t h e t ee t h , i s a l s o

sign i fi ca n t . B e s i d e s a ff e c t i n g, t h e m a s t i ca t o r y m u sc l e s , d y s fu n c t i o n

may

a l so a ffe c t t h e d i g a s t r i c u s : i ncre a s e d

t e n s i o n c a n b e fe l t i n t h e s u b m a n d i b u l a r regi o n . I f t h e r e i s g re a t e r t e n s i o n on o n e s i d e , t h e re m a y b e l a t e ra l d e v i a t i o n o f t h e h y o i d a n d t h y roid c a r t i l a g e , a n d i nc r e a s e d res i s t a n c e to s h i f t i n g o f t h e m i d - l i n e s t r u c t u re s

away

from

the

d e v i a t i n g,

c h a r a c t e r i s t i c m u sc u l a r i m b a l a n c e ity i n

t he

m a s t i c a t o ry

is

side.

The

i n cre a s e d a ct i v

m u sc l e s , w h i c h

a re

tigh t,

w h e re a s t h e m u s c l e s t h a t gov e r n t h e o pe n i n g o f t h e mouth

(m8inly

t h e d i ga s t r i c u s a n d t h e d e e p n e c k

fl e x ors) a r e re l at i v e l y w e a k .

Exam i n ation of d i st u rbed eq u i l i b r i u m I h a v e a l re a d y s h ow n t h a t t h e s p i n a l c o l u m n p l a y s an

i m po rt a n t

part

in

m a i n ta i ni n g

or

d isturbing

e q u i l i b r i u m , a n d i t i s t h e re fo re n e c e s s a r y t o a s s e s s t h i s fac t o r in c a s e s o f d i s t u r b a n c e , i f p o ss i b l e by d irect cl i n i ca l e x a m i n a t i o n . H a u t a n t ' s t e s t i s very s u i t a b l e

fo r t h i s p u r p o s e :

the

p a t i e n t i s se a t e d i n a c h a i r w h i c h s u p p o r t s h e r b a c k , w i t h b o t h a r m s s t r e t c h e d for w a r d . The e x a m i n e r s t a n d s fa c i n g h e r. w i t h h i s t h u m b s poi n t i n g a t t h e

Fi glll'e 4.43 Ha u t a n t 's t e s t : t h e p a t i e n t i s s e a t e d w i t h t h e exa m i n e r w a t c h e s d e v i a t i o n of t h e o u t s t r e t c h e d a r m s b y comp a r i n g t iJ e pos i t i o n o f t h e p a ti e n t 's h a nds wi t h iJ is o w n t h u m b s

b a c k s u p p o r t e d a n d t h e eyes close d : t h e

p a t i e n t ' s h a n d s . T h e p a t i e n t c l oses h e r e y e s w h i l e t h e exa m i n e r w a t c h e s f or a fe w s e c o n d s , t o see

i m b a l a n c e d u e t o c e r v i c a l l e s i o n i s so c h a ra c t e r i s t i c

w h e t h e r t h e p a t i c n t ' s h a n d s d e v i a te to one s i d e i n

that we

rc l a t i o n t o h i s o w n t h u m bs ( F i g u re 4 . 4 3 ) . A ft c r

ex a m i n a tion

can

s p e a k o f a ' ce r v i ca l p a t te r n ' ( see p .

273 ) .

out

if the

T h i s v e ry si m p l e e x a m i n a t i o n i s c a r r i e d

is

p a t i e n t c o m p l a i n s o f d is t u r b e d ba l a n c e a n d i f t h e t es t

re pe a ted i n d i f fe r e n t h e a d p os i t i o n s : b e n t b a c k , b e n t

s ta n d i ng o n t w o sc a l e s s h ows a d i ffe r e nce gre a t e r

fo rw a r d .

in

the

t u rn e d to

n e u t ra l

p os i t i o n ,

the test

t il e l e ft a n d t o t h e r i g h t . W h i l e

t h an 4

t h e patie n t c h a nges t he pos i t i o n o f h e r h e a d t h e e x a m i n e r ilo l d s h e r h a n d s i n

ne utra l posi t i o n t o

p re v e n t d e v i a t i o n d u e t o s y n k i n e s i s o f t h e a r m s .

up,

t h e p a t i e n t fe e l s s a fe e v e n i f d i zz y ,

a n d d e v i a t i o n i s n o t c a u s e d by ne rv o u s n es s , a s i s

case

o ft e n t h e

s t ructed

i n Rombe rg's t e s t ( w i t h t h e pa t i e n t

sta n d i n g) . T h e s e c o n d a d v a n tage i s t h a t w i t h t h e d e v i a t i o n o f t h e a rms i s poss i b l e . I n R o m b e rg ' s te s t , t h e o t h e r h a n d , i n w h i c h t h e s wa y i n g

of the

s i m ple

commu n i c a tion) b a s c o n tech n i q u e to regis t e r t h i s d e v i a t i o n :

o n e o u t s t re t c h e d h a n d s h e h o l d s a p e n c i l a n d m o v es i t fro m r i g h t to l e ft

body

and

b a c k to r a b o u t 1 cm o n p a p e r

th a t i s m ov i n g a t a c o n s t a n t sp e e d . I n th i s w a y d e v i a t i o n c a n b e reg i s t e r e d [o r v a r i o u s h e a d p o s i t i o n s (Figure

p Cll i e n t' s b a c k l e a n i n g, a ga i n s t a c h a i r , o n l y s i d e

on

a

t b e p a t i e n t i s se a ted a s b e fo r e , w i t h eyes c l o s e d : i n

Th i s t e s t h a s t w o g r e a t a d v a n t a g e s : b e i n g s e a t e d a n d p ropped

kg.

M . B erger ( p e rso n a l

4.44 ) .

T h e re is

s u b t l e d i ffe r e nce b e t w e e n t h e s i m p l e

a

H a u ta n t ' s t e s t deviation:

in

and

B e rg e r ' s m e t h o d of regi s t e r i n g

t h e fo r m e r

both

hands

a re

tested

w i t h eyes shut i s t e s te d , the c h a nge in the d i re c t i o n

fo r d e v i a t i o n , a n d i f t h e re i s o n l y d i ve rge nce

o f s w a y i n g t h a t occurs i n h e a d r o t a t i o n ( fo r w a r d s o r

co n v e rg e n c e , t h e r e s u l t

backwards)

i s i n t e r p r e t e d a s t h e re s u l t o f l a b y r i n t h

i m b a l a nce , t h e p a t i e n t s w a y i n g i n t h e d i rec t i o n o f the

laby r i n t h .

a ffe c t e d

d e v i a t io n t h a t t a k e s p l a c e

[n

Hauta n t 's

whe n

test,

any

t he patie n t turns h e r

h e a d i s t h e r e s u l t o f t h e h e a d pos i t i o n re l a t i v e t o t h e trun k .

i.e.

t h e pos i t i o n o f t h e ce r v i c a l s p i n e . W e c a n

t h us d i s t i n g u i s h p a t h oge n i c a n d re l i e f p o s i t i o n s o f the

head,

i.e.

pos i t i o n s

that

cause

or

fo u n d

rea c t i o n

to

i n t h t; n e u tra l

pos i t i o n . I n

fa c t , t h e

c h a nged

p os i ti o n

c a s t; s

h e <1 d

in

of

one h a n d

n e g a ti v e .

Devia tion

or is

d e v i a te s t o t h e s i d e w h i l e t h e

ot h e r re m a i n s i n n e u t ra l p o s i t i o n , beca use i t i s t h e d e v i a t i o n o f t h e c e n t re p o i n t b e t w e e n b o t h a r ms which

co u n ts.

However,

in

w r i t i n g h a n d d e v i a t e s th e re whether

the

d i re c t i o n ,

or

i n c re a se

d e v i a t i o n , a n d t h ose t h a t a bo l is h d e v ia t i o n if it h a s been

di agnosed jf

is

D iagnosis

ation

other

hand

B e rg e r ' s

is no

if

the

i n the same (d i ve rge nce). r e v e rsed ) if d e v i

d e v i a te s

to t h e o p p o s i t e s i d e

is

test,

w a y of k n o w i n g

corro b o r a ted (or

d i s a p p e a rs ( o r p e r s i s ts ) a fter tre a t m e n t .

I t i s n ec e s s a ry t o d is t i n gu i s h be t w e e n d i s t u r b a n c e

of

ba l a n ce c a u s e d b y t h e p o s i t i o n

Copyrighted Material

of

the neck , and

120

Manip l liative Therapy

in Rehab ilitation of the Locomotor System

9

f Figure 4.44 C e r v i cove r t i gogr a m (by c o u r t e s y of B e rge r ) : in v a r i o u s pos i t i o n s , w i t h e y e s

t h e p a t i e n t holds t h e h e a d

c l o s e d , a n d m a k e s osci l l a t ory move m e n t s wi t h t h e o u t s t re tc ll e d a r m s ; these move m e n t s a re recorded b y p e n ci l on a mov i n g s t r i p o f p a p e r . ( 1 ) D u ri n g h e a d

o w i n g to d i sease, sy mptoms w i l l occ u r . T h e test i s c a r r i e d o u t w i th the p a t i e n t s u p i n e , h e r he a d i n re troflexion over the e n d of the t a b l e . T u rn i n g the head fi rst to one side and t h e n to the other, we e x a m i n e nystagmus in e n d-posi tion a nd watch the p at i e n t for symptoms of d izziness, na usea , etc. Th is te st i s particu l a rly conclusive i f there is n o m o v e men t restriction i n the position that ca uses symptoms, thus ruling out blockage as t h e i r possi b l e cause. For d i agnostic pu rposes it may the refore be n ecessary to treat move m e n t restrict i on (e.g. if left rota t i o n i n retroflexion is restricte d a n d ca uses symptoms) a n d t o repeat the test a fter m o b i li ty has been restored. If the sym ptoms do not recur, then they were due to the move m e n t restrictio n ; i f they persist, then they a re d u e to vertebral a rtery i ns u ffic i e ncy (in this case, o n the left) . T h e pos i t i o n of t h e p a ti e n t d u ring de Kley n ' s t e st m a y sometimes cause posit i o n a l ver tigo; this is a benign cond i t i o n , n o t to be con fused with vertebral artery i n s u fficiency, w h ich is serious. T h e d istinction ca n be m a d e by repeating the test; i n positional vertigo t h e re is a ' t r a i n i ng' e ffect so t h a t no ve rtigo is p rovoked at the second o r t h i rd repe t i t i o n o f t h e t e s t . The con d i t i o n a l so disappears a fter a few seconds, even if t h e test position is m a i n ta i ned . I n true vertebral artery insufficiency i f the de Kleyn test i s positive the patient's con d ition gets worse owing to ischaemia i f she maintains the test position w h i c h i n v o lves conside rable risk.

rot a t i o n to t h e r i g h t ( r ) there is d e v i a t i o n to t h e left ; w i t h t h e h e a d s t r a i g h t ( g ) the a r m

returns to m i d

pos i t i o n ; a n d d u r i n g h e a d rot a t ion to t h e l e ft ( I ) t h e r e i s no d e v i a t i o n . ( 2 )

A ft e r t r e a t m e n t of r e s t ri c t e d r o t a t i o n of

t h e occiput/atl a s t o t h e r i g h t , t h e r e i s no l o n g e r a n y d e v i a ti o n

disturb a nce due to the position of the head with the rest of the body i n space, i . e . to laby r i n t h i n e l e s i o n s . To m a k e t hi s d istinction w e must ch a n g e the position o f the p a t i e n t's head and tr u n k s i m u l t a neo u s l y ( s i t ti n g u p , l y i n g down, t urni n g from o n e side to the other) to d e term i n e w h i c h position causes ve rt igo . This type of v e rt i g o is u s u a l ly v e ry i n te n s e b u t o f s h o rt d uration, so that it is enou g h to watch t h e patien t s reactio n . W e s h o u l d , however, i n sist o n t h e p a tien t k e e p i n g h e r e y e s o p e n w h ile c h a nging posi tion; we c a n the n o b s e rve s p o n t a n e o u s n ystag mus, which u s u a l ly lasts o n l y a few seconds. (The pati e n t w i l l alwa y s tend to close her eyes in t h i s type of v e r tigo . ) T o d e t e r m i n e the r o l e of the verte b r a l a r t e r y i n vertigo, d e K l e y n ' s te s t s a re u sefu l; here, too, it i s the posit ion of t h e h e a d r el a ti v e t o t h e tru n k that is decisive, i . e . neck positio n . If t he head is b e n t back a n d rotated to o ne sid e , blo o d flow i s impa ired in t h e vertebra l artery o n the side away from w h i c h the head is t u r n e d . Hence, i f t h e vertebral a rtery o n t he s i d e towa rds w h i c h t h e head is t u r n e d is insuffici e n t '

Exa m i nati o n of d i stu rbed m uscle f u n ct i o n The great d ifficulty here is t h a t there is no exact delimitation of what i s to be considered norm a l , a n d diagnosis must b e b a s e d a l most exclusively on c l i n ical e x a m i n a t i o n . Polymyoelectrography using s urface electrodes i s so cumbersome that its use is very l i m i ted. Clinical k i n esiological e x a m i n a t i o n should com prise: 1. N e u rological screen i ng. 2. Examination of m uscle strength ( musc le tests) . 3. Exa m in a tion of s hort m uscles, fascia e , etc. 4 . Exa m i n a tion of hypermobility. 5 . Examin a t ion of posture standing a n d sitting. 6 . Exa m i n a t i o n o f s i m ple movement. 7 . Examination of gait with vari a t ions such as walking o n tip-toe, on the heels, with a r m s raised, etc.

I n the n e u ro l ogical e x a m i nation the signs of speci a l i n te rest a re those c h a racteristic of m i n i m a l b rain dysfunction: m ar ked asymmetry i n particular of the face and t h e extrem ities, restlessness, c l u msi n e s s , etc.

Copyrighted Material

Exam ination M u scle

tes t i n g

was

origi n a l ly

i n t ro d u c e d

of locomotor function a n d its

disturbance

121

to

exa m i n e p a r e s i s of i n d i v i d u a l m u s c l e s or of m u s c l e g r o u p s i n s u c h d i s e a s e s a s p o l i o m ye l i t i s . Esse n ti a l l y , m u scle s t r e n g t h i s e x a m i n e d i n t h e course of s i m p l e coord i n a te d m o v e m e n ts which m a k e i t poss i b l e to exam i n e o n l y one sp e c i fi c m u s c l e or m u s c l e g r o u p . S t a n d a rd c o n d i t i o n s m u s t be m a i n ta i n e d . so t h a t

Results are g r a d e d a s

res u l ts a r e c o m p a r a b l e .

fol l ows:

O . N o m uscl e a c t i v i t y a t a l l . l . M u scle t w i tch w i t h o u t l o c o m o t o r e ffe c t . 2. Mov e m e n t w i t h exclusion of g r a v i t y ( i . e . o n l y i n t h e h o r i zo n t a l p l a n e ) . 3. M o v e m e n t aga i n s t g r a v i t y b u t n o t aga i n s t

4.

(a)

a d d i t i o n a l resi s t a n c e .

5 . The a b i l i ty to p e r fo r m m o ve m e n t resistance : (4) a gai n s t l i t t l e r e s i s t a n c e , ( 5 )

and

a ga i n s

t

normal

m u sc l e a c t i v i t y . Beca u s e , i n o u r p a t i e n t s

t r u e p a re s i s i s fo u n d

,

o n ly i n r o o t sy n d ro m e s . c h a nges a r e u s u a ll y fo u n d b e t w e e n gra d e s

4

and

5,

a l tho ugh t h e a b d o m i n a l

m u s c l e s a n d d e e p n e c k fl e x o r s m a y e x h i b i t g r ad e Thus the distinction between grades

4

and

5

3.

is not

fm e e n o ugh f o r o ur p u rpose . W i t h o u t go i ng

i n to deta i l s

a b o u t m u scle t e s t i n g . i t

i s esse n t i a l t o stress t h e fo l l o w i n g p ri n c i p le s : the pos i t i o n o f t h e p a t i e n t m us t b e c o n s t a n t ; fi x a tio n , because t h i s d e t e r m i n e s w h i c h m u s c l e s t h e p a t ie n t b r i ngs i n t o p l a y ; d i re c t i o n . s p e e d a n d re s i s t a n c e m u st be c o n s t a n t t h ro u g h o u t t h e m o ve m e n t . I s o m e t r i c

(b)

e x a m i n a t i o n c a n re ve a l t h e d e g r e e o f force i n the muscle but

not i m po r t a n t

fa u l ts o f coord i n a t i o n .

For t h e t y p e o f d i s t u rbance t o b e e x pected i n o u r p a t i en ts i t i s n e c e s s a r y to m o d i fy t h e origin a l m u scle test i n some p a r t i c u l a rs ; the most i m po r t a n t tech n iques are descr i b e d here.

In

the section o n

disturbed

move m e n t patterns I have distinguished those m u scles with a te n d e n c y to we a k e n ( , pred o m i n a n t l y p h a s i c

m u scles ' ) a n d tho se w i t h a t e n d e ncy to h y peractivity ( ta u t n e ss

-

'

pred o m i n a n t l y postu r a l m us c l e s ' ) a ft e r

J a n d a ( 1 972) .

Exa m i n ation o f m uscles te n d i n g to wea kn ess G l uteus maxi m u s B e fore examine

pe rfo rm i n g

(Figure

the

4 .45)

'classic'

( h y per)extension

of

m uscle

the

hip,

test

we

with

the

p a t i e n t p r o n e , i n o r d e r to d i agnose t h e

( c) Figure 4.45 Exa m i n a t ion of t h e g l u t e u s m a x i m u s by dors i fl e x i o n ( h y p e rt e n s i o n ) of the h i p : ( a ) w i t h the l e g s t r a i g h t ; ( b ) w i t h the l e g fl e x e d ; ( c ) w i t h t h e l e g in e x t e rn a l rota tion

p a t te r n .

we a k er t h a n on the h e a l t h y s i d e , a n d may even b e

Ele ctro m y o g r a p h y h a s es t a b l ished t h a t t h e p r i m e

a b s e n t - y e t t h e strengt h of h i p e x t e n s i o n n e e d n o t

reduced .

movers i n h i p e x t e n s i o n a re t h e h a m s t r i ngs, fo l l o w e d

be n o ticeably

a l most i m m e d i a t e l y b y t h e g l u t e u s m a x i m us a n d t h e

o f t h e l u m b a r e rec tor s p i n a e w i t h m a rk e d h y p e r

erector

spinae.

It

is

advisa b l e

to

palpate

the

h a m s t r i ngs a n d g l u t e us w i th o n e h a n d a n d t h e t w o lumbar

e rectores

spinae

g l u t e us m a x i m u s is w e a k ,

with

the

other.

con traction

If

th e

i s r e t a rd e d ,

I n v e ry m a r k e d o v e r a c t i v i t y

t o n u s , e v e n w i th t h e p a t i e n t p ro n e , t h is m u s c l e m a y c o n t r a c t fi r s t , before

t h e h a mstrings. I n the

most

s e v e re l y c h a n g e d m o tor p a t te r n s m u scu l a r c o n trac tion may start

Copyrighted Material

at

the upper part o f the t r a p e z i u s .

i 22

Mal1 ip ll/rilive Th erapy in Rehauili/(ll;ol1 or [he LocumolOr System

T h e m u s c l e test p r o p e r is p e r fo r m e d w i t h t h e p a t i e n t p r o n e , h e r k n e e fl e x e d so as to i n h i b i t t h e h a m s t r i ngs. Resista nce i s a p p lied against t h e t h i g h , a b ove the k n e e , t h r o u g h o u t t h e m o v e m e n t . I f w e w i s h t o faci l i tate t h e g l u te u s m a x i m u s to t h e gre a test

e x t e n t , we ex a m i n e h y pere x te n s i o n o f the h i p w i th t h e l e g i n e x t e r n a l rot a t i o n .

G l ut e u s m e d i u s ( F i g u re 4 . 46) W e fi rst ex a m i n e s p o n t a ne o u s a b d u c t i o n o f the h i p

w i t h t h e p a t i e n t l y i n g o n h e r s i d e . t h e u n d e r leg s l i g h t l y bent a t t h e k n e e a n d hip. Fi r s t we observe t h e patient to see w h e t h e r s h e m a k e s a t r u e abd u c t i o n , o r a combi ned movement rota t i n g t h e leg o u t w a rd s w h i l e

fle x i ng t he

(a)

h i p . T r u e a b d uct i o n

e m p l oy s b o t h t h e t e n s o r fasc i a e l a t a e a n d t h e abd uctors (glutei medii and minim i ) , and the co m b i n e d m o v e m e n t i s p r o d u c e d m a i n l y by the t e n sor fa s c i a e l a t a e . I t i s t h e refore a d v i s a b le to p a l p a t e the te n s o r fasc i a e l a t a e w i t h one finge r a n d t h e g l u t e u s m e d i us w i t h a n o t h e r , to s e e w h e t h e r b o t h c o n tract d u r i n g a b d u c t io n . I f t h e r e i s o u tw a rd rot a t i o n a n d h i p flex ion ( i n c o or d i m l t i o n ) t h e g l u t e u s m e d i u s i s co n t r a c t i n g t o o l a t e . t o o l i t t l e , o r n o t a t a l l . D u r i n g t h e m u sc l e t e s t t h e req u is i te resis t a nce

is given aga i n s t the l o w e r t h i rd o f the t h i g ll from t he pe l v i s i s fixed in such a way t h a t i n c oord i n a t i o n is preve n t e d . Even then one s h o u l d p a l p a te t h e c o n t r a c t i o n o f both t h e t e n sor the

s i d e , and

fa s c i a e l a t a e and

( b)

t h e g l u teu s med i u s , and w a tch

fo r u n d e sira b l e c o n t r a c t i o n o f t h e q ua d r a t u s l u m boru m .

Rectus a b do m i n i s ( Fi g u r e 4 . 4 7 ) The u s u a l t e s t o f t h e re c t u s a b d o m i n i s i s fo r t h e p a t i e n t to s i t u p f r o m t h e s u p i n e posi t i o n , w i t h fl e x e d k n e e s : to ' c u rl u p ' , l i ft i n g fi rs t t h e h e a d , t h e n t h e s h o u l d e r s a n d t h e n t h e rest o f t h e t r u n k , w i th t h e opera t o r fi x i n g t he fee t a nd p e l v i s . F o r o u r p u rposes it is b e t t e r if the p a t i e n t flexes her l e gs and s i ts u p u n a i d e d w i t h a r m s s t re tched forw a r d . T h i s c a n o n l y be d o n e i f t h e a b d o m i n a l m u scles a re f u n c ti o n i n g well - if these m u s c l e s a re very s t ro n g the p a t i e n t may be a b le t o sit u p w i t h h e r b a n ds h e l d b e h i n d h e r h e a d . A l t h o u g h b e nd i n g t h e l e g s i n h i bi t s the h i p fl e x o rs t o s o m e d e g r e e . s i t t i n g u p i s a l w a y s t h e re s u l t o f coord i n a te d s y n e rgy o f t h e

a b d o m i n a l m u scles a n d t h e h i p fl e xors. To e x a m i ne t h e rec t i a b d o m i n i s a l o n e . t h e exa m i n e r p u t s h is h a n d s u n d e r t h e h e e l s of the s u p i ne p a t i e n t . t e l l i ng h e r to press t h e h e e l s d o w n w a r d s . S h e is t h e n told to l i ft her head. s h o u l de r s and tfunk , i n success i o n : t h e m o me n t t h e pa t i e n t s t a r ts u s i ng t h e h i p fl e x o rs . t h e p ress u re of h e r h e e l s o n t h e e x a m i n e r ' s h a n d s c e a s e s . T h e s t r o n ge r t h e a b d o m i n a l m u s c l e s . t h e h i g h e r t h e p a t i e n t c a n l i ft h e a d a n d s h o u l d e rs w i t h o u t re l a x i n g the p ress u re of t h e h e e l s .

( c) Figure 4.46 Exa m i n a t ion of h i p abd u c t i o n w i t h t h e p a t i e n t s i d e (gl u teus m e d i u s and m i n i m us ) : ( { / ) p u re abduct i on correc t l y c a r r i e d o u t : ( b ) fillsc a b d u c t ion by s u b s t i t u tion hy t h e h i p fl e x o r s . p a r t icu l a r l y by the t e n s o r fasc i a e i a t a e : (c) t h e ' c l a s s i c ' t e s t f or t h e a h d u c t ms ( t h e e x a m i n e r p
o n 11er

Lower p a rt o f the tra pez ius ( F i g u re 4.48) To test t h i s m u sc l e t h e p a t i e n t m Li s t b e p ro n e . w i t h t he arm

on

t h e t e s ted s i d e s t re t c h e d fo rward . W i t h

o n e h a nd t h e e xa m i n e r g rasps t h e o u t s t r e t c h e d a nn a bove t h e e l bo w . w h i l e t h e o t h e r g r a s p s t h e i n fe r i o r

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EX(Jminali(J/1 of /ucOI1lOllJr fl lllC/ion a ll d ils dislllriJa n ce

1 23

t h e i n fe r i or sca p u l a r a n gle is s u f fi c i e n t to preve n t t h e o u r p u rposes , i , e , t o d i a g n o s e i n co o rd i n a t i o n , me re i n specti o n is u s u a l l y s u ffi c i e n t : w e te l l t h e pro n e p a ti e n t to p u l l o n e s h o u l d e r d o w n ( i n a c a u d a l d i re c t i o n ) I f t h i s m o v e m e n t is carried o u t correctly, t h e i n fe rior sc a p u l a r a n g l e moves i n a c a u d o me d i a l d i rection ( i , e , i n t h e d i r e c t i o n of t h e fi b re s of the l o w e r t ra pezi u s m u sc l e ) , I f t h i s m u s c le is w e a k , howeve r, t h e i n fe ri o r s c a p u l a r a n gle m o v e s med i a l l y l i ke a h o o k a n d p r o t r u d e s u n d e r t h e s k i n , n o t u n like a n a l a r s c a p u l a , Th is i s w h y the c a u d a l m o v e m e n t , usua l l y force fu l , c a n b e s o e a s i ly preve n te d b y t h e e x a m i n e r ' s h a n d , s c a p u l a f r o m m o v i n g d o wn , F o r

.

Serratus a n terior

This m us c l e i s t es t e d with t h e patient o n a l l [o u rs ; ca re m u s t b e t a k e n t o s e e t h a t s h e p u ts he r weigh t n o t on h e r k n ee s b u t on h e r a r ms, a n d t h a t t h e s h o u l d e rs are abd u c ted , The p a t i e n t i s w a t c h e d t o see w h e t h e r an a l a r sca p u l a appears, To m a ke t h e test m o r e d i ffi c u l t , t h e pati e n t may be t o l d to b e n d h e r e l bows, Al though t h i s test c o n c e r n s m a i n l y the serra t us a n t e ri o r i t i s a l s o affected by a we a k l o w e r p a r t o f t h e tra p ezi u s , I f w e a k n e s s o f the serratu s i s only s l igh t we m a y de tect a n alilr scap u l a e v e n b e t te r w h e n the p a ti e n t h o l d s h e r il r m s h o r i zo n t a l l y o u tstretc h e d for some t i m e , ,

D e e p flexors o f t h e neck ( Figure 4.49)

test t h ese m u scles t h e p a t ie n t is supine and i s to l d t o p u l. 1 h e r c h i n t o w a r d s h e r c h e s t i n a n a rc h i n g m o v e m e n t Th e e x a m i n e r fi x e s t h e p a t i e n t ' s c h e s t w i t ll o n e h a n d w h i l e t h e o t h e r , o n h e r fo re h e a d , res ists tle x i o n o f t h e h e a d a n d n e c k Th is m o v e m e n t m u s t b e ca r e f u ll y distinguished fro m t h il t o f the p a ti e n t pu s h i ng h e r h e a d fo r w a r d , w h i c h wi l l u s u a l l y h a ppen i f t h e d e e p fl e x o rs a re w e a k ( i n c o o rd i n a t i o n ) , b r i n g i n g i n to pla y t h e s t e rn o c l e i d o m a s t o i d s a n d a l so t h e s c a l e n e s , T h e re i s a usefu l q u a n t i ta t i v e

To

.

Figure 4.47 E x a m i n a t i o n of t h e rec t u s a b d o m i n i s : t h e p a t ie n t s i t s u p w i t h Ile x e d k n e e s , w i t h o u t fixa t io n : ( a ) 'exce l l e ll t ; ( iJ ) n o r m a I s t r e n g t h

,

'

Figme 4.48 E xa m i n a t i o n o f the l o w e r p a rt o f t h e t r a p ez i u s : t h e p � t i e ll l m o v e s the s h o u l d e r- b l a d e a c t i v e l y , i n a c a u d a l d i rect i o n ( a ga i n s t r e s i sl o n c e )

a n gle o f t h e scap u l a

t e l l i n g t h e p a t i e n t to pull h e r a n d s h o u l d e r d o w n : t h e e x a m i n e r r e s i s ts t h i s move m e n t w i t h bot h h a n d s a n d i f t h e l o wer t r a p e z i u s i s wea k , t l J e r e s i s t a n c e of t h e h a n d h o l d i n g ,

arm

,

Figure 4.49 Exa m i n a t i o n o f t h e

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deep n e c k fl e x o rs

1 24

Manip u lative Therapy

ill R ehabilitation of the Locomotor Systenl

test : we ask t h e p a t i e n t to l ie w i t h h e r head raised as t h o ugh i n te n d i ng to read ( w i t h o u t l i fting the t h o r a x ) . N o r m a l l y this posi t i o n can be m a i n t a ined for h a l f a min ute or even l o n g e r b u t pa t i e n ts w i t h w e a k dee p n e c k fle xors can h o l d i t for o n l y a few sec o n d s . ,

Exa m i n ati o n of s h o rt (ti g ht) m u sc l es We have a l re a d y seen w h i c h m u scles te n d to shorten t h e ' p red o m i na n t l y p o s t u r a l m us c l e s ' o f J a n d a ( 1 972). I n p ri n c i p l e we observe how f a r a m u s c le c a n b e stretc hed w i t h o u t the use of fo rce: as t h is is done m a i n l y by t h e same m a n o e u vres as post is o met r i c r e l a x a t i o n , o n l y t h ose tech n i q ues t ha t d i ffe r a re described here.

-

-

Tri ceps surae (soleus) I f t h i s m uscle is shorte n e d , d o r s a l flexion of the a n k l e j o i n t i s restricte d . This ca n be tested by a s k i n g the p a t i e n t t o s q u a t d o w n : i f t h e t r iceps surae (soleus) i s n o rm a l , s h e should be able to p l a c e the w h o l e foo t o n t h e floor, i n c l u d i n g the hee l , b u t if the so l e us is shortened, t h e heel w i l l n o t t o u c h t h e fl oor ( Fig u r e 4.50). I f, however, it is only the gas t roc n e m i u s t h a t i s s h o r t e n e d a s is freq u e n t l y t h e c a s e dorsiflexion o f t h e a n k l e joint will be red u ced i f t he knee is stretched and i n c reased i f s h e flexes t h e k n e e ( Figure 4 .5 1 ) . For this reason i t is a mistake to ex a m i n e the m obi l i ty o f t h e ankle j o i n t with t h e kn e e s e xten de d ,

( a)

,

.

H a mstr i ngs The h a m stri ngs a re tested t h e s a m e way as i n the s t r a i g h t l e g raisi ng test. The l e g t hat is not being e x a m i ned s h o u l d be fixed to the t a b l e from a bove. The h amst r i ngs a re considered s hortened i f t he s t re tched leg c a n n o t be raised to an a ngle of 80 degrees fro m the horizo n t a l . N o te t h a t i f the legs a re o u tstretched t h e l u m b a r s p i n e is n o t i n a neutral b u t i n a lordotic position. Therefore if we w a n t t o p e rfo rm t h e st r a i g h t leg r a i s i n g t e s t f ro m a n e utral pos i t i o n , t h e leg w h ich is not examined is bent a t t h e h i p a n d t h e k ne e , with the foot o n t h e t a b l e . In th is case straight leg raising to 90 degrees s h o u l d normally be expecte d . U nl i k e i n t h e straight l eg raisi n g test for root syndromes, the p a t i e n t feels onl y t h e stretch u n d e r t h e k n e e , b u t no real p a i n . This is the m o s t freq u e n t reason why a s u bject cannot touch the floor when be n d i n g fo rward with s trai g h t le g s .

H i p flexors ( Figure 4 . 52) Th e se co m p r i s e

the i l i opsoas, t h e rect u s fe moris a n d t h e tenso r fasc i a e latae. They a r e exa m i ned i n t h e p os i t i o n for M e n n e l l 's t e s t s . The patie n t is s u pine

( b) Figure 4.50 Scre e n i n g t e s t fo r s h o r t e n i n g of t h e s o l e u s :

t h e patient squats. (a) N o r m a l ; (b) shortened (the heel

d oes n o t t o u c h the fl o o r )

with the b u ttoc k s a t t h e ed g e o f the table, t h e leg of the exam i n ed s i d e h a n g i n g o v e r t h e edge. The p a t i e n t grasps t he flexed knee o f t h e o t h e r l e g a nd draws i t to w a rd s her chest close e n ough to fl a t t e n l u m b a r lordosis. I n t h i s position i t is possible to

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Examination

0/ locom% r fllnction and i t s disturbance

1 2S

Figure 4.51 ( a ) E x a m i n a t i o n of d o rs i fl e x i o n of t h e fo ot leg stre tched; (b) w i t h k n e e b e n t . M a r k ed i n c r e a s e i n d o r s i fl e x i o n w i t h t he k n e e b e n t i s c h a ra c t e r i s t i c of a

with

s h o r t ga s t ro c n e m i u s

assess t h e relev a n t c h a n g e s by i n s p e c t i o n : if the i l i o p s o a s is s h o r t e n e d , t h e knee of t h e leg h a n g i n g o v e r t h e e d g e o f t h e t a b l e wi l l be r a i s e d i n s t e a d of being b e l ow or o n t h e leve l o f t h e p a t i e n t s h i p . I f t h e rec t u s fe moris is s h orte ned , t he k n e e w i l l show too l i t t le fl e x i o n ; i f the te n s o r fasc i a e l a t ae is sh orte n e d , the leg w i l l be s l i g h t l y a b d u c t ed and t h e pat e l la d e v i a t e d slightly o u t w a r d . T h e e x a m i n e r c a n now pro c e e d to cons i d e r e a c h m u scle , w i t h t h e p a t i e n t i n t h e s a m e p o s i ti o n . W i t h one h a n d h e r e i n fo rc e s t h e fixation o f t h e k n e e ( h e l d i n t he p a t i e n t ' s t w o h a nds) a n d t h e n ( I ) e x e r t s press u re on t h e o t h e r k n e e from a b o v e in o r d e r t o dete r m i n e t h e exact e x te n t o f s h o r te n i n g o f t he iJ iopsoas ; ( 2 ) i n c r e a se s fl e x i o n of t he k n e e of t h e free l eg (over t h e ed ge o f t h e ta b l e ) o r t e l l s the patie n t t o fl e x i t a c t i ve l y - i f t h e rectus fe moris i s s h o r t t h e k n ee w i l l i m m e d i a tely rise a b o v e t h e h o rizon ta l ; a n d ( 3 ) t h e exam i n e r wi l l t ry t o a d d u c t t h e k n e e . I f t h e t e ns o r fasc i a e l a t a e is s h o rte n e d t h e re i s i m m e d i a t e re s i s t a n c e to adducti o n , a n d the i l i o t i b i a l tract can be seen to f o r m a groove o n t h e l a teral a s p e c t of the t h igh by tighte n i ng. '

( c) Figure 4.52 E x a m i n a t i o n of the h i p fl e x or s : t h e p a t i e n t i s s u p i n e w i t h h e r b u t tocks a t t h e e n d o f t h e t a b l e ; she p u l l s one bent knee to the a b d o m e n . t o fl a t t e n l u m b a r l o r d os i s , w h i l e t h e l e g t o be t e s t e d h a n gs o v e r the e d g e o f t h e t a b l e . ( a ) The e x a m i n e r n o t es w h e t h e r t h e t h i g h i s r a i s e d a b o v e t h e horizo n t a l a n d w h e t h e r t h e re i s e x t e n s i o n o f t h e k n e e ; ( b ) b y pre s s u re o n t h e k n e e fro m above he tests s h o r t e n i n g of t h e i l iopsoas; (c) be n d i n g t h e k n ee p r o d u c e s h i p fl e x i o n i f t he rect us fe moris i s short

The ( l u m b a r ) e rector spi n a e ( Figure 4 . 5 3 )

T h e r e is a s i m p l e t e s t for o ri e n ta t i o n : t h e s e a te d p a t i e n t is told to draw h e r for e h e ad to h e r k n ees. Th is i s h i n d e re d by a sh o r te n e d e re c t o r s p i n a e , but t h e re a re m a ny fa c to rs t h a t m a y i n v a l i d a te the test:

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Manipulative Th erap v in Reh((iJ ili({/tion of tile LocoJllotur Sv;·tem

l 26

figure 4.54

t h e q u a d ra t u s l u m b o r u m : t h e l i ft i ng t h e u p p e r p a ri o f h e r b o d y b y a d d u c t i n g t h e e l how ( t h e pe l v i s m u s t n o t be l i fted a n d may he fixed hy the e x a m i ne r) Ex a m i n a t i o n o f

pa t i e n t l i e s o n

he r

side.

me n t t h e p a t i e n t l i e s o n h e r s i d e a n d l i fts t h e u p p e r

p a rt o f h e r body by a d d u c t i ng t h e e l h o w a n d s i d e be n d i n g t h e t r u n k . C a r e m u s t b e ta k e n to see t h a t

d o e s n o t l i ft h e r p e l v i s , wh i c h i s b e s t fi x ed f r o m exa m i n e r. T h e tec h n i q u e of e x a m i n a t i o n of t h e pectora l e s , u p p e r t r a pe z i u s a n d l e v a t o r s c a p u l a e i s i d e n t i ca l t o re l a x a t i o n t re a t m e n t , a n d is d es c r i b e d i n t h e r e l e v a n t c h a p t e r . A t i n spection a s h o r t pectora l i s i s s h o w n by rou n d or forwa rd-d rawn s h o u l d e rs , w h i l e h y p e r ton u s of t h e u p p e r p a r t of t h e t r a p e z i u s is r e v e a l e d by t h e she

a b o v e by t h e

Figure 4.53 E x a m i n a t i o n of s h o r t e re c t o r e s s p i n a e . t h e p a t i e n t s i t t i n g . w i t h k n e e s bent : ( a ) d r a w i n g t h e fo re h e a d t o t h e k n e e s : ( iJ ) h u m p i n g h e r b a c k w h i l e fix i n g t h e p e ly i s w i t h h e r h a n d s

u pw a rd

convex

' G o t h i c ' s h a pe o f t h e s h o u l d e rs

( F i g u re 4 . 5 5 ) . F o r ra p i d asse s s m e n t o f b o t h u p p e r tra p e z i i a n d t h e o t h e r n e c k e x t e n sors , t h e s i m p l e s t test

i f t h e p a t i e n t h a s a s h o r t tr u n k a n d l o n g t h i g h s s h e w i l l p e r fo r m t h e move me n t e a s i l y even w i t h a short e r ec t o r s p i n a e ; con verse l y . i f h e r t r u n k i s l o n g a n d th ighs s h o r t , s h e w i l l fa i l e v e n w i t h a n o r m a l e rector s p i n a e . I t h e re f o r e p re fe r a m o d i fi c a t i o n of the tes t : t h e p a t i e n t se a t e d . fi xe s h e r pe l v i s b y p l a c i n g the h a n d s o n t h e i l i ac crests, and s i m p l y h u m p s her s p i n e . If t h e l u m b a r part o f t h e e r e c to r s p i n a e is

the

pa ti e n t s c h i n t o h e r c h e s t . I f '

is to

d ra w

the n e c k e x t e nsors

b re a d t h re m a i n s . S h o r t n e c k e x t e n s o rs a r e t h e most fre q u e n t c a u s e o f i n a b i l i t y to b r i n g t h e c h i n d o w n on to t h e c h e s t .

.

s h o rte ned, n o l um b a r k y p h os i s is o b t a i n e d . C l i n i c a l l y n o l e ss i m porta n t t h a n a s h o r t e n e d e r e c t o r s p i n a e i s hypertonus of t h i s m u sc l e e s p e c i a lly i n t h e thoraco l u m b a r region ; it is m ost often fo u n d i n p a t i e n ts w i t h i nc r e a s e d l u m b a r l o r d o s i s I t m a y b e s e e n w h e n t h e p a t i e n t s t a n d s re l a x e d , a n d d i s a pp e a r o n r e t ro fl e x i o n ( fi rs t degre e ) : i t m a y b e fo u n d o n re t r o fl e x ion a o d d i sap p e a r w h e n the p a t i e n t i s prone (second d e g r e e ) ; i n t h e m o s t s e v e re c a ses it is fo u n d e v e n whe n the pa t i e n t is p ro n e . T h e s e a re t h e c a s e s i n w h ic h h i p e x t e n s i o n from t h e p r o n e p o s i t i o n i s i n i ti a t e d b y t h e e r ec t o r s p i n a e . .

.

T h e q u a d ra t u s l u m b o r u m ( F i gure 4 . 5 4 ) The state of

t h i s m uscle c a n

be a s s e s s e d

while

the

p a t i e n t b e n d s s id e w a y s . b u t d i ffe r e n c e i n l e g l e n gth m u s t of co u rs e , be r u l e d out fi r s t . For e x a c t a s s e s s .

E xa m i n at i o n of h y p e r m o b i l ity ( ra n g e of m ovem e nt) N o t o n l y w e a k n e ss a n d t a u t n e s s , b u t h y p e rm o b i l i t y ,

too, i s m a i n l y t h e c o n s e q u e n c e o f m u sc u l a r a c ti v i t y is d e t e r m i n e d b y t h e m u s c u l a r s y s te m . T h e s i g n i fi c a n ce of hypermo b i l i t y fo r p a t h og e n e s is h a s a l re a d y b e e n p o i n ted o u t ; h e re we a re concerned o n l y w i t h e x a m i n a t io n a n d d i a gn os i s . T o S a c h s e ( l 969) goes t h e c r e d i t for e l a b o r a t i n g g u i d e l i n e s fo r t h e a s s e ss m e n t o f nor m a l r a n g e o f move m e n t , a n d fo r a t te m p t i n g t o d e t e r m i n e t h e c o n c ep t s o f h y p o m o b i l i t y , a v e r a ge m o b i l i t y a n d hyperm o b i l i ty , a l l w i t h i n t h e ra nge o f t h e normal. I t is, n e v e r t h e l e s s , i m po rt a n t t o b e a r i n m i n d the gre a t v a r i a b i l i t y n o t o n l y b e t w e e n i n d i v i d u a l s , b u t a ls o a c co rdi n g to a g e a n d s e x . What m a y be c o n s i d e re d h y p e r m o b i l e i n a n a d u l t m a l e m a y be pe r fe c t l y n o r m a l i n a fe m a l e . a n a d o l e s ce n t o r a c h i l d W i t h or

Copyrighted Material

.

Ewminillioll of locomOlOr fitiluion (/I/ d ils dislU rhllnce

Figure 4.55 Ty p i c a l a p pea rance of a p a t i e n t w i t h h y p e rt o n u s a n d h y pe ract i v i t y o f bo t h u p p e r t r a p e z i i , ' G o t h i c sh o u l d e rs '

1 27

( a)

t h e s e l i m i t a t i o ns i n m i n d , r a n g e A ( i n t h e d i a g r a m s ) s t a n d s for h y p o m o b i l e to n o rm a L ra n ge B fo r s l i g h t l y h y p e r m o b i l e a n d C fo r m a r k e d h y pe r m o b i l i t y , 1 g i v e t h e c r i t e r i a o f S a c h se w i t h a d d i t i o n a l d a t a f ro m K a p a n dj i ( 1 <) 74 ) ,

The s p i n a l c o l u m n T h e to t a l K a p a n dj i

range o f s p i n a l m o b i l i t y ( I <)7 4 ) , o n t h e b a s i s of X - ra y

a s L 4 5 d egr e e s

tor a n te l� e x i o n ,

135

is

g i ve n

by

examination, d e g re e s

fo r

r e t r o A e x i o n , 75 d e g r e e s fo r l a te ro A e x i o n to o n e s i d e , a n d 90-95 d egree s f o r

r o ta

t io n

to o n e

T h i s i s d i ffic u l t t o assess c l i n ic a l l y :

side, each

of the

pri n c i p a l s e c t i o n s o f t h e s p i n a l co l u m n m u s t b e

e x a m i n e d se p a ra t e l y

,

L umbar spine The a v e r a g e r a n g e

of r e t r o l1 e x i o n

i s 3 5 d e g re e s

acco rd i n g t o K a p a n d j i ( 1 97 4 ) , C l i n i c a l e x a m i n a t i o n sh ows a s h a r p be n d e i t h e r a t t h e l u m bosacral o r a t

t h e t h o ra co l u m b a r j u n c t i o n i n c a s e s o f h y p e rm o b i l i t y , I n o rd e r t o d e t e r m i n e t h e r a n g e w i t h i n t h e n o r m a l ,

Sachse ( 1 96<))

gives

t h e fol lowing

test: t h e p a t i e n t

l i e s p ro n e w i t h be n t e l bows po i n t i n g b a c k w a rds a n d h a n d s A a t o n t h e t a b l e by h e r shoulde rs (F i g u r e 4,56a ) , By e x t e n d i n g h e r a r m s a t t h e e l bow s h e l i fts the u p p e r p a r t o f her body w h i l e the e x a m iner fi x e s t h e p e l v i s from a b o v e ; i n t h is w a y t h e l u m b a r s p i n e

( b) Figure 4.56 Test i n g t h e range o f l u m b a r ( t ru n k ) re t rofl e x i o n , Ra nge A , h ypomo b i l e t o n o r m a l : B , s l ight h y p e r m o b i l i t y ; a n d C. m a rked h y p e r m o b i l i ty ( A ft e r Sach s e , 1 969)

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Man ipulative Therapy in Rehabilitation oj the Locomotor System

A

B

c

Figure 4.57

Tes t i n g t h e range

of l u m b a r

( t r u n k ) a n t e flexion

is force d into retroflex io n. Ra nge A is from up to 60 d e rees a t the e l bow, ra nge B between 60 and 90 degrees and range C above 90 d egrees (Figure 4.56b). The average ra nge o f a n te fl e x i o n is 60 degrees. C l i n ica l l y this is tested by the p a t i e n t b e n d i n g to touch t h e floor, with knees and finge rs stretche d . R a nge A g o e s u p to t h e po i n t w h e re the subject touches the floor with h e r fingertips, B fro m t h i s perform a nce to p u t t i n g t h e k n uckles on t h e floor, a n d C beyond this, t h e pa t i e n t n o t o n l y able to lay h e r hand flat on the fl oor, but sometimes even to bring the chest t o the t h i g h s ( Figure 4.57 ) . T h i s most popular test, unfortu n a tely, shows not only the degree o f a n te fl e x i o n of the t r u n k but a l so the exte n s i b i l i ty o f t h e h a m stri ngs; i t a lso l a rge ly depends o n t h e proportions of the l e g s t o t h e tru n k a n d arms. For simple t r u n k a n teflexion , t h e re fore, i t may be better for the patient to sit and touch he r knees w i t h her fore h e a d (see Figure 4 . 5 3 a ) , range A cove ring t h e range o f a n teflexion up t o w h e re t h is is poss i b l e , a n d r a n g e B is w h e re t h e pa t i e n t ca n p u t h e r fore head between h e r knees. The a v erage range of l a teral fl e x i o n is 20 degrees t o each side; the cli n i c a l criterion accord i n g to S a c hse ( 1 969) i s the s h i ft o f the axil l a re l a tive to the m id - l in e . I n range A, t h e a x i l la of the convex side sho u l d come to rest above the i n tergl u te a l l i n e ; in B it s h o u l d rest above t h e b u ttock of t h e other side , w h i le i n C t h e a x i l l a s h i fts beyond the l a te r a l aspect of the b u ttock o n t h e other side (Fi g u re 4 . 5 8 ) . The

range o f axia l rota tion is given by Kapa ndj i ( 1 974) as 5 d egrees but is not c l i n ica lly teste d . W h e n testing stoop i n g a n d side-ben d i n g the exa m i ne r m ust ta ke i n to account t h e mobi l i t y o f the h i ps a n d the proportions o f the p a t i e n t: t h e re may be ' fa lse ' h y pe rmobi l i t y d u e to a l on g t r u n k a n d sh ort legs, or ' fa lse ' h y pomo b i l i ty d u e t o long legs a n d a s hort tr u n k , while the le ngth o f the a rms p l a y s a part in stoop ing. Beca use o f its unfavourable consequences, h ow ever, clinically the most i m p orta n t sign o f l u m ba r h y pe rmobility is hy p e r lordosis when standing relaxed and exaggerated l u m b a r k y p h os is w h e n sitting rel axed. Th o racic spin e

Tru n k rotation is tested c l i nically. Kapandj i ( 1 974) gives 35 degrees to each side as the average. The patient sits astride the table, tur n i n g fi rst to one side a n d then the other. Accord ing to Sachse ( 1 969) range A is u p to 50 degrees to each side, B from 50 to 70 degrees and C beyond 70 d egrees (Figure 4.59). ( N ote that we have shown that t run k rotation l i ke side bending is a coupled movemen t concern i ng both t he thoracic and the l u mbar spine, see Chapter 3, p. 55.) O bvious l y the tests for stoopi ng, ret roflexion (ex t e n s i o n ) a n d side-be n d i n g show t h e m o b i l ity of the whole trunk, i nc l u d i n g the t h o racic spine, but i n c l i n ical practice they a re used ( w i t h t h e patient s t an d i ng) for assessme n t of t h e l u m bar s p i n e .

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Examination of locomotor function an d its disturbance

1 29

0'

_ _

A

....

.. ... .. .. .. ...

"

60'

80'

Figure 4.59 Te s t i n g t h e r a n ge of

Figure 4.58 Tes t i n g t h e range of A e x i on

l u m b a r (tru n k )

tru n k

rotation

l a te r a l

K a p a n dj i ( 1 974) g i v es t h e r a n ge o f m o v e m e n t for the t h o r a c i c s p i n e as 4 5 d eg re e s in a n t e fl e x i o n ,

25

degrees in r e t rofl e x i o n and 20 d e g rees to e a c h s i d e

i n l a te ro fl e x i o n .

Cervica l spin e Here, too , i t

is m a i n l y r o t a t i o n t h a t

is c l i n i c a l l y

tested . Acco r d i n g to K a p a ndj i ( 1 97 4 ) t h i s is o n l y 5 0 degrees t o e a c h s i d e , w h e r e a s S a c h se

range A as u p to 70

d egrees

( J 969)

gi v e s

to e a c h s i d e , B f r o m 70

Figure 4.60 Tes t i n g t h e range of h e a d (ce r v i c a l ) rota t i o n

to 90 d e g re e s and C ov e r 90 d e g r e e s . R o t a tion i s tested i n t h e e rect posi t i o n by b r i n g i n g t h e p a t i e n t ' s c h i n a bove t h e s h o u l d e r .

d i s c re pa n c y b e t w e e n

passive d o r s i fle x i o n , ra nge A i s u p to 4 5 d e g r e e s , B

the a n a t o m i c a l a n d t h e cl i n ic a l d a ta i s d u e to t h e fa ct

b e t we e n 45 a n d 60 d e g r e e s a n d C b e y o n d 60 d egrees

that rota t i o n t a k e s p l ace i n t h e e re c t p os i t i o n , a n d

(F i g u re 4 . 6 1 ) .

The

t h u s also i n v o l ves t h e u p p e r t h o r a c i c s p i n e . O n s l ig h t for w a rd - b e n d ing rota t i o n stops a t C7

and

t h e r a n ge

is red uced to a b o u t 5 0-60 d e grees ( Fi g u re 4 . 6 0 ) .

W i t h regard to t h e e l bow j oi n t , t h e re i s m ore v a lgosi t y

in

th e

hyperm o b i l e

e l bow,

and

the

fol l owi n g test i s t h e re fo r e c l i n i ca l l y v a l u a b l e . The

T h e range of a n te fl e x i o n ( K a p a n d j i , 1 974) i s 4 0

p a t i e n t h o l d s b o th a r m s b e fore h e r c h e s t , pa l m s

degrees. t h a t of re t rofl e x i o n 75 d e g r e es a n d of l a tero

u p w a r d s , w i t h h e r for e a rms h e l d together fro m e l b ow to w r i s t ; s h e i s t o l d t o s t r e tc h h e r a r m s ,

fl e x i on 3 5 de gre e s t o e a c h s i d e . T h e range o f mobi l i t y a t t h e c r a n i o ce r v i ca l j u n c t i o n i s g i v e n i n t h e c h a p t e r on

Functional

a n a to m y

s p i n a l co l u m n , p.

and

ra d i ogra p h y

of

t he

k e e p i n g t h e e l bows toge t h e r . R a n g e A m o b i l i ty w i l l e n able t h e pa t i e n t to k e ep t h e e l bows tou c h i ng u p to a n

62.

a ngle

of 1 1 0 d e g r e e s , B to 1 1 0-1 35 d e g r e e s ,

w h i le b e y o n d t h i s i s range C ( Figu re 4 . 62) . For t h e s h o u ld e r g i r d l e , t h e c h a r a c t e r i s t i c t e s t i s

Some extremity j o i nts

to bri n g t h e e l bo w towa rd s

the shoulder

o f t he

by

o p p o s i t e si d e ; r a n ge A m o b i l i ty e n a b l e s t h e p a t i e n t

Sachse ( 1 969) . For m e t a c a rpop h a l a n g e a l j o i n ts , a t

to br i n g t h e e l bo w t o m i d - l i n e , r a n g e B fro m t h e r e

He re aga i n I give

the fi g u r e s as d e t e r m i n e d

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iVlan ip l l lative Therapy in Rehabilitlltion of th e Locomotor System

Figure 4.61 Test i n g t h e range of dors i rlexion of t h e m e t a ca rpop h a l a n ge a l j o i n t s

Figure 4.62 Tes t i n g t h e r a n ge o f

e l bow

e x t e n s i o n , bo t h e l b ow s k e p t t o u c h i n g

to a p o i n t h a l f- w a y between t h e m i d l i n e a n d th e o t h e r s h o u l d e r , w h i l e i n ra n ge C t h e e l bo w m a y t o u c h t he opposite sh o u l d e r (Figure 4.63 ) . A n o t h e r t e s t is to try to m a ke bo th h a nds m e e t be h i n d t h e b a c k , o n e from a bove a n d t h e o t h e r f r o m b e l o w . W i t h ra n ge A m o b i l ity the fi ngers m a y n o t to u c h , o r m a y j ust c o m e i n t o c o n t a c t ; i n ra nge B t h e fi n ge rs -

m a y t o u c h o r o v e r l a p as fa r as to t h e fi rs t p h a l a n x ; i n C t h e w h o l e h a n d m a y ove r l a p ( Fi g u re 4 . 64 ) . I n t h i s t e s t i t is i m porta n t n o t t o a l l ow h y p e r l o r d o s i s t o occ u r .

I f we i n t e n d to e x a m i n e t h e sca p u l o h u m e r a l j o i n t

b y i t s e l f, i t i s m os t c o n v e n i e n t t o t e s t o n l y p u r e a b d u c t i o n w h i le o n e h a n d fi x e s t h e s h o u l d e r - b l a d e

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Exarninnliol1 of /oeolll% r fllne/ion lin d i/s dis/urbllnee I 1- - .... .... I B A I I I

.... .... '"

/

.... /

//

131

/

/ /�\\

/

c

\ \ \ \ \

...

Figure 4.63 B r i n g i n g t h e e l bow t o w a r d s t h e s h o u l d e r of t h e opposite s i d e

w i t h t h e c l a v i c l e , f r o m il b o v e . R a n g e A d e g r e e s , B fro m l) ( ) t o 1 1 0 d e g r e e s a n d

de grees

is u p to 9 0 C over 1 1 0

( Figure 4.(5 ) .

The knee

joint

i s t e s t e d Co r

e x t e n s i o n ) , r a n ge A

degrees ) .

e x t e n s i o n ( o r h y p e r be i n g up to fu l l e x t e n s i o n ( 1 80

r a n ge B u p to 1 0 d e gre e s h y p e re x t e n s i o n

( 1 90 d e g r e e s ) a n d C b e y o n d I h i s fi g u re ( F i g u re 4 . 6 6 ) . Fo r

are

the hip

j o i n t , i n t e rn a l

tes t e d , ra n ge

A

being

up

a n d exte r n a l rota t i o n t o l)() d egre e s ( e x t e r n a l

ro t a t i o n ) , B b e t w e e n 9 0 a nd 1 20 C m ore t h a n 1 20 d e g r e e s (Fi gu r e 4 . 6 7 ) . I t is i m po r ta n t to t e s t I he range o f m o b i l i t y i n various regions o f t h e b o d y , b e c a use t h e re m a y b e h y p e r m o b i l i t y i n o n e a n d a ve r a ge o r e v e n red uced mobi l i t y i n a n ot h e r , w i t h o u t restri c t i o n o f moveme n t . plus

i nternal

degrees

and

A

S l i g h t r c l a t i ve h y p e r m o b i l i t y o n t h e n o n - d o m i n a n t sid e is

p h y s i o l ogica l ( H inzma n n

a n d S a c h se , 1 (8 8 ) .

Exa m i nation o f coord i n ated m ove m e n t ( locom otor p atte r n s ) The exa mina tion

o f i n d i v i d u a l m usc l e s a n d t h e mo b i l i ty a re fo l l owed by t h e s t u d y o f m o re com p l e x m o v e m e n t p a t te rns, o r s t e re o t y p e s . We b e g i n w i t h a s s e ss m e n t o f p os t u re w i t h t h e p a ti e n t s t a n d i n g , as d e s c r i b e d a t t h e begi n n i n g of t h i s c h a p t c r ( s e e F i g u r e 4 . 6 , p . 95 ) . He re t h e fo l l o w i n g c r i t e r i a s h o u l d b e s t resse d : w he t h e r t h e vert ica l l i n e from t h e e x t e r n a l o cc i p i ta l pro t u b e r a n c e c o r r e s po n d s to t h e b o d y a x i s , i . e . whether o u r p a t i e n t s t a n d s sym m e t ri c a l l y , a n d to w h a t e x t e n t t h e two h a lv e s of h i s body d i ffe r. The re l a t i ve p r o p o r t i o n of t h e e x t re m i t i e s t o t h e asse s s m e n t o f o v e r a l l

B

tru n k a n d n e c k a re i m po r t a n t . a s i s l h e re l a t i o n s h i p u p pe r p a r t to t h e l o w e r p a r t o f t h e tru n k . T h e

of t h e

p r o p o r t i o n s o f t h e prox i m a l

the

e x t re m i t ies

a re e q u a l l y

to t h e d i s t a l s i g n i fic a n t .

c

s ec t i o n s o f

Figure 4.64 Ma k i n g bot h h a n d s m e e t be h i n d the s h o u l d e r

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Manipula live Therapy in Reh a b ilitation of

th e Locomotor System

Figure 4.65 Test i n g t h e ra n g e of a b d u c t i o n of t h e sca p u l o h u me r a l J o i n t , w i t h t h e s h o u l d e r- b l a d e fi x e d from above

B

� -

-

-

-

-

-

-

_

_ _

1O

-

�10 cm

_

c

Figure 4.66

Tes t i n g

e x t e n s i o n ( h y pe r e x t e n s i o n ) of t h e k n e e j o i n t

Figure 4.67

Testi n g i n t e r n a l a n d e x t e r n a l rota r i o n o f t h e h i p j o i n t

Copyrighted Material

_ _

10'

Examinlllioll of /ocornOfor jUl1cfiol1 and ifS disturbance The body c o n t o u rs i n form us a b o u t i ncreased tonus o r fl a b b i n e s s . Th i s i s particu l a rl y i m p orta n t if we com p a r e t h e two s i des ( t i g h t - loo s e c o m p l e x ) . Not o n l y exaggera ted protrusio n , b u t a l so s h a r p indent ations are i mpo r tan t , as is t h e flatte n i n g o f contours. Th is is further confirmed b y pal pa t i o n w h ich e n a b l es u s t o d i s t i n g u i s h t he t y p e o f resista nce ( resilience) o f i n d i v i d u a l tissue layers. A n a l ysis of patterns o f move m e n t a n d pos t u re may start with the p a t i e n t s i t t i n g on an a dj ustable stool ( F i g u r e s 4 . 68 a n d 4.69) . T h e examiner notes the po s i tio n of the fee t and o f t h e i l iac crests, the c o u rse of the ( l u m b a r) s p i n e a n d the ton u s of t h e abdom i n a l a n d gl u t e a l muscu l a t u re . I n correct pos t u re, seated, the fee t a re flat on t h e floor in sl i gh t exte rna l rota tion, t h e t h i g h s h o rizo n t a l a n d s l i g h t l y a p a r t , t h e pelvis rotated ( ti l te d ) fo rw a rd i f poss i b l e ; there shou l d b e s l ight l u m bar l o rdosis ( n o k y p hosis) a n d n o fl a b b i ness or t h e abdom i n a l or gl uteal m uscles. S tooping and stra igh tening up ( Figures 4.70

and 4 . 7 1 ) For co rrect stoopi n g o n e foot s h o u l d b e placed i n fro n t of t h e other a nd t h e k n e e o f t h e fo rward leg s h o u l d be s l i g h t l y b e n t . The tru n k bends forward ,

starti n g with the h e a d , t h e body c u rl i n g up from the head downwards as the g l u teal and a b d o m i n a l muscles cont ract . T h e erector s p i n a e contracts fi rs t a n d t h e n re l axes d u r i n g maxi m u m stoop i n g. Con-

Figure 4.68 S i t t i n g on a s t o o l : correct pos t u re

1 33

v e rse l y , at stra i ghte n i n g u p the k nees stretch w h i l e t he t ru n k u n c u r l s , s t a r t i n g w i t h the l u m b a r s p i n e , fol l owed by t h e t h o racic s p i n e , the neck a n d fi n a l l y t h e h e a d . Th i s , too, is the resu l t of coord i n a te d c o n t r a c t i o n of t h e glute a l , a bdo m i n a l a n d back m uscul a t u re . The t r u n k must never be l i fted l i k e a rod ( Ieve r l ) nor must t h e a b d o m e n be a l l owed to b u lge . Trun k ro ta tio n, sitting (Figure 4.72)

T h i s test is more close l y conce r n e d with t h e t h o racic s p i n e a nd shoulder girdle than w e re the p revious tests. Again the pre-cond i t i o n is correct s i t t i n g posture o n a s t o o l , w i t h a t e s t obj ect ( s u c h as a b o o k ) i n t h e h a n d res t i n g o n t h e l a p . Speci a l a t te n t i o n m u s t be p a i d to r e l a x a t i o n o f t h e arms a n d shou lders, w h ich m u s t not be d rawn fo rw a rd and e l e v a ted . Th e pati e n t is now asked to p lace t h e book on a s h e l f beh i n d h e r , a t t h e l e v e l o f h e r h e a d ; spec i a l attention m u s t be p a i d to t ru n k ro t a t i o n , t h e action o f the back a n d a b d om i n a l m uscles, fi x a t i o n of the s h o u l de r b l a d e s a n d tension i n the u p per p a r t o f the t r a p e z i u s . I f the test is perfo r m ed properly we see h a r m o n ious rotation from the thoraco l u m b a r j u nction u p wards w h i l e the pelvis and l e g s re m a i n in p lace; abdominal a n d back m u s c l e s a re m o d e r a t e l y active, t h e i n fe r i o r a n g l e s of the sca p u l a d o n o t d i verge and the n e c k m uscu l a t ure, i n particu l a r t h e u p p e r pa rt o f the trapez i u s , rema i n s relaxed .

Figure 4.69 Two types of fa u l t y s i t t i n g p o s t u re

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1 34

/V/{Il1 ip l i /{(/i ve

Th emp v in Reha/Jili/[i/i O I l of /he Locol1l()/or Sys/ell1

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Figure 4.70 ( a ) S t oo p i n g a n d ( b ) lift i n g a n

Figu re 4.71 T h e s a m e m o v e m e n t s

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Exa mina{ion

Figure 4.72 T r u n k ro t a t i o n . s e a t e d . h o l d i n g

a n o bj e c t in t h e

Test m o ve m e n ts for the head a n d n e ck ( F i g u r e 4 .73 )

First w e obse rve t h e h e a d pos i t i o n w i t h t h e p a t i e n t s t a n d i n g a n d s i t t i n g ; l or d o s i s s h o u l d n o t be too m a r k e d a n d if t h e re i s a flat t h o ra c ic s p i n e the n e c k w i l l a l s o be s t ra i g h t . T h e a n g l e b e t w e e n t h e m a n d i b l e a n d n e c k s h o u l d b e a b o u t 9 0 d e g ree s . D u r i n g h e a d t u rn i n g t h e e xa m i n e r observes n e c k ro t a t i o n as w e l l as m u s c u l a r act i v i t y : l a te r o fl e x i o n s h o u l d ta ke p l a c e o n l y a t e x t r e m e ra nge a n d sh o u l d not be e x a gge r a t e d . lordosis s h o u l d not i n c r e a s e , t h e

s h o u l d n o t be l i fted n o r s h o u l d o n e b e d ra w n fo rward; t h e ste rnocleidomastoid

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1 35

fa u l t y

L ifting th e a rms ( Figu re 6 . 1 46)

W h e n l i ft i n g the a r m s the p a t i e n t a l so r a i s e s h e r s h o u l d e rs c o n tr a c t i n g t he u p p e r fi xators o f t h e s h o u l d e r girdle ( u p p e r p a r t o f t h e t r a pezi u s a n d the l e v a to r sca p u l a e ) , fi x a t i o n o f t h e sho u ld e r - b l a d e s f r o m b e l o w ( by t h e l o w e r p a r t o f the trapez i u s ) b e i n g i n s u fficien t. H o w e v e r . l i ft i n g o f the s h o u l d e rs s h o u l d be o n ly sl i gh t a n d towards t h e e n d of t h e ,

m o v e me n t .

Weig h t carrying ( F i g u re 4 . 7 4 ) a fo rward-dra w n p o s i t i o n o f causing t e n s i o n i n t h e u p p e r fi x a t o r s of t h e s h o u l d e r gird l e . I f a w e i gh t i s ; 0 be carried co rrec t l y th e s ho u l d e rs a re b e h i n d the l i n e o f gr a v i ty o f t h e b o d y a n d t h e h e a d a n d neck r e m a i n e r ec t . Th e h a n d ca r r y i n g t h e bri e f- c a s e s h o u l d also be r e l a xe d .

Here the the

head

typica l

fa u l t i s

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Figure 4.73 H e a d rota t i o n .

sea ted: ( a )

c o r re c t : (b ) fa u l t y

Special atte n t i o n s h o u l d be p a i d to t h e m u sc l es and j o i nts o f t h e s u pp o r t i n g leg. t h e l i n e of g r a v i t y of t b e body. t he p e l v i s , i n p a r t i c u l a r t h e i l i a c crests, a n d t h e h i p s t a b i l i z e rs, especi a l l y t h e g l u t e a l m u scu l a t u r e , a n el t b e s p i n a l c u rv a t u re . In c o rre ct p o s t u re on o n e l e g . a l l j o i n ts of the s up porti n g leg are in the line o f gravity; the c e n tre of gra v i t y . c o m p a r e d with s t a n c e on two l e g s , m o ve s

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Manipulative Th erapy

in

Rehabilitation

of t h e

Locomotor System

a n d the quadrati l u mboru m , should contract i n a coord i n a ted fas h i o n to stabil ize the h i p a n d t r u n k . H t h e h i p abducto rs a re wea k . the m o s t fre q u e n t fa ult, the pati e n t w i l l l i ft t h e i l i a c crest of t h e side oppos i te to the s u pporting leg (Dej e r i n e , 1 90 1 ) , bringing t h e ce n t re o f gravi ty above t h e s u pporting leg and t h us rel i e v i n g t he a b d uctors. (Tre n d e l e n b u rg's sign , t h e lowering o f t he i l i ac crest on t h e u n s u p ported s i d e , i s re l a t iv e l y r a r e : i t is seen i n severe cases o f con ge n i ta l h i p l u x a t i o n but n o t even in myopathy w i th extremely weak m uscles . ) Gait

Figure 4.74 Carry i n g pos t u re

we ights: (a) correct: ( b ) fa u l t y

forward to the secon d a n d t h i rd m e t a ca r p a l h e a d . The pe lvis s h o u l d rem a i n h orizon t a l a n d s p i n a l c u rv a t u re s h o u l d there fore be a l most u ncha n ged . The s t a b i l iz e rs of t h e h i p, i n particular the g l u teus medius. s h o u l d contract. Both flexors and exte nsors o f the h i p as w e l l as t h e a bdomin a l and back m uscles,

Fi gure 4.75 S t a nd i n g

on

o n e leg. back v i e w :

The e x a m in e r takes pa rt i c u l a r note of how the heels touch the gro u n d fol l owed by the ball of t h e foot and the toes, w h i le the h e e l is l i fted : h e s h o u l d also n ote how weight is s h i fted fro m o n e l eg to the other, how the p e l v i s moves with the spi n a l co l u m n , t he position o f t h e head a n d the move m e n ts of the a rms. In n o r m a l ga i t the steps a re even and t he weigh t i s p l aced e q u a l ly o n each l e g in t u rn . The a rch of t h e foot does not sag a n d the toes are active i n p rop u lsion. The p e lv i s should re m a i n a l most hori zonta l , and i t sways from s i d e t o s i d e . more so in women than i n men. T h e spi n a l col u m n c u rves from one side to the othe r in a series o f w a v e s . the grea test excursion b e i n g in the m i d - l u m b a r region ; t here is some counter-exc ursion i n the t h o racic s p i n e . the t horaco l u m b a r j u nc t i o n rema i n i n g above t he sac r u m . Th e head s h o u l d move v e r y l i ttle a n d t he a rms s h o u l d swi ng sym metrica l l y or s l i g h t l y more on t h e

( a ) correct; ( b ) fa ulty. S i d e v i ew: (e)

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correct:

(d) fa ulty

Examination of locomotor /imclion and its disturbance

1 37

l e ft, t h e movem e n t com i n g from the s h o u l de r. The shou lder-blades are fixed from below, the upper fix ators of t he s h o u l d e r girdle re laxed. The ce n t re o f grav ity of the b o d y a n d that of the h e a d s h o u l d s h i ft as l i ttle as possible, e i t h e r from one s i d e to the othe r or u p and down, i .e. the pa t i e n t should n e i t h e r waddle nor roc k . Asymmetrica l ga i t a n d s t i ffness can also be h e a r d , and t he re fore the e x a m i n e r must l isten carefu l ly . Ce rta i n fa u l ts become more m a r ked i f t h e pa tie n t closes her eyes, w a l k s on tiptoe or o n t h e hee l s ; th ese sho u l d be exa m i ned a s req u i re d . Fi n a l l y , p a t i e n ts s h o u l d b e e x a m i n e d , if possible, i n the i r typic a l work i n g p osition (e.g. typi ng, l i fting weights, readi ng, a t a m a c h i n e , a t the computer, e tc . ) .

Exa m i nation of resp i ration We h a ve a l ready seen i n C h a p t e r 2 t h a t respira tio n is fi rst examined a t rest i n the s u p i n e posi tion and t h e n w i t h the pati e n t sea ted o r s t a n d i ng. In t h e supine posi tion a bdomi n a l respiration s h o u l d predom i n a t e . U n d e r post u ra l con d i t ions t h e tru n k broadens from the waist; the e x a m i n e r t h e r e fore places his h a n ds on the patie n t ' s lowe r ribs, from both sides. I f bre a t h i ng is correct, the h a n d s a re moved apart, b u t i f the patient l i fts h e r thorax as s h e breathes, the exami ner's h a n d s m o v e upwards. If this fau lty bre a t h i ng pattern ( w i t h raised thorax) i s v e r y p ronounced, the t h o r a x m a y rem a i n i n the inha l a t ion position even w h i l e a t rest, t h e upper clavicu l a r grooves are deep and t h e sternocleido mastoids, sca lenes and upper fixators o f the s h o u l d e r gird le are t a u t . D u r i ng i n h a lation the c o l l a r bones are l ifted, too. In less severe cases this fa u l t is noticeable only when the patient takes a deep breath while sitting; b u t i n more severe cases i t can be seen even during breathing a t rest a n d i n t h e most severe cases i t is evid e n t even a t rest in the s u pine position (Figure 4.76). Respiration can be so badly co ordinated that a patient may draw the a b domen in during i n h a l a tion a n d push it o u t while breathing out (paradoxical respirati o n ) . Inhalation and e x h alation s h o u l d h a v e about the same duration ; the patient s h o u ld be able to breathe i n for 7-1 0 s or longer, breat b i n g o u t for the same length of time (except for professional s i n gers, w h o breathe out for much longer) . There are, however, patients who c a n n o t breathe i n (or o u t) for more than 4 s , although they suffe r from n o respi ratory disease ' The nostri ls expand d u ring tbe dee p inhalation and t h e n n a rrow d u r i n g exhalatio n . It is i m porta n t that the fac ial muscu la t u re s h o u ld be relaxed , particu larly the lips, the m uscles of the j a w and t h e tongue. The exa m i n e r should watch c a refully fo r asym metry, partic u l arly i n a patien t who l ifts her shoulders during i n h a l ation.

Figure 4.76

L i f t i n g t h e t h or a x d u r i n g i n h a l a t i o n :

marked

t e n si o n in t h e s t e r n oc l e i d o m a s t o i d e i , sca l e n i a n d t h e u p p e r p a r t o f t h e t r a pezi i ; v e r y d e e p s u p r a c l a v i c u l a r fossae

o n bot h s i d e s a n d t h e a b d o m e n i s drawn i n a t

inhala tion

I n t h e prone position thoracic spine s h ould bre a t hing. The a bsence o f the t horacic sp i n e , pattern.

t h e respi ratory wave o f the be observed d u ring deep of a wave, a nd n o blockage i m p l ies a fa u l ty breathing

Syn d r o m es The l ower crossed sy n d r o m e ( a fter J a n d a , 1 979) There i s i m b a l an ce i n the fo l lowing p a i rs of m uscles: ( 1 ) weak glutei maximi a n d s hort h i p flexors; (2) weak a bd o m inals (recti a bdom i n is) and short lumbar erectores spinae; (3) we ak g l u te i m e d i i a nd s hort tensors of the fasciae latae a n d q u a d rati l u m b o ru m . There is n o t o n l y a n tagon i s m b u t a lso 'compe t i tio n ' o r s u b s t i t u t i o n : for w e a k g l u t e i m e d i i by t h e tensors a n d quadrati l u mborum; for weak abdomina I s by t h e i l i opsoas i n h i p flex i o n ; f o r w e a k g l u t e i maxi m i by t h e erector s p i n a e ( a n d t h e h a m s tri ngs ) . Obviously, i n this syndrome t h e correct mecha n i s m of c u r l i ng u p i n s i t t i n g u p from t h e s u p i n e position a n d i n stoopi n g is i n terfe red w i t h ; t h e res u l t is

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B e tw e e n t h e dee p neck fl exors ( l o ngus cervicis. longus capitis a n d o m o - a nd t h yro h y o i d e u s) on t h e o n e h a n d . a n d the n eck e x t e n sors ( cervica l section of t h e e r ec t or s p i n a e . u p p e r p a r t o f t he t r a p e z i us a n d leva t o r sca p u l a e ) on t h e o t h e r .

I n a d d i t i o n t h e re m a y be s h o r te n i n g o f t h e u p p e r m os t p a r t o f t h e l i ga m e n t u m n uc h a e w i t h fi x e d l o rdosis i n t h e u ppe r cervica l regio n . Obviously. i f t h e lower fi x a tors o f t h e s h o u l d e r girdle a re wea k . t h e u p pe r Il x a tors m u s t become h y p e r a c t i v e and te n s e . H y p e ra c t i v i t y o f the p ector a l e s prod u ces rou n d s h o u l d e rs a n d fo rw a rd - d r a w n s h o u l d e rs , n e c k a n d h e a d ; w e a k dee p neck Aexors w i t h s h o r t exte nsors prod uce h y p e r l ord osis of the upper cervical s p i n e . In ad d i t i o n to the re l e v a n t m o ve m e n t p a t t erns. t h e res p i ra t i o n ste reotype i s a l s o u s u a l l y a ffected . H e re , too. o n e h a s to b e a r i n m i nd w h a t has bee n s a i d a b o u t the l o w e r crossed s y n d rome. poss i b l e i n te rre l a t i o n s b e t we e n b o t h s y n d ro m es a n d dys function a t the h a n d a n d e l bow.

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Figure 4.77 ( II ) I n c r e a s e d h y p e r l o rd o s i s

pelvic l i l l a n d (iJ) l u m b a r

i n c re a s e d fo rwa rd t i l t of t h e p e l v i s a s we l l as i n c reased l u mbosacr a l ( Figure 4.770) a nd/or l u m bar l o rd osis ( Fi g u re 4 . 77b ) . The h a m s t r i ngs a re u s u a l l y s h o rt i n t h i s s y n d ro m e , b u t t h i s i s freq u e n t l y a co m pe n sa tory m e c h a n i s m t h a t lesse n s p e l v i c t i l t . I t m u s t be stresse d . however. t h a t e v e n the a n tagon i s m of hip flexors a n d e x te nsors. a n d of a d d uctors a n d a b d u ctors. i s o n l y one somew h a t s i m p l i s t i c aspect. fo r a l l these m us c l es stab i l ize t he h i p d ur i n g ga i t a n d stance . Some t i m e s t h e i m b a l a n ce c a n be d u e to d y s fu n c t i o n o u tsi d e t h e p e l v i s . e .g . of t h e foo t . as cou l d be guessed f ro m Fig u re 4 . 7 7 h . w h e re w e fi n d ( u n i n t e n t i o n a l l y ' ) u n p ropo rtionaJ ly strong m usc l e s a t t h e h i p and a v e r y wea k lower leg a n d foo t . i.e. an i m po r t a n t d is p ro p o rt i o n w h i c h c o u l d i m p l y com pensa tion o r w e a k s t a b i l izers o f t h e foo t b y h i p s t a b i l i z e r s .

1.

2.

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T h e u p per crossed sy n d ro m e T h e re

[ n t h is s y n d ro m e , strata o f h y p e r t ro p h i c a n d wea k m u scle gro u ps a l t e r n a t e : i n a ca u d ocra n i a l d i re c t i o n t h e re a re w e a k m u s c l es o f t h e f o o t a n d leg, h y p e r trop h i c i sch iocrur a l m uscle groups. h y p o t rop b i c weak gl u te a l s and u n d e rde ve l o p e d l u m b a r e rectores s p i n a e . and above these t h e b u l g i n g hype rtro p h i c thoracol u m ba r section o f t h e e re c t o res s p i n ae ; these a re fo l l ow e d by fl a b by i n te rsca p u l a r muscles w i t h h y p e rt ro p h ic ta u t u p per hxa tors o f t h e s h o u l d e r g i rd l e a bove t h e m . O n t h e v e n t r a l a s p e c t t h e lower sec t i o n o f the recti a b do m i n i s buIges, but m o re l a t e ra l l y t h ere is a groove correspon d i n g to t h e ta u t o b l i q ue a bd o m i n a l m us c l e s ; l a te ral from t h i s t he a b d o m i n a l wa l l m a y b u l ge aga i n i n t h e reg i o n o f t h e w a i s t ( ' ps e u d o hernia ) . Th i s s y n d ro m e i m p l i es i m b a la n ce i n t h e s t ra t u m o f h ypermob i l i t y ( l a x i t y ) t h a t a l t e rn a t e s w i t h s t ra t a o f i nc reased te n s i o n , h y pc r m ob i l ity b e i n g most pr o n o u n ce d i n the Iow-back regi o n . I t a l so i l l u s t r a t e s t h e i m porta nce o f d i s p r o p o r t i o n .

i s i m b a l a n c e i n t h e fo l lo w i ng m usc l e g ro u p s :

B e t w e e n t h e u p p e r
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b u t d i a g n o s i s on t h e s p o t , a n aspect t h a t i s indispe n s a b l e fo r t he c r i t i c a l t h era p i s t . T h i s b e co m e s clear i f we com p a re our p roced u re w i t h t h a t of t h e p h a r m acot h e ra p i s t . w h ose c l i n i c a l res u l ts a re a l w a y s d i fficu l t t o assess i n view o f t h e e v e r-ch a n g i n g a n d freq u e n t l y u n p re d i c t a b l e co u rse o f t h e d isease. I t i s a l l t h e m o re i m po r ta n t , t h e re fo r e , t h a t we c a n s e e i m m ed i a te l y c l e a r e ffec t s , o r com p l e te fa i l u res. However, a pos i t i ve test is n o t ta n t a m o u n t t o t h e r a pe u ti c success, beca use i f we h a v e t r e a t e d il n irre l e v a n t l esion t h e e ffect m a y b e b u t s h o rt- l i ve d . I f t h e i m m e d i a te e f fect i s i n co m p l e t e , t h i s l e a d s u s t o l o o k c a re fu l l y for y e t a n ot h e r l e si o n . I n p r i n c i p l e , e v e r y d e v i a t i o n from t h e n o r m fo u n d a t c l i n i c a l e x a m i n
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p a t i e n t h e rse l f ( a s is fre q u e n t l y t h e case ) fe e l s a n d i m m e d i a te re l i e f a ft e r t h e a p p ropria t e t r e a t m e n t . I t i s , i n fa c t . g o o d po l i cy to l e t t h e pa t i e n t h e rse l f p a l p a t e p a i n p o i n t s a n d t r i gge r p o i n ts b e fore a n d a fte r t r e a t m e n t , to assess the e ffec t h e rse l f. I f t h e t h e r a p i s t p a l p a tes a fter tre a t m e n t , t h e p a t i e n t s o m e t i m e s d o u bts w h e t h e r t h e s a m e a m o u n t o f force has been a p p l ied as bdore t re a t m e n t, beca use s h e fee l s l e s s . I n a d d i t i o n to i ts d i a g n o s t i c v a l u e , test i n g i s u s e f u l fo r i n d i ca t i o n of f u r t h e r t h e r a p y : e . g . i f traction h a s bro u g h t rel i e f. f u r t h e r t r a c t i o n trea t m e n t i s p r o b a b l y i n d i ca ted . a p p r ec i a t e s

The cou rse of exa m i n a t i o n with spec i a l reg a rd to c h a i n - react i o n patter n s T h e re i s a n i m port a n t q u e s t io n : w h a t s h o u l d t h e c a se s h e e t o f a p a t i e n t w i t h d i s t u r b e d fu n c t i o n of t h e l oc o m o t o r s y s t e m l o o k l i k e ? A ' m a n i p u l a t i v e case shee t " ) Once t h e ex a m i n a ti o n t ec h n i q u es a r e k n ow n , t h e q ue s t i o n o f h o w t o obta i n use fu l res u l ts i n p r a c t i ce a n d a v o i d e rr o rs as fil l' as is h um a n l y poss i b l e m u s t be a d d ressed . T h e a ns w e r is n o t s i m p l e , as t h e obj e c t o f e x a m i n a t i o n - d i s t u rbed fu n c t i o n of t h e loco m o t o r s y s t e m a nd i ts re A e x c h a nges - c o n c e r n s m a n y d i f fe re n t fi e l d s o f m e d i c i n e . Some p a t i e n ts prese n t th e m se J v e s w i t h p ro b l e m s b e l o n g i n g to t h e fie l d o f g e n e r a l m e d i ci n e : o t h ers w i t h m e t a b o l i c , e n docri n e , n e u rologic a l , rh e u m a t ol og i c a L o r t h o p a e d i c , gyn aeco logi c a L o t i a t r i c and o th e r s y m p t o m s : in some cases t h e t r o u b l e l ies i n d i s t u rbed j o i n t m o b i l i t y in o t h e rs i n d is t u r b e d m u scle fu n c t i o n , w h i l e i n o t h e r cases pa i n with its s p ec i fi c reflex re a c t i o n s d o m i n a te s . T o e x a m ine each patient from a l l o f t h ese aspects w o u ld d em a n d fa r m ore t i m e t h a n t h e c l i n i c i a n h a s a t h i s d isposa l . W e m u s t t h e refore a p p roach e a c h c a s e fro m t h e p o i n t o f v i e w o f t h e p a t i e n t 's com p l a i n t, a n d p roceed from one fi n d i n g to the n e x t . E x pe r i e nce has s h ow n t h a t t h e fi n d i ngs fo ll ow c e rta i n p a t t e r n s ( c h a i n s ) s o t h a t i f w e fi n d ( a ) w e expect ( b ) a n d m u s t t h e n l o o k for ( c ) . I f t h e p a t i e n t i s abso l u t e l y u n k n o w n t o t h e e x a m i ne r , h e m u st fi rs t l o o k a t g a i t a n d postu re, s e e h o w t h e m u sc u l a t u re i s develo p ed , m a k e scre e n i n g t e s t s of cerv i ca l . t h o racic and l u m b a r m o b i l i t y , p a l p a t e t h e p e l v i s w i t h the p a t ie n t s t a n d i n g e x a m i n e Pa t ri c k ' s s i g n w i t h t h e p a t ie n t s u p i n e , a n d exa m i n e rota t i o n of t he f o o t - a t l e a s t . A s , 11Ow e v e r the p a tie n t c a n be e x pected t o prov i d e i n fo r m a t i o n a bo u t h i s c o m p l a i n ts , we m a y proceed accord i ngl y . For i ns t a n c e , i f a p a t i e n t c o m e s w i t h h e a d a c h e t ro u b l es ( a n d n e g a t ive n e u r o l og i c a l fi n d i n gs) we m u s t t h o r o u g h J y e xa m i n e m o b i l i t y o f

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a d o p t s t h i s forw a rd - d r a w n pos i t i o n w h e n s e a t e d , we look fo r i nc re a s e d l u mb a r k y p h o s i s in the s i t t i n g posi t i o n . We a r a ised t h o r a x

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upper ribs, the

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a rc d u ri n g a b d u ct i o n , e x a m i ne j o i n t p l a y w i t h t h e

of p o s t u re and ga i t . F i r s t w e a n a lyse some b a s i c

a rm h o r i zo n t a l a n d e x a m i n e t h e c l a v i c u l a r j o i n ts .

fu n c t i o n s o f t h e loco m o t o r s y s te m .

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p a l p a te t h e e p i co n d y l e s a n d e x a m i n e j o i n t p l a y o f t h e c a r p a l b o n e s . H e r e , t o o , d i s t u rb a n c e o f m us c l e

c h a i n s of a ffec t e d s t r u c t u res, a re g i v e n i n T a b l e 4 , 3 . T h e p r a c t i c a l a d v a n t a g e s a re c l e a r ; n o t o n l y c a n

function in

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b u t e a c h o f t h e d is t u rb a n c e s l is t e d c a n be t r e a t e d i n

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s t r a i g h t l e g r a i s i n g test Th e n w e l o o k fo r t y p i c a l p a i n

T h e c h a i n re a c t i o n s g i v e n h e re a r e n o t m e a n t t o

p o i n ts a n d t e s t t h e l i ga m e n ts . I f pos t u re i s a ffect e d ,

b e c o m p l e t e n o r a re t h e y by fa r t h e o n l y o n e s . T h e y

t h e m u sc l es t h a t g o v e r n p e l v i c i n c l i n a ti o n s h o u l d

a re

be s y s t e m a t i c a l ly t e s t ed , a n d i f l o w - b a c k p a i n i s

' p r o g r a m m e s ' o f the m o t o r s y s t e m . A t y p i c a l c h a i n

p r o v o k e d b y we i g h t l i ft i n g , t h e p a t i e n t ' s s t o o p i ng

r e l a t e d to fo r w a r d - d r a w n pos t u re s t a n d i n g i s w o r t h

s t e r e o t y p e s h o u l d be e xa m i n e d . These

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s u ffi c e . T h e y s h o w h o w

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w i t h TrPs i n t h e a bd o m i n a l m u sc l e s , i n creased t e n s i o n in the w h o l e o f t h e bClCk a nd n eck m u seul a t u re ,

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which s e e m s v e ry

e l u s i v e , Y e t t o t re a t m a i n l y a t t h e s i te o f s y m p t o m s ,

l u m b a r regi o n , a g l u t e a l p a i n p o in t , T r Ps o f t h e

o f p a i n , i s t o fa i l , i f t h e t ro u b l e i s d i s t u rb e d f u n c ti o n .

coccygeu s a n d r e s p i r a t o r y d y s fu nc t i o n i n t h e u p p e r

Ill ,

It is by n o means e a s y to t h i n k i n terms o f

r e s p i r a t o ry t r a c t , ow i n g t o d y s fu ll c t i o n o f t h e p e l v i c

fu n c t i o n . I n s t e a d o f w e l l - d e fi n e d s t r u c t u re s , f u n c t i o n

d i a p h ra g m . T h e l a t te r fo r m s p a r t o f t h e a b d o m i n a l

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cavit y w a l l a l o n g w i t h t h e

d i a p h r ag m

a n d t h e abdom

re s p i ra t i o n . B r ugger d e s c r i b e s w h a t h e c a l l s t h e ' s t e r n o symp h y s e a l s ynd ro m e ' a s a c o n s e q u e n c e o f h a b i t u ally s i t t i n g i n a ro u n d - s h o u l d e re d p o s i ti o n : fo r w a rd d rawn h e a d wi t h i n creased t e n s i o n i n most of t h e m u sdes o f t h e s h o u l d e r g i r d l e i n c re a s e d t e n s i o n i n t h e short exte nsors o f t h e c r a n i o c e r v i c a l j u n ctio n , i n c reased t e n s i o n i n t h e a b d o m i n a l muscles a n d e v e n i n t h e m u scles o f t h e t h i g h s . T o w h a t a n extent t h i s d y s f u n c t i o n a l ch a i n i s reve rs i b l e can be d e m o n s t rated i f t h e pa t i e n t c h a n ges i n to a n e r e c t ( lordot i c) s i t t i ng p o s i t i o n w i t h t h e resu l t t h a t a re a s of t e n s i o n w i t h T r Ps i n . t h e s e m u s c l e s i m m e d i a t e ly d i s a p pear ( see p . 24 6 ) . I n a g r ea t n u m b er o f u s u a l l y s e v e re c a s e s w i t h a c h ro n i c c o u rse we fi n d w h a t m a y b e c a U e d a 'c h a i n reac t i o n from s e ve r e n o c i ce p t i o n ' . U n l i k e the fo rw a rd - d raw n p o s t u r e a n d t h e B r u gg e r c h a i n w h e re the c o - c on t r a c t i o n pa tte rn h a s b e e n t h ro w n o u t o f ba l a n ce , h e re we fi n d TrPs i n b o t h e x t e n s o rs a n d fl e x ors m a i n l y o n o n e s i d e , b u t m u c h m o re fre q u e n t ly on the r i g h t . T h e re may be some (eq u a l ly b a l a n c e d ) TrPs on t h e l e f t , too b u t these ar e m u ch l es s pr om i n e n t . T h e m o s t s t r i k i n g fe a t u re a t fi r s t g l a n c e is v e n t r a l pr o m i n e n c e o f t h e r i g h t s h o u l d e r ( w i t h t h e pa t i e n t supine) d u e to a TrP i n t h e u p p e r p a r t o f t h e p e c t o r a l i s m a j o r , w i t h c o n c o m i ta n t TrPs in the l o n gissi m us and s e r r a t u s a n t e r i o r . T h e m u s d e s i n v o l ve d a re g i v e n i n Ta b l e 4 . 4 . A s a r u l e i t i s s u ffi c i e n t t o t r e a t t h e m o s t r e le v a n t TrP, o r a rest ricted j o i n t re levant t o t h e corr e s p o n d i n g m usc l e ( e . g . t h e fi b u l a r h e a d a n d t h e b i ce p s fe m o r i s) , a n d t h e e n t i re c h a i n ca n be e x p e c t e d t o vanish. I t s h o u l d be p o i n te d o u t h e re t h a t v i sc e r a l c h a n g es prod ucing reactions i n the locomotor system fre quently t r i gg e r o f f c h a i n s o r p a t t e r n s t h a t a re o f gre a t d i a g nost i c v a l u e a n d p rov i d e a b a s i s for r a t i o n a l tre a t m e n t . I t i s o f p r a c t ic a l s i g n i fi c a n c e t h a t s u ch c h a i n s a r e u s u a l l y fo rmed on o n e s i d e of the b o d y . It is obvious t h at t h e se c h a i ns m a y c o m b i n e a n d fo r m m os t c o m p l ex p a t te r n s . The t h e r ap e u t i c c o n s e q u e nces a re n o less i m p o r t a n t , fo r t h e l i n k s in these c h a i n s r e a c t o n e a c h o t h e r : t h u s , t re a t i n g a j o i n t may n o r m a l ize a m usc le trigger p o i n t , o r v i c e ve rs a ; trea t me n t o f o n e tri gg e r p o i n t may a ffect o t h e rs i n the c h a i n , as does t r e a t ment o f a j o i n t i n a key r e g i o n . I n c h ro n i c c a s e s a n i mm o b i l e fa s c i a o r sca r m a y b e h i gh ly re l e v a n t - a n d re levance is d e ci s i v e . T h e k e y t o t h i s , h ow e v e r , i s a d e e p e r u n d e r s t a n d i n g o f fu n c t i o n (d y s fu n c t i o n ) . i n a l m u scl e s w h i c h a r e esse n t i a l f o r

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dis t l l rbance

i n the c o n v e n ti o n a l , i . e . p a t h ol o g i c a l , w a y or w h e t h e r w e s h o u l d a p p r o a c h i t a ccor d i n g to t h e p r i nc i p l e s o f fu n c t i o n a l p a t h o l o gy . fi r s t a n d fu n d a m e n t a l t a s k i n c l a s s i fi ca t i o n , a n d h e n c e a lso i n d i agnos i s , i s w h e t h e r we h a v e to deal ( m a i n l y ) w i t h patho logy o r d y s f u n c t o n . 2 . Fu n c t i o n ( p h y s i o l o g y ) is as re a l as is a n a t o m y 1 . The

( p a th o l o gy ) .

3 . P a t h o l og y

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l o c a l i z a t i o n and n a t u re . Fu n c t i o n o n the o t h e r h a n d i s t h e re s u l t o f t h e c o r r e l a t i o n

a n d i n ter p l a y o f a w h o l e ch a i n o f d i ffe re n t s t r u c t u r e s o f va rious loca l i z a t i o n . 4. E ve n w h e re t h e re i s s t ru c t u ra l p a th o logy t h e r e a re a l s o c h a n g e s i n fu n c t i o n w h i c h c a u se c l i n i ca l sy m p to m s . 5 . T h e c l i n i c a l p i c t u re c o r r e l a te s m a i n l y w i t h t h e c h a n g e s i n fu n ct i o n , m u c h l e s s w i t h s t r u ct u r a l p a t h o l og y . V e r y fr e q u e n tly i n deed p a t h o l ogical c h a n ges d o n o t m a n i fe s t t h e m s e l v es so lo n g as f u n c t i o n i s not i m p a i r e d . O n t h e other h a n d , c h a n ge s i n fu nction b y t h e m selves m a y c a u s e v er y m a r k e d c l i n i c a l c h a n g e s in t h e a b s e n c e o f a n y ( s t r u c t u ra l ) p a t h o l o gy . 6. Fo r t h e s a m e reasons even c l e a r ly d i a g n o s e d p a t h o l o g y ca n be c l i n i c a l l y i r re l e v a n t (d isc herniation

a t CT, s p o n d y l o l i s t h e s i s , sco l i os i s ,

e t c. ) , w h e re a s t h e d y s fu nc t i o n w hi ch c a n u s u a l ly

7.

8. 9.

10.

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The f u n ct i o n a l approach

of /oconlO/or jimc/ion

be d i a g n ose d o n l y by c l i n i c a l m e a n s c a n be o f d e c i s i v e i m po r ta n c e . If we d i rected o u r t h e r a peut i c efforts a t t h e p a t h o l o gi c a l c h a n g e s o u r t h e r a p y w o u l d fa i l i n s u c h cases; o n t he o t h e r h a n d , e v e n i f t h e p a t h o l og i c a l c h a n ge s a re i m po r ta n t , we s t i l l m a y i m p ro v e t h e p a t i e n t ' s c o n d i t i o n i f w e i m pro v e fu n ction - Eor t h i s is ex actl y wha t c a n be a c h i e v e d by rehabi l i tation . I t is, however, necessary to be a w a re o f the l i m its o f w h a t ca n b e a c h i e v e d . The d i a gn os t i c ta s k i n p a t h o l ogi c a l d i a g n o s i s i s t o l oca l i ze t h e l e s i o n e x a c t l y a n d to d e t e r m i n e its n a t u r e ( p r i n c i p l e o f l o ca l i z a t i o n ) . The d i a g n o s t i c t a s k i n d y s f u n c t i o n i s to d e t e r m i n e t h e p a t h o ge n e t ic c h a i n a n d to a s s ess t h e c o r re l a t i o n a n d r e l e v a n ce o f t h e i n d i v i d u a l l i n k s ( h o l i s t i c p r i n ci pl e ) . The mechanism p rod u c i n g p ai n d u e to p a t h o l o g i c a l c h a n ge s c o rre s p o n d s to t h e n a t u re of t h e p a t h ol o gy i n t he c a s e ; if, o n t h e o t h e r h a n d , f u n c t i o n is c h a n g e d , t h e m ec h a n i s m i s m a i n l y d u e to i n c re a s e d t e n s io n a s a resu l t o f d ys fu nct i o n . I f t her a py is s u ccess f u l i n c o n d i t i o n s ca used by pathol ogic a l c h a n ge s , it is co n t i n u e d u n t i l t h e l e s i o n h a s h e a l e d , o r t h e d e c i s i o n t o operate is taken.

the p rev i o u s c h a pt e r s i t s h o u l d be o b v i o u s t h a t th e d e c i s i v e fi rst s t e p i n d i a g n o s i s i s t o decide w h e t h e r we have t o a p p ro a c h t h e p a t i e n t ' s p r o bl e m From

1 2 . I f t h e r a py i s s u ccessfu l i n c h a n ges d u e to d y s

f uncti o n , we s h a l l a n o t h e r l i n k of

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142

Manipulative Th erapy i n Reha bilitation

of t h e Locomotor S vstflll

Table 4.3 Chain reactions Body

area

and .limCliol1

Fin dings

Paris

affected

Toe and foo t fl e x o r s , t r i ce p s s u r a e .

Lower e x t re m i t y - g a i t : s t a n c e p hase , e x t e n s i o n ( i m p a i re d fl e x i o n )

h a m s t r i ngs, g l u t e i . p i r i fo r m i s , p e l v i c

d i a p h r a g m , l u m b a r e re c t o r s p i n a e

C a l c a n e a l s p u r . A c h i l l e s t e n d o n , fi b u l a r he a d . i s ch i a l t u be ros i t y , cocc y x . i l i a c cres t , t roc h a n t e r J o i n t d y s f u n c t i o n ( b l o c k a ge )

m a j o r a n d s p i n o u s processes L4-S I

S m a l l j o i n t s of foot

a n d a n k le , A b u l a r

h e a d . s a croi l i a c j o i n t . l o w l u m b a r s p i n e

Lowe r e x t r e m i ty

-

g a i t : s w i ng

p h a s e , fl e x i o n ( i m p a i re d ex tension )

o f t h c fo o t a n d t o c s , a n t c r i o r abdomin is, t h o r a c o l u m b a r e re c t o r s p i n a e a n d u p p e r n e c k

[ n c re a s e d t e n s i o n

IldC<

E x t e n so r s

t i b i a l i s , h i p A e x o r s , a d d u c t or s , re c t i

e x t e nsors " H " h m ""

PO' " "

Pes a n s e r i n u s , pa t e l la . s y m p h y s i s ( u p p e r

and

l a tera l a s p e c t ) , x i p h o i d

J o i n t d y s fu n c t i o n ( b l o c k a g e )

K n e e . h i p , s a c ro i l i a c j o i n t , u p pe r l u m b a r s p i n e a n d t h oracol u m b a r j u n c t io n

Tru n k : body s t a t i cs

I n c re a s e d t e n s i o n (i n m u s c l e p a i rs )

I

Te n d e r

S C M : s h o r t c r a n i ocerv i c a l e x t e n s o r s , sca l e n i

+ d e e p n e c k A e x o rs + diga s t r i c i : t rapez i i

+ l e v a t o re s

sca p Lt l a e , i l i o p s o a s + rec t i

a b d o 01 i n i s : e r e c t o r s p i n a e + q u a d ra t us

a t ta c hmen t p o i n t s

( re fe rred pa i n )

I

J o i n t d y s fu n c t i o n ( b l o c k a g e )

Poste r i o r a t l a s a rch a n d t ra n sve rse processes. s p i n o u s p rocess o f a x i s . l i n e a n u c h a e . m e d i a l e n d o f co l l a r b o n e , h y o i d , u p p e r

a n d v e rt e b ra l lowest

m a r g i n of sca p u l a , x i p h o i d , s y m p h y s i s . r i b s , i l i ac c re s t s

Cra n i oce r v i Cil l j u n c t i o n ( T M J ) . c c r v i c o t h o r a c i c j u n c t i o n , u p p e r r i b s . t h orac o l u m b a r .i u n c t i o n , l u m b o s a c ra l

L i ft i n g t h e t h o r a x a t r e s p i r a t i o n

I n cre ased t e n s i o n

I I

Te n d e r a t t a c h m e n t p o i n t s

J o i n t d y s fu n c t i o n ( bl o c k a g e )

a n d s a c ro i l i a c j u n c t i o n

U pp e r se c t i o n s of a b d o m i n a l m u s c l e s , sca l e n i , SCM, l e v a t o r e s , t r a p c z i i . s h ort e x t e n s o rs o f t h e c r a n i oc e r v i c a l j u n c t i o n , p e c t o ra l e s ,

l e v a t or s c a p u l a e a n d t r a p e z i u s Pos t e r i o r a t l a s a rch a n d t r a n s ve r se processes, s p i n o u s process o f

s t e r n ocos t a l j u n c t i o n s a n d u p p e r r i bs Cra n i o c e rv i c a I

j u nClio n ,

j u n ct i o n . upper U pp e r e x t re m i t y i m p a i re d fl e x i o n

-

pre h e n s i o n ,

I n c re a s e d tension

I I

Te n d e r a t t a c h m e n t p o i n t s

J o i n t d y s fu n c t i o n ( b l oc k a g e )

a x i s , l i nea n u c h a e , me di a l m a r g i n o f s ca p u l a .

e n d o f col l a r b o n e . u p pe r

F i n ge r

ce rv i c o t h o ra c i c

ribs, t h o r a c i c s p i n e

a n d wri s t e x t e n sors. t h e n a r , s ll p i n at o r s , i n fraspi n a t u s ,

biceps, d e l t o i d e u s . s l I p r a - +

u p p e r tl x a t o rs o f t h e s h o u d e r g i r d l e , i n t e rsc a p u l a r m u s c l e s Proc. s t y l o i d e ll s + l a t e r a l e p i c o n d y l e .

a t t a c h m e n t o f s u p ra -

a n d i n fr a s p i n a t u s , sca p u l a e a n d t h e

a t t a c h m e n t poi n t s o f l e v a t o r

s p i n o u s process o f a x i s E l bo w . a c ro m i o c l a v i c u l
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1 43

Table 4.3 C h a i n react ions (cont inued) Boilv

a rell

Findings

111 1 11 l"n elio/l

U p p e r e x t re m i t y p re h e n s i o n . i m p a i r ed e x t e n s i o n

},""

PariS ajjecied

I n c re a s e d t e n s i o n

�

I

F i n g e r a n d w r i s t fl e x o r s . p ro n a to rs .

s u b sca p u l a ri s . p e c t o ra l i s . " ' , , " ,, "" p o i o ,"

a t l a s p r o c e ss ( b l o c k a ge )

e n d o f co l l a r b o n e . E r b ' s p o i n t . tra nsverse

M e d i u l e p i co n d y l e . mecl i a l ste rn o c os t a l j u n c t i o n .

J o i n t d y s fu n c t i o n

S C M , sca l e n i

C a r p a l b o n e s ( ca r p a l t u n n e l ) . e l b o w . g l e n o h u m e r a l j o in t , c e r v i co t h o r a c i c a n d c r a n ioce r v i c a l j u n c t i o n + u p p e r r i b s

Head and neck . fee d i n g. m a s t i c a l i o n . spee c h

s h ort e x te nsors o f t h e c ra n i oc e r v i c a l j u n c t i o n ,

M as t i c Mory m u s c l e s . d ig a s t r i c u s , SCM .

I n cr e a s e d t e n s i o n

t r a p e z i u s . l e v a t o r , d e e p n e c k fl e x o r s , pe c t o r a l i s

Hyoid.

poste r i o r a t l as

a rc h a n d t r a n s v e rse

proce s s , s p i n o u s process o f

axis, l i nea n uchae, upper ribs

u p per m a r g i n o f s c a p u l a , a ng l e of Joint dysfunction

T a b l e 4.4 C h a i n due

to

nocice p t i o n 011 Ihe dorsill {(sp eC!

SCM. sca l e n i

S h or t neck e x t e n s o r s ,

P e c t or a l i s m a j o r u p p e r p a rt

L o n g i ss i m u s . serra t u s a n I .

sp l e n i i . s e m i s p i n . c a p . . u p p e r t ra p e z i u s

S u bs ca p u l a r i s

I n fras p i n a t u s , te res m i n o r

Pe ct or a l i s m i n o r

R h o m boi d e i

Obl ique

abdom ina Is

Sh o r t t o e e x t e ns o r Biceps Pronator Fi n ge r fl e x ors

Te m po r o m a n d i b u l a r J o i n t . c r a n i o c e r v i ca l j u n c ti o n , ce rv i c o t h o r a c i c j u n c t i o n

1 5 . T h e refore w h oe v e r o n ly t r e a t s d y s fu n c t io n a t

O i l I i i I' l'elllJ'llI IIspecl

S h o r t adductors

( b lo c k a g e )

L o n g i ss i m u s

b i ce p s fe m o ris S h o r t t oe fl e x ors Trice p s Gl utei.

S u p i n a tor

Fi n g e r e x te nsors

h a v e to t re a t t h e same l e s i o n ag<1 i n , we s h o u l d

fi rs t c o n s i d e r w h e t h e r t h ere i s n o t <1 more i m por t a n t l e s i o n w h i c h we h a v e m i ssed o r u n d e r r a t e d t h e fi rst t i m e . To c h a n ge t re a t m e n t e a c h

t i me i s t h e rou t i n e approach. 13. I n p a t h o l ogica l co n d i t i o n s , s u ccess i s a c h i e v e d by e ffective d rugs ( p h a rmacotherapy), o r p o ss i b ly by su rge ry. r n d ys fu n c t i o n , s u c c e s s d e p e n d s on the correct c h oice o f t h e re l e v a n t link, o r links, o f a c h a i n a t the r i g h t m om e n t . 1 4 From w h a t h a s b e e n s a i d , i t fo l l o w s t h a t t h e f u n c t i o n il l a p p roach i s m u c h m o rc d i ffi c u l t . We may com p a r e p a t ho l o g y t o the ' h a rdware' a n d d ysf u n c tio n t o t h e ' softw a r e ' of t he m otor syste m .

t h e p o i n t w h e re p a i n i s fe l t i s lost - o r ra t h e r h i s pat ie n t i s . 1 6 . B e c a u s e c h il n ge s i n fu n c ti o n a r e re v er s i b l e i n n a t u re i t c a n b e e x p e c t e d th a t , i f a d e q u a t e l y t r e a ted ( a nd t h e c a s e i s n o t com p l i c a ted ) , t h e e f fe c t o f t re a t m e n t i s i m m e d i a t e , g i v i n g t h e i m p re s s i o n of a ' m i r a c l e c u re ' , w h i c h , h o w e v e r , c a n be p red icta b l e . 1 7. T h e r e l a t i o n sh i p between c a u s e a n d e ffe c t u s u a l l y pres e n ts n o m aj o r p r o b l e m i n co n d i t i o n s c a u sed by s t r u c t u r a l p a t h ology. O n t h e o t h e r h a n d , i t c a n be v e ry s u btle i n c h a n ges d u e t o d y s fu n c t i o n ; w h a t w a s o r i g i n a l l y t h e c a u s e m a y b e c o m e seco n d a ry a n d v i c e v e rsa . C h r o n i c p a i n o f a n y origi n w i l l p r o d u c e c h a n ges i n m o t o r p a t t e rn s o r stereotypes w h i c h , i n t u r n , w i l l c a u se dysfu nc t i o n p e r p e t u a t i n g p a i n . C h r o nic j o i n t m o v e m e n t re s tric t i o n a n d trigger p o i n t s c a u s e i mp a i re d m o b i l ity o f t h e fasc i a e , w h ic h i n t u r n p ro d uce j o i n t m o ve m e n t res t r i c t i o n a n d m uscu l a r t r i gg e r poi n ts . 1 8 . S t a t i s t i c a l m e t h o d s a re v e r y u s e f u l i n we l l. d e fi n e d p a t h o l o g y a nd should be m a n d a t ory i n t h i s fi e l d . I t i s , however, m u c h m o re d i ffi c u l t t o a p p l y t h e m i n c h a n g e s o f fu n c t i o n . E v e n fo r diagnos i s , t h e s a m e c l i n ica l c o n d i t i o n ( e . g . h e a d a c h e ) c a n be t h e res u l t o f a l o n g c h a i n o f v a r i o u s d i s t u r b a n c e s , t h e re levance o f e a c h l i n k con s t a n t l y c h a n g i n g . I n t h e r a p y , i f we h il v e t re a t e d o n e l i n k su cc essfu l l y , i t w o u ld be n on se n s i ca l t o repeat t h e s a m e t re a tm e n t . I f,

Copyrighted Material

1 44

Manip ula t i ve Th erapy

in

Rehabilitation of the Locom otor System

t h e r e fore, t h ere a re s t i l l sy m p t o m s l e ft, we have to treat another l i n k in the cha i n . If the p a t i e n t is t h e n withou t symptoms, t h i s b y n o m e a n s i m p l i e s t h a t t h e fi rst tre a tm e n t was o f n o a v a i l . Howeve r , t h is is very d i fficu l t t o assess by sta t i s t ics. 1 9 . Psyc h o l ogy i s i mporta n t in every type o f p a t i e n t fo r i ts i n fl ue nce on the a u to n o m o u s nervous syste m , e.g. stress. In dysfunction, h owever, psyc h o l ogy is part o f the pathoge n e t i c c h a i n because t h e locomotor system is the e ffector o f o u r m e n t a l a c t i v i t y , the orga n o f v o l u n ta ry mov e m e n t . T h i s i s fu rther borne o u t by the fact t h a t pa i n i s the most const a n t s y m p t o m , a n d t h a t t e n s i o n a n d i ts re lax a t i o n p l a y a very i m po r t a n t rol e . [ t is, however, necessary to decide h o w re l e v a n t t h e psychol.ogica l factor is i n e a c h c a s e and how am e n a b le to t re a t m e n t . 20. Mod e rn technol ogy e n a b les us to d i agn ose pa t h ol ogical lesions m u ch more e ffe cti v e l y , e v e n i f i r releva n t , a n d a lso to m a k e t h e m objective. I n dysfu nc t i o n , tec h n o l ogy i s usually of li ttle use a n d very c u m b e rs o m e . C l i n ical s k i l l rema i n s decisive. This, however, is considered ' s u b j ective'.

s u ffi c i e n t w a r n i ng; t h e mos t i m porta n t s i gns are re p e a te d relapses, the decreasi ng e ffec t of a l l the rape u t i c measu res a n d progressi ve deterioration. There is o n e i m porta n t warning note t o so u n d : how ever desirable i t i s to test immed i a te ly a fter treatment, a p ositive res u l t , i.e. i m med i a te i mproveme n t of objective fi n d i ngs, a n d s u bjective re l i e f, do not pre c l u d e pathology, i nc l ud i n g t u m o u rs . because of con com i t a n t b l o c k a ge a n d o t h e r reflex cha nges t h a t are s u sce p t i b l e to a d e q u a t e therapy. I n the case h istory described below, recurre n t b l ockage i rrespect i ve o f m a n i p ulation l e d us to s u s pect (correc t l y ) a t u m o ro u s grow t h . C a s e h istory ( A . F . , b o r n 1 9 1 5) T h i s p a t i e n t u n d e r w e n t s u rg e ry fo r a s u b c u t a n e o u s t u m o u r o n t h e l e ft h y p o t he n a r , w h i c h c a u s e d pa i n a n d , t h e

same

year, fo r a D u p u y t re n ' s c o n t rac t u r e o f t h e fo urth ri n ge r o n t h e l e f t h a n d . I n s p r i ng 1 95 9 . h e com p l a i n e d o f p a i n i n t h e

the n ec k , w i t h s t i ffn e s s . The p a i n g ra d u a l l y a d m i t t ed t o h o s p i t a l i n M a y 1 96 1 : pneu momye lography ( PMG) w a s n e g a t i v e . B y a u t u m n , fo u r m a n i p U l a t i o n s h a d g i v e n n o re l i e f. W h e n a g a i n a d m i t ted on 1 3 O c t o b e r . t h e p a t i e n t h e l d h i s h e a d back

of

i n c r e a s e d a n d t h e p a t ie n t w a s

s l i g h t l y b e n t forw a rd a n d ro t a t e d to t h e r i g h t . A l l rota t i o n ,

es pec i a l l y to t h e l e ft , w a s i m pe d e d hy pa i n . E r b ' s poi n t was

Prob l e m s of d iffe r e nt i a l d i a g n os i s T h e r e a re two m a i n catego ries: the fi r s t concerns h e a d a c h e , visceral p a i n e t c . , which may be due e i ther to d is t u rbed fu nction o f the vertebral col u m n or to some other l e s i o n o f the locomoto r system such as m uscle spasm, o r to visce ra l d isease. This ca tegory cove rs the w h o l e fi e l d of medi c i n e , and the p ro b l e m w i l l freq u e n t l y h a v e to b e solved w i t h the co l l a bor a t i o n o f speci a l ists in the releva n t branches o f m e dici n e . T h e seco nd c a tegory concerns lesions i n the locom o tor system which m a y be d u e e i t h e r to d i stu rbed f u n c t i o n or ( m a i n l y or p a r t l y ) to structu r a l c h a n ges ( p a t h ology ) . This i n v o lves diffe re n t i a l d i a g nosis i n the l ocomotor system itse l f, i . e . t h e m a i n object o f o u r therapy; e rrors i n d i ffe re n t i a l d i agnosis i n t h i s c a t egory a re most u n fo r t u n a te and lie e n ti rely w i t h i n o u r respo n s i b i l i ty . I n ge n e r a l t e r m s , t h e p i tfa l l s are i n fl a m m a tory, m e t a b o l i c o r neopla stic d i seases. S o m e scre e n i n g tests s h o u l d be perfo r m e d a s a r o u t i n e procedure ( e r y t h rocyte sed i m e n t a t i o n rate , u r i c acid level and X - ra y pictures). However, pa rtic u l a rly in the i nitial stage o f the d isease, i t i s u s u a l l y i m poss i b l e to recogn i ze the true n a tu re o f t h e co n d i t i o n , a n d such patie n t s m a y be j us t as we l l treated w i t h re fl e x ( p hysica l ) t h e r a p y , i nc l u d i n g m a n i p u l a t i o n , as w i t h a n a lgesics. T h e gre a t a d v a n tage of the u p - to-d ate tec h n i q ues descri bed i n this book i s t h a t they c a n n o t h a r m the p a t i e n t . I f i t is i m possible to recog n i ze p a t h ology i n the i n i t ial stages, the cou rse of t h e d isease s h o u l d g i v e

p a i n fu l o n the r i g h t ; s p i n o u s p rocesses

C2-C4 w e re pa i n fu l was a broad hypera lgesic z o n e o n the b a c k o f the n e c k . The r i g h t h a n d s h owed a s t a t i c ( fu n c t i o n a l ) t r e m o r . A t P M G w i t h 30 m l o f a i r by l u m b a r r o u t e w i t h t h e p a t i e n t s e iil e d a n d b e n t fo rward, i t w a s c l e a r t h a t a t C 2 t h e s p i n a l cord w a s m a r k ed l y d i s p l aced i n a d o r s a l d i re c t i o n . The a i r p e n e t r a t e d in f ro n t o r t h e cord a n d from t h e re u n d e r the a rc h of C l . T h e fl u i d s h owed t y pic a l a l b u m i n o c y t o l o gi c il l d i ss o c i a t i o n . A root syn d r o m e a p p e a r e d a f t e r P M G , s u r p r i s i n g l y , i n t h e C 8 segm e n t . D i ag n os i s w a s a n e u r i n o m a o n t h e v e n t r a l aspect o r t h e c o r d , p a r t i a l l y i n t ra d u r a l : a t o pe r a t i o n a n e u r i n o m a o f t h e root o f C 2 ( r i g h t ) , w h i c h pro t r u d e d i n t o t h e i n t ra d u ra l v e n t r a l c o rd s p a c e , w a s re m o v e d . T h e p a t i e n t w a s re l i e ved o n pa l p a t i o n . T h e re

o f u n b e il r a b l e pil i n so o n a ft e r o p e r a t i o n . a l t h o u g h s l i g h t p a i n p e rs i s te d .

I n o w l i s t s o m e typic a l p i tfa l.l s and suggest h o w t h ey m a y b e a v o i d e d . I f re l a pses occ u r regu l a r ly at the s a m e segme n t of the spi n e , despite pre ven tive m e a s u res ( i n cl u d i ng re med i a l exercise ) , the prin c i p a l cause w iJ I be v isce ral d i sease a ffecting that segm e n t , tumour, or some other pa t h ology of correspo n d i n g l o ca l i za t i o n . When sacroil iac b l ockage recu rs in you ng p a t i e n t s we m ust consider the possi b i l i ty o f a n kylosing spon d y l i t i s . In women a fter the c l i macteric, osteoporosis m ust be borne i n m i n d . D iffe re n t i a l d i agnosis i s p a r t ic u l a r l y d i fficu l t but i mporta n t i n the a c u te stage after i nj u ry . T here a re cases i n which we c a n a c h i e v e i m m e d i a te re l i e f. but i t is essen t i a l to rule out m aj o r trauma such as fract u r e , l ux a t i o n , torn l i ga m e n ts or m uscles a n d m u scle s h e a t h s , a n d h a e m a to m a . A b n o r m a l fu n c t i o n may be d u e to a n o m a l y , i n w h i c h case d i rect t re a t m e n t is useless a n d fu t i l e -

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I'vIanip lila/ivc

Ir/

Rehab ili/l1liOi!

Locom%

re fe r red for r a i n d u e to ' m e re ' d i s t u r b e d func t i o n

r o f t h e i n n u m e ra b l e p i t fa l l s a r o u n d h i m � no d a n g e r

a r e m o s t l y o u t p a tients w h o c a n n o t b e exa m i n e d a s

i s g re a te r t h a n t h a I o f o v e r-assu ra n c e . T h i s c h a p t e r

t h or o ug h l y a s t h o s e i n a hos p i ta l w a rd , T h e r h y

o n d i ffe re n t i a l d i a g n o s i s Cil n n ot b e m o re t h il n il

i n c h a rge 0 1

cases m u s t

-

a w a re

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5 Indications for treatment

Indications

for

treatment

should

not only or clinical d i a gnos i s but

be

mainly

genic analysis, determining which

the

result

of pa tllo

3. Soft tiss u e

(b) connective tissue stretch, pull or p ressure

lesion is most

(c)

i m po rtan t at a give n moment and is t he refore likel.y to be the most effective object of ther apy. Every

of the patient's condit ion . For if our the rap y is determined by the

(e )

at

and

(a) massage (b) local anae sthes ia - need l ing (c) electrica l stim ulation

control examination

the con dition of the p at ie nt should have changed. imp l ying

a

change

in

fu rther treatment.

(d) ac u punc t u re

If the

(e) treatment of scars

pa tient 's condition is u nc hanged , treatment was not

(f) other methods of physical therapy

(g)

adequate and should not be rep eated without good

reason. A series of repet i t i ve therapeutic me a s ures of t h e same type is more often than not out o[ place.

Critic
asse s sme nt or the preced ing treatment and

constant correction of pl anne d t h e ra peu tic

measures

5.

It should be poi nte d out again that this concerns

soft tissue manipulation versus reflex therapy.

Remedial e xerc i se.

6. Correct i on of fa u lty statics . 7. Jmmobilization (supports ) . 8. Pharmacot h erapy .

9.

are e s sen t i al .

e x teroce p tive stim u lation .

4. Reflex therapy:

p rin ci p l es set out he re , it is

effcctive

likely to be

shifting of fasciae

(d) post-isometric relaxation

measure we take should thus result from a fresh examination, to ke ep up to date w it h the course

m anipulat io n :

(a) skin stretch

10.

Surgery.

R e gi men.

pathogenesis and not conventional clinical d i agnosis . S truct ura l p a t hol ogy must first be ruled out or be

found irre l eva nt to the case. For example, if the

patient s uffe rs from headache or pain at the sh o uld e r

Manipulation

and if my an a l ys i s shows that this is the result of

Manipulative

dysfunction of the cervical sp ine , this will be the

movement re striction (blockage) of a joint or a

obj ective of treatment. If, however, d ysfun ction of

spinal mobile segment, and

the cervical sp ine is due to

relevant to the patient's symptoms.

a

forward-drawn postu re

stanciing, and clisappears when the patie nt sits, the cause must be sought at the pelvic girdle, or even at

the lower

extremity.

Hence treatment should start

only aiter compl ete examination.

Bea r i ng

treatment

this in mind,

is

indicated

is

if this is co n sid ered

many of the questions

frequently as k e d can be answered easily : what about

spond ylosis, disc p rolapse , scol ios is , j u ven ile osteo

c h ond rosis, spondylolisthesis, osteop oros i s , or anky losing s pondy l it is? The an s wer

Methods of treatment

if t h e re

is

st rai ght for ward :

these conditions do not form the obj ecti v e m a ni pulative treatment.

Nevertheless,

for

if in such

conditions movement restriction ( bloc kage ) is found

l. M a n i pu l
and considered harmful, then it should be treated

2. Traction.

with ad eq u ate manipUlative techniques.

147

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ill

of

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Indications for treatment usually very gentle (the 'indirect method' of the American

4

=

osteopat hs) .

S egmental hypermobility; all ty pes lative treatment,

pa rticularly

of

m a ni pu

thrust techniques,

should be avoided.

From

'She was manipulated three times within 1

149

week by a

qua l ifi e d chiropractor (the patient was supine an d the

reclination and ex

manipulation consisted of rotation,

tension of the head ) '. This was followed by a short period of

unconsciousness

and

later

by

t etraplegi a : artificial

respiration had to be ap plied and maintained for 36 hours.

po int of view we d i sti nguish between technique s which p r od uce relative shift of articu l a r facets a nd th os e whic h produce d istraction (gapping). As a rule the latter are the most effective. the technical

Recovery took several weeks and was co mp le te 4 months

later. Thrust techniques in acute wry neck ( tort ic ollis) are

questionable in themselves,

but to

use the d angerous

combination of 'rotation, reclination and extension'

This

problem

problem .

With

op i nion

up- to-date

it is rather a tec h niques

pseudo

no

harm

should ever ensu e fro m m a nipulat i on, and in fact the problem boils

need

mistakes.

what is contraind icated

is fault y

do wn to the To put it briefly, tec h niq ue .

to

avoid technical

What are the crucial faults? These are (1) the

p redom in a nt a

(2) applying p atient is properly

use of thrust techniques;

high-velocity thrust before the

relaxed and before taking up the slack (see Chapter

6): (3)

try ing

d isaster

to force

manipul a tion

of

any type

distraction as

de

rule brings relief, and therefore pain

a

aga inst painful muscle spasm or in a d irection that

in all d irections at

causes pain:

and

(4) th rust techniques should be avoided in cervical back - ben d ing and rot ati on, because of poss ible impingement on the vertebral artery; (5) thrust manipulation should not be repeated at short intervals ( le s s than 1-2 weeks). In this connection I must also stress that too insistent examination of mo bility in a painful direction can be positively harmful, and at the crani ocervical j unction even d angerous . The d iscussion of contraindications derives from the fact that serio us complications have been

des cribed in the literature, even with a fatal outcome (Grossiord, 1966; Lorenz and Vogelsang, 1972; the Memor an dum of the German Association of Manual Medicine, 1979: K rueger and Okazaki, 1980: D vorak and Orelli , 1 98 5) . Basing their calculations on the re sults of a questionnaire sent to doctors of the Swiss Association of Manual Medicine, the last two authors compute the number of serious c omplicati ons a fter m anipulation (thr u st techniques) at 1:400000. By f ar the most imp ortant cause of serious complication is undoubtedly damage to the vertebral artery. U nfort unately, it is an almost constant feature of this literature that the technique res pon s ible for the d am age is not described - as if posto perat ive complications were described with no details of the operation techn iq ue used. There is one example quo ted by Dvorak and Orelli (1985), however, which seems to me so characteristic that I s hall comment on it here:

A female patient of 35 collapsed while a ttendi ng a funeral from wry neck for 3 w e e k s afterwards.

and suffered

(see

A n other grave mistake is the

is given much space in the medical

literature, but in my

Kleyn's test , p. 120). use of thrust techniques in short success io n for painful conditions which d o not s how im provement ; co mplications occur m ost frequently wit h such repetit io ns . From this descript ion of a poss ibly dangerous 'technical mistake' s o m ething like a contraind ication can be deduced : if it is a mistake to per form manip u lation in a p a in fu l d irection, then manipul ative therapy must be discarded altogether if we prod uce p ain in all directions. In fact , in mere d isturbance of functi on (i.e. the object i ve of manipulati ve therap y ) pain is never found in all d i recti o n s at o nce: is court ing

Contraindications

o nce is usually a out of place.

sign of pathology

manipulation is

For

obvious

reasons

manipulation

of

hyper

mobility is undesirable, but not manipulation a

blocked

of

segment in an otherwise hypermobile

patient.

Thi s

b rings

indications'

us to another

which is often

category of

'contra

strongly emp h a s iz e d :

tumours, in particular those with destructive changes; acute i n flammatory conditions (such as tuberculosis) ; fracture, etc. It is clear that no one in his senses would try to treat this type of pathology by manipu lation; on the other hand, we know that, particularly in the initial

stages of

such conditions ,

diagn ostic s pecialist sees such pa t ients in h osp ital, at a later stage, when the diag nosis is already easier. Nevertheless, usin g adequate gentle techniques, the patient should come to no more harm than from the ad m inistration of analgesics - and suffer fewer side-effects. To m a k e the point even clearer: if in a case of diagnosed p athology concomitant blockage is considered harm ful to the patient's condition (as it frequently is ) , there is n o reason why this blockage should not be treated if we know ho w . I have myself given manipu lation in acute decompensation of (benign) posteri o r fossa tumour, with excellent temporary results. Blockage at the craniocervical j unctio n can cause great deter ior a tion in patients with insu ffi ciency of the vertebral artery, and should be treated by expert mobilization. It is most unfortunate that this condition is considered by m any to offer a cont raindicat i on, simply because technical errors in this s ituation are particularly dis astrous . error is often unavoidable. The

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ManipLiialivl'

/,01'01110101' Sr.,/(11I

ii1 Rehabi!ilalil1il

The course of manipulative treatment

treatment (mobilization)

In a routine case which is neithcr very severe nor ,1cute we treat those restrictions of we think

I

expect some unpleasant reaction at the end of the or during the next day or two, and if possiblc

IS �dvlsed about w hat to correct (or a vo id ) in her dally regimen. A bout 2 weeks is a reasonable in ter val the organisrn

to reac t and I

exami n a tio n is

more

(;x21mination; our di a gnu st i c

conclusions on first examination might be ca l led a working hypothesis (except for very simple cases),

a

hypothesis on w hich we base the first therapeutic ste ps : It IS at the second examination thilt th is hvpothverified and on a plan ITc;;liment.

the patient ffCi,

improved

tile conclusions

that

first exami

w ere

well founded. and we p roceed to treat what remains to be cl e a red up. We m ay invite the pa t ie n t for re e x amination after 3 or 4 w e e ks , and if all goes well,

agall1 after 6 weeks . However, even if improvement up the patient for sev eral

we should fol

1 lis, in view 01 Ihe

chronic

11

I I n p rovement

s,'(ond

1

examination, the first question must be: did she feel bet ter for a few days, or not at all ? Treatment sometimes produces a very marked but short-lived effect.

At r e- examin a tion (wo distinct conditions

he found: ( .1

l ived, followed by relaps e , we must seek the under

(e.g. cardiac ischaemia in recurrent lesions in the upper thoracic sp ine) , for to go on treattng 010\'[would be mOll

ion in such

usele,s

as a rule, be treated

by

expected to

10US cases w:11 not

manipulatIOn

have

alone

and can

a chronic course.

It

be

th en

is

important to. follow up the patient for a cO ll slde r a ble time, 6 months or more, at intervals.

ma ni pulatio n lor tile rliso be consJ(ic:reci.

of

True. IlE'l1Ipulation is the

only if we

cmc:nt restrictioll

lIIeally relevanl.

the other hand, when a dmi ni steri ng manipulative

tre atme nt we should ne ver overlook bloc k a g e in key regIOns, be cause this is mo st likely (0 c a us e relapse.

In other words , we indicate mi1nipulation for clinic-

h lock a ge in This i,

alh

. aspect

revic)J1s in on1,:r

lu

introduci::r:

III

re gu lar feal 11111](.1, t h e r e is n strong case to be made tor manip ula tive treatmcnt, for example, in ch ildre n , physically very exposed indi VIduals, etc. (see Ch a pte r 8). prevent

in to

�

rehabIiltalJon. Bcaring thiS

111

I.e.

Ilildings are

1

tre:ltment has given

ly reason is

lying cause, This then bec ome s our m a i n concern

preVclrlt

of these dlsturb:Jnccs.

1 he patien t feet;

because the

nostie enol. If the effect IS always good but shorl

menl

1I.self to restored

w ay the Important than the

,

whole

patient is

control examinal

it may be givell :1I:(\tI1l.:r chan ce , but illl re-examination

after

if painless (

? ay,

If manip u lat i on has brought no rel ief at alL nor any

impor t ant ,

which she can perform

seve ra l times a day.

Its or (which

uch

re l a psed ; (2) on g ll1 al have be e n corrected but new factors are

the condition

now producing similar symptoms. In the lat ter case, we can consider the pati ent . Improved even if her complaints (her pai n ) seem to be the s ame . There is even a highly characteristic legion: th e le:;inllS

to

from one

to

in a caudal next, until they

In

the

case ,

former

however,

we

must

ask

ourselves whether the first diagnosis was corr ect . 01 com plete ; whether we did not overlook an undcr

lyi n g condition which may have produced relapse at a key column, an

position

ill

altogether

whether the Ilw

at the othu

or the

elc.); serious

appeared

If the case is very severe, i.e. if the b l ockage is hard and palI1ful, and there is r estr i ction of larDer b .

.

sectIOns of the splllal column, then this type of treatment IS lI1sufficlent and repeated mobili z a t ion required, i.e. two we should

times a

such

teach the

',elf-

Traction is essenti ally

�

a

form of manipulation, but

unlI e other methocls it is ge n erall y accepted in tr aditIOnal medicine. W ithin the fr a m ewor k of mani pulative techniques, traction of the lumbar and role: it is :1 tli in (rue racllllllLn , y nd r o me s and l umb31 w hene ve r [ . of disc is miH.k. In fact, if traction relieves s ymptoms III lhe lu m bar regIon, then the diagnosis of disc lesion is corro b ora t ed . In both th e cervical and the lumbar cervlcti \jllllrtl column

region traction can be very use ful in sllch c onditio.ns

as acute wry neck and acute !umha go. Thc es<;enti21 tecl1l1icrd

ails are givcln

pter 6.

one i mportant ever:

llilkver our

10 be macie, 1

the lIsefulrr,::;:, ,)1

tractIOn, It IS esse nt i a l to. test each case and apply traction only where It gives reliel. If there is no relief. we m ust first modify the t e chni q u e and then . . deS is t lilt s til l fads. One of the reasons why traction IS

fi rst be

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badly to l er l l k d I rellkd by (e.g. in

hlockage, which

;

hefo e traction ;,ynclromcs). It

;

,

nUl

iUi/i, opillion that manual 1 Chapter 6 are much b,'1

scalp, to adjanlill tissue (metaca [[1;1!

In aid

of special tables,

151

nly by soft and even

II

to the ribs and

4.

m.'IIIi11etli

head).

Post-isometric relaxation (PIR): here, too, the barrier is first engaged by stretching the muscle

Soft tissue manipulation

to the pOint where minimal resistance is encoun tered. This method, which will be described in

Soft tissue,

in particular

the

deeper layers of

connective tissue in muscles and fascia, is closely

detail in Chapter 6, has a similar effect to that of the spray and stretch method (Travel! and

related to the motor system, both anatomically and

Simons,

III function. It is the function of soft tissue to be

to obtain muscle relaxation. It is effective not

stretchable while able to re�ist strf'tching, and to be

only in the trentment of points) in the [1111 ;11\0

shifted (even to a consldel ;Ible

yet

able to resist shift.

have

\983) and appears to be

most, pain point:;

usually been considered

points of attachment

secondary to changes

tension, or POIflIS

function. This is not

the muscle. It

particularly in chronic

or

Iginating in com

pletely painless

endocrine disorders (tile

be taught sell-IJ

or constitutional factol

only if there

!rI al it is possible to detect a (pathological) barrier that can be overcome by adequate treatment, thus restorIng function in the same way as in restricted joints or muscles in spasm. If there are significant hyper algesic zones (HAZ). and in particular increased resistance when shifting fascia, and, of course, trigger points (TrPs), it is advisable to treat such soft tissue lesions before performing joint mobilization (mani pulation), as the treatment itsf'lf miW howe con�idcr able mobilizing efFect.

(and should) effective particular

TrPs in the muscle; otherwise it is useless. An effective alternative is stimulation of the antag onist (reciprocal inhibition).

Exteroceptive stimulation The skin surface with its abundance of nerve receptors is frequently underrated. As a result of civilization it is largelY clepriveci of niltmal stimuli by clothing, and

regions,

the feet, by shoe,

I. Skin stretching: this algesic skin zones. II of some massage skin, (the like rolling a fold 01 'pince roulee' of Maiu,lk 01 L t'ube lies it and Dicke (1951)), but is absolutely painless, much less time-consuming, and can (and should) be used by the patient himself. Skin stretching should only be indicated for increased tension in the skin surface or, more precisely, for increased resistance to stretching over a specific area of the skin. It can be applied to a very small area, such as the hyperalgesic fold between the toes in a radicular syndrome, or the skin over a periosteal pain point, with very good applied effect. Being entirely even to hyperalgesic 2. Connective tissue connective tissue, and tissue, in taut muscles can form a fold bet\h'lll nUl hand) which engage, tension. Where a fold by the fingers may engage the baffler. 3. Whenever we find restriction of mobility of the deep layers of connective tissue against bone (mainly in the deep fasciae), restoration of normal mobility is indicated. This also applies to the ..

a specific method

stimulate must be

is by stroking of

C'hanges in

carefully chosen

lowered, most

muscular tonus, frequently require

t:hronic pain Lreatment, indication

points (e.g. epicond\

even if everything is reiative increased or decreased surface sensibility

over a certain area, most characteristically the sole of the foot. Self-treatment is easy and includes walking barefoot and playing with small objects.

Reflex therapy This acts on the same tissues and structures as manipUlative

traditional therapists. III the soft

methods, principally It acts particularly tissues.

Massage This term covers

(11

ues which

have developed from lime Immemoriai; they are applied to the soft tissues and even to the perio steum. It is not within the scope of this book to deal with massage in any detail. Rationally applied, i.e. from the clinical point of view, it should be used

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152

Manipulative Therapy in Rehabiliwlion oJ the Locomotor System

when and where changes are found in the tissue,

It is interesting that, just as after manipulation, so

changes that consist mainly in altered tension. The

after successful local anaesthesia or d r y needling, the

experienced masseur adapts his technique so as to

immediate relief we obtain is often succeeded the

give relief, i.e. to lessen tension in the muscles as

next day by a painful reaction, after which the thera

well as in the skin and the connective tissues. Deep

peutic effect establishes itself. This treatment should

fricton may

therefore not be repeated before 6 or 7 days have

be applied

to

pain points on the

elapsed. Repetition is indicated if the method has

periosteum. Bearing this in mind, it would seem that massage

proved successful, yet some pain remains.

is a universal method applicable in all reflex changes produced by pain (nociceptive stimulus); indeed, it

is widely used in this way. Some techniques are

Electrical stimulation

pleasurable, giving immediate relief and being very

Here we obviously face a variety of methods with

popular with patients. There are other massage tech

similar effects, which are apparently interchange

niques which are painful. Unfortunately, the effect

able. To these must be added methods of physical

of massage is usually only short-lived, whereas the

therapy such as transcutaneous electrical stimu

procedure is very time consuming. It is, moreover,

lation, and other forms of electrotherapy which

a

produce a similar effect on skin receptors and in the

purely

passive form of treatment, demanding

almost no cooperation from the patient. We there

subcutaneous tissue. They have to compete. too,

fore prefer to indicate massage only as a preparation

with other traditional methods including not only

for other, more active and more effective methods

massage, but poulticing, cuppin.g, capsicum plasters,

of treatment, and not as the sole therapy.

etc. The clinician has therefore

a

wide range of

choice, the 'ideal' method being painless, without risk, without side-effects and if possible applicable

Local anesthesia - needling

by the patient herself.

One of the most widely used methods of treating painful lesions is local anaesthesia, or needling. It may appear unorthodox to deal with these two

Acupuncture

methods together, yet one does not simply use local

It would be burying one's head in the sand not to

anaesthetics to relieve pain for the short period

mention the ancient method of acupuncture in this

during which the anaesthetic has effect; the popu

context, the more so as it is now w i de ly used and

larity of local anaesthesia is due to the fact that its

discussed. There can be no doubt that acupuncture,

e ffect far outlasts the direct (pharmacological) effect

too, achieves its results by evoking reflex mechan

of the anaesthetic, and seems not to be dependent

isms. Difficulties arise the moment we attempt closer

on it; in fact, Kibler (1958) uses sodium bicarbonate,

analysis and classification of the mode of action. The

and even subcutaneous air or gas have been used.

orthodox acupuncturist indicates treatment according

Direct proof has been provided by Frost e/ al. (1980)

to disease, without reference to the pathogenesis,

in their 'controlled

double blind comparison of

although the more 'enlightened' admit that acupunct

Mevipacain injections versus saline injections for

ure should be used in cases of disturbed function

myofascial pain',

rather than in structural pathology. The choice of

showing that, if anything, the

physiological saline solution was more effective. The

acupuncture points according to the viscera and of

common denominator of all these methods is, of

'meridians' without clinical examination of t hese

course, the use of the needle. The effect, how

points is based

ever, appears to depend very much on the needle

scientific verification. For scientific analysis. there

purely on tradition and not on

touching the painful structure exactly, if possible

fore, it will be necessary to examine not only t he

so as to reproduce the pain of which the patient

complex method as a whole, but its simpler elements,

complains, whether an anaesthetic is used or not. If

one by one. One such element is the effect of the needle: dry

we succeed in finding the exact spot, we produce analgaesia

immediately.

whether

we

use

local

needling was reintroduced to modern medicine by

anaesthetic, a saline solution, or simply a dry needle

Travel! and Rinzler (1952) and I myself proved the

(Lewit, 1979).

analgesic needle effect (Lewit. 1979) in 271 out of

Local anaesthetics are of course necessary if we

312 applications of the needle to pain points, in 241

want to induce anaesthesia of nervous structures,

patients. There is sufficient clinical evidence of the

for example in nerve-root infiltration or epidural

efficacy of the treatment.

infiltration in radicular pain.

On the other hand, there appears to be

a

growing

One special method using local anaesthesia is that

tendency even among modern Chinese doctors to

of producing blobs on the skin by intracutaneous

choose their points not according to the tradition.al

application within a hyperalgesic skin zone. Here

'meridians', but on the basis of the segme ntal t h eo r y

again a similar or more intense effect can be obtained

of innervation. Instead of needling. electrical stimu

by using d istilled water.

lation is also being introduced (Chang Hsian Tung.

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1i'·1/menl

lS5

established in a number oi

should be told

which should be great

increases: she

corr e ction

gra duall y , and

at regular

intervals of a few weeks.

Treatment of faulty statics The ci iagn () s is of fa u lty statics has been de s c ribe d in

Ch a p ter s:; ancl 4. In so far as the cause is muscular or extcl'Ilill in tl uences , faulty statics must be treated accordingly. The most i mportant is a

i m b a l an c e

forward-drawn posture due to dysfunction of the muscles of the pelVIC Here we are concerned in t he

pelvic region, (lnd

heel -p a d or by raisilil'. posit ion . This is a nH would a pp ear at first aid is const antly used.

if the pam

C'h ilpt c r 8, p 258). panlcularly by

a

sitting

than if the at a

It is not a matter of indifference whi c h type of correc t ion is used. A heel - pa d fitted into the shoe is practical, but has the disa d vantag e that the shoe fits

less well. If po ssible , it is better to lower ( sho rten) the heel

of th e other shoe. This is advisable on ly

where the d i fference is not greater than 1-2 cm. Where the difference is grea t er, the whole sole m ust be thicker on the side of

short

so as not to p osition of

make too much th e two feet .

If the pe I vis i:;

no apparent the base of

difference in the vertebral find that obliqu1I1

corrected, we shall

I

the patient

permanent chan ge in

is sitting or standi

be straightforward. [01 I Ilcrcnce in leg length is due to f ai rl y recent trauma. In flat foot on one s id e only, we can see the effect of an arch support if the p,ltient stan d s with her weig h t on th e outer edge o[ tile sole, ancl we observe that this stt'aightens the pelVIS. In the majontv of case s, how cve r , obliq uity develops slowlv d u nng g rowt h . and as it increases compensation dev elop s ancl assessment is i m poss ible without exact X - r a y analysis s\lch as that described correction in C hap ter 3. However. can never be a quesl alone, but must be decided Clinically, static pa i n h chronic course, as a rule dele! cXllmmation static load, i.e. standil!!; we expect signs of pel vlc d e viation, eO!Tcction and pelvic sh ift (sec Chapter should bring about clinical imp rov e ment . As shown, however. spinal stat i c s can be checked rel iab ly only by X-ray u n cler standard conditions: hence it would usually be incorrect to indicate static correction on clinical g rounds alone. If clinical and X-ray findings are in agree me nt , we are j usti fi ed in indicating correction. There arc some p r a ct ical poi n ts that must be st resse d here. The first is the immediate reaction to a heel- p a d . If a thin S(It., I uncler the foot of a no r ma l 10 put h e r legs her weig h t e qual ly on straight, she will II pelvic

correction ( a thlll Ischial tuber os ity when the patient is seated, in ad di tio n to the he el - pad when standing.

obliquity may re spo n d

in three

different ways: she may

c(Hofort-

able, she may feel no In t he first two cases

object. the I' ll1 ent to outset. and she should be i nstruc t e d to wear the pad in her house slippers as well as in her o ut d o or shoes. In the last case, however, there may be an un favoura bl e reaction, ancl time is needed for the p a tie n t to adapt . She

to prescribe

The most frequent and most serious fault in sitting. of course, is excessive lumbar ky p hosis due to hype rmob i lity of the lumbar s pi ne. If we do n ot presc r i h e supports we should adv ise the patie nt to sit in the oriental manner, with feet crossed and knees apart, or on her heels in the J a pa n e se

way. Another p o sit i on is thelt advocated by BrU g ger (see IO f ward and the

p. 246), in which I thoracolumbar

balanced,

sim ply to raise I

or

a saddle.

Immobilization In acute lesions �ysLem, muscle spasm clea rly indicates that r est and i mmobi .lization is required. This can be particularly evident acute trauma. when the healing

a fter of damaged tissue

makes immobi.lization imperative.

Immobilization

itself becomes a problem , however, once the con dition becomes chronic, and if we aim at full recovery, i.e. the restoration of normal function, immobiliza tion presents an outright obstacle. T h us immobiliza tion, for us, measure in

can never be more than a te m porary

provement no hope of functional immobilization Unlike immobilization. not g re a t ly interfere

ion, i.e. imwhere there is permanent necessary evil. supports need wllll(: p rotecting

L.J nf ort un a tel y , [L'1l1 in working conditions in techni cal l y advanced countries, and h y p er mobile subjects with lax muscle s and l igamcnts frequently find it diffficuIt to adapt, in particul ar if, as in most modern means of public transport, j olting the patient

agalns!

static over strain

is added.

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6 Therapeutic techniques

r e l ax at i o n

is essential in o rd er to

[n the precedi ng ch a pte r s the i m port a n ce and the

relaxed, and his

dia gn osis of disturbed function of the locomotor

proc u re relaxation of the patient. As a rlli e the

system have been explained, and [ have desc r ibed

direc t i on in wh i c h the thernpist's hand

the cl i n ic a l l y s i g nifican t reflex changes i n v o lve d and

tinues the line of his fore a r m , but whenever possible

m o ves

con

indicated the most important therapeutic m ethods. As

the movement should come from the whole body: it

it is impo ssible to describe nil these techniques in

often co m es from the Feet. as in throwing the d i scus .

detail in this ch a pte r , 1 here confine myself p rincip a l ly to ma n ipula tive techniq ues nnd the s peci fic forms of

reme d i al exercise, with a few anci llary tec h niques.

The t h e r a pi st' s movement must n e ver be forced,

c ram ped or e x haust i n g: if he is e asi l y tired he must

be making a t echni c a l error. For manipulation of the spi n a l column the body of the therapist and that of the p atie nt must

Ma n i p u l at i o n

m ov e

in harm ony , like a c oup l e of

dancers : this is the secret of ge n tl e , flowi n g and elegant tec h n iqu e and is also valid for examiniltion.

The sole a i m o f manipulation is to restore normal m o bility mainly of joints, inc l ud i n g j oi n t play, but <1lso mobility between soft tis sue l a ye rs , or soft t i ss ue

and bone. Two major types of man i pula t i o n can be

Fixation One o f the bon es a rt ic u l ati ng i n the joint bei n g

distinguished: (I) mobilization tec h n iques : and (2)

m a n ipul a ted should be fi xed

thrusting tech n i q ues. I will sta r t, however, wi t h a few

mobilized. In ex t re mity joints it is us u a l l y the proxi

wbile

the other

is

mal j oint that is fi x ed, i.e. supported by the table or

gene ra l p r inci ples.

by the body of the therapist. For elTective fix at i on it is advisable to move oilly one j o in t. Tn the spinal

The positi o n i n g of the pati e nt

column fixation is ach i e ve d by correct posi t ion ing

The p atie nt shou l d l ie (o r sit or s t a n d) so that she can

re l ax, so

thnt the j oin t to be treated is ac c essi b le,

and so that one of the arti c ul at i ng bones is either

('looking') and where poss i b l e by dire c t contact with the therapist's ha n ds . Good fixation of the pe l v is can

be obtain ed if the patient sits astride the table.

fixed by the pati e nt's own weight or can eas i l y be

fixed by the therapist. The height of the m a n ipu lation table from the floor should be adjustable as required: in g ene ral , it sho ul d c orr es p on d to the

The position of the joi nt a n d the d irection of treatm e nt

distance of the t herap ist' s fingertips from the floor

The j oint to be tre a t e d must not be in

when he sta n ds erect wi th arms hanging l oosely

ill w hich the c aps u le and the l igaments are over

down and fingers stretched.

a

position

stretched, i.e. it must not be locked. The direction oJ treatment (manipulation) may c or respo n d to the i mpaired j oi nt mobility or to joint play,

The position of the therap ist

i.e.

to

relative shi ft or di s t r a c t io n (Figure 6.1).

This is in many ways decisive fo r the therapist's

Ac cor d ing to Kaltenborn (J 976) the direction of

in or d e r to be

joint p l a y is not purely haphazard, and depends on

te ch ni q ue . He must be

com forta b l e

15K

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Therapeutic techniqlles

u u

n

n

Figure 6.1 Possible directions

LJ n

of joint play

whe the r the concavity of the joint is proximal or Figure 2,6, p, 14), In the for m e r case, shi ft of the distal partner. w h ich has to b e restored, is i n the opposite direction to t he impa i r e d movement. whe reas in the l atte r case t h e s hift of t h e distal partner is in the same dire c t i on as impa ired mobili ty, For this reason the first phalanx should be s h ifted main ly i n a p a lm a r direction (if flex ion i s rest ricted ) and t he ca rpa l bones against the radius in a dors a l di rection if pal m a r fl e x io n is res tricted (see F ig u r e 6.3, p, 162),

distal (see

s ure we have i nd eed reached the end-position. by s l i ghtly decreasing t h e range of mov eme nt and the n i n c reasing it agai n. to e s tablish w h e t h e r we mee t re s i s tance a t the same poin t : in ot h e r words, we spring the jo i n t in end -po s iti on . w h ich is exac t l y what we d o in pass i v e mobi l iza t i on, R e pe a ti n g tbis procedure several times will show that even in il norma.l joint the range of movement increilses. i,e, we rea c h t h e b a rrier ( take up the slack) after a l on ger interval. In a re stricted joint this increase w ill be much more abr u pt. The re are t wo m i s takes to be avoided in this t y pe of s pringing (repetitive) mobil izati on: (1) we must be careful to remain in end position a n d not return to the n e u t r a l position of the joint, i,e, t h e rang e of the springing movement must be sm al l and v e ry well con t ro l le d ; (2) springing back is even more importa n t fo r t h e re s t o ration of m o b ility than is t h e pre ssure we exert; therefore even i f t he ra nge of movement i n c reas e s. we must n ever i ncre ase o u r p r e ssu re , The join t must be al lowed to move back almost to the ini tial end-po s i tion, In t his

way

This i s a crucia l step before trea tment begins. whether merely s tre t c h ing of soft tiss u e o r s h iFti n g a fascia.

pos t-isometric muscle relaxation, or t r eatm e n t o f a join t. We try to b ring t h e joi nt to the barrie r, i,e, c l ose to end ra nge either of normal func tion or, m o re freq uen t l y a n d parti cularly in extremity joints, of j oi n t play, Distra ction of t h e joint is helpful, In the spinal col u m n it is not always possib l e to make t h e dis t i nc t ion between mobility and j oin t play. the move ment of a s ing l e mob i le segment (in i t s e l f i m po ssibl e to achi eve b y active moveme n t ) playing to some extent the role of joint p l ay , The barrier or end-position is never reac hed s ud d e n ly in norm a l m o v emen t ; sudden re sistance i n the end-position is a sig n of blockage, We know tha t we have taken u p the slack th e mome n t w e sense t h e first slight incre ase of resistance, This must be car ried out very gently, w ith t h e pat i en t rel axed, The most impo r t a n t so urce of error is to mistake active resistanc e by t h e pat i e nt for t h e sig n that w e h ave taken u p t h e s l ack, This in va ri abl y happens if we cause p a i n - s ome t h ing to be a v o i de d at all costs,

Ma n i p u l ation proper Afte r taking up

the range of s pringing will increase but

never pressure w e exert. Thi s type of mainly passive mobi l i za t ion is effe ct ive in joints that are not e x cessive ly fixed by m u s c l e spa s m whe n blocked. suc h as t h e sac roi l ia c and acromiocl avicular j o i nts. and many e xt rem ity joi nts, [t is les s efFec t ive in t h e spi na l column, howev e r. a n d here pas sive mobi l ization is used mainly as a p re p a r a t i on for thrusting te c h niques. and as after t reatment. To make mobiliza t i on of the spin a l column ful ly effective w e ha v e learned to u s e tec h niques of musc u l a r faci l it a t i on and inhibition (neuromuscular the amount o f

Ta k i n g up the slack (en g a g i n g t h e barrier)

we have two ma in me ans mov e m e n t: (l) by gen t l y sp r i n gi n g the joi n t in end-position (mobilization); or (2) by making a t h rust from en d -po s i t ion, of re s t o ring

ISl)

t h e slack

restric ted

Mobilization

At the first s lig h t inc rease in re s i s t a nc e while we are taking up the s lack (engage t h e barrie r), we make

techniques),

Mobilization using neuromuscular techniques

Some t ec h n iq ue s aim at spe cific muscles or muscle gro ups. w hile oth ers have a more gene r a l effec t .

by

Isometric confl'action of muscles i n tension, followed

( M it ch e l l et al., 1979) or. p refe r to cal l it, PIR - post-is ometric r e l axa tion , Un like the widely used t e c h niq u e developed by Kaba t (1965), we use onl y minimal resistance dur i n g t h e isometric pha se, Afte r the slack has been taken up, the pat i ent ex erts only a minimum of pres s ur e in the opposite d irectio n from tha t of t h e movement rest ricti on. holding it for about 10 s, She is the n told to ' le t go'. and the o p erator wa i ts, or even repeats the 'Ie t gol', u n t i l h e fee l s tha t the pat i e n t has tru ly relaxed, On ly t h en does he carry out his movement in the directio n of t h e re s t ric t io n - but then o n l y to t h e point where the s l i g h te st res i s tance is felt, i,e, only as fa r as t he pa tien t 's re l axa tio n w i l l a l low. It is important to pro fi t from h e r relaxat ion as long as the range of movement increases spontane ously: this may be for 10 s or even longe r. When the t h e rapis t feels no fu r t h er relaxation the procedure is repe a t e d from t h e ne wly ga ined position: the g r ou n d t h a t has relaxation - isometrics

as I

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160

in Rehabilitation of the LocomoLOr

Manipulative Therapy

been won must n o t be lost again. If re l a x a t i o n has been satisfactory, the time a l l owed for isometric resista nce m a y be s l i g h t l y reduced, but if rel axation is i n s u fficie nt, resista nce may be pro l o n ged for up to h a l f a m i n u t e . This procedure can be rep e a t ed for as long a s the the rapist con t i n ues to observe i n cre as i n g ra n ge of move m e n t, b u t u s u a l l y t h ree to five repe t i ti o n s suffice. I have to s t ress a t this poin t t h a t l e n g t hen i ng of a musc l e or i ncreased ra nge of move m e n t owing to re laxation must be achieved exclusively by the p a tie nt s re l a x a tion w hich is on ly m o n i tored by the t h e r a p i s t never by passive st retch! Re l axation i s an active process: 'we cannot relax the pa tient'. Antagonist inhibition - By stimulation of the a ntagon ists it is possib le to a c hie ve i n hib i t i o n of muscle s in s p a s m ( h arbou ring TrPs) as effectively as by PIR. This me t h od has been u n d u l y u n derrated, asssuming that it is effective o n l y if considera b l e fo rce i s used, t h e n giv i n g the i mp ressio n t h at t h e the rapist h a s t o strugg l e with t h e pa tie nt. This is avoided very simp l y: t he pat i e n t p u ts up o n ly moderate or s l ight resista nce (in the direction of the a n t agon ists) a n d t h e t h era pist uses rhyth m i c i nte r mitte n t sti m u l i. Th i s is so e asy th a t we n ow comb i n e PIR w i t h rhythmic a n ta go n i s t stim u l a tion ( w i t h t h e patie n t in t h e s a m e posi tion) Direct repetitive rhythmic muscle pull, under certain conditio n s, to produce mobiliza t i o n di rectly, e .g . t h e t h e r a p i s t ca uses r h y t h m ic a l contraction s of th e scale n us i n orde r to m o b i l ize the first t w o ribs o r o f t h e psoas to mobilize the thoracolumbar juncti on. These techniq ues are a p p l ied to specific musc l e s o r m uscle groups. The foll owing tec h n iques have a far more ge n era l ized e ffect . Respiration ( s e e p . 2 7 e t seq. ) - I t i s o f grea t practical significance that, as a rule, i n h alation h a s a facil itating a n d e xhalation a n inhibiting e ffect o n m uscles. Therefore, it i s usu a l l y a p propri ate t o com b i ne inh a lation with isome tric resista nce a nd exha l a tion with re l a x a tion. However, t h ere are i m porta n t e xcept ions t o t h i s rule: during re troflexio n o f t h e thoracic s p i n e , maxim u m exh a lation p roduces addi tional m obil ization of the t h oracic spi n e i nto retro flexion by contractio n ( facil ita tion) of the t h o racic e rector spinae, w h ile i n a kyphotic positio n o f the thorax deep in h a l a ti o n p roduces mobilization i nto flex i o n . Even m o re importa nt is the mobilizin g effect o f res pira t i o n during s i d e-bendi n g ( G ay m ans, 1980) , d u e to a lternating fa cilitation a n d i n h i b i ti o n o f indi v i d u a l segm ents o f the s p i n a l colu m n ( see p . 27) . As t h e e v e n segme n t s a re facilitated during in h a l a ti o n and inhib ited during exhalatio n , in these segmen ts we comb ine t h e isometric p hase w ith inhala tio n , a nd relaxation w ith e x h a l atio n; in the odd segm e n ts t h is i s reve rsed. To be effecti ve, respiratio n m ust be suffic i e nt l y s l ow, and dee p . The i ntense faci l i t ative ( inh ibi t ory) effect o n m u scles of '

,

.

System

'respiratory syn k i nesis' (see pp. 28-29) can be u sefully a p p l i ed, e . g . in isometric ce rvical or lumba r tract i on . Eye movemenls - These facilitate the movement o f t h e head a n d trunk i n the direction o f the patient's gaze and i n h i b i t m ov eme n t in t h e opposite direction . This h o lds for l i fting t h e head and tru n k a s we l l as for stooping and rota tion; it i s not t r u e for side bending, but loo k i n g up fac i l itates straighte n i n g u p from side -be ndin g. E y e movements s h o uld not be exaggerated, howeve r; accordi ng to G a y m an s (1980) maxim u m excu rsion has an i nhi bitory effect. A b o ut using t h e force o f grav ity fo r PIR, se e p . 210. Combinations - It is obvious t h a t t h ese methods le nd themse lves to use fu l com b i n ation, i n pa rticular PIR w i t h respiratio n and eye movemen ts. This has the e n ormous adva n tage of a u tomation: i n stead of te l l i n g t h e p a t i e nt to 'press w i th mi n imum force o n l y a few gra ms', we n ow te l l he r to look to the right and breathe i n slow l y (if rotation to the l eft is restric ted), a nd t h e n to l ook to the l e ft a nd breathe o u t, t h u s a u tomatica l ly producing the correct resist a nce during the isometric phase, followed by re lax a t i o n . For t h e m obi lization of side-bendi ng i n an eve n segm e n t, afte r taki ng u p the slack we ask the p a t i e nt to look u p a n d breathe i n slowly, and then to look down a n d b reathe out. I now come to some of t h e problems of correct com b i nati o n , w h ich is not a lwa ys an easy ma tte r. As l o o k i n g up faci l itates i n h a latio n and i n h ibits exhalation, and loo k i n g dow n has t he reverse effect, looki ng up mllst n o t be combined w i t h e x h a l a tion n or l ooki ng dow n with breat h i n g i n . We m ust a l so bear i n mind t h a t l o o k i n g up facili ta tes retroflex i o n a n d looking d o w n fac i l i tates a nteflexion (stooping) , w h i c h m a y o r m a y n o t b e useful i n a gi ven case . T h u s i n mobilizing s ide-bending i n a n even seg m ent i t will be use ful to p roceed in the mann e r described in t h e precedi n g pa r agr a ph. If, how ever, we wish to mobil ize an odd segme nt, it w o u ld be wrong to tell the patient to look u p and breathe o u t during the iso metric p h a se, beca use l ooking up i n h ibits exh alation. It could be e q u a l ly wrong to tell t h e p a t i e n t to look dow n, for t h at wo u l d in h ibit the straighte n i ng-up reactio n needed dur i ng the isomet ric .p h ase, w h i l e t h e si tuatio n wo uld b e e v e n worse i f the patient loo ked u p duri n g re l axa tion. The re fo re we do not com b i n e resp iration with eye movements i n mobil izatio n of side-b endi ng i n a n odd segm ent. In the cervicothoracic junction it is essen t i a l for the neck to be held in ret roflexion duri n g the mob ilization of side-bending. I t is therefore very convenient to comb i n e l oo k i ng u p with inhal a t i o n , b u t not look ing down w ith exh a l a tion because the p a t i e n t wil l bend h er n eck forward if she looks down . It is very impor ta n t that the patient brea thes s l owly so that b o t h the isometric a n d the re l axa tion phase are lo n g e n o ugh. It is t h e refore useful first to te l l the patie n t , for example, to l ook to t he right and

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,

Thallpeuric lechl1irlllCS only a moment later to tell her to breathe in slowlv: similarly, to tell her to look first to the left

only then

finds

difficult

hreathe out

If a

1f:nt

161

Records MGlhods of docllf1lt:ntatiol1

legion:

told to hold her breath for a few seconds at the end

marie, typed, every colollled, etc., practitioner will adopt the one he or she tinds most

of inhalation.

suitable. The essential is that in every case the

she should be

However, a patient with such bad

coordination that slow hreathing (no more than attained .. must be

cannot

correctly, because

to

4 s)

technique used and its precise location, side and

he

faulty respiration

direction are recorded. Without this docur1ltlntation it

impossible

evaluate results, to

from

compatible with normal functioning of the motor

faIlure or to deal with pOSSible complIcations as

system. If our combinations are well thought out,

described in the literature.

they not only improve the technique by what we may call automation, iveness

also Increase its

After-treatment

the'summa[lon of stimuli; frequentl)

or three repetitions are sufficient to restore normal

It is essential to advise the patient after the first

mobility.

treatment, so that he knows what he may do and what he should avoid. It is particularly important to tell

whether

shoud re"t cornpletely.

he should move about. This technique consists of a fast but not torcetul

Oil the

Ie ought

know

that there may be a painful reaction during the next

movement of small amplitude, starting from end

I or 2 days. If possible give him some some simple

position (i.e. after taking up the slack). A barrier

specific exercises. If possible, the patient should have

give way.

seems

as a rule

a comfortable

hear a

Immedll!llll.y afterwlHds we senStl

hypotonli1 and

observe increased mobility. The thrust must be applied only after the slack has been taken up completely, and this is possible only

patient

prlln

after treatment. If there

serious

analgesic should be prescribed and

fnrther

appointment arranged. After these general remarks, I will now deal with the individual joints.

completely relaxed. There are

three technical pre conditions:

must

(I)

Extremity joints

to sense the momt:nl of complek relaxation: (2) lhe patient having relaxed properly, the end-position is reached (the barrier is engaged) with a minimum of

In the manipulation of extremity joints we use almost

force;

excl

(3) the thrust

start from

end-position,

tensioll hefore delivt;nng

i.e. we must never

the thru,,[, as whell wt: lift tbe arm before delivering a blow - the typical beginner's error, because it

aimed

As examination

loint play

play.

restoring

lechnically identical

with tile mobilizallon of these joints, I desC(lbe both here.

corresponds to a type of movement we are used to. Here, however, it is enables

patient

this

thwart

II

crucial mistake, because it contract

IHuscles

Interphalangeal joints For mobilization (rind exarnIlHIIH)n), dorsop;limar

manoeuvre, which is

only if the patient's musculature is taken by surprise

and laterolateral shifts and distraction can be used.

(see Figures 2.7, 2.8 - pp.

The therapist fixes the proximal phalanx between

14, 15).

With Ihese conditions fulfilled, thrusting lation

never forceful; as can the thrust corresponds

4.3

the thumb and forefinger of

,ecn from II

weight

the not

or his of hiS

hand, either

body, whilc with the hand mobilizes

I

distal

more than 1000 g. Although the high-velocity thrust

phalanx in the required direction. It is advisable to

is typical of thrusting techniques, there are situations

keep one's fingers at right angles to the shifting move

in which

relatively slow incre8se in pressure

velocity thrust') release

even 1

suffice

ment, and at the same time to apply clistraction, which makes the shifting movement easier

obtain

more

'click'; indecd, we may

the click at times during mobilization and even just by engaging the barrier and waiting for complete relax8tion.

Testing

Metacarpophalangeal joints These joints me almost

and thc'refore

roLHion can be used as

dorsopalmar and

laterolateral shifts and (of course) distraction. Wbile

Immediately after treatment, whether this consists

with one hand the therapist fixes the patient's palm

of mohilizi1tion or thfllsting techniques, the effect

a[!ainq his own hody or the lahle, he may carry out

must

any

checked

k.sting (see

5).

these shi

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with the

By far

most

Maniplliative Therapy in Rehabililalion of Ihe LocomOlOr Syslem

162

e ffective m a noe uv re , however, is t ract i on , w h i c h ca n a ls o b e u s e d a s a t h ru s t ( p u l l). It is a s i m p le method to teach patie n ts for se l f- tre a t m e n t .

The carpometacarpal joint of the thumb This is the on ly ca r p om e ta c a r p a l j o i n t which is highly mob i l e, a n d of all t h e fi nger j o i n ts it i s p r o ba b ly t h e mos t s usce ptib l e to sy m p tom s . Treat m e n t is therefore i m por ta n t The t herapis t must first fix the trapeziu m b e twe e n t h e th u m b a n d fo refi nge r o f o n e h a n d . To find the t ra pe ziu m he should first p a l p a t e the styloid process of the rad ius; distal to t his there is a groove which corresponds to t h e sc aphoi d and then t he w r i s t broadens again: t h i s i s t h e site o f t h e tra p e zi u m . W ith the t h umb a n d forefi nge r o f t h e o ther h a n d , the the r a pi s t grasps the first m et acarp a l bone as close to the j oin t as possible, so as to exa m i n e join t p l a y between th e two. For m o b ilization it is better to gra s p the e n d p h a l a n x of the t h u m b w i th t h e l i tt l e fi nger of the hand that moves the firs t m etaca rpa l , so as to p u l l it and thus distract the joint. This can be don e w i th the p a tie n t s hand in p r onatio n or su p in a t ion (the t h e r a pist c han gin g hands ac cor di n g l y ) . This traction m a kes the s h ift i n g moveme n ts of joint p l ay much more effec t i v e If tr act i o n i s sufficien tly stro n g the t her a p is t can pr od u ce a gap p i ng effect (wit h ou t fixation of the t ra p e zium) by a s l igh t ( low ve l oc i ty ' ) thru st i n a palmar direction, with the pat ient's ha nd in supina tion, and in a dors a l direction with the hand in pron a tio n If the t he r api st is us i ng tra ct io n on l y ( w i th or wit h o u t a t hr ust) a n y fi x a t i on of the w r ist w i l l suffi ce : t h is tech n i q u e is t h e n very suitable for s e l f-t reat men t . Mobilization ca n also be carried o u t b y PIR, w h i c h is both e ffe c t i ve and ext rem e l y ge n tl e : w h i l e t h e t h era p i s t a p p l i e s v e ry sl i ght traction, t h e p a t i e n t is tol d to resi s t wi t h t h e least possible force for abo u t 10 s, after w h ich he is told to ' l e t go'. W i thout incre a s ing the force of h i s tra ctio n t he t he ra p i st wa tches the p a t i e nt relaxing, a n d repeats t h e p roce d u r e three to five times ( Figure 6.2) . .

,

'

.

-

.

,

Figure 6.2 Tre�tment of the first carpometacarpal joint: (a) in supination p,llmar shift of the first metacarpal: (b) in pronation dorsal shifl: both under considerable traction

The wri st j o i nts I f pa l m ar fl ex ion is res t r ict ed we m ust restore j oin t play by mov i n g t h e c arp a l bones in the radiocarpa l j o i n t in a d orsa l d i rec t i on. The the ra pis t grasps the s u p i nated hand of the pa tie n t close to the r a d i o car pa l j oi n t fixes the d istal end of the forea rm a ga i nst his own knee or the ta b l e , a n d prod uces a dorsa l shift of t he w r i s t (Figu re 6.3). Th is tec h n ique is w e l l suited for se l f- t reatme n t . I f ulnar flexion is restricted th e s a me tech n iq u e can be used, but pressure should be a pp l i e d m ai n l y a t t h e u l n a r e n d of the rad iocarp a l j oi n t i.e. against the pis i for m bone. If d o rsal flexion is restricted, j o i n t pl a y m ust be restored by m ov i ng the d istal r ow of the carpal ,

,

,

Figllre 6.3 Dorsal shift of the carpal bones against the foreann: mobilization of the rildiocarpal joint

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Thernp('/(Iic lecillliqlles

163

Figure 6.4 Palmar shift of the distal

of carpat bones against the row; mobilization of the miel-carpal joint row

proximal

n st the p roxi mal row, in a palm a r ( Fig ur e 6.4). The t herap ist grasps the patient's hand in pro na tion, round the p roxi m a l end of the metacarpal bones, fixes t he d ista l e nd of the forearm ag a i ns t his own knee or the t ab l e , a n d p rod uce s a pal m a r shif t of the d ist a l row of t h e carpal bones again st t h e proximal. Again this is an ideal technique fo r self-treatment. If r ad i a l flexio n is restricted ow i ng to b l oc kage between the scap h o i d and t he trapclium. t h e silme tech nique can be used but the pressure is a p p lied m ai n l y a t the rad i a l end of the mid-carpa l joi n t . There is a s i m p l e way t o l ocate the rad i o ca r p a I and the carpometacarpal .io ints exa c t l y : if we e x t e n d the wrist against t he forearm, t h e skin fold on the do rsal aspect is at the l e ve l of the c ar po me t a ca r p al .io i nt, and if we t1cx the w rist the skin fold on the palmar aspect is at t he le vel of the r a d i o c arpal jo i n t. The most specific and also t h e most important te ch n i que is that of shifting one carpal bone against its ne igh bo ur , in a dorsal or pa l m a r d ir ec t i on . This is part icu larly import a n t in the carpal-tunnel s y n drome (see p. 267). The exami n a tion te chni q u e is simple: one carpa l bone is grasped between the thumb and fore fi n ge r of each hand, and t he therapist m ov e s the two adjacent b on es against each other in the d orsa l a nd palm a r direction, respectively. For d i a g n os is it is crucial to use the m i n i mum of force, beca use u n d e r normal co n d i t i o n s fricti on here i s s o negligible that the slig h t est possible p res s u re will produce some movem ent. The ques t ion of fixa t ion is there fore less imp o rta nt he re , al tho u g h the therapist must s u pp ort the pillient's hand to ensure t h at it is com p l ete ly relaxed. If no movemen t c a n be fe l t w h e n t h i s mini mum rorce is applied, the re is restricti on: the LIse of greater force ren d e rs diagnos is i m pos s ib le . This techniq u e can a l so be used for mo b i li za tio n , but the f ol l o wing m e t h o d i s pr e fe ra ble , a s it p r o v i d e s be t ter fixatio n . The therapist p lac e s both thumbs on the dorsal aspect of o n e carpal bone and bo t h fore fingers (one above the ot h e r) on t h e p a l m a r aspect bon es

a gai

dire c tio n

the adjacent carpa l bone: he t h e n exe rts s light w i th pi n ce rs shifting one bone against the other. He t hen reverses the d ire c t i o n of the shift by pla c in g both t h u m bs on t h e p a l m a r aspect and both fo re fin ger s on t he dorsa l aspect of t h e same two bones (Figure 6.5). The m o v em e n ts a re rhythmic and r ep e t i t i v e . Obv i o us l y , t his moveme n t ca n a lso be effe cted with a s ingle h a n d, t h e t h u mb on one and the forefinger on the next ca rp al bone: in this way t h e patien t ca n be taught to p rac tise s elf tre a t m e n t (see p. 200). To locate single carpal bo n e s exactly we m ust start with o n e a n d f e e l o u r way to t h e n e x t . I have a l re a dy s h own how to l ocate t he sc a p h o i d and the t ra pe ziu m (se e p. 162). The capi t a t e forms the most p ro m i n en t po i n t of the w r i s t at pa l m a r flexion. The triquetrum lies below the p isifo rm . (The latt e r c an be m o b ili ze d against the triquetrum to both sides as w e l l as p rox imod i s tal l y . ) This te ch niq u e c a n be used both for d iagn o s i s and for t re a tm e nt , not o nly for t h e c a rpa l bones them selves but a l so for the carpometacarpal jo ints and the in te rmetacarpa l joi n ts . Tec h n ic a l l y it i s, of course, m ost importilnt to place the finge rs on ad.iace nt bones; if the thera pist p l aces his fi nge rs too close togeth e r (on the same bone ) by mistake, he will obtain no m o v e m e n t , w h i l e if they are too far a pa r t (so tha t t h ere is a bone i n b e tw e e n ) there will be t oo m u c h mobil ity. The range of shift between two ad j ace n t ca r p a l bones is only slig h t . In a d d i tio n to t hes e s h i fti ng tec h n iqu e s t h e re i s a d is t rac t i on t ech n i q u e with high - ve l o c i t y t h r u s t w h i c h is very effective a nd en t i r e l y innoc u o u s if c or r ec t l y applie d (Figure 6.6). The t he r a p is t stands in front of the pa t ien t , who is s eat ed with h e r arm stretched for w ard a n d downward . The therapist p la ces both thumbs on the p a t i e n t ' s distal bone (where r e s t r ic t i o n has bee n found), ilnd both hands round the wrist, w i t h tbe hand i n pronati o n . The slack i s t a k e n up by a very gentle p u l l i n the directi on o f the long axis of the patient's arm, a nd t h e w ris t is t h e n s ligh t l y dors i flexed over the t h e rap i s t ' s thumbs. The th rus t of

p re s s ure , as

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164

Manipulative Therapy in Rehabilitation of

the Locomotor System

Figure 6.6 Traction high-velocity thrust o n the os (a) finding the os capitum and making contact: (b) ta kin g up slack and delivering the thrust

capitum:

The elbow Here m o b i liza t i o n is used mainly for the trea tment of p a inful epico n dyles (in comb i nation w i t h m uscle rel axatio n ) . The most i m portant techniques a re distraction a nd l a tera l gapp i n g (springi ng) which is a l so sign ifica n t for diagn osis . Fi g u re 6.5 Shifting one c a rpa l bone against the examination; (b) mobilization by shearing

next:

(a)

is del ivered by a s u dden pull exactly alo ng t h e axis of the pa tient's arm, producing distractio n of the j o i n t. Th ere a re two mistakes to be avo i d ed: (1) traction m us t n o t be rele ased before the t h r u s t is delivered; and (2) no further d o rsiflexion at the wrist m ust occ u r d u r ing the t hrust (pull ) .

Distraction The patie n t l ies su pine. the a rm to be t rea ted flexe d a t the e l bow (Figure 6.7) . The therapist fixes the patient's forea rm aga i nst h i s sho ulder a n d p l aces the ha n d tha t w i l l perform the tractio n on the forearm. c l ose to the elbow. W ith his other hand o n the a rm, close above the elbow, he fixes the pati e n t's arm to t he t a b l e from above. Tra c t i o n is carried out a long the long axis of the arm by t he ha nd o n the forearm;

The dista l rad i o u l n a r j o i nt This is the last j o i n t that c a n be t rea ted a t the wrist, d e p e n d i n g fo r i ts function o n the u pper radiou lnar j o i n t . For both exa m i n ation and trea tme n t the tec h n i q ue is broadly tha t alre a d y descri bed for single ca rpal bo nes: the therapist grasps the end of t h e rad i us a n d the ul n a each be twee n the t h u m b a n d forefinger of o ne h and, p rod u c i n g a d o rs a l or palmar s h i ft . For treatme n t he p l a ces both t h u m bs o n the dors a l aspect of the rad i us a n d both forefin gers o n t h e palmar aspect of the u l na, to p rod u ce rel a tive s h i ft . After a few repeated rhy thmic m o biJiza tions he reverses the p i n cer m ovement by p l ac i n g both thumbs on t h e dorsal aspec t of the u l n a a n d both forefingers on the palmar aspect of the radius .

Figure 6.7 Traction of the elbow joint

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Therapeutic techniques

165

it is g re a t l y e n h a nced if the t he rapist presses the thu m b of the other hand (close above the e l bow) aga i n s t the hand exerting the p u ll , and a t the s a m e time increases t h e flexio n o f the e l b o w by pressing his shoulder against the patien t's fo rearm; this produces leverage at the elbow , t h e the rapist's th u m b serv i n g as the fu lcru m . Latera l gapping (springing) (Figure 6.8)

The p a tien t m a y be seated or s u p ine, w i t h t he affected a rm stre tched out b u t n o t ove rs t retched (the e l bow must not be locked). The t h erapist stand s facing t he elbow (from the radial or u l nar side) a nd wi t h one hand a bove t h e wrist fixes the forearm aga inst his body; w i t h the oth e r ha n d he takes the e l bow from the s i d e , the t h u m b above a n d fingers below. Pressing t his h a n d ge n tly a g a i n s t the elbow from the side, he takes up t h e s lack, and w i t h a ge n tle extra push springs the joi n t, producing gapping of the point on the o p posite side. If the rad i a l e p i c on d yle is pa i n fu l, as a rule t h e re i s no sprin g i n g ( o r it is i m paired) i n the u l norad i a l d irection, wh i l e if t h e u l n a r epic o n d y l e i s pai nfu l w e some t i m e s find re stJicted radio u l n a r spri nging. For the purpose o f mobi l ization, s p r i n g i n g is re p e a te d rhythmica l l y. The same tec h n i q u e is a l so used to deliver a h i g h -velocity t hrust after t a k i n g up th e slack ( i n a radial or u l n a r d i rectio n ) . Fast s h aki n g is most e ffective. For sel f- trea t m e n t see Figure 6.70, p. 200. The re a re two import a n t tec h n ical deta i ls: the thera pist stands a t the level o f t h e e l bow joint so that the h a n d s pri ngi ng the joint or delivering the t h rust is supported b y h is trunk, i. e . the move m e n t origina tes in the t he rap ist's p e l v i s or e v e n in h i s l egs; and the hand grasping the patien t's forearm is t h e re fo r fix ation o n l y, a n d must n ot be ( m is)used for leverage.

If a h igh-vel ocity t h rust i n a rad i a l o r u l n a r direction i s not successfu l, a th rust ca n be applied

Figure 6.9 Shaking mobilization of the elbow joint into

extension

aga i ns t t h e head of t h e radius w i t h the thu mb, fro m t h e d o r s a l aspect, t h e a r m b e i n g stre tched . Th i s tech nique may be too v i o l e n t , a n d we have i n t rod uced i nstead a n e q u a lly effective ge n t l e rocking techniq u e . The patient is s e a t e d o r s u pi n e; t h e t h e r a p i s t grasps the o u tstre tched a rm wi th both h a n d s , j u s t above the e l bow, ho lding it in maximu m supi n ation a nd s h akin g it gently a n d rhythm ica ll y w h i l e t h e p a t i e n t i s f u l ly relaxed (Figu re 6.9). Sachse (personal com munica t i o n ) a c h i eves a s i m i l a r effect by rhyt h m i c s t a bilization: w i t h t h e pa tie n t seated a n d t h e elbow flexed, t h e thera pist h o l d s the p a t i e n t's u pp e r a r m w ith both hands, fixi n g t h e h a n d i n h i s a rm p i t, a n d tells h e r to extend a n d flex t h e a r m rhyth m ic a l l y , wh ile h e resists the p a t i e n t ' s move m e n t s .

The sho ulder joint

Figure 6.8 Springing the elbow in a radial direction

Where w e find a typic a l caps u l a r pa ttern ( see p . 115), mobil iza t i o n techn i q ues a re pract ica l l y use less and even the usua l t raction tech niques give little or n o res u l t. Surprisingly , what w e might c a l l isometric tract ion brings re lief of p a i n and may even improve m o b i lity. It is best for the p a t i e n t to sta nd or t o s i t (Figure 6.10a); the t herapist p l aces h i s right s h o u lder u nder the right axilla (or the le ft u n d e r the left), pressing aga i n s t t he pa t i e n t's thorax. He grasps t h e affected a r m w i t h one h a n d a b ove t h e wrist a n d the other above the e l bow, a n d te lls the patient to re sist

Copyrighted Material

Monipulolive

I (i(\

traction very

Therapy in

Rehabilirmion of Ihe

s l i g h t l y a n d t h e n to

b re a t h e i n

L o col1loror Sysrem

s l ow ly

a n d t h e n to h o l d h e r b re a t h . Afte r t h i s t h e p a t i e n t told

is

l e t go a n d to bre a t h e o u t s l o w l y

to

If

.

re l a x a t i o n i s s a ti s fa c t o r y t h e t h e r a p i s t fe e l s t h e ' patie n t s arm l e n g t h e n i ng but he must not pu l l . -

This

p r o c e d u re

a cco rd i n g

re p e a t e d

is

to the degree of

i m po r t a n t t h a t t h e

is

a bo u t

three

times,

re l ax a t i o n a c h ieved . It

t hera pist

should

prop

his

s h o u l d e r a ga i n s t t h e p a t i e n t ' s t h o r a x , n o t t h e a r m , w h i c h is se m i - a bd uc t e d . Wi t h t h e a x i l l a o v e r t h e t o p o f a c u s h i o n e d c h a i r - b a c k t h i s tec h n i q u e is very .

s u i t a b l e fo r se l f- t re a t m e n t . I t i s u s e f u l if t h e p a t i e n t i s t a l l e r t h a n t h e t he r a p i s t . A n o t h e r tech n i q u e , w i t h t h e pa ti e n t s u p i n e

,

i s a s fo l l o w s : s h e a b d u c t s h e r a rm

as fa r as s h e ca n : t h e t h e ra p i s t p l a ces a b u t t oc k between the pa tient's arm a n d c hest, exerting a s l i g h t p u ll

on t h e a rm

to t a k e u p t h e s l ac k . T b e

p a t i e n t i s t o l d t o r e s i s t , b re a t h e i n , h o l d h e r b re a t h ,

a n d t h e n t o re l a x a n d b r e a t h e o u t ( F ig u r e 6 . l Ob ) If a b d u c t i o n o n l y

is r e s t r i c t e d , a n d

we

.

( a)

fi n d a t

e x a m i n a t i o n th a t j o i n t p l a y i s i m p a i re d w h e n w e s p r i n g t h e h e a d o f t h e h u m e r u s a ga i n s t t h e s c a p u l a

1 1 5 ) . w e r e s to re j o i n t a s fo l l ow s : t h e p a t i e n t s i t s w i th h e r a r m

from a b o v e ( s e e F i g u r e 4 . 4 0 , p . pl a y

a b d uc te d : t h e t h e r a p i s t p l a c e s h i s s h o u ld e r u n d e r t h e p a t i e n t ' s e l b o w , so t h a t

t h e a r m i s h o r i zo n t a l

.

He

t h e n p l a c e s o n e h a n d ( w i t h t h e ra d i a l a s p e c t ) o n t h e h e a d of t h e h u m e r u s fro m o n e sici e , w h i l e t h e o t h e r

h a n d t o u c h e s t h e fos s a g l e n o id a l i s of t h e s h o u l d e r b l a d e from t h e o t h e r s i d e . W i t h s l i g h t p r e s s u r e o f on e h a n d a g a i n s t the o t h e r h e takes u p t h e s l a c k a n d t h e n s p r i n g s t h e j o i n t p ro d u c i n g a t r a n s l a to r y m o v e

( b)

H e t h e n c h a nges h a n d s a n d s p r i ngs t h e j o i n t i n t h e o p p os i te d i re c t i o n . By r a i s i n g

F igure 6.1 0

.

m e n t ( Fi g u re

6.1 1 ).

o n e e l b o w a n d l o w e r i n g t h e o t h e r , t h e t h e ra p i s t m a y

s p r i n g t h e j o i n t i n a n o bl i q u e d i recti o n . t h u s fi n d i n g t h e d i re c ti o n o f m a x i m u m r e s t ricti o n a n ci t h e n t re a t i n g i t . Th i s t e c h n i q u e i s b o t h e a s y a n d e ffec t i v e . Ca re m u s t b e t a k e n , h o w e v e r , to have t h e t h e ra p i s t ' s h a nd .

located exac t l y a t

ther�pist. i n

( 0 ) Tra c t i o n

the

of t h e s h o u l d e r o v e r t h a t of t h e t h e l o n g a x i s o r t h e a rIll : t h c ( h ) T ra c t i o n o f t h e s h o u l d e r i n a x is o f t h e ar m . o v e r t h e

d i re c t i o n o r

pat i e n t m a y s i t or s t a n d . t h e d i re c t i o n o f t h e l o n g t herapisr's h i p . the patient

supine

t h e h e a d o f t h e h u me r u s , a n d h is

o t h e r h a n d a t t h e fo ssa g l e n o i d a l i s .

The acro m ioclavicu l a r j o i nt To

free

t h i s j o i n t , t h e most

i mporta n t t e c h n i q u e

c o n s i s t s of s p r i n g i n g i t i n a ve n t rodorsa l a n d a c r a n io

c a u d a l d i rec t i o n ( Fi g u r e 6 . 1 2) . T h e p a t i e n t is s u p i n e , t h e t h e ra p i s t s t a n d i n g b y t h e s i d e o f t h e t a b l e . To c a r ry o u t ve n t roclorsa l s p r i n g i n g he p l a ce s h i s ( r i g h t ) t h e n a r e m i n ence aga i ns t t h e ( r i g h t ) c l a v i c l e , fi x i n g t h e p a t i e n t's shou l d e r with his o t h e r ha n d He now .

a p p l i e s ge n tl e pre s s u re a g a i n s t t h e c l a v i c l e from a bove , a nd

t h e n re l e a ses it. If j oin t p l a y

is normal ,

he w i l l fe e l t h e c l a vi c l e s p ri n g b a c k a n d wiJl bot h

fe e l a n d s e e m o v e m e n t b e t w e e n t h e e n d of the cl a v i c l e a n d t h e s h o u l d e r . Th is s p r i n gi n g i s a bs e n t i n ac rom i oc l a v ic u l a r

blockage.

To

re s t o re

it.

the

t h e ra p i s t re p e a ts t h i s g e n t l e p u s h w i t h h i s t h e n a r

F igure 6 . 1 1 Tra n s l a t o r y m o h i l i za t i o n o f b o t h h a nds i n o p po s i t e d i re c t i o n s .

using

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the shoulder

joint

t h e p a t i e n t seated

Th erapeU lie lechn iques

1 67

( a)

( c)

( b) Figure 6. 1 2

Mooilization

v e n t r o d o rs a l

ami (h)

of t h e

a c r o m i oc l a v ic u l a r j o i n t by s p r i n g i n g

the

e m i n e nc e , w i t h o u t e v e r i n creasi ng fo rce, a n d t h e n re l eases i t . A fter a bo u t five repe t i t i o n s a t t he rate o f two p e r seco n d , h e u s ua l l y se nses some spri ngi ng: after 1 5-20 repe titions the ra nge n o longer i ncreases. For cran ioca u d a l s p r i n g i n g , t h e t h e ra p ist a t the side o f t h e t a b l e fixes the ben t e l bow from below w i t h h i s cupped hand, placing t h e t henar e m i n ence of the other h a n d on t h e clavicle from a bove a n d giv i n g a s l ig h t s p r i n g i n g p u s h fo l lowed by release, a t t h e r a t e o f t w o p e r seco n d . I f h e n e i t h e r fee l s n o r sees springi n g between t h e c l a v i c l e a n d t h e s h o u l de r , he rcpeats the m a n o e u v r e , as t o r dorsoven tral springi ng. I t a p pears that i t i s t he s p r i n g i n g back that frees the j o i n t, a n d t here fore t he worst mistake i s to i n c re ase p ress u re if no s p r i n g i n g has bee n felt ( a s t h o u g h t r y i n g t o re l ease a s p r i n g by press u re o n i t ) . Trea t m e n t shou l d a l ways be a p p l i e d i n both d i rections, as move m e n t m a y be b l o c k e d s e p a ra t e l y i n each . A n o t h e r use fu l t echn i q u e is t h a t o f tracti o n

the acromion i n acrom iocln v i c u l a r j o i n t

c l a v i c l e aga i n s t

a c r a n i o c a u d a l d i re c t i o n . (e) T ra c t i o n m o b i l iza t i o n of t h e

(a) a

m o b i l iza tion ( F i g u re 6 . J 2c) . T h e p a t i e n t i s s e a t e d o n a l o w stoo l , w i t h the t h e rapist o n t h e s i d e o f t h e l es i o n . be h i n d t h e a bd ucted a r m . He grasps t h e a r m a bove t h e e lbow a n d w i t h t h e t h e n a r e m i n e n ce o f t h e o t h e r ( r i g h t) h a n d o n t h e ( le ft) c l a v i c l e h e fixes t h e l a te r a l e n d o f t h e cl avicle b y s l ight pressure from above . He a p p l i e s tracti o n th ro u gh t h e a r m , w h i c h i s s l i g h t l y raise d , a b d ucted a n d d r a w n forward, making a ge n t l e movement of rota tio n ; h e m a y se n se a d i s t i n c t crack i n g sou n d under the h a n d fi x i ng t h e clav icle .

The stern oclavicu l a r joint S i m p le b l ockage o f th is joint without a r t h rosis is re l a t i v e l y rare. The most e f fect i ve tech n iq ue i s ga p p i n g t h e j o i n t: w i t h h a nds cross e d , t h e t h e r a p i s t p laces one pisifo r m aga i nst the m e d i a l e n d of the clavicle from b e l ow, and t h e o t h e r p isi form against the m a n u b ri u m o f t h e s te r n u m from above. B y s l ig h t p ress u re p a r t i n g t h e h a n d s , t h e s l a c k is t a k e n u p : t h e

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Manipulative Therapy

in Rehabilitation of the Locom% r

System

from the trunk, so that both his ha nds p e r fo rm as a s i ngle u n i t .

The toes

Figure 6.13 S pr i n g i ng t h e s t e r n o c l a v i c u l a r j o i n t w i t h

c ro s s e d h a n d s

t herapist t h e n springs t h e j o i n t i n to d istraction (Figure 6 . 1 3 ) .

T h e shou lder-b l a d e T h e s h o u l der-blade l ies fl a t o n t h e t h o racic wall a n d a l though t h e re is no a rtic u l a t i o n , i t i s free l y m o b i l e beca use of the synov i a l b u rs a e . A l t h ough t h e r e c a n n o t be blockage o f the t y p e fo u n d i n a rticu l a t i o n s , t here may be some res trictio n (bin d i ng); mobi liza tion c a n t h e re fo r e be use fu l . The p atie n t l i e s prone w i t h h e r head turned towards t h e t he rapist a t the side o f t h e table ( Figure 6. 1 4) . The t h e r a p i s t grasps t h e h e a d of the h u m e ru s i n both h a n d s - one a bove a n d t h e other b e l o w rou n d the patient'S s h o u l d e r , a n d carries o u t a c i r cli n g mov e m e n t . W i t h the upper h a n d he m a y exe rt s o m e press u re o n the moving sca pula from a bove, or o n the con trary he may l i ft the sca p u l a from t h e t h orax with h i s finge rti ps. [ t i s import a n t t h a t t h e m o v e m e nt the t h e rapist i m parts to the sca p u l a over t h e p a ti e n t ' s shoulder should come

Figure 6.14 M o b i l i za t i o n o f t h e s h o u l d e r- b l a d e a g a i n s t w a l l ( a lso use ful fo r r i b m o b i l i z a t i o n )

t h e t horacic

What has been sa i d a b o u t the fi nger j o i n ts i s e q u a l ly valid for the toes. However, the co n d i t i o n that is spec i fi c for the foot i s pa i n i n the metatarso phal a ngea l j o i n ts ; here t h e tech n i q u e that gives most rel ief is traction i n a s l i g h t ly plantar d i rect i o n . Fo r this m a noeuvre the t h e rapist grasps t h e first p h a l a n x o f the toe betwee n h i s t h u m b a n d t h e fl e x e d fi rs t phalanx of h i s fore fi nger, w h ich is p l a c e d u n d e r t h e first p h a l a n x of the patient's toe. W i t h the o t h e r h a n d he fix e s t h e correspo n d i ng metatarsa l . A ft e r ta k i n g u p t h e s l a c k he i ncreases traction s i m u l ta n e o u s l y w i t h s o m e p l a n t a r flexion, u s i n g t h e first p h a l a n x o f h i s flexed fore fi nge r a s a fu l c r u m . A l t h o ugh t h e r e i s n o real t h rust. o r only a v e r y l o w v e l o c i t y thrust, a c l i c k c a n freq u e n t l y be h e a r d . T h i s i s a s i m p l e tec h n i q u e , b u t ca re m ust b e taken not t o press the j o i n ts , w h i c h a r e v e r y t e n d e r. A t e c h n i q u e t h a t pa t i e n ts fi nd agree a b l e consists of s p re a d i ng t h e metata rsals fa n-wise ( Figure 6 . 1 5 ) . T o d o t h i s t h e therapist s t a n d s a t t h e foot of the t a b l e w h i l e t h e p a t i e n t s i t s fac i n g him, on t h e t a b l e , with k nees be n t a n d h e e l s res t i ng on t h e t a b le . The therapist ta kes the m e t a t a rs a l s in both h a n d s , the t henar above w h i l e the fi n gers form a fulcrum on the p l a n t a r aspect: he then s p re ads the dors u m o f the foot.

The tarso metata rsa l j o i nt and the joi nts between the tarsal b o n es The term ' Lisfra nc's a n d C h o p a rt' s j o i n t ' is fre q u e n t l y used for these j o i n ts . As a r u l e i t i s better to d i a gnose a n d t re a t speci fi ca l l y t h e j o i n t s betwee n s i n g l e t a r s a l bones a s we ll as the t a rsometa t a r s a l j oi n ts . A very effective t ech n i q u e for t re a t i n g Lisfra nc's j o i n t (al l t h e t a rsometa ta rs a l j o i n ts) and Chopart's j o i n t ( t he articu lation between both the cuboid a n d nav icular bone wi th the talus and calcaneus) toge t h e r is a s

Figure 6.15 S p r e a d i n g t h e m e t a t a rs a l s fa n -wise .

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Therapeutic techniques

169

fol lows ( F i g u r e 6 . 1 6 ) . T h e p a tie n t l i e s s u p i n e w i t h t h e l e g b e n t a t t h e k n e e , t h e h e e l o n t h e t a b l e . The t h e r a p i s t s t a n d s a t the s i d e of t h e t a b l e and grasps the p a t i e n t ' s l e g abo ve the a n kJ e w i t h one h a n d , from a b o v e . H e t h e n p l aces t h e r a d i a l aspect o f t h e o t h e r h a n d p a r a l J e l e i t h e r t o Lis fra n c ' s o r t o Chopart's j o i n t on

t h e p l a n t a r aspect

from t h e

m e d i a l s i d e o f t h e foo t , a n d ta k e s u p t h e s l a c k w i t h s l i g h t press u r e ; h e t h e n s p r i ngs t h e j o i n t i n a c r a n i a l d i re c t i o n ( Fi g u re 6 . 1 6 ) . H e s h o u l d k n o w t h a t t h e prox i m a l

end

of

the

fi ft h

m e t a t a rs a l

( w h i ch

is

p ro m i n e n t) l i e s m o r e prox i m a l t h a n t h e prox i m a l e n d o f t h e fi r s t m e t a t a rs a l , so t h a t h i s i n dex fi n g e r

Figure 6.17 Trac t i o n m a n i p u l a t i o n ( mo b i l i za t i o n ) o f t h e by t h rust or b y r h y t h m i c a l s h a k i ng

t a rsa l b o n e s

fo l l ows a n o b l i q u e c o u rse . The

fo l l o w i n g tec h n i q u e s c o r r e s p o n d

to

t h ose

described for s i n g l e c a r p a l bones: for d i a g n o s i s o f

b e t w e e n t h e c u n e i fo r m b o n e s a n d t h e n a v i c u l a r , a n d

j o i n t p l a y t h e t h e ra p ist fi x e s t h e p r ox i m a l b o n e ( m ost

between

fre q u e n t l y a tarsal b o n e ) b e t w e e n t h u mb a n d fo re

c a l c a n e u s . T h e m o s t fre q u e n t s i t e o f re s t r i c t i o n i s ,

the

navicular

a nd

the

cuboid

and

the

fi n ger. w h i l e t h e t h u m b and fo r e fi n g e r o f h is o t h e r

h o w e v e r , t h e seco n d , t h i rd a nd fo u r t h ta rso m e t a

h a n d g r a s p t h e b a s e of a m e ta t a r s a l b o n e , t o e x a m i n e

t a rs a l j o i n ts .

d o rso pl a n t a r s h i ft . To c a rr y o u t t h i s m a n oe u v r e

A ft e r t h i s s h i ft i n g tech n i q u e a s i m i l a r l y ' u n i v e rs a l '

e x a c t l y i t i s b e s t fi rs t to t a k e u p t h e s l a c k i n a d o r s a l

t ra c t i o n tech n iq u e s h o u l d b e e m p l oyed ( Fi g u re 6 . 1 7 ) .

d i rect i o n , s p r i n g i n g t h e j o i n t i n t h e s a m e d i re c ti o n ,

The patie nt lies prone, h e r legs slightly bent at the

a n d t h e n to t a k e u p t h e s l a c k in a p l a n t a r d i re c t i o n

k n e e . T h e the r a p i s t p u ts t h e fi ngers of b o t h h a n d s

a n d a g a i n s p r i n g the j o i n t i n e n d - p os i t i o n .

r o u n d t h e p a t i e n t ' s i n step w i t h b o t h t h u m bs o n t h e

F o r m o b i l i za t i o n , h o w e v e r , i t i s be tte r fi rs t to p l ace

p l a n t a r a s p e c t o f t h e d i s t a l o f t w o adj a ce n t b o n e s

b o t h t h u m bs o n t he p l a n t a r aspect and both fo re

( e . g . o n t h e b a s e of t h e t h i rd m e t a t a rs a l ) . H e t a k e s

fi n g e rs o n the d o rs a l aspect of two a d j a c e n t b o n e s ,

u p t h e s l ac k b y s li g h t p l a n t a r flex i o n a n d t r a c t i o n

to t a k e u p t h e s l a c k by s l i g h t p re ss u r e , a n d t h e n by

a l o n g the l o n g a x i s of t h e foo t , a n d ca n t h e n d e l iv e r t h r u s t b y a s u d d e n p u l l . Rece n t l y I h a v e d ev e l o p e d

s l ig h t l y i n c r e a s i n g and t h e n re l e a s i n g p re s s u r e ( a t

a

t h e b a r r i e r ) r h y t h m ica l l y t o m o b i lize t h e j o i n t i n o n e

a t ec h n i q u e t h a t i s ge n t l e r , m o re e ffec t i v e , a n d agree

d i re c t i o n . T h e p os i t i o n o f t h e t h u m bs a n d fore fi n gers

able t o the p a t i e n t ; t h i s c o n s i s t s in s i m p l y s h a k i n g

i s t h e n reversed to pe rfo r m m o b i l i z a t i o n in the s a m e

t h e fo o t r h y t h m i c a l l y u p a n d d o w n r a t h e r fa s t ( s e v

w a y i n t h e o p p os i te d i re c t i o n ( s e e F i g u r e 6 . 5 , p . 1 64 ) . T h i s is

an

a l m o s t u n iv e rs a l t e c h n i q u e w h i c h m a y

be u s e d fo r t h e t a rs o m e t a t a rs a l j o i n ts , t h e j oi n ts

e r a l s h a k es per seco n d ) , w h i le m a i n t a i n i n g t r a c t i o n . T h i s m u s t b e d o n e w i t h a rel a x e d h a n d , s o a s to s e n s e

A

t h e o p ti m u m r h y t h m .

f e w seco n d s o f t h i s s h a k i n g

m o b i l i z a t i o n i s s u fffic i e n t . I t c a n a l s o b e u s e d t o t re a t t h e cun e i fo r m , t h e c u b o i d a n d t h e n a v i c u l a r .

The s u bta l a r j o i nt T h i s j o in t is form ed by t h e t a l u s , the calca n e u s a n d t h e n a v i c u l a r . T o e x a mi n e j o i n t p l a y a n d m o bil i ze t he j o i n t , t h e t h e r a p i s t gra s p s t h e p a t i e n t ' s i n s t e p with one h a n d and cups the other round h e r heel ( F i g u r e 6 . 18) ; t h e p a t i e n t i s s u p i n e . W i t h t h i s g r i p the

t h e ra p i s t c a n p e rform

most

of t h e

possible

m o v e m e n ts b e t we e n t h e c a l c a n e u s and t h e fo r e fo o t : l a t e r a l fl ex i o n , r e l a t i v e r o t a t i o n , p l a n t a r fl e x i o n a n d d o r s a l fl e x i o n o f t h e i n s t e p .

A

v e ry

e ffec t i v e

traction

tech n i q u e

has

been

d e v e l oped fo r t h e pos te r i o r p a r t o f t h e s u b t a l a r j o i n t ( Fi g u r e 6 . 1 9 ) . T h e p a t i e n t i s s u p i ne w i t h t h e h e e l o v e r t h e free e d ge o f t h e ta b l e ; t h e t h e r a p i s t sta n d s a t t h e f o o t o f t h e t a b le a n d g r a s p s t h e l e g a bove t h e a n k l e , w i t h o n e h a n d , from t h e s i d e , h is th umb a b o v e t h e m e d i a l m a l l eo l u s , for fi x a t i o n . The o t h e r h a n d

Figure 6.16 M o b i l i za t i o n of t h e t a rsom e t a ta r s a l a n d t r a n s verse t a rsal j o i n ts (After Sachse , ( 973)

cups t h e h e e l f r o m t h e m e d i a l a s p e c t a n d p u l ls i t i n a d i s t a l a n d u p w a rd d i rec t i o n . A ft e r t a k i n g u p t h e

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1 70

Mflnip l I /fl l i v e Th erapy

in

R ei1f1 h ililflliun of lire LOCU / 1 / U l O r SyslCl l 1

Figure 6.19 G a p p i n g t h e s u b t � l a r heel

joi n t b y p u l l i n g o n

the

c o u l d l o c k t h e a n k l e j o i n t . H e n ow t a k e s u p t h e s l a c k by

a

s l i g h t p u l l a l o ng t h e l o n g a x i s a t t h e l e g , a n d

t h e n m a kes

a

t h r u s t i n t h e s a m e d i re c t i o n .

as a

ru l e

o b ta i n i n g a ' c l i c k ' . A n a l t e r n <1 t i v e t e c h n i q u e i s to gr a s p t h e fo re fo o t w i t h o n e h a n d a n d t h e h e e l w i t h t h e o t h e r .. ca r r y i n g o u t t r a c t i o n : i n t h i s c a se t h e s u b t a l " r j o i n t i s a l so t re a te d . In b o t h c a s e s t h e m o s t

C O III III on

m i s t a k e is

e x a gg e r a t e d d o rs i fl e x i o n of t h e fo o t . a n d too m u ch

Figure 6 . 1 8 E x a m i n a t i o n o f m o b i l i t y ( m o b i l i z a t i o n ) of t h e calca n e u s a g a i n s t t h e i n s t e p i n a ( 1 1 ) m ed i a l a n d ( h ) l a t c r
fo rce a p p l i e d to t a k i n g u p t he s l a c k .

The t i b i ofi b u l a r j o i nt Fo r d i a g n o s i s .

s l a c k h e m a y m o b i lize

or

de l i v e r

a

t hr u s t t o ga p t h e

fi b u l a r

head

as

on

fo r m o b i l iza t i o n ,

the tibia

in

il n

d i rec t i o n , a s o n t h e c i rc u m fe re n c e o f

p o s t e r i o r p a r t o f t h e t a l o c a l ca n e a l j o i n t .

we

move the

il n t c ro p o s t c r i o r il

c i rc l e ( Fig u r e

6 . 2 2 ) . T h e p a t i e n t i s s u p i n e , t h e k n ee b e n t a n d t h e fo o t o n t h e t a b l e . T h e t h e ra p i s t s i t s s o as t o fi x t h e

The a n k l e j o i nt H e r e j o i n t p l a y c o n s i s t s of a r e l a t i v e a n te ro p o s t e r i o r s h i ft o f t h e t a l u s a ga i n s t t h e fo r k fo r m e d b y t h e d i s t a l e n d o f t h e t i bia a n d fi b u l a . For e x a m i n a t i o n a n d m o b i l ization t h e p a t i e n t i s s u p i n e , t h e k nee s l i g h t l y be n t a n d t h e h e e l o n t h e ta b l e ( F i g u re

6.20).

The

t h e ra p i s t s t a n d s a l o n gs i d e l h e l e g a n d gr a s p s t h e h e e l i n o n e h a n d , s u p p o r t i n g t h e fo o l w i t h h i s fore a r m to h o l d it a t r i g h t a ng l e s to t h e l e g . He t h e n t a k e s up t h e s l a e k by s l i g h t p r e s s u r e f r o m a b ove a n d s p r i n gs

i t r h y t h m ica l l y in t h e sa m e d i re c t i o n . T h e re i s a l s o a v e ry e ffec t i v e trac t i o n t e c h n i q u e ( Figure

6.2 1 ).

The

patient

is

su pine

s t r e tc h e d ; t h e t h e ra p i s t s t a n d s at t h e

end

with

legs

of the ta b l e

a n d grasps t h e p a t i e n t 's i n s t e p w i t h c l a s p e d h a n d s , t h e t h u m bs p a ra l l e l o n t h e s a l e to s t a b i l ize t h e foot at righ t a n g l e s t o the l e g .

He

m u st ta k e c a re not to

h o l d the foot in m a x i m u m d o r s i fle x i o n beca use t h a t

Figure 6.20 E xa m i n a t i o n o j" j o i n t p l a y a n d m o b i l i z a t i o n t he a n k l e j o i n t b y s p r i n g i n g t h e l e g a gd i n s t t h e h e e l

of

Copyrighted Material

TilempC l I lic reci1 l 1 i q l l fs

17 1

b l o c k a g e : w h a t we Il nd is s o m e resi s t a nce , as t h o u g h t h e pate l l a w a s m o v i n g o v e r a n u n e v e n o r r o u g h s u rface. T h is s e n s a ti o n i s e v e n m ore m a rk e d i f s o m e pressure is a pplied to t h e p a te l l a fro m a bo v e . W h i l e t h e p a t i e n t l i es s u p i n e w i t h t h e l e g s t re t c h e d a t t h e k n e e , t h e t h e r a p i s t g r a s p s t h e p a te l l a betwee n t h e t h u m b a n d fi ngers of o n e h a n d , w h i l e t h e o t h e r h a n d e x e r t s s l i g h t press u re fr o m a bo v e w i t h t h e t h e n a r e m i n e nce o r w i t h t h e t h u m b . W i t h b o t h h a n d s a c t i n g i n u n i s o n , t h e t h e r a p i s t n o w moves the p a te l l a s o a s to sense w h e re t h e ro u g h n e s s l i e s ; h e t h e n s l i g h t l y i nc reases p r e s s u r e so a s to sm oo t h o u t t h e r o u g h ness, w i t h o u t c a u s i n g p a i n A ft e r a fe w re p e t i t i o n s h e fe e ls t h a t r o u g h n e s s a n d r e s i sta n ce h a ve s u b s i d e d . A t t h i s m o m e n t , t o o t h e p a t i e n t fee l s c o n s i d e r a b l e re l i e f. Th i s t e c h n i q u e ca n be t a u g h t to pa t i en ts fo r

,

Figure 6.2 1 TI'a c t i o n m a n i p u l a t i o n of t h e a n k l e j o i n t

,

pat i e n t

'

s t o e s w i t h h i s b u t t o c k s , g r a s p i n g t h e fi b u l a r

h e a d b e t w e e n t h u m b a n d fo re fi n ge r :

h a n d h e fi x e s t h e t i bi a b e l o w

the

with

the o th e r

k n e e . With

his

fingers ro u n d t h e fi b u l a r h e a d h e m a k e s a d ors a l a n d v e n t r a l sh i ft ro u n d t h e t i bi a , t o d e t e r m i n e w h i ch restrict e d . Fo r m o b i l i z a t i o n h e s l a c k i n t h e r e s t r i c t e d d i re c t i o n a n d r h y t h m i c a l l y s p r i n gs t he e n d -posi t i o n . I t i s u s e fu l t o r e i n fo r c e t h e t h u m b a t t h e fi b u l a r 11 e a d with t h e t h u m b o f t h e o t h e r h a n d , w h i c h fo l l ows t h e r o t a t o r y m o ve m e n t round t h e t i b i a . The same e f fect c a n be a c h i e v e d b y susta i n e d m o d e r a te press u re a ft e r e ngaging the b a rr i e r t o o b t a i n m y o fa s c i a l re l e a s e . d i rect i o n

is

mos t

takes up the

s e l f- t re a t m e n t .

treated first b y ( d i s ) t r a c t i o n (Figure 6 . 2 3 ) . The s i m p l e s t is t o l a y t h e p a t ie n t p r o n e o n a m a t on t h e fl o o r t h e knee b e n t a t r i g h t a n g l e s . T h e t h e r a p i s t ( s t a n d i n g ) p u ts o n e foo t o n t h e t h i g h j us t a bove t h e k n e e a n d gra s p s t h e l e g w i t h b o t h h a n d s ro u n d t h e a n k l e , p u l l i n g i t i n a v e rtica l d i r e c t i o n . A s a t t b e e l b o w , l a t e r a l. spring i n g t o g a p t h e j o i n t o n t h e m e d i a l o r l a te ra l a s pect i s a n i m p o r t a n t t ec h n i q u e ( Figu re 6 . 24 ) . The p a t i e n t l ie s s u p i n e , t h e l e g st re t c h e d b u t n o t o v e r - s tre t c h e d . T h e t h e r a p i s t sta n d s b y t h e t a b l e a l o n gs i d e t h e a ffected k n e e ; w i t h o n e h a n d h e g r i p s t h e p a t i en t s a n k l e , l i ft i n g i t s l i g h t l y a bo v e t h e ta b l e . W i t h t h e o t h e r h a n d s u p ported b y t h e t r u n k he e x e r t s s li g h t p r e s s u r e a t t h e l e v e l of t h e j o i n t s p a c e to t a k e u p t h e s l a c k , a nd t h e n s p r i n g s t h e j o i n t m e d i a l l y . I n o r d e r to s p ri n g t h e j o i n t l a te ra l l y , t h e t h e r a p i s t m u s t s i t o n t h e t a b l e be t w e e n t h e p a t i e n t s l e gs f a c i n g t h e k n e e j o i n t . F a s t sh a k i n g i s t h e m o s t e ffect i v e m o b i l i z a t i o n . T o a p p l y a s l i g h t t h r u s t , w b i c h i s s o m e t i m e s u s e fu l , w e us e t h i s t e c h n i q u e b u t fi r s t a s k t h e p a t i e n t to b e n d a nd s t retc b t be k n e e ; w h i l e t h e p a t i e n t a c t i v e l y stretc h e s t h e j o i n t t h e t h e rap i s t d e l i v e rs a s l i g h t The

knee j o i n t c a n b e

te c h n i q ues

,

'

The k n ee j o i nt Th e tech n iq u e of e x a m i n a t i o n a n d r e s t o r a t i o n of j o i n t p l a y begi n s w i t h t h e p a t e l l a : w i t h t h e l e g e x t e n d e d a n d t h e q u a d r i c e ps m u s c l e re l a x e d , t h e

p a t e l l a should b e fr e e l y m o b i le a g a i n s t t h e fe m ur i n a l l d i re c t i o n s If t h e re is rest rict i o n , t h e r e i s no re a l .

Figure tibia

'

6.22 M o h i l i z a t i o n o f t h e fi b u l a r h e a d a ga i n s t t h e Figure

,

6.23 K nee traction w i t h t h e p a t i e n t pro n e

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Manipulalive Therapy

Figure 6.24 L a t e ra l

in Rehabilitation of the Locomotor

springing (gappi ng) of the k nee joint

t h rust a t t h e k n ee joint, with his ha n d , i n a m e d i a l or l a te r a l d i rection w h i le fi x i n g t h e h e e l w i t h h i s other hand. A s w i t h t h e e l bow, i t is i mporta n t t h a t t h e t h e ra p i s t s h o u l d s t a n d a t the l e v e l o f the k n e e , so that the hand that s prin gs the j o i n t is s u pported by the move m e n t of the trunk; the h a n d t h a t grasps the h e e l is t h e re fo r fixation only, a n d should never deliver a thrust.

The hip j o i nt T h i s j o i n t , as an a l most idea l b a l l -a n d -socket joint, h ardly a l l ows s h ifting m o ve m e n t . I t here fore o n l y descri be tract i o n tech n i q ues he re ; t h e y are t h e most i m p orta n t a n d t h e most e ffec t i v e . Traction m a y be carried out e i t h e r a l ong the l o n g a x i s o f the leg, or i n t h e d i rection o f the fe m oral neck. In the fo rmer case ( Fi g u re 6 . 2 5 ) , t h e p a t i e n t i s s u p i n e w i t h a strap fi x i n g the p e l v i s . The t h e r a p i s t s t a n d s a t the foot o f the t a b l e ; a stra p pass i n g rou n d h i s w a i s t is fas tened r o u n d t h e p a t ie n t ' s l e g above the a n k le . W i t h both hands on this strap, the t h erapis t t akes u p the sla c k b y very sl ight tracti o n , t h e leg b e i n g in 1 0 d egre es a b d uctio n , flexion a nd ro t a t i o n at t h e h i p j o i n t . W h e n he fe els that the

Figure 6.25 Trac t i o n of t h e h i p j o i n t a l o ng the l o n g � x i s s t r a p ; ( b ) a p p l y i n g the s e c o n d s t r a p

of

System

p a t i e n t has re laxed h e de l i vers a h igh-veloc i ty th rust b y p u l l i n g sudd e n l y with both h a nds a n d t r u n k , thus p u l l i n g the femora l head sl ightly out of t h e socke t . (This mov e m e n t i s o n l y of a fe w m i ll i m etres , a s v i s u a l ized b y X-ra y . ) W h e n traction is re leased t here is a t i n y t h u d . T h e fo l lowi.n g tec h n i c a l details are i m port a n t : ( 1 ) t h e therapist s h o u ld take up the s l a c k w i t h as l i t tle force a s possi b l e , i . e . by w a i t i n g for t h e patient to re l a x or by begi n n i ng w i t h P I R ; (2) the therapist m ust not release h i s p u l l before giv i n g the t hrust; (3) h e must n o t sq ueeze the a n k l e with h i s hands. I use traction by P I R muc h m o re ofte n than this h i gh-velocity thrust. As the fo rce used in t h e former is m i n i m a l , strap p i n g is u n necessary. G rasping the p a t i e n t 's heel t h e t herapist te l l s h e r to resist tracti o n , i . e . t o p u l l up h e r l e g w i t h m i nimum force and h o l d t h i s movem e n t for a bo u t t o s . Tow a rds t h e e n d o f t h i s i s o m e t r i c p h ase the pa t i e n t should b reathe i n ; s h e i s then t o l d to ' l e t go' a n d to breathe out. A l l t h a t t h e t h e rapist now fe els i s t h a t the leg l e ngthens b y re laxation, without any fu rther p u l l . This man oeuvre is re peated t h ree to five times. For traction i n the d i rec t i o n o f the fe moral neck the pa t i e n t i s supine a n d t he bu ttock is on the edge o f the t a b l e , fo r m i n g a fu lcrum ( Figure 6 . 26 ) . The therapist sits o n a stool by the side of the table, t h e patie n t's l e g o v e r h i s s ho u l d er, wi th be nt k nee . He now grasps tbe patien t 's t h igh w i t h both h a nds, his fo rea rm in the gro i n , a n d gives a s l ig h t obliq ue pu l l i n t h e di rection o f the fe moral neck. The patient p u ts up slight res i s t a n ce by p u l l i n g t h e b e n t leg in t h e opposite d i rection, w i t h the pel vis ( i . e . in t h e di rection o f the opposite shoulde r ) . The patie n t holds t h i s resistance duri n g s l o w in h a l a t i o n , then s h e h o l d s his breath, aft e r w h i c h s h e is told to 'let go' a nd bre a t h e o u t . A ga i n , d u r i n g re l a x a tio n t h e t h igh i s fe l t t o l e n g t h e n ( g i v e ) s l i g h t l y . T h i s tech n ique is much less e ffective when passive pull only i s used. with or w i t h o u t t h rusting. The d i ffi c u l ty w i t h t h i s techn i q u e l i es i n maki ng the p a t i e n t u n derstand w h a t to do during the

the leg. using

Copyrighted Material

two

s t r a ps: ( a ) fi x a t i o n o f

the

pa t i e n t w i t h one

Th erap e l l lic lechlliques

1 73

Figure 6.26 Tra c t i o n of the h i p j o i n ! a l o n g t h e a x i s of t h e n e c k , o v e r t h e edge of t h e ta b l e

Figure 6.27 M o b i l i z a t i o n of t h e t e m p o ro m a n d i b u l a r j o i n t

isometric p h a s e , for i t is not j ust t h a t s h e h a s to flex he r h i p . She has a t the same time t o pull her hip up in a cra n i a l d i recti o n but not to flex t h e k n ee. To achieve t h i s , it is best i f the t h e ra pist d e m o n s t ra t e s this moveme n t by passively fl e x i n g t h e p a t i e n t ' s knee a n d push i ng t h e h i p u p w a r d s . O n l y w h e n the patient h a s fu l l y u n d e rstood this, c a n she d o i t a ct i v e l y . D u r i n g re l a x a t i o n i t is m o s t import a n t for the p a t i e n t to l e t t h e therapist bear the full weight of h e r l eg o n his s h o u ld e r . O n ce t h e p a t i e n t has fu l l y u n d e r stoo d a n d l e a r n e d how to do t h is , a n ybod y with w h o m t h e p a t i e n t lives or w h o is at h a n d c a n rep l ace the t h e r a p i s t as a l l h e d o e s is to h o l d h i s h a n d s i n the pa t ie n t s g r o i n . A s t h e l o w e r e x t r e m i t y i s accessi b l e to both the patie n t ' s hands, many o f t h e tech n i q ues descri bed a re u s e f u l fo r s e l f- t re a t m e n t .

a n d t h e b e n t fo re fi nger o n the c h i n , the s l a c k is t a k e n u p b y p ressu re on t h e m o l a rs from above. The patient resists t h i s pull d ur i n g exhalation and relaxes d ur i n g i n h a l a ti o n . M o s t freq u e n t l y , however, m o v e m e n t res trict i o n is d o m i n a te d by s p a s m o f t h e m a s t i catory m u scles which have to be relaxed (see Post -isometric re l a x ation, p. 211).

fe m o r a l

.

'

The temporo m a n d i b u l a r j o i nt For t re a t m e n t , l a te r o l a te r a l move m e n ts of t h e j a w are m o s t conve n i e n t , a n d aga i n PI R p r o v i d e s t h e g e n t l e s t a n d m o s t e ffect i v e tec h n i q u e ( F i g u r e 6.27 ) . T h e p a t i e n t i s se a t e d w i th h e r h e a d tu rned to o n e side; t h e therapist stands b e h i n d h e r , s t a b i l izing t h e pati e n t 's head aga i ns t h i s ow n chest. The p a t i e n t i s told to o p e n h e r m o u t h , i . e . to let h e r c h i n d r o p ; t h e t hera p i s t cradles the m a n d i ble from the side, betwe e n t w o fi n ge rs , m o v i n g i t t o t h e opposite s i d e , towards his chest. When h e has ta k e n up the slack h e a s k s the pa t i e n t to breathe o u t d u r i ng the isom e t ric p hase a n d i n d u r i n g re l a x a t i o n (see p . 29). D u ri n g re lax ation t h e ma n d i b l e moves i n the d i re c t i o n o f t h e a ffected j o i n t . The proce d u re i s r e pea t e d t h ree to fi v e times. A g oo d a l ternative is s i m p l e tract i o n . With a t h u m b on the m o l a rs on each side of t he ma n d i bl e , ,

T h e sp i n a l c o l u m n The p r i n c i p l e s set o u t a t t h e begi n n i n g o f t h i s c h a p t e r a l s o h o l d fo r t h e spi n a l col u m n . There a re , however, s o m e s p e c i fi c tech n ic a l p o i n t s t o b e d e a l t w i t h ; for i n s t a n ce , i t is obviously more d i fficu l t t o m o v e a s i ngle m o b i l e segm e n t t h a n a s i ngle extre m i ty j o i n t . F u r t h e r m o r e , i t is more d i ffi c u l t to d i s t i n g u i s h j o i n t p l a y f r o m functi o n a l move m e n t i n t h e s p i n a l col u m n . A s i t i s n o t possible to m ove a s i ngle segm e n t acti v e l y , passive m o v e m e n t repres e n t s a s it w e re j o i n t play. This d i fficu l t y appJies particu l a rly t o s hif t i n g tec h n i q ues, a n d less to d i stracti o n . Tech n iques that p rod uce ga p p i n g t h us c l e a rl y use j o i n t p l a y for t h e i r e ffe ct, ( e . g . rota t i o n i n t h e l u m b a r s p i n e , d o r s ov e n t r a l t h rusts i n t h e t horacic s p i n e ) . Because of t h i s r e l a t i v e d i ffi c u l ty in m o v i n g s i ngle joints we d is t i ng u i s h specific a n d n o n -specific tech n iques. There a re several w a y s o f a c h i e v i n g a specific effect: the ideal w a y , a l t hough n o t a l ways practicab l e , is d i rect fi x a ti o n of a t l e a s t o n e p a r t n e r ( t h i s c a n a l ways b e d o n e i n a n e x t re m i ty join t ) . A n other w a y is to a p p l y ' locking' tech n i q ue s i f l e v e rage is u se d ; t h i s i s t o gre a t a d v a n t a g e , for exa m p l e , w h e n moving t h e head i n o r d e r to m a n i p u l a te the c e rv i c a l s p i n e , or t h e legs a n d pelvis i n order to m o b i l ize t h e l u m b a r

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Munipululive Th erapy

ill

Rehabili/alion of Ihe

Locom olOl' Syslem

such a t ec h n i que speci fic we m u s t the segm e n ts e x c e p t for the o n e we w i s h t o m a n i p u l a te . T h e p r i n ci p le of ' l oc k i n g ' consists of b ri ngi ng i n to an ex t r e m e p o s i t i o n the s e g m e n t s w e do not move, u n d e r a cert a i n degree o f te n s i o n . The me c h a n i s m is e i t h e r a pp o s i t i o n of bony s tr u c t u res or tension of l i ga m e n t s . Even h e r e , h ow e v e r . we have to t a k e u p the s l a c k to m a ke a n y type o f m a n i p u l a t i o n e ffec t i v e . I t c a n t h us be s e e n t h a t t h e ' lo c k i ng' i s o n l y rel a t i v e , a n d i f leverage i s forc e f u l , treatm e n t w i l l never be speci fic. Leverage i s , of course, very a d v a n t ageous, but i t m u s t b e a p p l i e d w i t h v e ry l i t t l e force t o make l ock i n g tech n i q ues e ffe c t i v e . I t i s , t h e r e fore, p r e fe ra b l e to rely

s p i n e . To

ma ke

try to ' l o c k ' a l l

on fi x a t i o n rat h e r t h a n on l o c k i ng. Loc k i n g i s a c h i eved m a i n ly by a carefu l combi n a t i o n of s i d e - bend i n g and rot a t i o n , m a k i n g use of coupled m o v e m e n t s . L o r d os i s i n t h e l u m b a r s p i n e m e a n s th a t t h e re is s i d e - be nd i n g coup l e d w i t h rot a t i o n i n t h e o pp os i t e d i rect i o n ; he nce we ach ieve l oc k i n g by r o t a t i on a n d s i d e - b e n d i n g in the s a m e d i rection . I n k y p ho s i s t h e o p p o sit e i s t r u e . and we t h e re f o r e h a v e t o co m b i n e s i d e - b e n d i n g a n d rotation i n t h e o p p os i t e d irect i o n . In t h e th oracic spine, s i d e b e n d i n g i s a l w ays co u p l e d w i t h rot a t i o n t o t h e op p o s i t e s i d e ( i n s c o l i o s i s , r o t a t i on is a l w a y s to t h e s a m e s i d e ) a n d therefore l oc k i n g e n t a i ls s ide-ben d i n g a n d rota t i o n t o t h e same s i d e . I n t he cerv i c a l s p i ne there is a l wa y s s i d e - b e n d i n g a nd r o t a t ion to t h e s a m e side, a n d h ere we a c h i e ve l ock i n g by s i d e b e n d i n g and ro t a t i o n t o t h e o p p o s i te s i d e . A n o b v i o u s way of a c h i e v i n g so m e deg r e e of s p ec i fi c i t y i s by d i rect contact. C l e a r l y , a v e r te b r a m a y be fi x e d by d irect contact i n a t l e a s t one d i rection: for i n stance, by fi x a tion of a sp i no u s process from t h e side w e p r e v e n t rotati o n of that vertebra i n t h e o p p o s i te direction . If we exert p r ess u r e , s p ri n g a v e r te b r a o r a p p l y a t h r u s t , som e of t h e force w i ll be e ffec t i v e a t t h e site w h e r e it i s a p p l ied . Indeed, c h i ro p r a c t o r s b e l i eve t h a t a h i gh v e l oc i t y thrust a pp l i e d w i t h s u fficie n t e n e rgy acts l i k e a h a m mer o n a n u ncemen ted b r i c k wa l l , throw i n g one brick out and leaving all t h e rest i n p l a c e . To achieve t h e m a x i m u m s p e c i fi c e ffec t , a combi nation of l everage a n d locking t ech n i q u e s w i t h d i rect contact and fixation i s most com m o n l y u s e d . How e v e r a d v a n t a g e ous t hese tec h n i q ue s , t h e y a re e ffect i v e o n l y i f l e v e rage a nd lock i n g a r e a p p l i e d e x a c t l y to the site w h e re t h e oth e r h a n d m a ke s co n t a c t . From t h i s it w o u l d a p p e a r ob v i o u s t h a t the h a n d t h a t m a k e s con t a c t fi x e s o r m o v e s the v e r t e b r a in a d i r e c t i o n opposed to t h e d i recti on of le ve rage a p p l i e d by the o t h e r h a n d . T h i s i s u s u a l l y true, b u t t h e re are certa i n t e c h n i q u e s i n w h i c h both h a nds move in t h e s a m e d i rectio n , a s a single fo rc e , t h e segme n t b e l. ow the treated v e rtebra b e i n g fi xed b y p o si tion i n g ( e . g . the pelv i s fi x e d by t h e pa t i e n t s i t t i n g a s t r i d e t h e ta b l e ) . T h i s type of tec h n i q u e g iv e s consi d e rable leverage, a n d m ust d e pe n d m a i n l y o n

loc k i n g . I t i s u s e d m o s t fre q u e n t l y i n p u re t r a c t i o n tech n i q u e s w h i c h , a l t hough t h ey a re w i t h o u t ri s k and a re ce r t a i n l y effec t ive , are o f doubtfu l spec i fi c e ffect u n less very gen t l y a p p l i e d . Th e r e a re a l s o n o n -s p e c i fi c t e c h n i q u e s t h a t c a n be u s e f u l in m ob i l i z i n g l o n g e r sect ions of t he s p i n a l c o lu m n . S u c h a

g e n e r a lly

n o n - s p e c i fi c

but widely

u s e d tec h n i q u e is t h a t o f traction a l ong the l o n g a x is of t h e s p i n e . I t s i m p o r t a nc e a n d i n d ica t i o n h a v e b e e n d iscussed i n C h a p t e r 5 ( p . 1 5 0 ) . I n o r d e r to a v o i d c o n f u s i o n i t is i m po r t a n t to d istinguish between trClction a lo n g t h e l o n g axis o f t h e s p i n a l col u m n a n d d istrac t i o n of i n te rverte b r a l j o i n ts . T h i s d i s t i nc t i o n is c l e a re s t i n t h e l u m b a r r e g i on , wh e r e t ra c t i o n a lon g t h e l o n g ax is acts on t h e i n te rvertebral d i scs, w h e re a s d i straction o f th e a po p h ys e a l joi n ts is p rod u ced by r o t a t i o n ro u n d t hat sam e a x i s . I n t h e cervica l spi n e , on t h e o t h e r h a n d , t ra c t i o n a l o n g t h e l o n g a x i s a llects t h e d i scs a n d t h e j o i n ts.

The lu mbar spi n e

Traction tech n i q ues I n te r m i t te n t m a n u a l traction is t h e most i m p or t a n t o f t hese m e t hods. I f t h e p a t i e n t c a n l i e p r o n e i t i s b e s t i f sh e p rovide s h e r o w n fi x a t i on b y h o l d i n g o n t o t h e e n d o f t h e t a b l e . T h e t h e rapist grasps b o t h t h e p a t i e n t ' s l eg s j u s t a b o v e t h e a n k l e , a n d w i t h slight traction m a k e s s u re t h a t s h e i s c o m p l e t e l y re l ax e d . He m ust t h e n e s t a b l i s h t h e cor re c t r h y t h m o f t r a c t io n , i n order to l ocal ize t he e ff ec t i n t h e low b a c k . I f t h e rh y t h m is too slow, t h e patie n t ' s w h o l e body w i l l m o v e sl i g h t l y , up a n d dow n , on t h e t a b l e . B y q u i c k e n i n g t h e r h y t h m t h e t h e r a p i s t w i l l fi n d a t w h ic h poi n t o n l y t h e legs a n d p e l v is m o v e w h i l e t h e l o w back re m a i ns s t i l l , l i k e a n o d a l poi n t i n a s t a n d i n g wave. W h e n t h i s rhy t h m h a s bee n fo u n d , t h e p a t i e n t fee l s t h e i n t e r m i t te n t t ra c t ion exactly i n t h e l o w b a c k . Th i s s h o u l d b e d o ne w i t h l i t t l e force . b u t once t h e r hy t h m is e s ta b l i sh e d e a c h p u l l m a y be re i n fo rced a n d occasion a l l y som e t h i n g l i k e a t h r u s t d e l i ve red. I t can be a l so v e r y use fu l t o a p p l y r h y t h m i c t ract i o n by o n e l eg o n l y , i f t he p a t i e n t fe e l s re l i ef. O b v i o u s l y t h i s m e t hod i m p l i es m a n ua l tra c t i o n o n l y . The t h e r a p i s t must avoid s q u e e z i n g t h e l e gs a bove th e a n k l e . I f t h e p a t i e n t ca n n o t s t re tch o u t , a s i s o ft e n t h e c a s e in t h e a c u t e s t a ge . i n te r m i t t e n t t ract i o n is c a rr i e d o u t i n kyphosis (Figu re 6.280 ) . For t h i s the p a t i e n t l i es on her b a c k with her l eg s bent a t the h i p a n d k n e e . I f t h e t a b l e i s a d j u s ta b l e i t s h o u l d be a s l ow as possi b l e . T h e t h e r a p i s t s t a n d s a t t h e s i d e o f t h e t a b l e , h i s foot o n i t , s o a s t o h a v e h is k n e e a n d t h i g h u n d e r the pa t i e n t ' s rl e x e d knees. u s i n g h e r l e gs as a l e v e r . Exe r t i n g pressure on t h e p a t i e n t ' s a n kl e s fr o m a bove. h e l i fts t h e p a t i e n t ' s p e l v i s w i t h a

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Therap eutic techniques

t h a t s h e is r e l a x e d w i t h her b u t t ocks clea r o f t h e tab l e . By i n c re a s i n g a n d loweri n g t h e pressure u p o n t h e a n k les i n te rm i tt e n t traction i n k y p h osis is a c h i e ved ( a t a rh y t h m o f about two p e r second ) . Obvious l y this t e ch n i q u e wo r k s o n l y i f t h e t h e r a p i s t s l ow e r l e g is l o nger t h a n the p a t i e n t ' s thighs; i t i s usua l l y necessary f o r h i m to kee p h is shoe o n , a n d pe r h a p s p l a c e a l i t t l e board u nd e r t h e foo t . As i n t h e a c u t e s t age o f l u mb ago a n d r o o t pai n , ky phosis i s fre q u e n t l y t h e r e l ie f positi o n ; i f w e l l to l e ra ted , t h i s t ec h n i q u e p l a y s t h e ro le o f fi rst a i d . T h e r e a re t w o v e r y e ffe c t i v e a n d ge n t l e traction m e t h o d s t h a t m a k e u s e o f PIR. For t h e fi rst th e p a t ie n t l i es p ro n e ( Figure 6.28b ) , w i t h h e r h e a d ne a r roc k i n g m o t i o n , m a k i n g s u r e

'

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to the e n d o f the t a b l e . The t h e r a p ist s t a nds at t h e head o f t h e table and p u t s t h e h e e l of h i s h a n d s o n t h e p a t i e n t ' s b u t tocks from above. He tells t h e patien t to b re a t h e o u t slowly a n d d eepl y , and feels resistance i nc re a s i n g . T h e patie n t i s t h e n to l d to t a k e a s l ow , d e e p b re a t h , a n d a s s h e does s o t he b u t toc k s move down a n d t h e l u m b a r s p i n a l l o rdosis fl a t t e n s This is fo l lowed by long, deep e x h a l a t i o n a n d agai n t h e buttocks tend to move upwards. The therap i s t resists t h i s m o ve m e n t , w h i c h is fo l lowed by re l a x a t i o n or a c a u d a l m ove m e n t of t h e bu ttocks d u r i n g i n ha l a t i o n . Resistance to each u pward move m e n t o f the b u ttocks d u r i ng e x h a la t i o n i ncreases t h e i n t e nsity o f t h e tracti o n . This resist a nce i s even more e ffective if i n te r m i t t e nt. As a n a lte r n a t i v e : the t h e ra p ist s ta n d s a t the side of t h e patient and prod uces traction with his crossed h a n d s , one over the low thoracic spine and the o t h e r on the sacru m . For traction w i t h P I R i n k y p hosis t h e p a t i e n t i s prone ove r t h e e n d o f t h e tabl e , h e r legs h a n g i n g down from t h e h i ps ; t h e t a b l e should be h i g h e nough fo r t h e fee t to be clear of the floor; i f t h e fee t d o t o u c h t h e floor, t h e l e g s must s ti l l h a n g re l a x e d . T h e t h e rapist s t a n d s a t t h e s i d e of the p a t i e n t ' s low back. placing t h e h e e l o f o n e o f h i s c ro ssed h a nds o n the sacrum ( from above ) a n d t h e other from b e low o n t he sp i n ous p rocess o f a l umbar v e rtebra , accord i ng to t h e s i t e w h e re t ract i on is req u i red . H e now te l l s t h e p a t i e n t to give s l ig h t re s i s t a n c e to t h e traction h e a p p l i e s by a s l i g h t p u s h on t h e sacr u m , i n a cauda l directi o n , a n d with the oth e r h an d in a cranial d irecti o n . The patient is told to breathe o u t s l o w l y a n d t h e n to ' l e t go' a n d bre a the i n . T h i s tec h n i q u e c a n b e u s e d for se l f-tre a t m e n t , t h e p a t i e n t ra i s i ng h e r b u ttoc k s w h i l e breat h i ng o u t , a n d d ro pp i n g ( re l a xi ng) t h e m whi le bre a thing i n . Th e effect of .

,

( a)

( b) Figure 6.28 (a) Tract i o n of t h e l u m b a r s p i n e i n k y p h os i s ( s u p i n e ) . ( 0 ) I s o m e t r i c tract i o n of t h e l u m b a r s pi n e (pro n e ) : l e f t . i n creased re s i s t a nce d u r i n g ex h a l a t i o n ; r i g h t . t he b u t tocks m o v e i n a c a ud a l d i r e c t i o n d u r i n g i n h a l a t i o n

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Manipulative Th erapy i n Rehah ilitation of t h e Locomotor Syslel11

e x h a l a t i o n i s , however, m u c h less i n t e nse i n l um b a r kyp hosis t h e n i n t h e prone lord o t i c positio n . T h e re a re m a n y wel l - k nown methods o f traction pe r formed on spec i a l tables, i nc l u d i n g i n te r m i t te n t tracti o n , b u t n o n e c a n compete w i t h m a n u a l t raction by a s k i l l e d therapist. There is one pri nciple that m u s t be stress e d , h owever, both in man u a l a nd especi a l l y i n ta b l e tractio n : it must not be p a i n f u l. I f t h e p a t i e n t fee l s d iscomfort, t h e t he r a p i s t m u s t fi n d a pos i t i o n i n w h i c h t ra c t i o n i s we l l tole r a t e d , or e l se a b a n d o n it. Pa i n d u ri ng traction i s freq u e n t l y due to b l o c k a ge in the l u m b a r s p i n e or t h e sacroi l i a c j o i nts; t h i s c a l l s fo r tre a t m e n t .

M a n i p u lati o n I n m a n i p u l a t i o n i t i s useful t o b e g i n by u s i n g t h e s p r i ngi ng tech n i q u e described fo r the examina t i o n o f retrofl e x i o n i n i n d i v i d u a l m o b i l e segm e n ts (see pp. 1 02-1 03). T h e patie n t l i es with b o th h i ps and knees flexed. The t h e r a p i s t l e a n s his thigh a g a i n s t t h e pati e n t ' s k n ee s , fixing the s p i n o u s process o f the upper verte bra of the treated segme n t w i t h one fi n ger, re i n forced by the fi n ge rs of the other h a nd p l aced over it. H e now tells t h e p a t i e n t to p ress her k n e e s s l ightly agai nst t h e t h e rapist's t h igh (but not s o h a rd as t o p u s h him a w a y ) a n d to breathe i n a n d then t o h o l d h e r breath. A t t h e e n d o f t h i s isometric phase the p a t i e n t is told to ' l e t go' and bre a t h e out. W h i l e the p a t i e n t relaxes t h e t h e ra p i s t has the i m pressi on th a t the h a n d s on the s p i nous process a re s i n k i ng i n to a hoUow, as the m o b i .l i zed spi n a l segme n t moves i n to lordosis. T h e proce d u re i s re peated from t h is posi t i o n , a bo u t th ree t i m e s (see Figu re 4 . 1 6 , p . 103). The most popu l a r m a n i p u l a t i ve tec h n ique is p rob ably that o f ro t a tio n , with t h e pa t i e n t lying on her

side (Fig u re 6.29). S h e should be i n a ' n e u t ra l ' posi t i o n , i . e . n e i t h e r i n fl e x i o n n o r e x te nsi o n . The leg t h a t lies o n the table is not fu l l y e x t e n ded w h i le the o t h e r is b e n t a t the h i p a n d k n e e , so t h a t the foot i s fixed by the s l i g h t l y ben t k ne e o n t h e t a b l e ; t h e o t h e r k n e e is b e n t a n d p roj ects over t h e e d g e 0 1' t h e t a b le . The t he rapist stands in fro n t o f t h e p a t i e n t so as t o fi x t h e fl exed knee w i t h h i s t h igh . Passi ng h i s h a n d ove r t h e pati e n t s h ip, he fixes i t with h i s fo rearm w h i l e w i t h t h e u l n a r aspect o f the h a n d h e fixes the pa rt of t h e l u m b a r s p i n e t h a t is ca u d a l to t h e l o w e r vertebra of t h e segm e n t being treated; o ne or two fi n ge rs are used to fi x the spinous process o f t h a t ve rtebra . I n t h i s w a y h e c a n completely fix t h e l umbar s p i n e , up t o the segme n t to be t re a t ed . T h e e l bow of t he therapist's o t h e r arm l ies o n the patie n t's s h o u l d e r ( u n less the p a tie n t is much t a l l e r t h a n the th e rapist, i n w h i c h c a s e i t l i es o n t h e a r m b e l ow t h e sho u l d e r ) a n d i t i s h e l pfu l i f the p a t ie n t s l i ngs t h i s a rm rou n d t h a t o f t h e therapist. W i t h the t h u m b o f the h a n d com ing from the s h o u l.der the t h e ra pist esta blishes contact w i t h the spi nous process o f the u p per vertebra of the segme n t to be t rea ted . Obviously i f t h i s is t h e l u m bosacra l segment it i s s u fficie n t for t h e h a n d passing ove r t h e p a t i e n t ' s h i p to fi x the pelvis a lo n e . I n o r d e r to t a k e u p t h e slack it is best to tell t h e patient t o look i n the d i rect ion o f m ob i l ization ( i . e . away from the t hera p i st ) a s fa r a s he c a n a n d t o wa i t fo r c o m p l e t e rela x a t i o n a t t h e ba rr i e r . W i t h t h e pati e n t th us posi tioned , t he thera pist fixes the shou l d e r ( o r a r m ) from a bove and t e l l s the pa t i e n t to look towards h i m a n d brea t h e i n s lo w l y , a n d t o h o l d his b re a t h ; the therapist resists rotation ( i n the opposite d i rection from m o b i l iza t i o n ) . The p a t i e n t is then told to look in the d i rection o f m o b i l i z a t i o n and to breathe ou t s l ow l y . I n this way the range of rota t i o n a u tomatica l l y i ncreases, '

Figure 6.29 R o t a t i o n m o b i l i z a t i o n o r t h r u s t m a n i p u l a t i o n o f t h e l u m b a r s p i n e w i t h t h e p a t i e n t o n h e r s i d e . i n n e u t r a l pos i t i o n

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Figure 6.30 A c t ive repe t i t i v e m o b i l i z a t i o n of t h e l u m b a r s p i n e w i t h t h e p a t i e n t l y i n g on h e r s i d e

pos i tion is r each e d a n d fixed by t h e p ro c e d u re i s repe a ted a bo u t th ree t i mes. Q u i te freq u e n t ly a spontaneous ' c l i c k ' is heard d u ri n g re l a x a t i o n . W h e n the s l ac k i s ta k e n u p ( a n d end-position is re a ched ) , h e m a y m a k e a n a d d i t i o n a l t h r u s t aga i nst t h e s h o u l d e r. Th i s is a fu l l y a u toma t i c m o b i l i za t i o n t e c h ni q ue , t h e p a t i e n t res i s t i n g w h i l e l ooking towards t h e t h e ra pist and b rea t h i n g in, a n d re l a x i n g when l o o k i n g a w a y from h i m a n d brea t h i ng o u t . I t s h o u l d b e t h e basic tec h n i q ue u s e d i n ex te nsion restrict i o n . I t prod uces ga p p i n g o f t h e u p p e r i n te rvertebra l j o i n t a n d c a n b e used through o u t t he l u m b a r s p i n e a n d e v e n a t t h e t h or a colu m b a r j uncti o n . A repeti t ive tec h n i q u e from t h e e x tr e m e pos i t i o n re a c h e d by r e l a x a t i o n ca n b e u s e d , as a mod i fica t i o n . With h i s h a n d over t h e pa t ie n t s b u t t ocks to m a i n tain fi x a t i o n , the thera pist te l l s h e r to t u rn t o a n d fro ; h e may ev e n rei n fo rce t h e fi x i n g h a nd by t h e other ( F i gu r e 6 . 30) . T h e o t h e r te c h n i q u e o f si m i l a r i m p orta n c e i s mo b i l i z a t i o n i n fl e x i o n ( fo r fl e x i o n r e s t r i c t i o n , F i g u r e 6 . 3 1 ) . The p a tien t a ga i n l i es o n her sid e , b u t in a somewhat k y p h o t i c posi t i o n , th e l eg on t h e t a b l e fl e x e d a t t h e h i p a n d k nee. T h e o t h e r ( u pper) l e g h a ngs ove r the e dge of t h e t a b l e (exce p t w h e re t h e s t ra i g h t l eg ra i s i ng test is h i g h l y posi tive, i n w h i c h case s h e b e n d s t he leg so as to fix t h e foot a t t h e k n ee o f t h e low e r l i m b ) . T h e t he r a pis t fi r s t fixes t h e p e lv i s i n a n obliq ue pos i t i o n , i . e . not pe r pe n d i c u l ar to t h e table b u t ti l t e d forwa rd so t h a t t h e w e i g h t of t h e h a n gi n g leg e n h a nces k y p hosis. The t h e rapist uses h i s other h a n d to p u l l fo rwa rd t h e a r m o n w hi c h the pati e n t i s l yi ng, s o as t o i ncrease kyp hosis s ti l l furt h e r. Th i s m u s t b e done w i t h great ca re, s o a s not to stra i ghten t h e pel v is, i.e. not to re t u rn i t to t h e perpe n d i c u l a r . T h is pos i ti o n is e ss e n tia l for the success o f the tec h n i q u e . a nd

it

new

t h e ra p i s t . T h e

'

The therapist fixes the pa t i e n t s l e g w i t h h i s th igh , pass i n g h is fore a r m over the h i p , the h a n d p o i n ti n g i n the d i rection o f t h e c a u d a l ve rtebra o f the segm e n t to be treated. With t h e e lbow of t h e other arm against the p atie n t s shoulder, the the rapist te l l s t h e patient t o look t o t h e ce i l ing i n ord e r to obta i n rotati on of the trunk away from h i mself, to take u p the s la c k . The t h u m b of t h e h a n d over the shoulder fixes t h e spinous p rocess of the u pper v e r te b ra fr o m a bo v e , by a downward p ul l with t h e d istal p h a l a n x of t he t h u m b . Aga i n , i f t h e t h era p i st is not t a l l , i t i s better for t h e p a t ie n t to sling h e r a rm rou n d t h e t h e ra p ist's, so t h a t t h e therapist can exert pressu re a g a i n s t t he patien t ' s a r m below the s h o u lder. I n t h i s posi t io n t h e patient is told to p ress h e r hip s l igh tly aga i n s t the th e r a p i s t ' s hand so a s to l i ft both hip a n d leg, a n d t o hold t h is press u re fo r about 10 s, w h i l e b rea t h i n g i n a n d to h o l d her breath. She is then t o l d to ' let g o ' a n d b rea th e o u t and , as she re l a x e s , the h a n g i n g leg a n d h ip '

'

Figure 6.31 M o b i l i z a t i o n or thrust m a n i p u l a t i o n of t b e l u m ba r s p i n e w i t h t h e p a t i e n t o n h e r s i d e i n k y p h o s i s , t h e l o w e r l e g be n t a n d t h e u p pe r h a n g ing d o w n ov e r t h e e d g e of t h e

table

Copyrighted Material

1 7R

Manip ll iarive Th erapy

il1 Rehab iliriltion of rh e LocomOlOr System

produce fu r t h e r hip rota t i o n a n d l u m b a r k y p h o s i s , a n d t h e t h era p i s t c a n fe e l t h e d i s t a n ce between his

b a r r i e r is re a c h e d b e t w e e n t h e s o ft t i s s u e s a n d b o n e . The m o s t se r i o u s m i s t a ke i s t o i ncrease p re s s u r e

h a n d s i n c r e a s i n g . Th i s p rocedure ca n be re peated

b e fore a n y m o v e m e n t h a s b e e n fe l t . A p p a r e n t l y , i t

th re e to five times. If the slack has b e e n taken u p , th e

i s t h e r e l e ase o f press u re I h ilt m a k e s t h e j o i n t s p r i ng.

h a n d on t h e p a ti e n t 's h i p may a ls o give a t h r u s t i n t h e sa m e d i recti o n . I n every case, t h e t h u m b o n the s p i n o u s p rocess m llst m a i n t a i n fi x a t i o n . How t llis te c h n i q u e ca n a l s o b e u s e d fo r m u sc u l a r re l a x a t i o n a n d s e l f- t re a t m e n t i s d escri bed l a te r i n t h i s c h a p te r s t retch i n g .

(see

F i g u re

6.115),

a l so

it

se rves

The t e c h n i q u e p r o d u c e s s o m e d e g r e e of rota t i o n a n d ga p p i n g o f t h e j o i n ts a n d e ffec t s tra c t i o n w i t h a n t e f1 e x i o n a nd gre a t m uscu l a r re l a x a t i o n . Fo r t h i s r e a s o n i t i s a d v is a b l e to u s e t h i s fl e x i o n tech n i q u e i n d is c l e s i o n . f o r both fl e x i o n o r e x t e n s i o n re s t r i c t i o n o n t h e p a i n fu l s i d e .

There a r e v e ry m a n y o t h e r t e c h n i q u e s i n u s e , p a r t i c u l a r l y t h ru s t i n g m a n i p u l a t i o n i n a dorsov e n t ra l d i re c t i o n w i t h the p a t i e n t pron e o r o n h e r s i d e , b u t t h e y d o n o t s e e m t o m e to be of s u c h v a l u e as to b e worth descri b i n g h e r e .

The pelvis T h e o n ly j oi n t t h a t i s t r e a ted by m a ni p u l a t i o n i s t h e sacroi l i a c . F o r m o b i l iza t i o n , excel l e n t r e s u l t s ca n b e a c h i e ve d w i th mov e m e n ts i n t w o a l m o s t p e rpe n d ic u l a r p l a n e s , the s a g i tta l ( n u t a t i o n of the s a c r u m in re l a t i o n

to

the

innominate)

and

the

h o rizon t a l

( g a p p i n g t h e d o rs a l p a r t o f t h e sacroi l i a c j o i n t by

( b)

spr i n g i n g the i l i u m a g a i n s t the s a c r u m ) . A s t h e re a re no m u s c l e s to m o v e or fix t h e sacroi l i a c j o i n t , t h e s i m p l e p a ss i v e r e p e t i t i v e t e c h n i q u e w i t h a m i n i m u m of force is a l w a y s effe c t i v e , prov i d e d t h a t t h e r e i s n o s t r u c t u r a l c h a n g e p re s e n t . F o r m o b i l i z a t i o n i n t h e s a g i t t a l pla n e , t h e p a ti e n t i s pron e , w h i l e t h e t h e r a p i s t s t a n d s a t t h e s i d e o f t h e t a b l e , faci n g t h e p a t i e n t ' s p e l v i s , a n d w i t h crossed h a n d s p l a c e s o n e p i s i form on t h e pos t e r i o r s u p e ri o r i l i a c s p i n e from b e l o w , a n d t h e o th e r on t h e c a u d a l e n d o f t h e sac r u m ( F i g u re 6.320 ) . With s l i g h t p ress u re he t a k e s up the s l a c k a n d ca n n o w s p r i n g t h e j o i n t n o t s o m u c h b y press i n g b i s h a n d s d o w n w a rd s a s by s e p a ra ting t h e m , aga i n w i t h v e ry l i t t l e forc e . It i s m o s t i m porta n t t h a t a ft e r s l i g h t l y

i n c r e a si n g h i s

p re s s u r e t h e t h e r a p ist r e l e a s e s i t , e v e n i f a t fi r s t t h e re is no r e s p o n s e i n t h e b l ocked j o i n t . A fter a b o u t five

repe t i t i o n s w i t h n o i n cr e a s e i n fo rce h e s h o u l d b e g i n to s e n s e m o v e m e n t , a n d m o b i l ity i s u s u a l l y restored to n o rm a l a ft e r about 15 r e p e t i t i o n s . T h e tec h n i q u e s h o u l d be perfor m e d a t o n e o r t w o moves t o t h e seco n d . The fo l l o w i n g p o i n ts a r e i m po rt a n t : t h e p i s i fo r m m o v i n g t h e s a c r u m m u s t be a t t h e c a u d a l e n d , j u s t a bove t h e coccy x , o t h e rwise t h e l e v e r i s too s h o r t ; and t a k i n g up the slack i m p li e s bony con tact - t h e t h era p ist m u s t mov e b o n e . not s k i n . There fore I1 rs t t h e s o f t t i ss u e s a re very s l i g h t l y s h i ft e d u n t i l a

( c)

Figure 6.32 ( a ) M o b i l i z a t i o n of the s a c r o i l i 8 c j o i n t . w i t h c r o s s e d h a n d s ( a l so u s e d for e x a m i n a t i o n ) . ( h l M o b i l iza t i o n o f the upper pari o f the s a c r o i l i a c j o i n t . ( c ) M o b i l i za t i o n o f t h e l o w e r p a ri o f t h e sacro i l i a c joint

Copyrighted Material

Th erapelllic Icc!Jniqllcs For mo b i l i z a t i o n i n t h e h o r i z o n t a l p l a n e , a diag n o s tic tech n i q u e ( see F ig u r e 4 . 1 0 , p. 98) c a n be use d , w i t h the pa t i e n t l y i n g on h e r s i d e . Once a ga i n , a l l I h a ve s a i d a bo u t a p p l y i n g m i n i m um pressu re a n d the i m po r t a n c e o f r e l e a si ng i t i s v a l i d . Th e r e i s o n e i m po r t a n t det a i l to be b o r n e i n m i n d : a l t h o u g h t h e therapist m ov e s t h e a n t e r i o r s u p e r i o r i l i a c s p i n e , h e m u s t n o t r o t a t e t h e pe l v i s , b u t s h o u l d only p r od uc e gapp i n g o f t he posterior p a r t of t h e sacro i l i ac j o i n t; t h e p a t i e n t 's upper or bot h be n t k n ee s m u s t l i e o n t h e t a b l e , a n d t h e t h e ra pist must th e r e fo r e p u s h the i l i a c spine d o w n w a rds a n d b a c k w a rds with h i s fo r e a r m o b l i q u e l y po i n t i n g ( a n d s l i d i n g ) i n a ve n t r o cra n iomedial d i recti o n . U s i ng t h i s tech n i q u e h e m a y a lso a p p l y a t h r u s t a ft e r ta k i n g u p t h e s l a c k . I f t h e upper p a r t of the s a c r o i l i a c o n l y is i n volve d , t h i s s t r u c t u re i s m o s t e ffe c t i v e l y t re a t e d w i t h t h e p a t i e n t l y i n g o n t h e o t h e r s i d e , t h e l ower leg s l i gh t l y b e n t . t h e u p p e r k n ee ( or b o t h b e n t k n e e s ) o n t h e t a b l e . T h e t h e r a p i s t s i ts below t h e p a ti e n t ' s bu t t o c k s , fa c i n g h e r h e a d : w i t h one h a n d he e xe r ts press u re aga i n s t t h e a n t e r i o r s u p e r i o r s p i n e i n a d or s a l d i re c t i o n , t h e t h u m b o f h i s o t h e r h a n d prod u c i n g co u n t er-press u re o n t h e b a s e o f t h e s a c r u m , j u s t b e l o w t h e p o s t e r i o r s u pe r ior sp i n e , i n a v e n t r a l d i rec t io n , r h y t h m i c a l l y sp r i n g i n g t h e i l i u m a ga i n s t t he s ac r u m ( Fi g u re 6.32b ) . I f i t i s m a i n ly t h e lo we r e n d o f t h e sacru m w hich is i n v o l ved , t h e p a t i e n t l ies i n the s a m e p o s i t i o n b u t t h e t h e ra p i s t s i ts a b ove h e r p e l v is. W i t h o n e h a n d h e g r asp s t h e s u p e r i o r i l i ac s p i n e a n d w i t h t h e u l nar a spect or the other h a nd h e m a kes c o n t a c t a t the c a u d a l e n d of t h e s a c r u m ; r o t a t i n g b o t h h a n d s i n oppos i te d i r e c t i o n s h e p roduces n u ta t i o n o f the s a c r u m agai nst the i l i u m ( F i g u re 6.32c ) . K u b i s ( 1 970) h a s described a no t h e r thrust t e c h n i q u e i n t h e s a g i t t a l p l a n e (Figure 0 . 33 ) . T h e p a t i e n t l i es o n h e r s i d e , o n e i c g o n t h e t a b l e s t r e t c h e d a n d t h e o t h e r be n t a t h i p a nd k n e e , w i t h t h e foo t stabi l ized b y t h e k n e e b e n e a t h i t . T h e t h e r a pi s t s t a n d s a t

Figllre 6.33

Thrusting tech nique i n

a

179

t h e side o f t h e t a b l e , f a c i n g the p a tien t ' s pelvis, and fi x e s t h e k n ee with his th igh w h i le r o t a t i n g t h e sh o u l d e r a w a y fro m h i m s e l f . H e now m a kes contact with h i s p i s i fo r m (or th e fi rst p h a l a n x o f the b e n t fo r e fi n g e r ) press i n g o n th e caudal t i p of the sacru m , to t a ke u p t h e s l a c k i n a d o rsove n t ra l d i rec t i o n , a n d d e l i v e r s a t h r us t i n t h e same d i re ct i o n . Th e re a re two i m p o r t a n t t e c h n i c a l p o i n ts to be n o t ed: t he thera pist's fo r ea r m de l i v e r i n g the t h r u s t must l ie i n t h e d i re c t i o n of the t h r u s t , w h ich means that h e m us t bend over t h e p a t i e n t ; a n d p e l v i c rota t i o n m u s t b e a v o i d e d , t h e t h ru s t b e i ng o n l y dorsove n t r a l . T h i s tech n iq u e produces a n a n te ri o r sh ift o f t h e e n d of t h e sacrum aga i n s t t h e i l i um which i s fi x e d beca use the patie n t i s lying o n it; the re s u l t is a move m e n t of n u tation rou n d a fro n t a l a x i s a t S2, a c tin g o n t h e j o i n t on the side o n wh i ch t h e p a t ie n t is l y i ng. For tre a t m e n t of symphyse a l s h i ft we h a ve decid ed not to use ' r e po s i t i o n m a n oe u v res', as w e a r e n o w awa re o f p a l p a to ry i ll us i o n (see Figures 4 . 1 0 , 4 . 1 1 , p . 98) a n d r e l y s u ccess fu l l y o n s o ft tissu e tec h n i q u e s , i. e . mo v i n g t h e b U l t ocks (deep fasc i a e ) i n a c r a n i a l d i rect i o n , o r susta i n ed s l i g h t p ressu re a t t h e s i te o f hyperto n u s o f the b u t tocks.

I n n o m i n ate shear dysfu n ction

( G re e n m a n )

Here , w h a t c a n b e c a l l ed a ' r e p o s i t ion m a n o e u v r e ' is always very s u ccessfu l . On t h e s i d e of ' o u t fl a r e ' ( s e e p. 99 ) , i . e . w h e r e t h e a n te r i or su p e ri o r i liac sp i n e ( A S I S ) is fl a t t e r a nd m o r e l a t e r a l , t h e t h e r a p i s t adducls the t h i g h w i t h t h e hip a n d k nee be n t at rig h t angles ( s e e Fig u re 4. 1 3 ) u n t i l t h e s l a c k i s ta ke n u p . The pa t ie n t is t h e n told to e xert s l i g h t coun ter pressure i n t o a b d u c t i o n for about 10 s a fter w h i c h re l a x a t i o n i nto adduction ta kes p l a ce : t h is i s repeated two to t h r e e t i me s . T h i s ca n b e fol l o w e d b y i n ter m i t t e n t resisted add uction ( a n tago n ist i n h i b i t i o n ) . On the o p pos i te s i d e ( , i nfl a re ' ) wh ere t h e AS IS i s m o re prom i n e n t a n d med i a l , t h e s l a c k i s taken u p

dorsove n t r a l d i rect i o n , aga inst the t i p o f t h e sacrum

Copyrighted Material

( A fter Kubis, 1 970)

1 80

Manipulative Therapy in Rehab ilitation of the Locomotor System

4.41)

aga i n st t h e w a l l , h e r h e a d a g a i n s t h e r a rms . The

a n d a d d u c t i o n r e s i s t e d fo r a b o u t 1 0 s ; r e l a x a t i o n i n to

t h e r a p i s t stands b e h i n d h e r , p u t t i ng t h e heel or j us t

a d d u c t i o n fo l l ow s . T h i s is r e p e a t e d two or t h ree

a fi n ger o f o n e h a nd o n t h e s p i n o u s process o f t h e

in a b d u ct i o n l i k e in P a trick 's test ( s e e Fig u re

t i m e s , and may be fo l lo w e d b y i n te r m i tt e n t a n t a go n

c a u d a l v e r t e b r a o f t h e s t i ffest segm e n t , a n d te l l s the

ist i n h ibition.

p a t i e n t to re l a x i n t o e x t e n s i o n so as to take u p the s l a c k . The p a t i e n t then i s told to press h e r back gently aga i n s t the hand at the spinous process a n d

T h e c o ccyx

to b r e a t h e i n s l owly. A s l i g h t i n crease i n k y p h os i s

In t he m aj o r i t y of cases o f a t e n d e r coccyx , P I R of

6 . 1 23)

fo l l o ws at this stage . T h e p a t i e n t t h e n is told to h o l d

is v e r y effective,

h e r b re a t h , to s t r a i g h t e n u p aga i n a n d t o b r e a t h e o u t

and c a n be a d m i n i s t e red a s self-tre a t m e n t . I t is o n l y

a s m uch a s s h e ca n . The t h e r a p i s t u s e s j u st h i s fi nge rs

i n e x c e p t i o n a l c a s e s t h a t m a n i p U l a t i o n p e r rectum i s

t o i n d i c a t e t h e point i n to w h ich the p a t i e n t s h o u l d

t h e g l u t e i m a x i m i ( see F i g u r e

necessary; e v e n w h e n c a re fu l l y p e rform e d t h is i s

b r e a t h e o u t , w i th o u t e x e r t i n g a n y press u r e : m a x i

u n pl e a s a n t a n d e v e n p a i n fu l . I t i s a v e r y e ffec tive

m u m l o r d o s i s i s a c h i e v e d by t h e s y n k i n e t i c co n trac

te c h n i q u e , y e t t h e me c h a n i s m i s s t i l l o b s c u r e ; the

tion o f t h e p a t i e n t ' s back m u sc l e s . N o t only i s t h i s

s a crococcyge a l j u n ct i o n i s not a true j o i n t , and t h ere

tech n i q u e v e ry c o m fo r t a b l e fo r t h e p a t i e n t , b u t i t

i s no m o v e m e n t restri c t io n .

l e n ds itse l f r e a d i l y t o sel f-tre a t m e n t , a s soon a s t h e

For m a n i p u l a ti o n t h e p a t i e n t l i e s p r o n e w i t h h e r h e e l s r o t a t e d o u tw a r d s , o r is o n k n e e s a n d e l bows.

patient

has

r e a l ized

b re a t h e i n to ( F i g u re

w h ich

s e g m e n ts

6.34) . Th i s

she

m us t

te c h n i q u e , w h i c h i s

The t h e r a p i s t i n s e rts his fore fi n ger i n to the rect u m ,

n o t q u i te s p ec i fi c , is p a r t i c u l a rl y s u i te d fo r t r e a t m e n t

fi rs t asce r t a i n i n g w h e t h e r t h e l e v a t o r a n i i s n o t t e n s e

o f s t i ff th oracic k y p h o s e s . For spe c i fi c e x t e n s i o n m o b i l i z a t i o n i n t h e t h o racic

o n b o t h s i d e s ; i f i t i s , h e m u s t re l a x i t by massage o r

6.35),

P I R o f t h e g l u t e i m a x i m i w h i c h co n t r a c t a n d rel a x

spine (Figure

a t th e s a m e t i m e a s t h e l e v a t o r a n i . Th e n by m o v i n g

h e r h a n d s c l a s p e d be h i n d h e r h e a d ; t h e t h e r a p i s t

t h e coccyx h e fi nd s t h e e x a c t s ite of the sac ro

s t a n d s i n fro n t o f h e r , h is s h o u l d e r a n d u p p e r a r m

coccyge a l s y n c h r o n d rosis . H e m a y now move the

l e a n i n g a g a i n s t t h e pa t i e n t ' s e l bows, h is fore a r m

the p a t i e n t l i es o n her s i d e w i t h

coccyx in a dorsal d i rect i o n , o r s i m p l y e x e rt p r ess u re

u nder the arm lying on the t a b l e . I f the pat i e n t can

on

b r i n g h e r e l bows toge t h e r i n fro n t of h e r neck , t h e

the

sac rococcygea l

synchrondrosis

with

the

i n s e rted fi n g e r and the t h u m b o n the e n d of t h e

therapist

s a cr u m .

fore fi n g e r of h i s o t h e r h a n d is p l aced on the sp i n o u s

A ft e r two or t h ree

repe t i t i o n s h e

must

d e te r m i n e w h e t h e r t h e coccyx i s s t i l l te n d e r o r n o t .

p roce ss

may of

the

grasp them ca u d a l

with

verte b ra

one of

hand. the

The

blocked

segme n t . He n o w m o v e s t h e p a t i e n t i n to r e t r o A e x i o n ( a s a t exa mi n a t i o n ) , so a s t o t a k e u p t h e s l a c k . A t

T h e t h o ra c i c s p i n e

t h i s p o i n t h e te lls t h e p a t i e n t t o p ress h e r e l bows

H e re t h e re a re n o p u re traction t ec h n i q u e s s u c h as we

use

in

the

lumbar

and

cerv ica l

re g i o n s .

A

m a n o e u v re freq u e n t l y practised by l a y m e n p e r h a ps provides t h e n e a rest t h i n g to t ra ct i o n : t h e p a t i e n t ( s t a n d i n g o r s e a t e d ) crosses h e r a r m s o v e r h e r c h e s t , with

her

hands

on

her

s h o u ld e rs

or

fa ce .

The

therapist s tands beh i n d her a n d passes his hands r o u n d t h e p a t i e n t ' s body to c u p t h e fu rt h e r e l b o w , pre s s i n g t h e p a t i e n t ' s t h o racic s p i n e a n d ribs a g a i n s t

his own chest,

to

take

up the

s l ack.

He

then

s t ra i g h t e n s u p i m p a r t i n g a t h r u s t t o the p a t i e n t ' s e l bo w s , i n a n u p w a r d d i rect i o n , a t t h e s a m e t i m e pre s s i n g h e r c l os e r to h i s o w n c h e s t . T h i s u n sop h i s t i c a t e d a n d n o n -spec i fi c t e c h n i q u e i s q u i te h a r m less u n less the p a t i e n t s u ffe rs fro m s e v e r e o s t e o p orosi s . A s s t i f f i n c re a s e d k y p h o s i s i s p r o b a b l y t h e most freq u e n t

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b e n d i n g mob i l iz a t i o n i s pro b a b l y the tech n i q u e most freq u e n t l y c a l l e d fo r . I n order to m a k e fu l l u s e of the

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e m pl o y n o t o n ly PIR b u t a l so t h e a c t i v e c o n t ra c t i o n of t h e e r ector s p i n a e d u r i n g m a x i m u m e x h a l a ti o n .

For t h e fi rs t te c h n i q u e , t h e p a t i e n t sits fa c i n g a

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Figure 6.34 M o b i l i z a t i o n o f the t h o r a c i c s p i n e i n t o s i t t i ng (ex h a l a t i o n )

extension

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Therapeutic tech niq ues

Figure 6.35 Mob i l i z a t i o n of t h e t h o r a c i c s p i n e i n to e x t e n s i o n w i t h t h e p a t i e n t l y i ng on h e r s i de ( ex h a l a t ion)

s l igh t l y i n to a n t e fl e x i o n ( th e t h era pis t resisti ng) a n d t o b re a t h e in slow l y . As i n the prece d i n g tech n i q ue , a s l i g h t i n crease i n kyphosis i s u n a vo i d a b le a t this st age . A fter this the p a t i e n t i s told t o relax and ach i eve max i m u m e x h a l a t io n , especial ly a t the poi n t w here she fee l s t h e therapist's fi nge r . A s e x h a l a t i o n reac hes t h e maxi m u m , t h e tho racic s p i n e m o v e s spo ntaneo us l y i n to retro flex i o n . The p roce d u re i s re peated a b o u t t h ree t i m es. Befo re proceed i n g to describe thrusting tech n i q ues i n t h e tho racic spine I will deal with m o b i l ization i n to flexion . Flexion restriction i s usually fou n d where t h e k y p h o t i c a rch of t h e th oracic s p i n e i s flattened, w h ich i s most freq u e n t l y t h e case i n the upper thoracic region a n d a lso a t t h e thoraco l u m b a r j u nction. A very co n ve n i e n t way o f m o b i l izing i n to fle x i o n is prov ided by the e x a m i n a t i o n tec h n i que (see Figure 4 . 2 2 , p . 105 ) . The t herapist thus moves the pa tient into a n teflex i o n w i t h t h e s u m m i t of the arch at t h e po i n t whe re his finger is p laced ; h e tells the pa t i e n t to look u p and breathe in, and t h e n to look down a n d breathe out. Th i s p roce d ure is repeated t h ree to five t i m es . F o r the u pper t horacic spi n e , w h e re restricte d anteflexion is re l a t ive l y freq u e n t , t h e r e i s another mobi lization tec h n i q u e t h a t is p a rt i c u l arly effective. It is applied on the side w h e re m uscu l a r spasm (TrPs) i n the spinal erectors is fo u n d . The patien t (Figure 6.36) s i ts on the ta b l.e a n d tbe thera p i s t s t a n d s behind h e r ; w i t h o n e h a n d h e g r a s p s t h e p a t i e n t ' s h e a d , h i s pa l m o n the occ i p u t o n the s i d e of the l e s i o n ( i . e . h e uses t h e l e ft h a n d i f t h e l e s i o n is on t h e righ t ) . He m o v e s t h e head i nto a n teflex i o n , side-be nding a n d rot a t i o n to t h e opposite s i d e t o take u p t h e slac k . W i t h the t h u m b o f t h e o t h e r h a n d he fi x e s t h e transve rse p rocess o f the lowe r vertebra

181

of t h e segm e n t to be treated . He then tells the p a t i e n t t o look towards the side o f the lesion and to bre a t h e in slowly, then to look in the other d i rection a n d breathe o u t . This proced u re i s repeated a b o u t t h re e t i mes. To restore side-be n d i ng we use the s a m e tech n i q u e as for examination (see Figures 4 . 2 3 , 4.24, p . 1 0 6 ) , t h e only d i fference b e i n g t h a t the thu m b i s placed o n t h e s p i n ous process o f the ca u d a l vertebra to fi x it, a n d n o t a t the i n terspace for p a l p a t i o n . For m o b i l ization we m a ke use of the a ltern a t i n g muscle faci l i tati o n and i n h i b i t i o n described by G a y m a n s ( 1 980) . The patie n t is s e a ted on the t a b l e , h e r legs h a ng i n g o v e r the s i d e ; the t h e r a p i s t sta n d s b e h i n d h e r w i t h o n e h a nd ro u n d her r i b s a n d t h e t h u m b o n the s i d e o f t h e s p i n o u s p rocess. T h e o t h e r h a n d i s p l aced o n the p a t i e n t ' s n e c k (fo r t h e u pper thoracic), s h o u l d e r ( fo r t h e m id-thoracic), or u n d e r h e r a x i U a ( for t h e lower t horacic s pi n e ) , a n d b e n d s the p a t i e nt's t r u n k s i deways so a s to t a k e u p t h e s l a c k . I f a n e v e n segm e n t is b e i n g treated, t h e p a t i e n t is told to l o o k u p a n d b r e a t h e i n , the t h e r a p i s t t h e n feel i n g i n c reased resistance to t h e s i d e - be n d i n g ; a fter a slow deep brea t h the patie n t is told to h o ld h e r breath a n d then t o relax a n d b rea t h e o u t (but n o t to l o o k down , w h ich would i n volve ben d i n g forward). D u ri n g t h i s exh a l a t io n t h e therapist m u st w a i t u n t i l he fee l s resista nce to s l a c ke n ; the r a n ge of s i d e - bend i n g a u t o m a ti ca l l y i ncreases. I n t h e o d d segm e n ts fa ci l i tation a n d i n h i bi t i o n a re reversed: t h e patie n t i s t o l d to breathe o u t slowly ( afte r breath ing in) , t h e t h e r a p i s t feeli n g resistance to side-ben d i ng. Whe n

Figure 6.36 One-sided m o b i l iza tion o f t h e t h oracic s p i n e i n to k y p h o s i s , t h e p a t i e n t s e a t e d : t h e t r a n sverse process i s fixed w i t h the t h u m b

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Man ip u lrl live Th erapy in Rehabili/{Ilion of {he

Locorn o{nr S VSICIIl

e x h a l a t i o n is com p l e te s h e i s told to b re a t h e i n s l ow l y , a n d towa rds t h e e n d o f i n h a l a tion resi s t a n ce to side-be n d i n g s l a c k e n s a n d the r a n ge of m o v e m e n t i ncreases. Th is p roce d u re is r e p e a t e d two o r t h r e e ti mes. I n very b r o a d s h o u l d e red p a t i e n ts, w h e n a t h e r a p i s t w i t h sma l l h a nds h a s d i ffic u l t y i n reach i n g t h e s p i n o u s process w i t h h i s t h u m b , w e d e sc r i bed ( C h a p t e r 4 , Figure 4.24 ) a s u i t a b l e tec h n i q u e : t h e t he r a p i s t s t a n d s a t t h e s i d e o f the p a ti e n t u s i n g h e r f a r (raised ) e l bow fo r s i d e - be n d i n g; the t h e nar a n d t h u m b o f h i s o t h e r h a nd form a fulcru m . D u ri n g m o b i l i z a t i o n h e h a s to stabilize t h e p a t i e n t ' s t horax with his own t ru n k , lea n i n g back and b e n d i n g h i s knees. Th ere a re s e v e r a l i m porta n t tec h n ica l poi n ts to n o t e : the t h e ra p i s t m u s t never fo rce sid e - b e n d i n g b u t w a i t for it to i ncrease s po n t a n e o u s l y , a n d on l y fol l ow the p a t i e n t ' s re l a x a t i o n w i t h h i s h a n d s . Th i s u s u a l l y occu rs towards the e n d o f brea t h i n g in or o u t . The e ffect of t h i s phenome n o n d e c re ases i n a ca u d a l d i rect i o n , particu l a r l y i n t h ose seg m e n ts w here resi s t a nce i ncreases d u r i n g ex h a la t i o n , to be foH owed b y rel a x a t i o n d u r i n g i n h a l a ti o n . Th is is prob a b l y because the s t a bi l i ty of the t h o r a x as a w hole i n c reases d u r i n g i n ha l a t i o n . T h e o t h e r p o i n t t o w a t c h , a s I p o i n te d o u t w h e n describing e x a m i n a t i o n tech n i q u e is t h a t t h e h a n d which s t a b i l izes t h e t h o r a x f r o m t h e s i d e m u s t c re a te a s t r o n g f u l c r u m , the p a l m l y i n g i n the a x i l l a ry l i n e a n d t h e t h er a p i s t ' s fo re a r m b e i n g perpe n d i c u l a r t o t h e lateral chest w a l l . E v e n i f t h e patient is broad s h o u l d e re d a n d tbe t he ra p i s t h a s small hands, h i s t h u m b s t i l l reaches t h e spinous p rocess d u ring si d e - b e n d i ng , owing to rota t i o n of the ver t e b r a e . T n e v e ry d a y practice t h e therapist ra re ly co u n ts to see w h e t he r he is dea l in g w i t h a n odd o r a n e v e n segm e n t , b u t si m p ly starts by t e l l i n g t h e pati e n t to look u p a n d brea t h e in; if resista n ce i ncreases d u ri n g i n h a l a t i o n and re l a x a t i o n fo l lows d u ri n g e x h a l a t i o n , h e i s s a t i s fi e d . I f n o t , h e t ries the reverse proced u re , begi n n i n g w i t h e x h a l a t i o n . T h i s tec h n i q u e is a lso v ery usefu l fo r mo b i l iza tion of the r i b , but not to d e l i v e r a t h rust . For m o b i l i z a t i o n i n rota t io n t h e patient s h o u l d s i t a s t r i d e t h e e n d o f t h e t a b l e w h i l e t h e t h e ra p i s t sta nds b e h i n d h e r a t t h e end, pass i n g o n e a r m under t h e p a t i e n t ' s a x i l l a t o g rasp t h e o pposite s h o u l d e r ( Figure 6 . 37). A s l i g h t l y ky p h otic pos i t i o n is reco m m e n d e d , t o m a ke t h e spi n o u s p rocesses more prom i ne n t . The o t h e r h a n d is placed w i t h the palm a ga i n s t the ribs and the t h u m b o n t h e spi n o u s process of the c a u d a l vertebra o f t h e t re a te d segm e n t , from t h e s i d e . To a c h i e v e good fi x a t i o n t h e t h e rapist's a rm is abd ucted so that the fo r e a r m fol l ows t h e d i re c t i o n o f the t h u m b , a n d the p a l m s t a b i l izes t h e ribs. rt fixation i s a d e q u a te little l o c k i n g i s n e e d e d . T h e p a t i e n t i s now to l d to l oo k toward the s i d e to w h ic h m ob i l ization i s being ca rried o u t ta k i n g u p t h e s l a c k i n t h is way. The pa t i e n t is t h e n t o l d to l o o k t o the o pp os i te side , ,

,

brea t h i n g i n slowly , to h o l d h e r b reath ( t h e i s omet r i c p hase ) , a n d t h e n t o look t h e o t h e r way aga i n , b re a t h i n g o u t s l o w l y . D u r i ng t h i s re l a xa t i o n p h a s e the range of mobi l i ty i n creases s p o n t a n e o u s l y . T h e proce d u re is re p e a ted t w o o r t h ree t i m es . Th e fo l l o w i n g tec h n ic a l po i n t s a re i mporta n t : fixa tion s h o u l d h e s u c h t h a t t h e t h u m b a t t h e s i d e o f t h e spi n o u s p rocess of t h e caucl a l v e rt e b r a rema i ns in p l a c e . W h e n t h e pa t i e n t l o o k s t o wa rds the s i d e of mohi l izati o n , t h e re fo r e , her eyes a n d h e a d s h o u l d n a t u r a l l y t u r n as fa r a s t he c l asped h a n d s b e h i n d h e r head a l low, i n t h e d i re c t i o n of rot a t i o n ; the t ru n k , however, s h o u l d o n l y re l a x , a n d not active ly press. T h e t r u n k m u s t a l way s ro t a t e a b o u t i t s ow n a x i s . The sa m e t e ch n i q u e ca n a lso b e u s e d t o d e liver a t h ru s t , a fter t h e slack has b e e n t a k e n u p , i . e . at t h e e n d o f t h e re l a x a t i o n p h a s e , if i t is thought a d v isa h l e . I n t h i s c a s e t h e t h e r a p i s t m a y i n cr e a s e k y p h osis a n d s l ightJ y sid e - b e nd t h e t r u n k i n t h e d i r e ct i o n oppos t te to t h a t o f rota t i o n , to o b ta i n be t l e r l o c k i n g I r t h e fi x a t i o n is good a n d t h e pa t i e n t re l a x e d , t h i s is n o t absol u tely necessa ry. Th i s tech n i q u e is u s e d m a i n l y i n the low t h o r a c i c spine and t h e t h o r ac o l u m ba r regi o n , b u t i t c a n a lso be a p pl ie d t o the l u m h a r s p i n e . T h e re is a no t h e r v e r y e f fective a n d l e ss s p eci fi c t e c h n i q u e fo r mo b i l iz a t i o n a s we l l as to d e l i v e r a t h r u s t fo r m a n i p u l a t i o n of t he t h o r a c i c s p i n e i n t o rotation ( Fi g u re 6 . 3 8 ) ; the t h e ra p i s t 's h a n d on t h e pa t i e n t ' s s h o u l d e r ro t a t i n g her, a n d t h e t h u m b or t h e pisi form of t h e o t h e r h a n d on t h e t r a n s v e rse p roces s , a c t i n g i n t h e s a m e d i rec t i o n . C a r e fu l l o c k i ng i s esse n t i a l . T h e pa t i e n t is seated a s fo r t h e p re c e d i ng tec h n i q u e a n d the t h e r a pis t grasps t h e fa r s h o u l d e r, w i t h his arm across the p a t i e n t ' s chest , r r o m b e h i n d . .

Figure 6.37 Ro t � t i o n m o b i l i za t i o n ( m a n i p U l a t i o n ) i n k y p h o s i s , wi t h t h e l owe r ve r t ebra o f t h e t e s t e d segm e n t Il xed b y t h e t h e r il p i s t ' s h a nd a n d t h u m b

slight

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Therapeutic rechniques

( b)

Figure 6.38 (II)

R o t a t i o n m a n i p u l a t i o n of t h e t h o ra c i c scakd with her trunk l e a n ing s l ig h t l y b a c k w a rds, ro t a t e d a n d b e n t t o t h e s a m e s i d e , b o t h the t h e r a p i s t ' s h a nd s a c t i n g in t h a t d i re c t i o n . W i t h t h e pa t i e n t s i t t i ng e r e c t , t h e s a m e rot a t i o n tech n i q u e c a n b e u sed t o ma n i p u l a t e a r i b , c o n t a c t b e i n g m a d e a t t h e a n g l e o f t h e r i h i n s t e ad o f a t t h e t ra n sverse p rocess. spine, t he patient

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g i v i n g a p u s h to the tra nsvers e process in the s a m e d i rect i o n . The fo l l ow i n g tec h n i c a l p o i n ts a r e i m porta n t : t h e a x i s o f rota t i o n is t h e p a t i e n t ' s t ru n k , a n cl h e r h e a d m ust not d e v i a te from side t o s i d e . O n l y a l i tt l e s i d e be n d i n g is needed a n d i s performed by m e a n s of t h e h a n d across t h e p a t i e n t 's c h es t , n o t by the therapist bending his own t ru n k s i deways. T h e thrust is d e l iv e red by the t h e ra p ist rota t i n g his own body from t h e l e g s a n d p e l v i s , so that b o t h h i s h a n d s a c t exactly a t t h e s a m e m o m e n t . A s t h e re i s n o fixa t i o n from be low, o n l y very l i ttle force m u st be use d . I nstead o f h i s thumb, t h e thera p i s t m a y use h i s the n a r or pisifo r m . Mobi l izat i o n a l o n e is, howeve r , u s u a l l y s u f fi c i e n t , as m uscu l a r spasm a n d he nce a lso m u sc u l a r relaxation a re d e c i s i v e a t t h e t h o raco l u m ba r j u n cti o n . A tec h n icaJJy s i mp l e b u t not v e ry spec i fi c tech n i q u e fo r mob i l izing the thoraco l u m b a r j u nc t i o n h a s been s uggested by F. G a y m a n s ( u n p u b l i shed observ a tion s ) , m a k i ng use of t h e r h y t h m ic a l pull o f the psoas ( Figure 6 . 3 9 ) . The patie n t l i e s o n h e r s i d e , w i t h t h e uppe r h i p be n t a t right angles. The t h e r a p i s t s ta nds a t t h e side of the tab l e so a s to res i s t further fl e x i o n o f the p a t i e n t ' s k n e e w i t h his o w n t h i g h . He now te l l s the p a t i e n t to l o o k as fa r to t h e opposite side a s she can, p ro d u c i n g ro tation of t h e head a n d trun k ; a t t h e s a m e t i m e t h e p a t i e n t pushes h e r b e n t k n ee aga i n st the t h e r a p i s t ' s t h i g h . A l te rn a t i v e l y , t h e therapist may tel l t h e p a t i e n t to res i s t w i t h h e r k nee w h i l e h e h i mse l f r h y t h m ically p u s h e s i t i n to e x te ns i o n . M o b i l i z a t i o n is obta i n e d by t h e t ru n k rota t io n a n d t h e r h y t h m ical p u l l o f t h e psoas m u scle a t the u p p e r tra n sve rse p rocesses o f t h e t h o raco l u m b a r j unction i n a n opposite d i rect i o n , T h e techn i q ue s h o u l d be performed at a b o u t two pushes per seco n d . T h i s tech n i q u e i s ideal for s e l f- t re a t m e n t , t he p a t i e n t resisti n g rhy t h m i c a l k n e e fl e x i o n w i th h e r o u ts t retched a rm .

(b) D e t a i l o f ( a )

T h r u st tec h n i q ues He n o w ob t a i ns l o c k i n g by side-be n d i n g a n d rota tion to the same s i d e , so that the a rch so fo rmed c u l m i nates a t the sit e o f the segm e n t to be trea ted . Rota t i o n o r I h e t r u n k m ust be carried o ut a b o u t the v e r t i c a l a x i s of t h e t r u n k , t he head rem a i n i n g fixed . This is a c h ieved by t h e t herapist bend i ng the patien t s i d eways, u s i n g h i s e l bow on the p a t i e n t ' s c h e s t a n d h i s h a nd o n the shou l d e r; h e m u s t s t a n d be h i n d the pa tient w i t h h i s l e gs we l l apart so t h at h e h i mse l f c a n ro t a t e a ro u n d t h e p a t i e n t . A fter ta k i n g u p t b e slack h e has two options: f o r m ob i l ization he te l l s the p a t i e n t t o loo k i n t h e opposite d i rection and s lowly to brea t h e in, hold h e r brea t h a n d then t o look i n the d i rection o f m ob i l iz a t i o n a s fa r as s h e ca n a n d brea t h e ou t . This i s re peated two o r th ree times. Or he d e l i ve rs a t h rust by fu r t h e r i ncreas i n g rota t i o n a t t h e p a ti e n t s s h o u l d e r , s i m u l ta n e o usly '

First a very ge n tle yet very e ffective traction tec h n i q u e : the t h e r a p i s t s t a n d s beh i n d the sea ted p a t i e n t w i t h a c u s h i o n between h i s chest a n d the p a t ie n t 's b a c k , so t h a t t h e top edge o f t h e c u s h i o n fixes the s p i n o u s process o f the lower vertebra of the segm e n t to be treated. H e n o w t h re a d s one a rm t h ro u g h t h e patie n t 's a x i l l a a n d w i th t h e fore arm a n d p a l m sta b i l izes the patie n t 's h e a d a n d n e c k o n o n e s i d e , T h e o t h e r ha n d reaches across t h e p a t i e n t's c h e s t to grasp h e r fa r h a n d . He now p u l l s that ha n d through the other axi l la , a t the level of the upper edge of the cushion. B y p u l ling i n a d o rsa l d i rection o n t h e h a n d i n the a x i l l a a nd on his o w n a r m i n t h e p a t i e n t ' s a x i ll a , th e s l a ck i s ta k e n u p; t h e t h rust fol lows a s t h e therapist straightens h i s c h e s t , t h u s p u s h i n g t h e c u s h i o n fo rwa rd a n d a t the s a m e ti m e s l i g h tly l i fti ng the p a t i e n t w i t h his chest and a r m s (Figu re 6040).

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Rehabilitation of the

Locom otor System

Figure 6.39 R o t a t i o n m o b i l i z a t i o n o f the t h o r a co l u m b a r j u n c t i o n witiJ the p 8 t i e n t on h e r s i d e . l oo k i ng t o the o p p o s i t e side d u r i n g r h y t h m i c a l i s o m e t r i c c o n t r a c t i o n o f t h e r i g h t i l i o p s o a s

T h e fo l l o w i n g tech n i q ue i s v e r y wi d e ly used . The

t h e s p i n o u s p r o c e s s l y i n g i n t h e groove b e t w e e n t h e

p a t i e n t i s s u p i n e her h a n ds clasped b e h i n d h e r neck

b e n t m i d d le fi n ge r a n d t he t h e n a r e m i n e n c e . A ft e r

and

this

,

b o th

( F i g u res

e lbows

t o u c h i n g in fro n t o f the

chin

6 . 4 1 and 6 . 4 2 ) . The t h e rapist stands by t h e

th e t h e ra p i s t t ur ns t h e p a t i e n t

on

t o h e r b a c k so

t h a t she i s l y i n g o n the h a n d m a k i n g c o n t a c t a t t h e

s i d e o f t h e t a b l e a n d grasps b o t h e l bows w i th t h e

tra n s verse

hand

e lbows t h e t h e r a p i s t n o w b r i ngs t h e t h o ra c ic s p i n e

n e a re r

t o t h e p a t i e n t s h e a d . t u r n i n g the '

w i t h t h e h a n d gras p i n g t h e

p rocesses:

c u l m i n a te s e xa c t l y a t t h e s i te n o w two a l t e rn a t i v e s :

p a t i e n t� t o w a r d s h i m . He b e n d s t h e m i d d l e fi n g e r of

in t o k y p h o s i s , w h i c h

t h e ot h e r h a n d so t h a t the fi n ge r t i p touches the p a l m ,

of t h e c o n t a c t h a n d . He h a s

a n d a pp l ie s t h e m i d d l e p h a l a n x o f

t h e b e n t fi n g e r t o

( 1 ) h e m a y fu r t h e r i n crease flex i o n s o a s to ta k e u p

t h e t r a n s v e rse process o f t h e c a u d a l vertebra o f t h e

the s l a c k . t e l l i n g t h e p a t i e n t t o b re a t h e i n a n d o u t

bloc k e d s e gm e n t o n t h e n e a r s i d e , a n d t h e t h e n a r

(this can be

e m ine n c e t o th e t r a n s v e rs e process o f t h e fa r s i d e ,

a n d d e l i v e r t h e t h r u s t i n t o fl e x io n d u r i n g exha l a t i o n :

o r ( 2 ) he

repeated as

a

p re p a ra tory m o b i l i z a t i o n ) ,

b e n d t h e t h ora x b a c k ( o r l e t fulcrum fo rmed b y t h e h a n d p a t i e n t ' s b a c k ( b u t n e v e r s o f a r as t o l e t

may

slightly

i t fa l l b a c k ) o v e r t h e u nd e r the

Figure 6.40 Trac t i o n thrust t e c h n i q u e a p p l i e d t o t h e t ho r a c i c s p i n e , u s i ng a c u s h i o n , t h e p a t i e n t seated

Figure 6.41 P o s i t i o n o f t h e t h e r a p i s t ' s h a n d s d u r i n g m a n i p u l a tion o f the thoracic s p i n e w i t h the pa t i e n t s u p i ne

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Figure 6.42 M a n i p u l a tion of t h e t h or a c i c s p i n e w i t h the

1 85

Figure 6.43 M a n i p u l a t i o n w i t h crossed hands m a k i n g

patient supi ne

t h e o p p o s i t e tra nsverse p roce sses of t w o vertebrae, w i t h t h e p a t ie n t pro n e

contact on a dj a ce n t

the shou lder-blades touch t he t a bl e l ) i n order to ta ke u p the s l ac k , asking t h e p a ti e n t to breathe i n a n d out s l ow ly ( t h is m a y b e re p e a te d ) a n d t h e n deliver t h e thrust i n the same d i rect i o n , d u r i n g ex h a l a t i on . I t may be d i ffic u l t for t h e p a t i e n t t o bring h e r elbows toge ther, i n w h i c h case i nstead o f c l a s p i ng her h a n d s s h e should hold them w i th t h e finge rtips j u st touching. A n o t h e r possib l e d iffic u l ty i s t h a t some t h e rapists beg i n to fee l pain i n t h e m i d d l e fi n g e r ; they s h o u l d use the c u s h i o n tech n i q u e ( s e e Figure 6.40) , o r try a p iece o f I n d i a r u b b e r i n t h e croo k o f the m iddle fi n ger. Because of t h e i r s i m p l i c i t y a n d p o p u l a rity, d i rect t h rust tech niq ues a pplied to the thoracic s p i n e , with the pati e n t prone. m u s t be descri bed . N o sop h i s ti cated loc k ing tec h n iq u e is i nvolved, and t h e re is no question of d istinguis h i ng fle xion and exte n s i o n . The thrust m ust be d i rected a t the caudal vertebra i n t h e blocked segm e n t , prod ucing ( l i k e a l l poste roanterior thrusts) gapping o r d istraction o f t h e i n tervertebral a pophysea l j o i n ts , which a re a l most i n the coro n a l plane i n the thoracic spi n e . The springing tech nique described for exa m i n a t i o n , with the patient s u p i n e (see Figure 4 . 1 5 , p . 1 0 3 ) can be u s e d after t a k i n g u p the s lack. Another tec h n i que can be used b o t h fo r mobi l iza tion a n d for a h i g h -ve locity t h rust, p rod ucing some rota tion as we l l . The patient l ies prone, and the therapist by the side of t h e table crosses h i s hands, pl a c i n g the p i s i form of one hand on the transverse process of o ne verte b r a and t h a t o f the o t h e r h a n d 0 0 t h e transverse process of the adjace n t ve rtebra (Figure 6.43). He takes up the slack by s l ight d i rect press u re and w h i l e the p a ti e n t b re a t h e s o u t he m a y deliver a th rust to prod uce ga p p i n g of t h e a rticu lation o n the side of the h a n d movi n g the caudal vertebra o f the b l oc ked segm e n t , i n this w a y ,

res t o r i n g r o t a t i o n to t h a t side . I nstead of delive ring a h igh-ve l oc i t y t h rust, he m a y s i m p l y ge n t ly increase his press u r e , springing the j o i n t w h i l e the p a t i e n t bre a t h e s o u t . T h i s type o f m o b i l iza tion c a n b e c a r r i e d o ut a s a n o n -specific treatment, i n the rhythm of resp i r a t i o n , i n one segm e n t after t h e other, rathe r l i k e massage. All t h e tec h n i q ues described fo r the t h o racic s p i n e a re applicable f r o m T 3 dow n ; t h e cervico t horacic j u n ction req u i re s tec h n iques that are d escri bed i n the s e c t i o n o n t h e ce rvica l s p i n e . Rotation tec h n iques are t h e methods o f choice i n the thoraco l u m b a r reg ion.

T h e ribs The tec h n i q u e I mysel f u s e most frequ e n tl y , particu l a r l y for t h e upper ribs, is a modi fication of the d iagnostic technique o f Kubis t h rough the shoulder b l a d e (see Figure 4.26, p. 1 07 ) . It is a lso used by Mitche l l el at. ( 1 979) with the patie n t s u p i n e . As presented h e r e , it closely resembles the m o b i lization tec h n i q u e o f t h e thoracic spine i n to extension ( Figu re 6.44 ) . The patie n t lies o n h e r s i d e , the u p p e r arm r a i s e d o v e r h e r h e a d , w i th t h e e lbow b e n t. The therapist s t a n d i n g a t t he side of t h e table p u ts o n e pal m a g a i n s t t h e p a t i e n t ' s e l bow a n d t h e fi n g e rs o f t h e o t h e r h a n d o n the r i b to be treate d . B y push i n g t h e e l bow b a c k , u s i n g t h e h a n d fixing t h e r i b a s a fu lcrum, he takes up t h e slack i n to retroflexion . A t t h i s point t h e p a t i e n t is told t o press aga i nst t h e therapist's h a n d s l i g h t l y , slowly breathing i n . S h e i s t h e n told to ' l e t g o ' a n d breathe o u t fo r as l o n g a s possible, d i recting h e r b r e a t h to t h e ri b i n q uesti o n . W h e n maxi m u m e x h a l a t i o n i s reache d , r e t roflexi on

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of the Locomotor System I f we fi n d , on co m p a r i n g t h e t w o sides, t h a t o n e is restricted d u ring ex h a l a t i o n , t h e fo llowing t ec h n i q u e ( G ree n m a n , 1979) is usefu l : the p a t i e n t l i e s s u p i n e , w h i l e t h e t h e ra p i s t s t a nd i ng a t t h e side of t h e table p l aces his t h u m b on o n e o f t h e u p p e r r i b s fro m a b o v e , c l ose to t h e stern u m . The patie n t i s t o l d to b re a t h e i n a n d o u t ; d u ri ng m a x i m u m e x h a l a t i o n t h e t h e ra pist l i fts t h e p a t i e n t 's tru n k i nto s l i g h t a n te fl e x i o n a n d gives a l i ttle push on th e rib from a bove , with his t h u m b . For t reatme n t of a l owe r r i b the t h e r a p i s t ' s t h u m b m u s t l i e m o re l a t e ra l ly on the a rch of t h e r i b , a n d d ur i n g e x h a l a t i o n t h e p a t i e n t's t r u n k i s n o t o n l y l i fted i n to a n teflexion but is a l so b e n t to t h e side o f t he ri b be i n g trea t e d . I f i n h a l a t i o n is restricted , Gree n m a n ( 1 979) m a kes use o f m uscle p u l l . I n the regi on o f t he two Li pper ribs h e uses t h e p u l l of the sca l e n es, fo r the m i d d l e r i bs t h e pectora l i s a n d fo r t h e lower ribs the se rra t u s l a t e r a l i s . The pa t i e n t i s s u p i n e a n d m usc l e p u l l i s o b t a i n e d by res i s te d side-be n d i n g o f the p a t i e n t ' s h e a d ( sca l e n e s ) , b y res isted a d d uction o f the a r m ( pectora l i s ) a n d by ra ising t h e a r m a g a i nst resistance (serra t u s ) . The the r a p i s t ' s other a rm reaches across the p a t ie n t 's n eck o r chest w i t h the fi n ge rs c x e r t i n g a m o b i l izing force aga i n s t t h e l a t e r a l a rch o f t h e b l ocked rib from be l ow, or fi x i n g t h e a d j a c e n t l ower rib from a bove d u r i ng i n ha l a t io n . Fo r t h i s the t h e ra p i s t bends t h e pa t i e n t's neck or further arm towa rds h i m se lf. p rod u c i n g s i d e - be n d i ng o f the neck and thorax towards h i ms e l f. I f severa l ribs a re restricted i t is i m porta n t to t r e a t the 'key' rib; t h i s i s t h e u p permost o f t h e gro u p if i n h a la t i o n i s restricted, a nd t h e lowest i f e x h a l a t i o n is a ffecte d . T h e re a re t h ree w a y s o f a p p l y i ng a h i gh-velocity thrust. Tn t h e fi rst, t h e p a t i e n t is s u p i n e w i t h h e r arms c rossed o v e r her chest and hands o n h e r s h o u l d e rs , t h e a r m o n the s i d e o f t h e r i b t o b e treated l y i ng u p permost . The t h e ra p i s t sta n d s a t the op posi te side o f the ta b l e a nd grasps t h e fa r s h o u l d e r or upper a rm so a s to t u rn the pati e n t 's s h o u l d e r towa rds h i mse l f. He now a p p l i es the t h e n a r e m i n e n ce t o t h e a n gle o f t h e b l oc k e d r i b ( Figu re 6.45 ) . T o d o t h is e ffectively he m u s t h a v e h i s t h u m b i n op posi t i o n , fo r o n l y then is the t h e n a r e m i nence con t racted a n d fi rm (Figu re 6.46) . W i t h h is free h a n d t h e t h e r a pist now grasps the upper a rm l y i n g benea t h the one h e u s e d to t u rn t he p a t i e n t t o w a rds h i m s e l f and t u rns her a w a y o n to t h e thenar e m i n e nce o f t h e contact h a n d , so t h a t the a ng le of t h e r i b fo rms t h e m ost p rom i n e n t poi n t o f t h e b a c k . H a v i n g s t a b i l ized t h e p a t i e n t i n t h i s pos i t i o n , t h e s l a c k i s t a k e n Li p by t h e p a t i e n t ' s o w n weight, a n d s h e is t o l d to b re a t h e i n a n d o u t . D u ri ng e x h a l a ti o n t h e th rust is d e l ivered through t h e u p p e r a r m , v e rt ica l l y towards t hc t h c I"
Figure 6.44 R i b m o b i l i z a t i on i n to dorsili A e x i o n d u ri n g t h e pa t i e n t o n h e r s i d e

exhalation,

i n c re ases spontaneo usly, t h e t h e r a p i s t o n l y mon i tor ing the re l e ase . Th i s p roc e d u r e i s re p e a te d a b o u t t h ree t i m e s . A ga i n , a s i n d i agnosis, t h e s h o u lder-b l a d e i s n o o bstacle to t h e fixation o f t h e r i b d u ri n g re t ro fl e x i o n . T h e fi r s t r i b , however, c a n b e nei t h e r treated n o r d i a gnosed i n t h i s w a y , w h i le t he second r i b i s t h e m o s t d i ffi c u l t . The ri bs to w h i c h th i s technique i s m ost fre q u e n t l y a p p l i e d a re t h e t h i r d , fo u r t h a nd fi ft h . It is tech n i ca l l y i mporta n t to raise the u p p e r a r m vertic a l l y to obta i n a p u re m o ve m e n t o f re troflex ion a s , i f t h i s i s n o t t h e case, one e a s i l y o bt a i n s rot a t i o n , w h ich i s h i g h l y u n de s i r a b l e , M a x i m u m e l e v a tion o f t h e s ho u l d e r i s th e re fore necess ary; i f t h e re is pain in t h e shou l d e r this may prove t o be an obstac l e , and t h e re fore I fre que n t l y begi n w i t h t re a t m e n t of t h e sho u l d e r i tse l f ( a necess i ty i n a n y case i f t h ere is a s h o u ld e r l es i o n ) before go i n g on to tre a t t h e r i bs , Some ge n t l e m o b i l iz a t i o n m a y b e obta i n ed w h i l e e xa m i n i ng t h e ' ov e r t a ke p h e n o m e n o n ' (see p . 1 07 ) ( w h ic h i s fre q u e n tly fou n d a t t h e second to fifth ribs). The t h e r a p i s t has both t h u mbs on the re l e v a n t r i b o n e i t h e r sid e , a b o u t 5 c m l a te r a l t o the stern u m , resisting r i b m o v e m e n t from a bove, w i t h very l i t t l e force , d u ri n g i n h a l a t i o n ; h e exe rts s l i g h t p ress ure from above d uring exh a l a tion ( m a i n l y on the s i d e t h a t i s ' overta k e n ' , i . e . restricte d ) . As a r u le t h e overtake p h e n om e n a disappear i m m e d ia te ly . T h e tech n i que described f o r m o b i l i z a t i o n o f t h e s h o u l d er- b l a d e ( s e e Figure 6. 1 4 , p. 1 68 ) c a n a l so b e u s e d for the r i b s . T h e t h e r a p i s t l i ft s t h e shou l d e r w i t h t h e h a n d t h a t h a s grasped i t from below, w h i l e t h e oth e r h a n d o n t h e s h o u l d e r- b l a d e exerts s o m e pres s u re o n the sca p u l a fro m above, u s i n g the m e d i a l e d g e o f t h e sca p u l a a s a fulcru m . B y m o v i n g t h e sca p u l a u p a n d dow n , i n creasing p ressu re t o t h e ribs d u r i ng e x h a l a t i o n , m o b i l iz a t i o n c a n be a c h i e ve d . I f corre c t l y a p p l i e d , pa t i e n ts l i ke t h is tech n iq u e .

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Therapelilic lechn ill " l!s

Fi g ure 6.45

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M a n i p u l a t i o n of t h e r i b s w i t h t h e p a t i e n t

s u p i ne , p re p a ra t o ry p h a se : t h e t h e r a p i s t t u rn s t h e p a t i e n t

towards h i m s e l f'

Figure 6.47 D e l i ve r i n g t h e t h r u s t t h ro u g h the p a t i e n t 's u p p e r a r m vertica l l y t o w a rd s t h e t h e ra p i s t ' s t h e n m ( s e e F i g u re 6 . 4 6 ) i n co n t a c t w i t h t h e a n gle o f t h e r i b therapist's

trunk and

shou lders,

v e r t i ca l l y

from

a bov e . Fo r t h e l o w e r r i b s a

oppos i t i o n o f t h e t h u m b l )

d i ffe re n t t h rust is fre q u e n t l y effective, u s i n g a tech n i q ue close l y simil a r t o m a n i p u l a t i on i n ro ta t i o n res triction of t h e t horacic s p i n e (see Fig u re 6.38) . F o r this the pat i e n t s i t s a s t r i d e t h e e n d of the ta b l e , w h i l e t h e t h e ra p ist s ta n d s behind h e r , his fe e t w e l l apart, a n d p a s s e s his a rm under t h e a x i l l a of t h e oppos ite side, t o g r a s p t h e s h o u l d e r o n the side o f the rib to be tre a te d . T h e th u m b o f t h e othe r h a n d i s o n t h e a n g l e o f t h e r i b, w i t h t h e fo r e fi n g e r e ncircl i ng i t . B y rota t i ng the patient round her body a x i s t h e s l ac k is taken u p a n d t h e t h rust fo l l ows b y the t h e r a p i s t s i m u l t a n e o u s l y i nc r e a s i n g rota t i o n a t t h e s h o u l d e r w h i l e t h e

u p p e r t h oracic s p i n e i n fl e x i o n . A t t h a t p o i n t the contact h a n d must be in m a x i m u m s u p i n a t i o n so as not to make c o n t a c t betwe e n t h e r i b a n d t h e b o n y base o f t h e fi r s t p h a l a n x of the t h u m b , i n stead of the m u s c u l ar thenar e m i nence . A s i m i la r b u t· h a rd e r t h r u s t i n g tech n i q u e i s p e r fo r m e d w i t h t h e p at i e n t p ro n e , h e r h e a d tu rned to the side of the r i b t o be t re a ted ( F i g u re 6.48) . I f t h i s is a n u p p e r rib, t h e p a t i e n t ' s a r m h a n gs down over t h e edge of t h e t a b l e i n order to produce abduct i o n of t h e s h o u l d e r - b l a d e ; o t h e r w i s e i t m a y l i e p a r a l l e l t o t h e pa t ie n t 's t ru n k . The t h e rapist sta nds a t t h e side o f t h e rib t o b e treated a n d a p p l ies the p i s i fo r m o f one hand to t h e a n g l e o f t h e r i b . He m a y now r e i n fo rce this h a n d by grasp i ng i t j u s t a b o v e t h e w r i s t w i t h h i s o t h e r h a n d . The s l a c k i s the n t a k e n up by press ure o f both a rm s a n d t h e t h rust is d e l i v e r e d d u r i n g e x h a l a t i o n . I t co m e s from the

Figure 6.48 T h r u s t ma n i p u l a t i o n a t t h e w i th t h e p a t i e n t p ro n e

m o re

Figure

6.46

Pos i t i o n o f t h e t h e r a p ist's h a n d s d u r i n g r i b w i t h t h e pa l i e n t s u p i n e ( fu l l

m a n i p U l a t i o n of a

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a n gl e

of a rib,

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Manip ulcll i ve Therapy in Rehab ililation

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c o n t a c t h a n d on t h e r i b d e l i v e rs a p u s h or a p u l l i n

a n d m o b i l i za t i o n . T h e t h e r a p i st s t a n d s b e h i n d t h e

t h e s a me d i recti o n .

se a te d p a t i e n t , s u p p o r ti n g h e r b a c k a g a i n s t h i s own

Tre a t m e n t o f t h e fi r s t r i b : a s i n d i a g n o s i s , t h e

c h e s t w h i l e o n e band su p p o rts t h e b e a d ; t b e fi rst

t r e a t m e n t o f t h i s r i b d i ffers fro m t h a t o f a l l t h e

p b a l a nx o f h i s o t h e r fo re fi n ge r is p l a ce d on t h e first

o t h e rs . F o r m o b i l i z a t i o n I u s e

a

tech n i q u e t h a t i s a s

s i m p l e a s i t i s effec t i v e : t h e t h e r a p is t s t a n d s b e h i n d

rib from a b ove ; with s l i gh t pressu re d o w n w a rd s he

t a k e s up the s l a c k . Q u i c k rep eti tive s p r i n gi ng ( s h a k

t h e p a t i e n t sea ted o n t h e t a bl e , a n d s t a b i l izes t h e

i n g) ca n n o w be a pp l i e d , or

n e c k o r s h o u l d e r fro m t h e s i d e . H e p l aces h i s o t h e r

s a m e d i re c t i o n d u ri n g e x h a l a t i o n

a

t h rust de l i v e re d i n t h e

( Fi u re 6 . 5 0 ) .

h a n d o n t h e s i d e o f t h e pa t i e n t ' s h e a d , o n t h e s i d e o f t h e l e s i o n , a n d t e l l s h e r t o re s i s t a rh y t h mic p u s h ( t w o p e r se co n d ) d e l i vered s o ft l y a n d g e n tly from t he s i d e ; t h i s p ro d uces a r h y t h mi c c o n tracti o n of t h e scal e n u s w h i c h

m ob i l izes b o t h t h e fi rs t a n d

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6.49) .

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T h e cervical sp i n e Tract i o n M a n u a l t r a c t i o n c a n be p e r fo r m e d w i t h t h e p a t i e nt

I n o r d e r to d e l iver a t h r u s t , t h e s p rin g i n g tech n i q ue i s m o s t e ffe c t i v e . I t is a l so use f u l for d i a g n o s i s

s u p i n e or s e a te d ; i n t h e fo rm e r case t h e h e a d m u st

p roj e c t o v e r the edge o f t h e t a b le . As t h e m e t h o d o f c h o ice is a u to m a t i c i so m e t r i c t r a c t i o n , re q u i r i ng v e ry l i t t l e f o r c e , t h e t h e ra p i s t s i m p l y cradles the h e a d w i t h b o t h h a n d s , a nd te l l s t h e p a t i e n t to l o o k u p

t o w a r ds h e r b row w h i l e b re a t h i n g i n ; w h e n he s e e s t h e s t e rn o m a s t o i d s a n d sca l e n i a u t o m a tic a l l y con

t ra c t

,

and a t t h e same t i m e fe e l s re sista nce aga i n s t

t r a ct i o n , he te l l s t h e p a t i e n t to h o l d h e r b re a t h , a n d

then t o l o o k d o w n t o w a r d s h e r ch i n w h i le b re a t h i ng o u t a n d rel a x i n g . D u r i n g t h is re l a x a t i o n t h e t h er a p i s t

6.5 1a).

fee l s the p a t i e n t 's n e c k l e n g t h e n i n g ( F i g u re

So as to e n h a n ce r e l a xa t io n a n d to g i v e c o m f o r t , t h e t h e r a p i s t may p r o p t h e p a t i e n t s h ea d up a b o v e '

h i s thighs a n d move b o t h h i s h a n d s on e i t h e r s i d e o f h e r n e c k f ro m t h e s h o u l d e rs u p towa rd t h e o cc i p u t

carryi n g o u t m a s s age a n d tract i o n a t t h e s a m e t i m e .

Figure 6.49 R e pe t i ti v e m o b il i z a t ion o f t h e fi rst a n d rhy t h mic c o n t r a c t i o n o f t h e

s e c o n d r i b s b y i s o m e t ric sca le n u s

If t h e p a t i e n t is s e a te d

( F i gu re 6 . 5 1 b ) , t h e

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pist s t a n d s be h i n d h e r d ra w i n g h e r ag a i n s t h i s c h e s t ,

to f a c i l i t a t e re l a x a t i o n . He t h e n t a k e s h e r head i n

b o t h h a n d s , h i s pa l m s on h e r c h e e k s , t h u m bs a t t h e m a s t o i d a n d e l bows o n h e r s h o u ld e rs, w i t h o u t e x e r t i n g p r e ss u r e . H e g i v e s t h e s a m e o r d e r a s be f o r e ; h e d o e s n o t s e e t h e s t e rn o m a s t o i d s con t r a c t , b u t fe e l s i n creased res i s t a n ce e v e n m o re s t r o n g l y t h a n i n t ile fo r m e r posi t i o n

,

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d u ri n g re l a x a t i o n .

A s i t e m p l oys P I R , m a n u a l trac t i o n i s b o t h gen t l e r and m o r e e ffe c t i v e t h a n m e c h a n i c a l tr a ct i o n . The l a t t e r may b e app l i ed w i t h the p a t i e n t s u p i n e o n ta ble t i l t e d d o w n w a rd tow a r ds

t he fee t ,

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a s l i ng p u l l i n g u p w a rd s . I t is m o s t i m p or t a n t t h a t t h e p u l l s h o u l d be exerted o n t h e occ i p u t a n d n o t o n t he c h i n .

with

M o b i l izat i o n Side - b e n ding This ca n b e c a r r i e d o u t w i t h t h e p a t i e n t se a te d or s u p i ne . T h e p h e n o m e n o n o f a l te r na t i n g Il x a t i oll a n d re l a x a t i o n

Figure 6.50 S p r i n g i ng a n d t h r u s t i n g m a n i p U l a t i o n of the fi r s t r i b

d u ring

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Therap eutic tech niques

1 89

(a)

Figure 6.52 S i d e - be n d i ng m o b i l i z a t ion w i t h t h e patie n t seated

( b) 6.5 L ( a ) Tract ion w i t h t h e p a t i e n t s u p i n e : v e ry t r a c t i o n w i t h b o t h h a n d s c ra d l i n g t h e p a t i e n t ' s occ i p u t . ( b ) Tract i o n o f t h e cerv i c a l s p i n e w i t h t h e p a t i e n t se a t e d : t h e t h e r a p i s t res t s h i s a r m s o n t h e p a t i e n t 's s l lO u l d e rs Figure

ge ntle ( isometric)

one h a n d a n d a

to fi x t h e tra nsve rse of t h e segm e n t b e i n g t r e a t e d , w h i l e h i s o t h e r h a n d o n t h e ot her s i d e o f t h e p a t ie n t ' s h e a d b e n d s h e r h e a d a n d n e c k so as t o t a ke u p t h e s l a c k i n t o s i d e - b e n d ing ( F i g u re 6 . S2) . I n t h e even s e g m e n t s ( CO , C 2 , C4 ) , resistance increases d u r i n g i n h a l a t i o n a n d w e ca n t h e refore a c h i ev e grea te r fa c i l i t a t io n by te l l i n g the p a t ie n t fi r s t to l o o k u p a n d then to b re a t h e i n slowly. A fte r t h i s she is told to look down and b rea t h e out slowly, u n less we prefe r to keep t h e n eck i n s l i g h t re troflex i o n (in the lower ce rvi cal s p i n e , i f the patient is seated ) . in which case it is better to tell h e r to 'let go' or ' relax' and t h e n t o brea t h e o u t . I n t h e odd seg m e n ts ( C I , C3 , C S ) , the patient i s o n l y told to b re a t h e o u t slowly ( a ft e r ta k i ng a s h o r t brea t h ) , a n d t h e n t o b r e a t h e i n s l o w l y a n d d ee p l y . A tech n i q u e w h i c h is i d e n t i c a l w i t h that d escribed fo re fi n g e r

p r o c e s s o f the lower v e r t e bra

fo r e x a m i n a ti o n (see Figure 4.30, p . 1 1 0) c a n a lso b e u se d . T h e t h e ra pist t a k e s u p t h e s l a c k in t h e segme n t w h e r e he h a s d i agnosed res t r i c t i o n , a n d fee l s i n crea s i n g resistance as t h e p a t i e n t l o o k s t o w a r d s h e r b r o w a n d breathes i n (in t h e e v e n segme n ts ) o r bre a t h e s o u t ( i n t h e o d d segm e n ts ) . A ft e r t h i s h e w a its u n t i l h e fee l s resistance d is a p p e a r d u ring e x h a l a ti o n and l oo k i ng towards the ch i n or i n ha l a tion respect ivel y , a n d e ncou rages the p a t i e n t to re l a x i n to si d e - be n d i ng. I f h e m a ke s t he cruci a l m i s t a k e o f fo rc i n g side-be n d i ng, t h e e ffects o f spontaneous rel a x a t i o n w i l l be l ost. T h i s tec h n i q u e i s a p p l ica b l e fo r segm e n t s C I -C6. T h e m a n o e u v re i s u s u a l l y repe a te d o n c e o r twice . S i d e - b e n d i ng s u pi n e as described i n C h a p t e r 4 ( Figu re 4 . 30 b ) s t a rtin g w i t h exh a l a tion is the t e c h n i q u e o f cho ice for mobil ization o f t h e atlas/axis; m o re t h a n one repe t i t i o n is o n l y excep t i o n a l l y re q u i re d . T h e t e c h n i q u e s for side-be n d i n g m o b i l iza t i o n o f t h e cervicothoracic j u nction a r e t h e s a m e a s fo r d i agn osis (see Fig u re 4 . 3 1 ) . Th rough o u t t h e cervico t h o racic j u nctio n i n h a lation i n creases resistance to s i d e-bending w h i le e x h a l a t i o n h a s a mobi l iz i n g e ffec t . T h e p a t ie n t i s therefore told fi rs t to look u p a n d then to breathe i n s l o w l y , a n d a ft e r i n h a l a t i o n to relax a n d breathe o u t ( i f she w a s told to l o o k d ow n , s h e w o u l d b e n d her h e a d fo rward a n d t h u s ' u n lock ' t h e ce rvical spine a n d lock the ce rvico thoracic j u n c t i o n ) . Care must be taken to h o l d the patient's head in the s i d e - b e n d i n g position, using t h e fi n g e r s , m a i n ta i n i n g retroflex i o n a n d rotation to t h e opposite s i d e w h i l e t h e upper vertebra i s fixed by the therapist w i th the t h e n a r e m i nence o f t h e same hand. The t h u m b o f the o t h e r hand m e a n w h i l e fixes t h e spinous process o f t h e lower vertebra o f the segm e n t b e i n g t re a t e d .

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/vlaniplIlative Therapy

in Rehab ilita tion of th e Locomotor System

It is tec h n ica l l y e a s i e r ( though l ess c o m fo r t a b l e for the t h e r a p i s t ) to carry o u t t h i s mob i l iza t i o n w i t h the p a ti e n t lying o n her side. H e holds th e p a t i e n t as d u ring diagnosis (see Figure 4.34, p. 1 1 3). S t a n d i ng i n fro n t of the patie n t , the t h e ra p ist cradles the head a n d n e c k in h is fore a r m , with h i s elbow o n the ta b le o r slightly above it. He now t e lls t h e pati e n t to look up to h e r fo re h e a d , a n d to b r e a t h e i n slowly . After i n h a la t i o n the p a t i e n t i s t ol d to h o l d her b re a t h a n d t he n t o re l a x a n d to breathe o u t slow l y . When the t h era p ist fee l s the re l axation h e has o n l y to move his e l bow s l i g h t ly forw a rd , fol lowing the p a t ie n t 's re l a x a t i o n a n d h i s h a nd wil l a u toma tica l ly move t h e p a t i e n t ' s h e a d i nto l a t e r a l flex i o n , r e t r o fl e x ion a nd r otati o n i n t h e d i rection opposite to the side be n d i n g W i t h both these tech niq u e s ( t h e pa t i e n t l y i n g on h e r side, o r s e a t e d ) i t i s pos s i b l e to d e l iv e r a t h rust a fte r t a king u p t h e s l a c k , a n d t h i s a l s o a fte r m o b i l iza tion. I f t h e p a t i e n t is s e a t e d the thrust is d e l i v e re d by t h e t h u m b aga i nst t h e s p i n o u s process, the hand h o l d i n g t h e h e a d and neck prov id i ng the fixation. I f t h e p a t i e n t i s l y i n g o n h e r s i d e , i t i s t h e h a n d crad l in g t h e h e a d a n d n e c k t h a t d e l ivers t h e th rust i n t h e s a m e d i re c t i on as m o b i l izatio n , w h i l e t h e t h u m b o n t h e s p i nous p rocess p r o v i d es the fixation. ,

.

,

Rotation

This is carried out w i t h t h e p a t i e n t seated . Ag a i n the tech n iq u e is b a s i ca l ly that of exa m i n a tion ( s ee Figure 4.32a, p . 11 2) . W h i l e the the r a p i s t fixes t h e arch o f t h e lower ve rtebra o f t h e t r e a t e d segm e n t b e t w e e n t h u m b a n d fo r e fi nge r h e r otat e s t h e h e a d i n t h e direction of m o b i l i za t i o n u n t i l t he s l a c k i s t a ken u p . He t h e n te l l s t h e pati e n t to l oo k up and t o brea the i n slowly, to hold h e r bre a t h a n d t h e n to l o o k down and to b reathe out, obtain ing automatic mobi l ization in the restricted d i recti on, w h i l e h e m a i n t a i ns fi x a t i o n of t h e lower ve rtebra . Th is i s r e pe a te d t w o or th ree times. (Lo ok i n g up a n d breathing i n sl i g h t l y increases r e s i s tance against rota t i o n w h i l e l oo k i ng down and e x h a l a t i o n b ri ngs a bo u t re l a x a t i o n . ) If this v e r y ge n tle tec h n i q ue i s n o t s u ffic i e n t l y e ffecti v e , i t i s poss i b l e to te l l t h e patie n t a fter the slack has been t a k e n u p i n rota t i o n , to look i n the o pp o s i t e d i rection to m o b i l i z a t i o n and t o bre a t he i n , t h e n to h o l d h e r brea t h , a nd t o loo k i n t h e d i rection o f mobi lization a n d to b re a t h e out. This m e t hod seems very logica l , b u t is fre q u e n t l y too forcefu l . For rot a t i o n i n t h e ce r v i coth oracic j u nc t i o n the patie n t is seated, w h i l e the t h e ra p i s t s t a n d s be h i n d h e r a n d fi x e s the s p i n o u s process o f t h e lower v e r teb r a o f t h e se g m e n t to be treated, placing h i s t h u m b on th e side from w h i c h the h ea d a n d n e c k a r e ro t a t e d . H e h o l d s t h e pati e n t s head with h is arm, from a b o v e , so t h a t h i s e l bow is i n fro n t o f h e r forehea d a nd h i s l i t t l e finge r at t h e a rch of t h e upper ,

'

vert e b ra o f th a t segm e n t . H e rot a tes the h e a d t o t a k e up t h e slack, t h e n te l l s t h e p a t ie n t to l o o k i n t h e di rection away from rota tion a n d to breathe i n a n d hol d h e r breath. S h e then looks in t h e d i rection of mobi l ization and b rea thes o u t This m a n oe u v re is r e p e a te d from each new position g a i n e d ( see F ig u re 4.32d). With the same tec h n iq u e i t is p os s i b le t o d e l i v e r a t h rust by i n c reasing h e a d r o t a t i o n a n d t r a c tion t he t h u m b p ro v i d i n g fi x a t i o n a t t h e sp i n o Lls .

,

process.

Mob ilization of the occi put a g a i nst the atlas T h i s is p e r fo r m e d by exactly t h e s a m e tec h n i q ues a s u s e d i n d ia g n osis I n t h i s s eg m e n t t h e fac i l i t a t i n g e ffe c t of i n h a l a t i o n a n d the i n h i b i tory e f f ect o f e x h a l a t i o n o n m uscle a ct i v i ty i s t h e greatest, a n d t h i s is t r ue fo r a l l directions. .

Anteflexion (see Figure 4.37, p . 1 1 4 )

U s i n g t h e s a m e techn i q u e , the t h e r a p i s t b e n d s t h e to ta k e u p t h e s l a c k : h e t h en t e l l s t h e p a t i e n t t o l o o k t o w a r d s h e r fore h e a d a n d bre a t he i n . T h e t h e r a p i s t resists the p a t i e n t ' s a u tomatic head retroflexion. A ft e r i n h a lation t h e p a t i e n t i s t o l d t o l ook d o w n w a rds a nd to b re a t h e o u t s l o w l y : head a n t e fl e x i o n a u tom a t i c a l l y fo l lows. This i s re peate d two or three times. h e a d fo r w a rd

Retroflexion ( se e Figu re 4.36, p . 1 1 4)

After ta k i n g u p t h e s l a c k w i t h the head r o t a ted a n d i n retro1k x i o n , t he t h e r a p i s t a s ks t he p a t i e n t to d o no more t h a n to breathe i n s l o w l y H e w i l l se nse i ncreased resista nce to ret rofle x i o n , t h e n he te l l s t h e p a t i e n t to bre a t h e o u t s l o w l y a n d le t t h e h e a d fa l l back. ( In this case, l oo k i n g u p d u r i n g t h e firs t p h a s e w o u l d i n terfe re w i t h i n creased resist
Side-bending (see Figu re 4 . 3 5 , p . 1 1 4)

Afte r t a k i n g u p t h e s l ack w i t h the patie nt's h e a d ro t a t e d a n d side- b en t , t h e t h e ra pist tells h e r to l o o k t o w a r d s h e r brow and to b re a t h e i n s l o w l y : h e w i l l fe e l i ncreased resistance to s i d e - be n d i ng. After h o l d i ng h e r b r e a t h t he p a t i e n t is told to look towards her chin and breathe o u t ; t o w a rds the e n d of exha lation t h e patient s p o n t a n e o u s l y re l ax e s i n t o l a te ra l A e x i o n . ( S e e a l so gravi t y P I R o f t h e sterno m astoid musc l e , Figure 6.96.)

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Thel'llp elllic techn iq l l es

Rotation p a t i e n t s ea ted ,

the t h e r a p is t b r i n gs t h e h e a d w i t h t h e m i n i m u m o f for c e , ta k i n g u p t h e slac k a n d st a b i l i z i n g t h e h e a d , i n a x i a l r o t a ti o n , a g a i n s t h is c h e s t . H e n o w t e l l s t h e p a t i e n t to l o o k up a n d to b re a t h e i n s l o w ly , w h i l e h e fe e ls i n cr e a s e d re sis t a nce to r o t a t i o n . The p a t i e n t is t h e n told t o l o o k downwa rds a n d b re a t h e o u t : d ur i ng o r tow a r d s t h e e n d o f e x h a l a t i o n , rota t i o n o f t h e he a d i n c r e a s e s a l m o s t s p o n t a n e o u s l y . I n t h i s cas e l o o k i n g u p a n d d o w n is b e t t e r t h a n l o o k i n g fi r s t to o n e a n d t h e n t o t h e o t h e r s i d e , because l ess f o rc e i s p r od u c e d . A ft e r atlas · mo b i l i za t i o n , t h e t h e ra p i s t should make s u r e that t h e T r P s o f t h e short e x te nsors c ro s s i n g t h e p o s t e r i o r a rc h o f t h e a t las and a t t h e upper e n d of t h e ste rnomasto i d h ave d i s a p p e a r e d : t h i s i s t h e m o s t i m p o r t a n t c r i t e r i o n o f s u c c es s f u l trea t m e n t of t h i s segme n t . W i t h the

i n t o m a x i m u m ro t a t i o n ,

19 1

p a t i en t ' s h e a d ca n b e v e ry s l ig h t l y r o t a t e d a w a y from t he t h e r a pis t , b u t c a r e m u st be t a k e n n o t t o ro t a t e so fa r t h a t t h e segm e n ts we w a nt to t r e a t are l o c k e d . I n t h e p o s i t i o n described ( Figure 6.53a ) , t h e t h e r a pist t a k e s u p t h e s l a c k b y g i v i n g a s l i g h t p u l l w i t h both h a n ds i n a c r a n i a l d i rect i o n , a ft e r w h i c h t h e t h r u s t i s d e l i ve red e i t h e r ( I ) w i t h both h a n d s g i v i n g a p u l l ( p us h ) i n t h e s a m e d i re c t i o n , o r ( 2 ) d e l i v e r i n g t he t h r u s t i n t o t r a c t i o n w i t h a s l i g h t l a t e r a l l1 e x i o n tow ards the t h e r a p i s t . I n b o t h cases t h e t w o h a n d s m u s t o p e ra t e as a si ngle u n i t . The t h r u s t m u s t t h ere fore c o m e fro m t h e t h e ra p i s t ' s tru n k , o v e r t h e s h o u l d e r s to t h e h a n d s , w h e t h e r p u re t r a c t i o n i s a p p l i e d or t r ac t i o n w i t h s i d e - b e n d i n g. Th is t e c h n i q u e c a n b e used for C I -C5 .

Thrust tech n i q u es W i t h few excep t i o n s , cases o f s e r i o u s c o m p l i c a t i o n s a fter m a n i p u l a t i o n occ u r red a fter h i g h - v e l o c i t y t h rusts had been used in thc cerv ica l r e gi o n . F u rt h e r sc r u t i n y

showed t h a t

m a n i p u l a t ion h a d bee n a pp l ie d w i t h fo rce , w i t h o u t fi rs t t a k i n g u p the slack. T h i s i s a n

e x t re m e l y fa u l t y t e c h n i q u e , a n d t o m a ke m a t t e r s worse a c o m b i n a t i o n of m a x i m u m ro t a t i o n w i t h re t ro fl e x i o n w a s e m p l oy e d . T h e l o g i c a l conseq u e n c e is t h a t . o f the large n u m b e r o f t e c h n i q u e s t o c h o o s e fro m , we a v o i d t h o s e t h a t p ro d u c e m u c h ro t a t i o n a n d p a r t i c u l a rly r o t a t i o n i n re t ro fl ex i o n . T h e m o s t im p o r t a n t a n d freq u e n t l y u s e d t e c h n i q u e s a re t h ose in w h i c h t h e t h r u s t is d e l i v e re d i n t h e d i r ec t i o n of tra c t i o n , in a c ra n i a l d i rection ; w i t h the a p o p h y se a l j o i n t s t i l ted a t a bo u t 45 d e g ree s from t h e h o r i zo n t a l p l a n e i n the m i d - a n d l o w e r ce r v i c a l s p i n e , a n d a lm os t h o r i zo n t a l a t CO, C I a n d C 2 , tra ct i o n pro d u c e s g a p p i n g oJ these j o i n ts, i n a d d i t i o n to d i s t r a c ti o n o f the i n terverte b r a l d iscs.

( a)

Traction high - velocity th rust applied to th e crania l vertebra of th e blocked seg m e n t, with th e patient supine

The p a t i e n t ' s h e a d i s o v e r the e d g e of the t a b l e , w i t h t he t h e ra p i s t faci n g a n d c r a d l i ng i t [rom a bo v e w i t h t h e o cc i p u t o n h i s fo re a r m a n d t h e fi n g e r s o n the p a t i e n t ' s c h i n . W i th the rad i a l s u r face o f the fi rs t p h a l a n x of t h e fo r e fi n g e r o f t h e ot h e r h a n d h e m a kes c o n t a c t with t h e t r a n s v e rse p rocess o f t h e u p p e r vertebra o f t h e t rea ted segme n t , side - b e n d i n g t he cerv i c a l s p i n e o n l y so fa r as n o t t o s l i p o v e r t h e tra n sve rse p rocess ( i f t h e u p p e r v e r te br a i s t h e a t l a s , v e ry l i t t l e si de - b e n d i n g is n e e d e d be c a u s e the tra ns ve rse p r o c es s e s o f t h e a t l as a r e l o n g e r and n a t u ra l l y j u t b e y o nd t h e o t h e rs . The l ower t h e t r a n s v e rse process, the fu r t h e r we bend the cerv ica l s p i n e ) . T h e

( b) Figure 6.53 T r a c t i o n t h rust i ng m a n i p u l a t ion of t h e c e rv i c a l s p i n e w i t h t h e pa t i e n t s u p i n e : ( a ) co n t a c t i s m a d e a t t h e t ra n s v e rse process o f t h e u p p e r v e r t e b r a o f t h e s e g m e n t t re a te d , o r ( b ) a t t h e mastoid p r o c e ss for COi l , w i t h t h e h e a d rota ted

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M an ip l l ialive Therapy in Rehabililalion of Ihe L o co rn O l O r Syslem

For t h e occipitoatlantal segm ent t h e t h e r a p i s t rotates t h e h e a d so as to lock the a tlas/ax is at a b o u t 45 d e g r e es a n d m a k es contact a t t h e mastoid pro cess. If h e w a n ts to a pp l y l a teral flexion a t t h e s a m e t i m e , h e m u s t bea r i n m i n d t h e rot a t i o n o f t h e h e a d , i . e . the s i d e b e n d i n g m us t be a t r i g h t a n g l e s to the s a g i t t a l p l a n e o f t h e ( rota ted ) head ( F i g u r e 6.53b). ,

-

s e g m e n ts

t he

C4-C7 .

Below

this

t h e t h e ra p i s t ' s

finge rs b e c o m e i n e ffe c t i v e ; t h e y m e re l y p ro d u c e a

slight

pu l l

of

the

c e r v i ca l s p i n e i n a n u p w a r d i s g i v e n b y t h e o pe r a t o r s t h e s p i n o u s p r o c e s s of T 1 or T2 .

d i re c ti o n w h i l e t h e t h r u s t ,

b reastbone Both

aga i nst

these

traction

'

techniques

a re s a fe

a nd

if

c o r r e c t l y a p p l i e d a re v e ry ge n t l e . H o w e v e r , t h e y a re n o t a b s o l u t e ly s p e c i fi c beca use t h e t h r u s t is g i v e n to ,

the u p p e r ve rtebra o f the blocked segme n t , w h i l e

Traction lo w- velocity th rust applied t o th e cra nial vertebra of the blocked segm e n t, with th e p a tie n t sea te d ( Figure 6 . 5 4 )

cl as p ed h e a d a n d t h e e l bows fa r a p a r t . T h e t h e r a p i s t sta n d s b e h i n d t h e p a t i e n t a n d th re a d s h i s fo r e a rm t h r o u g h t h e tr i a n g l e fo r m e d by t h e pa t i e n t s u ppe r a r m a n d fore a r m , fi rst on o n e a n d then on the o t h e r s i d e . H e m a k e s c o n t a ct w i t h b o t h fore fi ngers and m i d d l e fi n g e rs crossed o n the s p i n o u s proccss of the u p per vertebra o f t h e s e gm e n t t o b e t re a te d . T h e pa t i e n t is n o w t o l d t o re l a x a n d l e t h e r head fa l l fo rw a r d . The t h r ust i s d e l i v e r e d b y t h e fi n g e r s i n c r e a s i n g t h e i r press u re i n a forw a rd a n d u p w a r d d i r e c t i o n . T h i s t e c h n i q u e is most e a s i l y app l ie d to

The

pa t i e n t

l ow e r v e r t e b ra i s n o t fi x e d . T r a c t i o n m a y t h e r e fo r e a rfect s o m e of t h e m o r e c a u d a l s e g m e n t s ; t h i s n e e d n o t , h o w e v e r , b e c o n s i d e re d h a r m fu l . the

s i ts o n t h e t a b l e w i t h h e r h a n d s

b e hi n d h e r

Rota tion thrust with the patie n t sea ted ( Fi gure

6.55)

'

T h e p a t i e n t s i ts o n a l o w s t oo l ; t h e t h e ra p i s t s t a n d s b e h i nd her, pass i n g o n e h a n d a n d fo r e a r m i n fro n t of t h e p a t i e n t ' s face ( b r o w ) s o t h a t t h e e l bo w i s i n fro n t o f t h e fo re h e a d a n d t h e h a n d be l o w t h e

occ i p u t , t h e l i t t l e fi n g e r c l a s p e d ro u n d t h e a rc h o f t h e u p p e r v e r t e b r a of t h e b l o c k e d s e g m e n t a n d t h e occiput com forta b l e aga i n s t t h e t h e ra p i s t s c h e s t . T h e nec k is t h u s he l d i n a k y p h o t i c p os i t i o n W i t h t h e t h u m b o f t h e o t h e r ha n d , t h e t h e r a p i s t fi x e s t h e '

.

s p i n ous process o f t h e l o w e r v e r t e b r a o f t h e segm e n t o pp o s i t e t o t h e d i rec tion i n w l1ich t h e h e a d i s r o t a t e d , so as to k e e p it i n n e u t ra l p o s i t i o n . T h e a r m ro u n d t h e p a t i e n t s h e a d now r o t a tes i t a n d t h e u p per v e r t e b r a o f t h e b l o c k e d segm e n t , so a s [ 0 t a k e up t h e s l a c k , t h e t h u m b o f t h e o t h e r h a n d h o l d i n g t h e s p i n o u s p ro c e s s o f t h e l ow e r v e r t e b ra i n m i d p o s i t i o n T h e t l H u s t i s t h e n d e l i v e re d w i t h t h e o n the s i d e

'

-

Figure 6.54 ( a ) Tr a c t i o n m a n i p u l a t i o n of t h e the fi n ge r s

c e r v i co t h o r a c i c j u n c t i o n : ( b ) a p p l ica t i o n o f

.

Figure 6.55 Ro t a ti o n t h rust i n g m a n i p u l a t i o n o f t h e ce r v i c a l s p i n e w i t h t h e p a t i e n t seate d , u n d e r t ra c t i o n , i n k y p h o s i s w i t h t h e t he ra p i s t s ' s t h u m b fl e x i n g t h e l o w e r vertebra o f t h e treated s e gm e n t a t t h e s p i no u s p rocess

Copyrighted Material

Th erapelilic Icchniques h a n d ro u n d

the

1 93

p a t ie n t ' s h e a d , m a i n l y i n t o t r a c t i o n

i n a c r a n i a l d i re c t i o n , s l i g h t l y i n cre a s i ng rota tion a t

the same time. T h i s tech n i q u e i s h ig h l y s p ec i fic , a s t h e l o w e r ve rte b r a i s fi x e d ; i f t h i s fi x a t i o n i s c o r r e c t . rota ti o n is o n l y m o d e r a te a n d t h e re i s a lw a y s k y p h os i s a n d t ra c t i o n

d u ri n g t h e t h r u s t .

This means t h a t t h e

te ch n i q u e i s q u ite sa fe .

Self- m o b i l i zati o n S e l f- t rea t m e n t - se l f- m o b i l i z a t i o n - c o n s t i t u t e s a l i n k b e tween m a n i p u l a t i v e t h e r a p y a n d re m e d i a l e x e r c i s e .

( a)

As t h e m o d e rn m o b i l i z a t i o n tech n i q u e s m a k ing u s e of m u scu l a r fa c i l i t a t i o n a n d i n h i b i t i o n a re a l re a d y b a s e d o n t h e a c t i v e coope r a t i o n o f t h e p a t i e n t, it i s logi c a l t h a t t h e t r e n d s h o u ld be t o t e a c h t h e pa t i e n t i n c r e a s i n g l y h o w to d e a l w i t h h e r p r o b l e m s h e rs e l f. To use o n e ' s o w n m us c l e s to m o v e o n e ' s s p i n e , e v e n w i t h con s i d e r a b l e force , is n o t h i ng n e w . I n d e e d ,

t h e u s u a l mov e m e n t s p e r fo r m e d i n p h y s i c a l tra i n i n g - som e w h a t force f u l , fa s t a n d n o n -specific - do m o re h a rm t h a n go o d . M o v e m e n t re s t ri c t i o n goes h a n d i n hand

w i t h m u sc l e s p a s m p r o t e c t i n g t h e

b locked

segme n t . Force f u l m o v e m e n t s u d d e n l y a p p l i e d to that segm e n t i s l i k e l y o n l y to i n c rease s p a s m , w i t h t h e re s u l t t h a t t h e n orm a l a n d h y p e r m o b ll e se g m e n ts w i l l be m o b i l i ze d , w h i l e t h e a ffected segm e nt s w i l l

b e fi x e d eve n m o re fi r m l y b y m u s c l e s p a s m . S e l f- m o b i l i za t i o n m u s t t h e re f o re b e a s g e n t l e a n d

( b) Figure 6.56 (II) S e l f- m o b i l i z a t i o n of the l e ft s a c ro i l i ac ( a fter S a c h s e ) : ( b ) s e l f- m o b i l i za t i o n of the s a c r oi l i a c j o i n t w i th t h e p a t i e n t l y i n g o n h e r s i d e

joint

slow a s t h e m o b i l i z a t i o n t e c h n i q u e s w e u s e , m o v i n g

t h e segme n t a fter t h e s l a c k h a s b e e n t a k e n u p ; i t m u s t a l s o be a s s p e c i fi c a s poss i b l e . P r e c i s e c l i n i c a l d i agnosis a n d i n d i c a t i o n a re m a n d a tory.

s u p e rior, so a s to p r o d u c e r h y t h m i c a l s p r i n g i n g p r e s s u re i n a v e n trocra n i a l d i recti o n , a n d re i n forces i t w i t h t h e o t h e r fo r e a r m a n d h a n d , i n t h e d i re c t i o n o f m o bi l i z a t i o n ; t h i s prod u c e s gapp i n g of t h e s a cro i l i ac j o i n t (Figure 6 . 5 6b ) . In i t s e lf, t his i s an e a sy m a n

Self-mobil ization of the sacroi l i a c j o i nt ( S a c hse a n d S c h i l d t , 1 98 9 ; Fig u re 6. 5 6 0 )

o e u vre , t h e d i ffi c u l t y l y i n g i n t h e n e e d t o t e a c h t h e p a t i e n t t o e x e rt pressure i n t h e correct d i recti o n , a n d

The p a t i e n t is k n e e l i n g on t h e t a b l e , c lo s e to t h e

n o t t o u s e force .

edge, h e r t r u n k s u p po r t e d o n h e r e l b o w s . O n e k n e e

ha ngs ove r t h e e d ge o f t h e t a b l e , w i t h t h e i ns t e p s u p p o r t e d j u s t a bo v e t h e h e e l o f t h e o t h e r f o o t . I n t h i s pos i t i o n t h e p a t i e n t m u s t r e l a x s o t h a t t h e p e l v i s

Self- m o b i l i zation of the ( l ower) l u m b a r sp i n e. a nte- a n d retrofl exion ( F i g u re 6.57)

s l o p e s o b l i q u e l y d o w n w a rds f r o m t h e i l i u m , w h i c h

T h e p a t ie n t s i t s on her h e e l s , s u p p o r t i n g h e r s e l f w i t h

is s u p p o r t e d b y t h e k n e e o n t h e t a b l e . I n t h i s w a y

o u ts t r e tch e d a r m s r e s t i n g o n h e r k n e e s . B y c o n

the s l ack is raken up al t h e sacroi l i ac joint o f t he s u p p o r t e el

s i el e . T h e

tension in

t h e re g i o n of h e r s a c ro i li a c j o i n t , s h e

moment

the

p a t i e n t senses

t r a c t i o n o f t h e g l u t e a l m u s c l e s ( g l u te i m a x i m i ) s h e

r a i s e s h e r pe l v i s , p r o d u c i n g k y p h o s i s o f t h e l u m b a r spine;

after

relaxation

the

pel v i s

fa l ls

fo rw a r d ,

m a k e s a ve ry s m a l l el o w n w a rd s p r i n g i n g mov e me n t

p r o d u c i n g l o r d o s i s a t t h e l u m b o s a c ra l j u n ct i o n . Th i s

w i t h t h e k n e e o v e r t h e edge o f t h e t a b l e , movi n g i n

exe rcise

a ve r t i c a l d ire c t i o n a n d t h u s m o b i l i z i n g t h e s a c roi l i a c

position of t h e p e l v i s w h i l e s ta n d i n g .

is i m po r t a n t fo r t ra i n i n g i n

t h e correct

joi n t on the supported side. A n o t h e r v e r y effe c t i v e t e c h n i q u e i s d e r i ve d from m o b i l i z a t i o n l y i n g o n the s i d e (see F i g u r e

4 . 1 0,

p.98).

Ly i n g on h e r s i d e w i t h h e r l o w e r l e g exte n d e d , t h e p a t i e n t s t a b i l i ze s h e r p e l v i s w i t h t h e k n e e o f t h e

Self- m o b i l i zati o n of t h e l u m b a r spi n e. rotation ( F i g u r e 6.58) T h e p a t ie n t l i e s on h e r s i d e n e a r t h e edge of t h e

u p p e r fl e x e d l e g o n t h e t a b l e . S h e n o w p u ts t he w r i s t

t a b l e . The l o w e r l eg i s s t r e t c h e d o u t , t h e u p p e r l e g

of h e r u p p e r h a n d o n h e r u p p e r s p i n a i l i a c a a n teri o r

b e n t a t t h e k n e e s o t h a t t h e t o e s a r e h o o ked be h i n d

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M a n ip u la t i v e Therap v

in Rehab ilita tion of t h e L o c o m o tor System

t h e l ow e r l e g . I f sel f- m o b i l i z a t i o n i s d i re c t e d to t h e

p e r s e co n d , p rod u c i n g repe t i t i v e m o b i l i za t i o n ; o r s h e

l ow l u m ba r spine, the t o e s r e s t b e l o w t h e knee of

m a y e x e r t s l i g h t pressure o n t h e k n e e w i t h t h i s h a n d , f r o m a b o v e , re s i s t i n g h e r o w n press u r e [ o r a b o u t

t h e s u p p o r t i n g l eg ; i f t h e u p p e r l u m b a r s p i n e , o r u p t o t h e t h o r a co l u m b a r j u n c t i o n i s t o be t r e a t e d , t h e

1 0 s w h i l e b r e a t h i n g i n , a n d t h e n re l a x i ng , b re a t h i ng

u p p e r l e g i s s u p ported a b o v e t h e k n e e a n d t h e n t h e

out

l o w e r l e g s h o u l d b e s l i g h t l y fl e x e d a t t h e k n ee . W i t h

repe a te d t h re e to fi v e t i m e s .

t h e h a n d t h a t l i e s u p p e r m o s t t h e pa t i e n t h o l d s t h e fa r e d ge o f t h e t a b l e fo r s t a b i l i za t i o n , w h i l e t h e o t h e r

and

i n cr e a s i n g

There is

rota t i o n . T h i s

m a n oe u v r e

is

a l s o a v e r y e ffe c t i ve g ra v i t y - i n d u c e d

pa t i e n t shou l d turn h e r head to the

e x e rc i s e fo r s e l f- m o b i l i z a t i o n . i n t o rota t i o n a n d fl e x i o n i n t h e l u m b a r s p i n e , w h ic h i s i d e n t i c a l w i t h P I R of t h e l u m b a r p a r t of t h e e r e c t o r s p i n a e a n d i s

t hat

d e s c r i b e d l a te r ( s e e F i g u re 6 . 1 1 5 ) .

( l ow e r ) h a n d l i e s o n t h e

( u p per)

fl e x e d k n e e . T h e

sicle o p p o s i t e t o of ro t a ti o n ; she m a y now e x e r t press u r e r h y t h m

i c a l l y w i t h t h e h a n d l y i n g o n t h e k ne e , o n c e o r t w i c e

Self- m o b i l izat i o n o f the l u m b a r s p i n e i nto retrof l ex i o n a n d latera l flex i o n , sta n d i n g ( Fi g u re

6.59)

H e r e , fi x a t i o n i s d e c isive . The p a t i e n t m a y e i t h e r fi x t h e u p pe r v e r t e b ra o f t h e s e gm e n t t o b e t r e a t e d , w i t h t h e ra d i a l s u rface of

her

fore fi n g e r , from a b o v e ; o r

s h e m a y fi x t h e l o w e r v e r t e b r a w i t h t h e t i p s o f h e r t h u m b s , t h u s crea t i n g a fu l c r u m . B y b a c k b e n d i n g a s fa r

as

or

side

t o t h e fi x a t i o n p o i n t ( fu l c r u m ) s h e

t a k e s u p t h e s l a c k , a n d t h e n m a kes a s l i g h t r e p e t i t i ve m o ve m e n t , r h y t h m i ca l l y s p r i n g i n g t h e se g m e n t a bove o r b e l o w t h e t h u m bs o r fo re fi n ge rs respect i ve l y . F i x a t i o n fro m a b o v e ( b y t h e fore fi n ge rs ) is i n d i c a ted if t h e re i s h y p e r m o b i l i t y a b o v e the seg m e n t t re a t e d , and

from

b e l ow

(by

the

t h u mbs)

if

t h e re

( a)

( b)

( b) Figure

6.57 Se l f- m o b i l i z a t io n

(a) a n teAexion:

Figure o f t h e lowe r l u m b a r s p i n e :

( b ) re t ro A e x i o n

6.58

spine. the

R o t a t i o n se l f- m o b i l i za t i o n or t h e l u m b a r pa t i e n t l y i n g o n h e r s i d e : ( a ) l o w e r . ( h ) u p p e r

lumbar spine

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is

Th uap eli lic lech n i q l l e5'

( a)

( b)

( e)

( d)

Figure 6.59 S e l f- m o h i l i za t i o n of the l u m h a r s p i n e . t h e p,l I i e n t s t a n d i ng. Fi x a t i o n of t h e upper v e rt e b r a of t h e tre a t e d segme n t from a b o v e , w i t h t h e forefi nge rs: (a ) b a c k - be n d i n g : ( b ) sid e - b e n d i n g . Fi x a t i o n wi t h t h e t h u m h s from b e l o w :

(e) back-be n d i ng:

(d) side-bending

Copyrighted Material

[ 95

1 96

Manip u la t i v e Therapy

in Rehab ilitation

of the

LocomolUr

Svstem

hyperm o b i l i ty below. Obvious l y t h e l u m bosacra l segm e n t is a l ways treated from above. I t is esse n tia l t h a t a n y fo rceful moveme n t of l a rge range s h o u l d be avoid e d ; o n l y t h e s m a l l, specific spri nging move ment s h o u l d be pe rfo r m e d , ab ove or below the fu lcrum w i t h t h e sp i n e fixed b e l ow or above respect ivel y , moving once or twice per seco n d ,

Self- m o b i l i zation o f the th oraco l u m b a r spine i n t o rotation Th is corresponds to the tec h n i qu e d e scribed a bove ( see Figure 6.39, p. 1 84). The p a t i e n t l ies on h e r side w i t h the l ower leg stretched o u t and the upper leg be n t both at the h i p and at t h e k n e e a t a b o u t right angles, Wi t h h e r o u tstretched lowe r arm the patient fi x es t h e t h igh o f t h e flexed leg from a bove, turn i ng h e r h e a d a n d neck i n to maxim u m rotation w h i l e l o o k i n g a t a n o bj e c t pl a ced be h i nd h e r b a c k , I n t h i s posi t i o n s h e e x e rts rhythmic pressure a ga i n s t the o u tstretched arm, w i t h h e r k n e e , about twice per seco n d . It is the rhyt h m ic contraction of the psoas that prod uces the m o b i l i z a t i o n effect . ,

Ante- a n d retroflexion self- m o b i l i zation o f the t h o racic spine (Figu re 6 . 60) The

p a t i e n t is s u p ported o n both knees a n d elbows. Mov i n g t h e thoracic spine into kyphosis she breathes i n , t h e n moves i n to lordosis while s h e breathes out to t h e m a x i m u m . T h e more c r a n i a l t h e m o b i l ization req u i red, the further fo rward the e l bows a re p l a ce d ( a n d t h e chest lowere d ) , w h i l e for mobi l izat i o n a t t h e t horaco l u m bar j u n ction it may be bette r t o p e rfo rm t h e exe rcise o n h a n ds a n d knees.

Fi gure 6.60 Sel f- m o b i l iz a t i o n of (a) a n te fle x i o n and ( b ) retro A e x i o n

o f the m i d - a n d lower t h o ra c i c s p i n e

Retroflexion self-mobil izat i o n of t h e t h o racic spine d u r i n g exha l ation (Figure 6 . 6 1 ) The p a t i e n t s i ts o n t h e table w i th b o t h arms s t retched by h e r side a n d t h e h a nds i n s u pi na t i o n wi t h t h e fi n ge rs s p r e a d fa n-wise, S h e now breathes i n l i g h tly, then d ur i n g max i m u m exh a l a t i on she bends h e r tho racic spine backwards, at the same time i ncreasi ng s u p i n ation o f the hands, C a re m u s t be t a k e n n o t t o r a i s e t h e s h o u lders a n d n o t to b e n d e i t he r t h e h e a d or the l u m b a r s p i n e backwards. I f t h i s exe rcise is correctly p erformed the patient s h o u l d fee l s l ig h t pain in t h e t horacic sp i n e a t m a x i m u m e x h a l a t i o n a n d retroflex i o n . A v e r y good a l tern ative is described o n p, J 80 (Figure 6.34) ,

Antefl ex i o n self- m o b i l i zation of the t h oracic sp i n e i n i n h a l at i o n (Figure 6 . 62) Th e p a t i e n t s i ts on h e r heels, bending forward so as to have her fore head o n the t a b le , In t h i s pos i tio n s h e breathes into her bac k . She e a s i l y l e arns h o w to

Figu re 6.61 Retro fl e x i o n sel f-m o b i l i z a t i o n of t h e t h oracic

spine with the p a t i e n t seate d . using max i m u m e x h a l a ti o n a n d o u t w a rd r o t a t i o n o t t h e a r m s . w i t h fi ngers w idespread

d i rect i n h a l a t i o n into the s t i ff s e g m e n ts ; t h is s h o u l d w i t h t h e t h e ra p i s t ' s fi n g e r , a n d t h e n

fi rs t be c h e c k e d by t h e p a t i e n t .

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Therapelllic lechniq lles

197

s l a c k a t t h is s e g m e n t . B y r e pe a t e d r h yt h m ic a l move m e n ts i n t h e s a m e d i rection s h e sp r i n g s t h e s e gm e n t i n to retrofle x i o n , t h e head moving back horizo n t a l ly.

Rotat i o n self- m o b i l ization at the cervicothoracic j u nct ion ( F i g u r e 6.65) Rota t i o n o f t h e o u t st re tch e d arms w i t h fi n ge rs s p rea d w i d e h a s s o m e m ob i l i z i n g e ffect on t h e cerv icothoracic j u nc t i o n ; t h i s e ffe c t i s e n h a n ce d if each a r m rota tes i n a n o p p os i te d i rectio n , one f r o m s u pi n a ti o n i n to p ro n a t i o n a n d the other v i c e v e rsa . T h i s a l o n e is n o t e n o ug h , however; t h e e x e rcise becom e s very effective i f t h e h e a d i s a l s o rota ted , i n t h e s a m e r h y t h m a s t h e a r m s a n d pre fe rabl y faci ng t h e h a nd that is ro ta ti n g i n to p r on a t i o n ( t h e thumb down ) . Care m u s t be taken n o t t o l i ft t h e should ers, w h ic h s h o u l d be relaxed. This tech n ique s h o u l d n o t be u s e d i f t h e re i s hypermobi lity i n the u p p e r th oracic region.

Figure 6.62 A n te fl e x i o n se l f- m o b i l i z a t io n or t h e t h o r a c i c s p i n e in i n h a l a t i o n . t h e pa t i e n t s q u a t t i n g a n d bending fo r w a rd

I n h a lation self-mobil ization of the u pper ribs (Figure 6.63) p a t i e n t i s s e a ted ove r the e d ge of the table w i t h k nees a part, i n anteflexion, a n d h e r h e a d i s t u rn e d t o w a rds the s i d e to b e m o b i l ized . O n e arm h a n g s b e t w e e n t h e k n e e s a n d t h e o t h e r at h e r s i d e . I n t h i s pos i t ion t h e r i b s [0 be m o b i l ized b u lge s l i g h t l y a n d i f t h e p a t i e n t r e l a x e s h e r s h o u l der- b l a d e s . she fee l s s o m e t e n s i o n a t t h e s i t e ( t h e s l ack is b e i ng t a k en u p ) . S h e now b r e a t h e s i n t o t h ose r i b s . s e p a ra t i n g the m d u ri n g i n h a la t i o n . The

her

Retroflex i o n self- m o b i l ization o f t h e u p p e r thoracic s p i n e a n d t h e cervicothoracic ju nction ( Figure 6.64) The p a t i e n t i s seated, h e r back s u pported by t h e chai r-back a t t h e l e ve l o f the lower ve rtebra ( s p i n o u s process) of t h e se g m e n t to be t reate d . S h e now s h i f t s her h e a d a n d sp i n e backwards, so as to take up t h e

Self- m o b i l ization of the fi rst rib Th is corresponds to t h e te c h n i q u e d e s c r i b e d above ( s e e F i g u re 6.49, p . 1 88 ) ; the p a t i e n t si m pl y uses her o w n arm, r e s is t i n g w i t h head and neck the r h y t h m i c a .l i m p u lses gi v e n by h e r h a n d .

Retroflexion a n d rotation self m o b i l izatio n of the cervical spi n e (Figure 6.66) With t h e u l n a r s u rface o f bo t h h a n d s the p a t i ent fixes the lower v e r te b r a o f t h e segment to be t re a te d . Now she ei t h e r s h ifts h e r head back s o as to t a k e up t h e slack a n d t h e n springs the segme n t i n to retro flexion by a small rep e t i t i v e m o v e m e n t (see a l s o Ret roflexi o n sel f-mobi l iza tion of t h e u p p e r thoracic spine a n d cervicot horacic j u n c t i o n ) ; or she r o t a t e s h e r h e a d to take u p the slack and then makes rhyth m ica l ro ta t i o n movements springing ( m o b i l iz i n g ) the segme n t i n to rotatio n . Instead of s p r i n g i n g the segment i nto rotatio n , s h e may ( a ft e r ta k i n g u p the slack) l o o k u p , br e a t h i n g i n slowly, a n d then l o o k t o t h e s i d e o f t h e desired mobilization w h i l e s l o w ly b r e a t h i n g o u t , a u t o m a t i c a l l y i ncreasing the r a n ge of r o t a t i o n . The e x e r c i s e is re p e a t e d t h r e e t i m e s .

S ide-be n d i n g self- m o b i lization of the cervica l spine ( Fi g u re s 6.67, 6.68) p a t i e n t m a y place the p a l m of h e r h a n d aga i nst t h e side of h e r n e c k , so t h a t t h e thumb is s u p p o r t e d by the clavicle a n d t h e u l n a r s u rface forms a fulcrum a t t b e transverse process of the lower v e r t e b ra o f t h e affected segm e n t , u s i ng h e r o t h e r h a n d to bend the h e a d to t h a t side to take u p the slack ( F ig u re 6.67), a tec h n ique that is only s u i ta b l e for se gm e n t s C l -2 a n d C2-3 . A l te r n a ti v e l y , she may p u t h er t h i r d

The

Figure 6.63 I n h a la t i o n se l f- m o b i l ization o f t h e right u p pe r ribs

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1 98

Maniplila/ive Th erapy in Rehabili/a/ion of /he Lucom u/or S vs/em

Figure 6.64 A n t e · a n d r e t r o fl e x i o n s e l f- m o b i l iza t i o n of t h e u p p e r t h o r a c i c s p i n e a n d t h e c e r v i c o t h o r a c i c j u n c t i o n . t h e s e a t e d o n a ch a i r w i t h t h e back s u p p orted a t t h e l o w e r v e r t e b r a o f t h e a ffe cted seg m e n t : t h e h e a d a n d t h e s p i n a l co l u m n a re s h i fted (0) fo r w a r d s a n d (/J) backwa rds pa t i e n t

a n d fo u r t h fi n ge r s r o u n d h e r n e c k from b e h i n d . fi x i ng t h e a r c h o f t h e l o w e r v e r t e bra o f t h e s e g m e n t :

w i t h t h e o t he r h a n d p a s s i ng o v e r t h e c rown o f h e r

head she pulls

i t away

fro m t h a t s i d e . o v e r t h e

fu l c r u m fo r m e d b y he r fi n g e rs, t o t a k e u p t h e s l a c k ( Fi g u re 6.68) . I n b o t h pos i t i o n s P I R i s n o w a p p l i e d . m a k i n g u s e of

the

p ri n c i p l e

of

a l te rn a t i ng

inh i b i t i o n d u r i n g i n h a l a t i o n a n d

faci l i t a t i o n

and

exha l a tion ( see p.

1 89 ) . W h e n t re a t i n g an even s e gm e n t t h e p a t ie n t fi rst l oo k s u p a n d b r e a t h e s i n s l o w l y . holds h e r b re a t h , a n d t h e n re l a x e s w h i l e l o o k i n g d o w n a n d bre a t h i n g o u t . F o r a n odd segm e n t s h e b eg i n s b y b r e a t h i n g o u t s l o w l y . re l a x a t i o n ta k i n g p l a c e d u r i n g i n h a la t i o n . T h e e x e rcise is r e p e a t e d t h ree t i m e s : c a re m u s t be t a k e n t h a t s i d e - b e n d i ng is p e rfo r m e d s t r i c t l y i n t h e c o ro n a l p l a n e . With h e r fi n gers rou n d h e r n e c k t h e pa t i e n t m a y a c h i e ve good fi x a t i o n d o w n to C5 , or to C6 if her n e c k i s s l e n der. T h e fi n g e r s s h o u l d go round

the

posterior

arch

from

behind

one

tra nsverse process to t h e n ex t .

Ante- a n d retrofl exio n self- m o b i l i zati o n between occiput a n d atlas ( F i g u re 6 . 69 ) Th e p a t i e n t t u rns h e r h e a d s o as t o l ock t h e a t l a s/axis.

Figure 6.65 R o t a t i o n

sel f- m o b i l iza t i o n

at the

c c r v i co t h o r a c i c j u n c t i o n . b y a c o m b i n a t i o n o f rh y t h m i c

rota t i on o f t h e a r m s i n o p p o s i t e d i r e c t i o n s . w i t h t h e s pre a d . a n d h e a d rota t i o n i n t h e d i rec t i o n o f t h e p ro n a t e d a rm tl n gers

To m o b i l i ze i n t o a n te A e x i o n . s h e take

nose .

u p the

sl a c k . b re a t h i n g out

p u l l s her ch i n in to sha rply t h rough t h e

looking down. a n d m a k i ng

i n t o a n te Ae x i o n

a

b r i s k m ove m e n t

a t the s a m e t i m e . To m o b i l i z e i n to re troflex i o n s h e l i ft s he r ch i n to t a k e u p t h e s l a c k .

Copyrighted Material

TherapCUlie lecl1l1iqucs

Figure 6.66 R h y t h m i c re pe t i t i v e se l f- m ob i l i z a t i o n o f t h e c e r v i c a l s p i n e , w i t h t h e

u l n a r c d ge of

both h a n ds: ( a )

fo rwa rd s h i ft ; ( i» ba c k w a rd s h i ft : ( e ) ro t a t i o n

the upper s p i n e : w h i l e o n e h a n d s i u e - b e n d s t h e head to t h e o p p o s i t e side, t h e o t h e r fi x e s t h e t r a nsve rse p rocess o f t h e l ower v e rt e bra o f t h e t r e a t e d seg m e n t Figure 6.67 S i d e - b e n d i ng s e l l'- m o b i l i z a t i o n o f

cerv i c a l

arch o f t h e l o w e r

v e r tebra

.1 99

fixed by t h e

Figure 6.68 S i d e - b e n d i n g se l f- m o b i l i z a t i o n o f t h e m i d h a n d fi x e s t h e ve r t e b r a l a rc h w h i l e t h e o t ll e r r e a c h e s o v e r t h e c r o w n to b e n d the h e a d s i d e ways

a n d lowe r ce rv i c a l spi n e : o n e

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2 00

Manip u / a r i v f Th e rojJ v in Rehabilira rioll of r h e L o mrn o r o r Svsrnll

Figure 6.70 Sc: l f- m o b i l i za t i o n o r t h e e l bow i n d i re c t i o n

a

rad i a l

Self- m o b iliza tio n o f th e e lb o w i n a ra dial dire ctio n ( Fi g u re 6 . 70 ) T h e p a ti e n t grasps t h e e dge o f a t a b l e , w i t h t h e stretched

in

supination

that

so

the

arm

thumb

l ies

p a r a l l e l w i th t h e e d ge of t h e t a b l e . T h e o t h e r h a n d grasps

the

elbow

fro m

the

u l n a r side,

ga p p i n g

( m o b i l i z i n g ) i t by r e p e a t e d r h y t h m i c a l p r e s s u r e o r

by a fa s t s h a k i n g m o v e m e n t i n a r a d i a l d i r ec t i o n . Figure 6.69 S e l f- m o b i l iza t i o n b e tween a t l a s and o cc i p u t w i t h t h e h e a d r o t a t e d ( a ) i n t o a n t e fl e x i o n a n d (b) i n to r e t r o fl e x i on

Mob iliza tio n o f o n e c a rp a l b o n e against th e n ex t ( Fi gure 6 . 7 1 ; see a l so Figure 6 . S b , p. 1 64 )

The tip o f the t h u m b is p l a c e d o n o n e c a r p a l b o n e l o o ks up a n d b re a t h e s in s h a r p l y , m a k i n g a b r i s k b u t

( e . g . the os ca p i ta t u m ) a n d the t i p o f the fo reflnger

s l igh t

on

m o v e m e n t i n t o r e t r o fl e x io n . Ca re m u s t be

taken n o t to move the c e r v i c a l sp i n e b e l ow the a x i s .

i ts n e i g h b o u r

s m a l l s h i ft

Latera l flexi o n self- m o b i l i z a t i o n between occ i p u t and a t l a s

(in

this

case

t he

os l u n a t u m ) ,

prod uci n g a s lig h t s h e a r i n g p r e ss u r e re s u l t i ng i n a ( Fi g u re 6 . 7 1 a ) .

I f tile fi n g e rs c h ange

p osi t i o n , the s h ift w i l l t a k e p l a c e i n i h e oppo s i te d i recti o n . P a t i e n ts w h o fi n d th i s too d i ffi c u l t m a y use a s i m p l e t r a c t i o n t e c h n i q u e : the r a ti e n t fi x e s her

T h e b e s t t ec h n i q u e i s i d e n t i c a l to g ra v i ty- i n d u ce d

fo re a r m aga i n s t her k n e e , w h i le her o t h e r h a n d

PIR o f t h e s t e r n o c le i d o m a s t o i d m u sc l e ( s e e Fig u r e

grasps t h e carpa l (or

6.96).

w i s h es to t r e a t , b e tw e e n h e r t h u m b a n d fo refinge r

even

m e ta c a r p a l ) b o n e s h e

(Fi gure 6 . 7 1 b ) .

S e l f- m o b i l i z ati o n o f t h e ext r e m ity j o i n ts O b v i o u s l y , se l f-trea t m e n t c a n a l s o b e a p p l i e d to t h e e x t rem i t y j o i n t s . T h i s i s p a r t i c u l a rl y t r u e fo r t h e

lower e x t r e m i t i e s , b ec a u se

the

p a ti e n t

has

both

Tra ctio n o f th e fin g e rs, i n c l u ding th e first m e ta ca rpa l T h e d i s t a l p h a l a n x is gras p e d by t h e l i t t l e fi n ge r

the other hand, w h i le

h a n d s f r e e . I t h e r e fo r e d e a l o n l y w i t h a fe w i n s t a nces

of

o f t re a t m e n t of t h e u p per e x t re m i ty j o i n t s .

fll1 g e r grasp

Copyrighted Material

the

first

the

phalanx

t h u m b a n d fore the m e t a ca r p a l

or

Th erapeutic tech niq ues

20I

F u n cti o n a l tech n i q u es

( a)

( b) Figure 6.71 ( a) S h e a r i n g se l f- m o b i l i z a t ion of c a r p a l b o n e s , u s i ng th u m b a n d fo re fi n g e r . ( b ) S e l f - t re a t me n t o f the c a r p a l bones using traction

of the th u m b . Traction a n d even m o b i l ization can be ap p l ied to t h e metaca rpophalangeal joints a n d t h e ca rpometaca rpa l j o i n t of the t h u m b (see Figure 6.2). Self-applied traction a t th e shou lder This can b e performed over the padded back of a c h a i r , prefera b l y by the tech n i q u e of isometric tract i o n a nd r e l a x a t i o n , t h e o t h e r h a n d grasping t h e a rm a b ove the e l bow . The patient resists h e r o w n (slight) t r a c t i o n a nd bre a t hes i n aga i n s t t h e b a c k o f t h e c h a i r ; she t h e n rel axes and breathes o u t , d i strac t i o n r e s u l t i n g from re l a x a t i o n (see Figure

6.9).

Two very gentle a nd s u rprisi ngl y e ffective tec h n i q ues of (oste o p a t h ic) ' i n d i rect' m a n i pu l a t i o n s h o u l d b e m e n t i o n e d . Their popu l a rity i s l i ke l y to i ncrease i n fu ture. The t e r m ' i n d i rect' mea n s that, u n l i k e tech n iq ues described so fa r, the p a t h o logical (restrictive) ba rri e r i s e ngaged n e i t h e r fo r d i agnosis n o r i n order to obta i n re lease. T h e fi rs t of these techn iq u e s has b e e n termed 'functio n a l ' . T h i s method a t t e m p ts to fi n d a re l i e f posi t i o n in w h i c h p a t h o l ogica l te nsion ( a nd pain) is re l ieved a nd to o b ta i n good re l a x a ti o n i n t h i s positi o n . Once this is fo u n d a n d re lease i s obta i n e d ten s i o n ( te n derness) gra d u a l l y n o r m a lizes i n every pos i t i o n . T h i s m e t h o d i s b a s e d s o l e l y on p a l p a t i o n a n d t herefore i t is d i fficu l t t o present let a lo n e i l l ustrate i n a textbook. A t best this is a n a t t e m p t to give an idea of what s h o u l d b e a c h i e v e d by the m e t h o d . At palpa tory e x a m i n a t i o n o f t h e l e s i o n e d segme n t w i t h t h e patient seated, t h e t h u m b a n d t h e fore finger o n both sides of t h e spinous process, i ncreased tension is fe l t o n one side, described as rota t i o n ( G re e n m a n ) ( p a l p a tory i ll usion ow ing to one-sided m uscul a r spasm). I n de e d , one of t h e fi n gers se nses p ro m i n e n ce and t h e other a groove . O n b e n d i n g forward, backward, to t h e s i d e s a nd possibly a t rotati o n , t h e exa m i n e r fee l s that i n some pos i t i o n s this a s y m m e try i n creases, i n o t h e rs i t d i s a p p e a rs . W e h a v e to b e a r i n m i n d t h a t i f t h e p a t i e n t side-bends t h e joint o n t h e side o f l a t e roflexion moves i n to extension a n d t h a t on t h e opposi te s i d e i n to fl e x i o n (see F i g u r e 4.4), ow i ng to coupled movem e n t ; t h i s i s a lso true f o r rota t i o n . H a v i n g localized t h e a s y m m e t r i ca l , lesioned segm e n t with t h e patie n t seated , both h a nds clasped beh i nd her neck, the e x a m i n e r grasps bo t h h e r arms a bove t h e elbows (see Figure s 4. 1 6, 4 . 1 7 ) a n d first bri ngs t h e patient i n to t h e position i n w h i ch asym m e try d i m i n ishes. Th is u s u a l l y h a ppens either in flex i o n or e x t e n s i o n . In t h e l a t te r , side-flexion to t h e side of spasm is a d d e d , a s i n t h i s c a s e side flexion a m o unts to furth e r exte n s i o n . I f i n this way good rel a x a t i o n a n d s y m metrical te n s i o n i s a c h i e v e d , t h e exa m i n e r first supports t h e patie n t i n this position to e n h a nce relaxatio n . Wi t h the patient well relaxed, h e now slowly reduces back- a n d side-fle x i o n , re turn i n g i n to re l ie f position t h e m om e n t te n s i o n reappears, re peating t h e m a n o e u vre u n t i l n o m o re asym metry recurs. Then he moves fu r t h e r i n to a n teflexion u n t i l he notices t h a t fu l l flexion a n d side b e n d ing to t h e opposite side n o l onger creates tension or tenderness, i . e . fu l l re lease is obta i ned. I f , on the o t h e r hand, symme try i s obta i ne d i n flex i o n , t h e exa m i ne r moves the patie n t i n to side fle x i o n to t h e opposi t e side of spasm (of ' rota t i o n ' ) , support i n g h e r i n t h i s r e l i e f positi o n , a n d t h e n proceeds grad u a l ly as described fo r re trofle x i o n . I n t h e cerv ica l s p i n e the tech n i qu e is simi l a r . T h e

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Therap eulie lechniques

203

of re l e a s e we m a y c h a n ge b o t h t h e i n t e n s i t y a n d t h e d i rect i o n

of

p ress u re ( p u l l )

to

a c h i e v e b e t t e r re s u l ts .

I t mus t n o t be fo rce d , a n d t h e p
s h o u ld

neve r

pa i n .

S k i n stretc h i n g As

explained

in Chapter

4 (p. 86),

a n a re a

of

the

before

s k i n m a y b e h e l d b e twee n t h e fi nge r t i ps or w i t h the

aspect of the c rossed h a n d s , from the l i t t l e fi n ge r to t h e wrist ( a ccord i n g t o t h e size of t h e a re a i n v o l ve d ) , a n d s t r e t c h e d w i t h a m i n i m u m o f force , so as to ta k e up t h e s l ac k . On f u r t h e r s t re tc h i n g a s p r i n g i n g resi sta nce is fe l t . I f t h e r e is a h y pera l ge s i c z o n e ( H A Z) , t he s l a c k is t a k e n u p soon e r a n d t h e re is m u c h less s p r i n g . I f t h e t h e ra p i s t t h e n h o l d s t he sk.i n i n t h is end -posi t i o n , res i s t a n c e w e a k e n s u n ti l ul n a r

( a)

nor m a l s p r i n g i n g i s restored ( Fi g u re 6.72) . T h e H A Z

usua l l y n o l o n g e r d e t e c t a b l e . I f t h e H A Z i s a c a u s e of pain, t h i s stre t c h i n g m e t hod is q u i te a s effe c t i v e as ne e d l i ng, e l e c t r os t i m u l a t i o n a n d s i m i l a r t r e a t m e n t . Moreove r , i t is e n t i re l y p a i n less a nd c a n b e us e d by is

the pa t i e n t h e rse l f.

I f t h e a re a

is

m a r k ed o n t h e s k i n , t h e e f fe c t

tre a t m e n t can b e m e asure d ; co m m u n i c a t i o n ,

M.

of

B e rg e r ( pe r s o n a l

1 982) h a s c o n s t r u c t e d a n e l e c t r i c a l

i n s t r u m e n t t h a t s t re t c h e s t h e s k i n r h y t h m i c a l l y w i t h

a c o n st a n t

after

( b) 6.73 D e r m a tote n s i og r a m recorded by Berge r com m u n i c a t i o n ) : ( a ) be fore s k i n s t retc h i ng. poor e l a s t i c i t y : (b) i n c r e a s e d ( n o r m a l ) e l a s t i c i t y a ft e r

Figure

( p erso n a l

st retching

c a n b e reco r d e d ( F i g u re 6 . 7 3 ) . S t re t c h i n g i s partic u l a r l y u s e fu l i n s m a l l areas where i t is d i fficul t to fold t h e s k i n , a s b e t w e e n t h e fi n g e rs o r toes i n root synd romes i f t h e re i s a n H A Z . S k in s t r e t c h i n g i s a lso very u s e f u l a c ro s s t h e c a r p a l

Fo lds of soft c o n n e c t i v e tiss u e me t a k e n be tw e e n

tunnel.

t h e t h u m b a n d fore fi n g e r

force t h a t

Stretching a connective tissue fold ( F igure 6 . 74)

way

of the two h a nds;

in this

p u l l o r s t r e tc h i s p roduced a n d t h e s l a c k i s t a k e n

o n l y to s t re t c h . n e v e r t o secon d s r e s i s t a nce g i v e s a n d t h e tiss u e fo ld s t re tc h e s un t i l a n e w ba r r i e r is reached a n d n o r m a .1 springing i s re s to r e d . This t e c h n i q ue c a n b e a p p l ied to subcut a n e o u s t i s s u e a n d t o active s c a r s w i th t e n d e r p o i n t s and s u rroun d e d by a n HA Z . I t u p . C a re m us t b e t a k e n

p i n c h . A ft e r

a

few

c a n a l s o b e u s e d f o r s h o r t ( t aut) musc l e s . I n t h e c a s e o f a l a rge m u s c l e

such as

t h e h a m s tri ngs , t h e

prod u c e d b e t w e e n t h e p a l m o f o n e fi n gers of

of

the o t h e r . Th i s

obta i n i ng

m u sc l e

is

hand

fold

is

a n d the

the most effe c t i v e way

stretch

while avoiding

the

s t re tc h r e fl e x (Fi g u re 6.74 ) .

Pressure If a

fo l d c a n not with a

e x e rted

b e fo rm e d . s l ig h t pre s s u r e m a y be finger

(Figure

6.75).

With

l i ttle

p re s s u r e t h e s l a c k i s fi rs t ta k e n u p , a n d a ft e r a s h o r t l a te n cy

period

t h e fi n g e r s i n k s i n t o t h e d e e p l a ye rs

is r e a c h e d . T h i s is m o s t e ffe c t i ve s u pe r fi c i a l m u sc l e s i n c l u d i ng t h e e re c t o r s p i n a e a n d t h e g l u t e u s m a x i m u s ; i t c a n a lso b e a p p l ied by u n t i l a n e w ba r r i e r

in

a p i nce r m o ve m e n t i n m u s c l e s in w h i c h TrPs a r e

d i a g n o s e d i n t h i s w a y , a s in t h e tra p e z i u s Figure 6.72 S k i n

st r e t c h i ng

sternoc l ei d o m a s t oid .

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and t h e deep

I t i s a l so u s e f u l i n t re a ti ng

204

Mal l ipula l i ve Th erapy

in

Rehab ililalion of lhe Locomolar

5yslem

figure 6.76 St retch i n g ( s h i ft i n g) t h e g l u t e a l fascia

is u s u a l ly a p p l i e d . The rh y t h m i s t h e e v e ry case: fi rs t we t a k e u p t he s l a c k , a n d a f t e r a f e w s e c o n d s t h e t h e r a p i s t fe e l s t h e b a r r i e r g i v e : myofasc i a l re l e a s e con t i n u es u n t i l t h e n o r m a l ba r r i e r is re a c h e d . M a n y o f these tech niq ues h a v e b e e n e l a borated by R. W a rd ( p e r s o n a l c o m m u n i c a tion , 1989) . Som e a re desc r i b e d i n d e t a il b e l o w . a n d s t retch i n g

sa me in

Figure 6.74 Fo l d i ng connective t i s s u e

Shifting (stretching) the deep gluteal fascia from abo ve

Figure 6.75 Pressing d e e p soft t i s s u e s

scars w h e re i t i s i m p os s i b l e to fo r m a skin fol d . Pressure o n m u scles appears t o h a v e a n i n h i b I tor y , relaxing e ffect a n d is a n a l te r n a tive to PI R .

S h ifti ng (stretch i n g ) deep fasciae The m o s t i m p o r t a n t function restored by soft t i ss u e m a n i p u l a t i o n appears to be t h a t of m o b i l. i ty of t h e fasc i a e ; t h i s is bound up w i t h t a u t nes s ( s h o r t e n i n g ) o f the m uscles, esta b l i s hed o nly a ft e r ca refu l d iag nosis o f res t rict i o n . Ch a n ge s i n the fa sciae a re most ch a r a c t e r i s t i c i n t h e c h r o n i c s t a ge ; i t i s i m p ort a n t to k n ow t h a t the restricted s i d e need not be the side w h e re pa i n is fe l t . However, i t i s t h e a s y m m e t ry w h i c h is c h a racteri s tic ( t h e ' t ight-loose complex ' ) . F o r t re a t m e n t o f fa sc i a e a com b i n a t i o n o f s h i f t i n g

T h e t h e rapi s t s t a n d s a t t h e side to be treated; t h e p a t i e n t i s p r o n e , her fe e t o v e r t h e end of t h e t a b l e . He p u ts s li gh t p ress ure aga i nst t h e m a s s o f t h e gl u t e i f r om abov e , and some p re s s u r e i n t h e t h o r a co l u m b a r area w i t h t h e o t h e r h a nd . T h e patient i s n o w t o l d to p r e s s her to e s upwa rd aga i n s t t h e edge o f the t a b l e (on the t r e a t e d s i d e ) a n d t o stretc h t h a t a r m above her h e a d , w i t h fi n g e r s exte n d ed ; s h e m u s t l oo k towards t h e t h e r a p i s t a n d b re a t h e o u t . t o i n c r e a s e tension ( ex h a l a tion i n c r ea s e s tension in this situ a tion , as in isometric l u m ba r t racti o n ) . T h e n s h e i s told to b r e a t he i n s l ow l y : d ur i ng i n h a l a t i o n , resista nce s l a c k e n s and reJease occ u rs . T h i s m a n oe u v re i s re p e a t e d t w o or t h ree t i mes. I f there is no s a t i s factory release, the p a t i e n t s h o u l d be told to c o u g h occa s io n a l ly a f t e r i n h a l a ti o n . A f t e r t re a t m e n t , w h ic h should be a g re e ab l e to t h e p a t i e n t , t h e s k i n is o f t e n flushed (Figure 6.76) . The gluteals c a n also be s h i fted from be low, and o n the re s t ric t e d s i d e r e l e a s e can be o b ta i n e d a ft e r e ngagi ng t h e barrier. H e re b re a t h i n g in or o u t has little e ffe ct. M e r e p r e ss u r e where m a x i m u m h y p e r to n u s is fe l t h a s a s i m i l a r e f fect. Shifting the lumb odorsa l fascia upwards The p a t i e n t t a k e s the

same p os i t i o n as above: the t issues of t h e t h orax i n a c r a n i a l d i recti o n with one h a n d , w h i l e t h e o t he r a p p l i e s pressu r e i n t he l u m b a r regi o n . The p a t i e n t is told to breathe i n , to h o l d h e r brea t h , a n d t h e n to b r e a t h e o u t : re lease occu rs d u r i n g e x h a l a t i o n . t h e r a p is t s h i fts t h e soft

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Therapelltic techn iques

Figure 6.77 Stretching the s h o u l d e r- o l a cle

(sh i fting)

t h e dorsal fa scia

205

over

Figure 6.79 S t retch i n g ( s h i ft i n g ) the fascia over the l a t e r a l a s pect of t h e tru n k

e x a m i n e a n d t o t r e a t t h i s cond i t i o n . t h e t h e r a p i s t

F i g u r e 6 . 7 8 S t retch i n g ( s h i rt i n g) t h e e10rsa l fasc i a e

s t a n d s be h i n d t h e se a t e d p a t i e n t , s l i g h t l y to t h e s i d e

t ra n s v e rs e l y

sid e - b e n d i n g m u s t

which

to

p il t i e n t p u ts h e r

arm

be

p e r fo r m e d .

The

over her head, with the hand

Aga i n . i f re le a s e i s n o t s a t i s fa c t o r y . a s li g h t c o u g h

a t t h e n a pe o f t h e n e c k . o n t h e s i d e w h i c h i s to

w i l l i m p rove i t ( F i g u re

s t re tc h e d Th e t h e r a p i s t g r a s p s

6 . 77 ) .

.

t he

e l bow w i t h

be one

h a n d w h i l e t h e o t h e r fix e s t h e p a t i e n t ' s h i p f r o m a b o v e . He b e n d s her si d e w a y s over h i s own t h i g h s o

Sh ifting the tissues from side to s ide in

ilS

opp osite directions F i r s t we co m p are the

to t a k e u p t h e s l a c k . H e

t e l l s t he p a t i e n t to re s i s t a n c e)

then

look up and b r e a t h e i n ( w h ich i n c re a s e s

degree o f s h i ft

a t ta i n a b l e in t h e

so ft t i s s u e s ; w i t h aile h a n d a t the l e v e l o f t h e s h o u lde r

b l ades a n d t h e o t h e r a t t h e w a i s t . w i t h the pa t i e n t

to h o l d h e r b re a t h , a n d t h e n to

re lax

.

a nd

brea the

o u t , t o o b ta i n re l e a s e . T h i s i s repe a t e d t w o o r t h re e ti m es (Figure 6.79) .

p ro n e , we m o v e t h e h a n d s i n o p p o s i t e d i re c t i o n s , a n d com p a re res i s t a n c e . If t he r e i s a n y d i ffe r e n c e , t h e d irec t i o n o f r e s t r i c te d m o t i o n i s t r e a t e d . T h e p a t i e n t looks t o w a r d s t h e s i d e

a ll

w h i c h s h i ft i s r e s t r i c ted i n

t h e t h o r a c i c reg i o n , w h i l e fi n g e rs , a n d

stretc h i n g

b re a t h e i n . t o hold her b re il t h , slo w l y .

that arm a nd

r a i s e s t h e t o e s . S h e the n i s t o l d

A ga i n ,

i f re l e a s e

occa s i o n a l c o u g h m a y

be

is

to

a n d to breathe

out

sa tisfactory,

an

not

h e l p fu l

Treatmen t of fasciae on the ven tral aspect o f the tru n k W i t h t he p a t i e n t s u p i n e w e c a n s h i ft t h e m a s s o f t h e

pectora l is f r o m t h e s i d e a n d c o m p a re t h e tw o s i d e s . Restriction

on

one

side

ca n

be

tre a te d

d i r e c t i o n o f i n c re a s e d resi s t a n c e , s i m pl y

in

the

by e n g a g i n g

t h e b a r r ier a n d J e tt i n g t h e pa t i e n t b r e a t h e i n s l o w l y ,

(Fig u re 6.78).

h o l d h e r bre a t h , a n d the n taken that our

Stretch ing the tissues on both sides of th e

but

trun k

fi n ge r s

b re a t h e

O Ll t . Ca re m u s t b e

do n o t p o k e

the p il t i e n t ' s r i b s g l i d e a s o n t h e s u r f a ce o f a b a rre l . Re s t r i c t i o n

t h e re is fre q u e n t l y l i n k ed w i t h TrPs of t h e s u bsca p u

R e s t r i c t i o n m a y a f fe c t b o t h s i d es o f t h e t r u n k . i n

l a ri s , t h e p a t ie n t c o m p l a i n i ng of c h e s t a n d ( w o m e n )

w h ich c a s e t h e re i s re s t r i c t i o n a t s i d e - be n d i n g. T o

of b r e a s t p a i n

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.

206

Manipulative Th erapy ill

Rehabilitation of the Locomotor System

I n cases of deep p e l v i c or perinea l p a i n . s h i ft i n g o f soft tissues ove r t h e e d ges o f t h e p u b ic b o n e m a y be i m p a i red o n o n e s i d e ; to restore m o b i l i t y we e n gage t h e barrier so as to obta i n re lease, w h i c h fo l l ows a fter a s h o rt l a tency per i o d .

The sca l p W i th t h e pati e n t s i t t i ng, we ca n e x a m i n e mobi l i t y o f t h e sc a l p i n re lation to the s k u l l , i n a l l d i rect i o n s , a n d compa re t h e t w o sides. One o r two fi ngers (or t h e t h u m b ) a re s u fficie n t to e ngage t h e restricted b a rr i e r , a n d afte r t h e typica l l a te n cy p e r i od re l e ase fo l l ows, u n til n o r m a l mobi l i ty i s restored . The t h e ra p i s t uses h i s free h a n d t o fix the p a t i e n t 's h e a d . C a r e m u s t be t a k e n not to l e t t h e fi n gers s l i p over t h e patie n t ' s h a i r. Res t r icted m o b i l i t y o f the sca l p i s a v e r y i m po rta n t fi n d i n g i n p a t i e n ts w i t h h eadache a n d/or v e r t igo a n d s h o u l d never be m i ss e d .

The neck a n d t h e extre m ities A t t h e neck a n d the e x t re m i ties t h e re is gre a t m o b i l ity of the s o ft tissues. i f w e a p p ly rota t i o n a l m o ve m e n t around t h e i r l o ng a x i s . At t h e extremi ties and even at the cervicothoracic j u n c t i o n we can e i t he r move the w h o l e mass of so ft tissue in one d i rection. or twist one hand aga i nst the o t h e r , as w h e n wri ngi ng a cl oth. A t the n e c k we m a y rotate soft tissues i n the d i rection o f t h e t h u m b o r o u r fi ngers. I n t h e fo rmer case w e c a n act o n l y u p o n a n a rrow strip, i n the latter u pon the grea te r p a r t o f t h e n e c k . as o u r d i a gnosis req u i res. The importa n t poi n t is h o w best to iden ti fy a n d e n gage a p a t h ological barrier, a n d t h e n to obta i n re l e a s e . A typical barrier is regu l a r l y fou n d i n the soft tissue close to periost e a l pain p o i n ts (m astoid processes, e p i c o nd y l e s . wrists, ro u n d the k n ees and a n kles ) . T h e a n a l gesic e ffec t o f norma l iz i n g s u c h a barr i e r i s most rewa rd i n g . A t the neck, norm a l i za tion o f soft tissue m o b i l i t y can gre a t l y increase t h e range of ce rvical motion w h e re restri ction i s u s u a l l y a t t r i b u ted to j oi n t d y s f u n c t i o n ( Figu re 6.80 ) .

Figure 6.80 Rot a t ion of s o rt l i ssues rou n d t he neck for t re a t m e n t of re s t r i c t e d mobi l i t y

the s o ft tissue p a d on t h e p l a n t a r s u r face o r t h e heel is n o t re a d i ly s h i fted on one s i d e . The t h e rapist then app l i es s o ft tissue m a n i p u l a t i o n by p ressi ng with h i s fi ngers o r t h u m b s i n the rest ricted d i rect ion ( Fi g u re 6 . 8 1 ) . I n cases of p a i n fu l A c h i lles t e n d o n (see p. 235 ) and p a i n a t i ts a t t a c h m e n t po i n t . we a l so freq u e n tl y fi n d tenderness i n t h e soft tissue b e t w e e n t he t e n d o n a n d the bones. I n such cases t h e t i ssue must be s t retched betwee n two fi ngers; if t h e re is i n creased resista nce t he t i ssue must be held i ll s t re t c h u n t i l rel e ase occurs ( Fi g u re 6.82 ) .

S o m e speci a l soft tiss u e tech n iq u es I n root s y n d romes rad i a t i ng to t h e toes a n d fi n gers t h e re i s not o n l y a n HAZ a t the s k i n fol d between the t oes ( fi ngers ) , but as a r u l e t h e re i s also i ncreased resistance ( ' b i n d ' ) i f we t r y to move one m e tacarpa l / ta rsa l b o n e aga i ns t t h e n e x t , i n a d o rsopl a n t a r d i rection , i n t h e a ffected segme n t . I n s u c h a case i t i s most e ffec t i v e t o e ngage t h e barr i e r i n a p i n c e r move m e n t , w i t h b o t h t h umbs o n one metatarsal a n d both fore fingers o n t h e o t h e r ; s l ig h t p r e s s u r e is m a i n t a i n e d u n t i l re l e ase is fel t . We t h e n c h a nge the t h u m b a n d fo refi ngers over, to restore mobi l i t y in t h e opposite d i rectio n . [ n cases o f pa i n fu l c a l c a ne a l s p u r we may fi n d t h a t

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pa t h o l ogica l i n t h e v ic i n i t y of a t t a c h m e n t po i n t s o f t e n d o n s a nd l iga m e n t s , i . e . w h ere t e n s i o n i s c re a t e d . I f we s h i f t t h e s u b p e r i os t e a l t i s s u e close t o t h e p a i n p o i n t , w e fi n d t h a t sh i f t i n g i s r e s t r i c t e d i n a t le a s t o n e d i re c t i o n a n d t h a t t h e re i s a h a rd ( p a t h o l ogical) b a r r i e r . I t i s , h o w e v e r , n e ce s b a r r i e r s , m o s t fre q u e n t l y

s a ry t o com p a re i t w i t h a s y m m e t ri c a l p a i n l e s s a re a o n t h e n o n - a ffected s i d e . O n exa m i n a t i o n o f t h e e p i c o n d y l e s we m a y fi n d i t e a s y to s h i ft soft tissues i n a l l d i re c t i o n s , b u t n o t , h o w ev e r , i f t h e r e is ( ch r o n i c ) pa i n . I n the d i re c t i o n of res t r i c t i o n we eng a ge t h e b a r ri e r i n ord e r to obta i n re l ease. As on l y m i n i m u m force is used t a n ge n ti a l to the p a i n p o i n t . t h i s te c h n i q u e i s p a i n l es s , u n l i k e pe r i o s t e a l

m a ssage o r d e e p fr ict i o n , y e t q u i t e as e f fec ti v e a n d e a s i e r to c o n tro l b e c a u s e we k n o w e x a c t l y w h e n the b a rri e r has been re a c h e d a n d w h e n fu l l release is ach ieved ( Fi gu r e 6.83 ) . Wh a t h a s bee n s a i d a bove h o l d s fo r most p e r i o s te a l p a i n p o i n t s , such a s t h e a n t e r i o r p o s t e r i o r i l i a c s p i n e s , t h e pes a n s e ri n u s o n t h e t i b i a e tc . Spe ci a l m e n t i o n , h owever, h a s t o b e m a d e o f t h e s p i n o u s p r o c e s s es . Te n d erness, as a ru l e , is fo u n d at t h e i r t i p ; h o w e v e r , o n care fu l e x a m i n a t i o n i t i s n e v e r e x a c t l y i n m i d -l i ne b u t e i t h e r on t h e r i g h t o r t h e l e ft s i d e o f t h e t i p o f t h e s p i n o u s p r o c e s s . O n t h e te n d e r s i d e w e t h e n p a l p a t e i ncreased resista nce t o p ress u re p a r a l le l to t h e sp i n o u s p ro ce s s , i . e . in a ve ntra l d i re c t i o n . For t r e a tmen t we t h er efor e a p p l y p a r a v e r t e b ra l press u re w i t h o u r fi n g e r t i p : a fte r e n ga gi n g t h e b a r r i e r w i t h m i n i m u m fo rce, re l e a s e is o b t a i n e d . Te n d e r s p i n o u s processes a re m o s t freq u e n tly fo u n d i n y o u n g h y p e r m o b i l e p a t i e n ts , b u t n e v e r w h e n morph ological c h a n g es l i k e B a a s tr u p ' s p h e n o me n o n a re p re s e n t i n e l d e r l y p a t i e n ts . A n o t h e r v e ry fre q u e n t l y te n d e r spi n o u s process is a t t h e a x i s . I t i s t h e l a t e r a l bord e r w h i c h is t e n d e r a n d t h e r e fo r e o n e h a s t o s i d e - b e n d t h e p a t i e n t 's h e a d t o t h e n o n p a i n fu l s i d e to fi n d t h e p a i n p o i n t . T h e re we sh i f t the soft t i ss u e s o v e r l y i n g th e p a i n fu l a re a so as t o fi n d re s t r ict i o n , co m p a r i n g t h e fi n d i ngs w i t h t h e n o n p a i n f u l s i d e . A fter t a k i n g up t h e s lack i n t h e re s t r i c t e d d i re c t i o n , re l e ase i s o b t a i n e d .

S elf-treatment p a t i e n t h ersel f can e a si l y pe rfor m s tr e tc h i n g o f a n a re a o f s k i n , fo l d i n g o f s u b c u t a n e o u s ti s s u e i n c l u d i n g a s c a r , o r e v e n s t r e tch i n g of a m u scle b y t h i s t e c h n iq u e , p rov i d e d t h a t t h e s i te o f t h e lesi o n i s w i t h i n r e a c h o f her h a n d s . S h i ft i n g ( m ov i n g) t h e sc a l p a g a i n s t the s k u l l , o r t h e p a d o f s o ft t i s s u e o n t h e h ee l , s h o u ld prese n t n o p ro b l e m , n o r sh o u l d t w i s ti n g the soft t i s s u e o n t h e extre m i t i e s ( i n the c a s e o f t he

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n i ques d es c r i b e d i n t h e li tera ture ( A n d e r s o n 1 980) . N e v e r t h e l e ss a few t e c h n i q u e s a re prese nted h e r e . To stretch t h e fa sc i a o n o n e s i d e o f t h e t r u n k , t h e p a ti e n t s t a n d s w i t h h e r legs a p a rt a n d p uts o n e a r m

g e n e r o u s l y re p r es e n te d i n t h e cere b r a l c o r t e x are t h e fa c e , i n p a r t i c u l a r t h e l i p s t h e hands a n d t h e fe e t w i t h t h e t h u m b a n d t h e b i g toe . C l i n ica l d i s t u r b a n c e i n t h e fe e t i s c h a r a c t e r i zed b y

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i n a d e q u a t e re a c t i o n t o m e re s t r o k i n g, w h i c h is p e rc e i ve d e i t h e r as u n p l e a s a n t e . g . t i c k l i n g o r t h e re is n e x t to no re a c t i o n t h e fee t g i v i n g t h e i m p r e s s i o n o f b e i n g ' d e a d ' . The two s i d e s c a n a l s o be asym m e t r i ca l . T h e s e c h a n g e s a s a r u l e go hand i n h a n d w i t h a l te red ton u s o f the soft t i ss ll e s a n d m u s c l e s . Ch a n ges i n s e n s i b i l i t y a n d to n u s c a n b e t r e a t e d b y e x t e r oce p t iv e s t i m u l a t i o n s t ro k i n g . A s t h i s m ll s t b e d o n e re p e a te d l y s e l f- t re a t me n t i s req u i red . Fi r s t h ow e v e r , t h e t h e r a p i s t m u s t d e c i d e t h e c o r r e c t i n te n si t y : i t req u i res co n s i de r a b l e experience t o sense t h is . S ti m u la ti o n c on s i s t s o f a s t e a d y s m o o t h move me n t o f t h e r e l a x e d a n d s e n s i n g h a n d i n fu l l co n t a c t w i t h the b o d y su r fa c e . Not o n l y s y m m e try of p e rce pt i o n a n d t o n u s i n c l u d i n g tha t o f m u sc l e s i s a c h i e v e d i n t h i s w a y ; b o t h h y po t o n u s a nd i n c re a s e d t o n u s a r e co r r e cted as n o r m a l iza t i o n i s a c h i e ve d . F o r se l f· t re a t m e n t t he p a t i e n t uses h i s h a n d s o r d r y r o u gh face fl a n n e ls. We do n o t encou rage b r u s h e s or m a s s a ge fl a n n e l s . Fo r sel F- t r e a t m e n t of t h e h a n d s w e re c o m m e n d a d i s h o f r i ce o r l e n t i l s i n w h i c h t h e p a t i e nt m ov e s h e r fi n ge rs, or a s m o o t h s p h e re ( b a l l )

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t h e n grasps the e l b ow and increas i n g t h e p u l l so as to ta k e u p t h e sla c k . L o o ki n g u p , s h e b r e a t h e s i n s l ow l y h o l d i n g her bre a t h a n d t h u s i n c r e 2 s i n g r e s i s t a n c e to s i d e be nd i n g S h e t h e n l o o k s d o w n w h i l e b re a t h i n g o u t ; s i d e b e n din g s h o u ld i n crease. Th is is repeate d t h ree t i m e s ( F i g u re 6.84). T o s t r e t c h t h e fa s c i a a t t h e s i d e o f t h e n e c k , t h e p a t i e n t si ts a n d s t a b i l i z e s h e r s h o u l d e r b y h o l d i n g t h e e d g e o f a c h a i r or a b e n c h w i t h h e r b a n e! . The o t h e r h a n d p a sses over t h e crow n of her head , p u l l i n g i t i n to s i d e - I� e x i o n to t a k e u p t h e s l a c k S h e t h e n l o o k s u p a n d b re a t h e s i n , h o l d s h e r b r e a t h t h u s i n c r e a s i n g resis t a n c e , a n d t h e n re l a x e s to o b t a i n r e l e a s e (F i g u re 6 . 8 5 ) . and

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rol led between t h e fi ngers; fo r t h e fe e t a bag fi l l e d w i t h rou n d pebbles o r wooden b e a d s o n w h ich t h e pat i e n t ca n s t a n d is usefu l . Therapy i s t h us a p p l i e d to a re a s o f c h a nged percept i o n of tact i l e s t i mu l i . I f every stroking by the thera pist is pe rce ived as u npleasa n t , the patie n t sho u l d start w i t h se l f- t re a t m e n t ; i t i s t h e n bet ter fo r her to stro k e herse l f u n t i l s h e c a n tole rate b e i n g touched by t h e t h e ra p is t . T h e trea t m e n t chosen d e p e n d s o n a n a l ysis of the dysfu n c t i o n , i.e. w e start w h e re we expect the most important l i n k o f the pat hoge n e t i c c h a i n . This can be a n a rea o f sudden c h a nge (see ' s trati fication syndrome ' , p . 138). I n genera l , hypotonus is more l i kely to be the p r i m a ry cause as it is freq u e n t l y com pensatory. Hypoto n u s s h o u l d n o t be confused w i t h re laxation: the fo rmer is fl a b b y , the l a tter wel l sprung. Com p l i a nce o f the patient i s o f p a r a m o u n t tech n i cal i m porta nce fo r i n te n s i t y , rhythm and d i recti o n . O u r aim i s t o a c h ieve e l astici ty w h e re flabbiness i s fou n d , o r re lease o f hyperto n u s . M ucb h a s t o b e l e a r n e d by experience. The d i rection i n w h ich stro k i ng is carried o u t m u s t be cons i d e red. M o s t freq uen tly strok ing is d o n e i n t h e d i rection o f the l o n g a x is o f t h e treated e x tremities and o f the trunk and neck , i.e. i n t h e d i rection o f the principa l m usc l e fi b r e s . A t t h e a b d o m e n , w h e re fi b res fol low d i ffe re n t d i rect i o n s a n d w h e re peristaltic m o t i o n o f t h e i n te s t i n e s p l a y s a role , the therapist m u s t fi n d t h e a p propriate tech n i q u e . If i nc reased sensibil ity is d u e to d i s t u rbed d iges t i o n the hands have to move i n c i rc l e s . A fter a bdom i n a l opera t i o ns w i t h lowe red t o n u s of the abdom i n a l muscles both cra n i ocaud a l a n d transverse, latero latera l s t ro k i ng is i n d icated . In t h e a x i l l a r a n d ingu i n a l region w h e re n u merous m u s c l e s cross we reco m m e n d s t ro k i n g both in t h e d i rection of the m uscle fi b res a n d i n a perpe n d i c u l a r d i rect i o n . Active scars surounded by a n H A Z w i t h cha nged sensib i l i ty and tissue tonus a re i n d icated for this type of trea tment. I t i s particu l a r l y i m porta n t to give trea t m e n t to the soles o f t h e fee t if there is i ncreased or l owered sensibi l i t y - i n order e i t h e r to ' q u i e te n ' them or t o 'wake t he m u p ' . T h e l a tter c a n be o f p a r t i c u l a r i m porta nce i n fl a t fee t caused by dysfu n c t i o n . H e r e repeated s t i m u l a t i o n is usua l l y requ i re d . As cha nges i n surface sensibi l i t y g o h a n d i n h a n d w i th cha nges i n t o n u s we can i n fe r t h a t w h e n we fi n d changes i n t o n u s , sensi b i l i t y w i l l b e a t least s l i g h t l y a l tered. Hence ex teroce p tive s t i m u l a t i o n c a n b e rega rded as a spec i fi c m e t h o d of reg u l a t i n g t h e t o n u s of soft t i s s u e s a n d o f m uscles, e v e n i n v o l v i ng l a rge a reas, whether tonus is i n creased or lowere d . It i s therefore very useful to p repare t h e p a t i e n t fo r remed i a l exercise. Poss i b l e cou n te r i n d ications are skin d isease and burns. Once the skin has recov e re d , adequ ate ext ero ce ptive s t i m u l a t i o n can be o f gre a t he l p to restore adequate fu nction i n s k i n receptors . I n a d e q u a te

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e m o tional reaction is a co n tra i n d i c a t i o n to some degree. The t h e r a p i s t h a s t o keep c a l m a n d create confidence by letting the p a tie n t stroke h e rse l f u n t i l she fee l s comfor t a b l e a n d h e r a n x iety subsides.

Post- iso m etric m u s c l e r e l axati o n (PIR) ( M ET) as d escribed b y M i tc h e ll e l at. ( 1 979) is t he most prom i ne n t o f t h e m ob i l iza t i o n t e c h n iques using m u scu l a r faci l i ta ti o n a nd i n h i b i t i o n . A s it obviously acts o n m u scles with i ncreased te n s i o n , I bega n to use i t pre fe re n t i a l ly for the treatm e n t o f t h e s e m uscles. T h i s i s a t v a r i a nce w i th M i tc h e ll h i m s e l f, w h o writes: ' I sometric con t raction . . . c a n be used fo r a rticu l a r m o b i l iza t i o n tech n i q ue s . W h e n isome t rics a re used fo r j o i n t m o b i l ization , max i m a l co ntractions a re n o t d e s i r a b l e si nce they tigh t e n , o r freeze, t h e j o i n ts . Mod e r a te co n tractions a r e m uch more appropriate for j o i n t m o b i l ization . . . W h e n a m u scle a n d i ts fasciae m u s t be stretch e d , h a rd m a x i m a l con tract i o n s a re usefu l . . . . I n m y experience, howeve r , t h i s m e th o d is as a d v a n tageous fo r m uscle re l a x a t i o n as i t has p roved to be fo r j o i n t mobi l iz a t i o n , if t h e re is m uscle spasm and particularly if there a re trigge r poi n ts (TrPs) . If, however, a m u scle or (especi a l ly ) fasciae are s h o r t o r ta u t , stretch is used to o b ta i n m y o fasc i a l re lease (see S o ft tissue m a n ipulati o n ) . The p roce d u re I reco m m e n d is as fol lows: the m uscle is fi rst brought i n to a position i n w h i c h i t attains i ts maximum l e ngth without stretching, taking u p the s l a c k in t h e same way a s in joint mobi l iza t i o n . I n t h i s ( e x trem e ) posi t i o n t h e patient is asked to resist w i t h a m i n i m u m o f force (isometrica l l y) . T h i s res i s t a n ce is h e l d for a b o u t 10 s , a ft e r w h i c h the p a t i e n t i s told to ' l e t go' ( re l a x ) . It i s now essen tia l to w a i t u n t i l the therapist senses t h a t the patient h a s i n d e e d re l a x e d , a fter w h ich he c a n u s u a l l y o b ta i n a greater range o f move ment by p ure relaxa tio n , not stretc h . The time d u ring w h ic h relaxation takes place c a n v ary considera b l y , from several seco n d s to half a m i n u te ; t h e longe r , the better: we s h o u l d neve r cut i t s h o r t , fo r re l a x a t i o n is t h e re a l goa l . The refo re i t is essen t i a l to sense i t . I f re l a x a t i o n p roves t o be u ns a t isfactory, however, t h e re i s a s i m p l e and relia b l e way of i m p ro v i n g i t : by len g t h e n i n g t h e isome tric phase to a s m u c h a s h a l f a m i n u t e . However, i f r e l axa t i o n h a s b e e n sa tis factory from t h e start, i t is possible to shorten the isom e t ric p h ase. The p roced u re i s repeated t h re e to five t i m e s ; the gro u n d g a i n e d each time s h o u l d n o t be lost d u ring t h e follow i n g p h a s e . If re l a x a t i o n i s g o o d , t h e t hera pist s e n se s t h a t t e n s i o n is, so to s p e a k , ' th a w i n g away', i n w h i c h c a s e rep e t i t i o n a d d s n o t h i n g to t h e res u l t . T h e good res u l ts obta i ne d w i t h P I R techn i q ue s a s descri bed here ca n be sign i fi can t l y i mproved b y com b i n i n g P I R with m e t h od s t h a t affect t h e pos t u ra l PIR

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Manipulative Therapy in

Rehahilitation of the Locomotor System

m uscul a t u re as a w h o l e , such as e y e move m e n ts , i n h a l a tion a n d e x h a l a t i o n . Lo o k i n g to th e s i d e fa c i l i t a tes r o t a t i o n ( b u t not s i d e - b e n d i n g l ) ; l o o k i n g u p fa c i l i t a te s s t raigh te n i ng u p , a nd l o o k i n g d o w n faci l i t at e s s t oo p i n g I n h a l a t i o n fac i l it a tes m uscu l a r con traction, wh ereas p ass iv e e x h a l a t i on inhi bits m u sc u l a r a ct i v i ty a n d faci l i tates re laxa t i o n . Th e r e a re importa n t exce p tions a n d m o d i fica t i o n s however ( e g t h e j a w ) , attributable t o r e s p i r a t o r y syn k i n e s i s i . e . w h e n movem e n t i n o n e d i re c t i o n i s c ou p l e d w i t h i n h a l a t i o n w h i l e move m e n t in the opposite d i re c t i o n g o e s w i t h e x h a l a t i o n : t h u s , b e n d i n g fo rw a rd i s usua l ly l i n ked w i t h e x h a l at i o n a n d stra i g h t e n i n g up w i t h i n h a .l a ti o n : it is difficult to brea t h e in w h i le stoop i ng, or to b rea t h e o u t wh i l e s trai g h t e n i n g u p . This i s a l s o true for s i d e-be n d i ng and b ac k w a r d -bend i ng ( s e e M o b i l ization i n to r e t ro fl e x i o n p. 1 80 , F i gu re 6 . 3 4 ) . The fO l l o w i n g p o i n t i s of practical v a l u e : a t i n h a lation with t h e t ru n k i n e x t e n s i o n the d ee p back m uscles re l a x , w h e reas during e x h a l a t i o n t h e y c o n t r ac t (see Isometric traction, p. 1 75 , Figure 6 2 8 ) . This is i m port ant for the m a s t i c a t o r y and s u b m a n d ib u l a r m uscl e s , t h e stern o m a s toids, s ca l e n i , pectora l e s , q ua d rati l u m bo r u m , e tc. See a l s o ' G a y m a n ' s effect' , p. 27 . W h erever poss i bl e , t h e fo rce o f gra v i ty is used a s d escribed by Z bo j a n ( 1 988 ) , fo r i s o m e t r i c res i s t a n ce and for relaxa t i o n . The force of grav i t y is used t o give resis t a nce, fo llowed by rela x a t i o n . Accord i n g to Z b oj a n , w h e n gra v i ty i ndu c e d re l a x a t i o n i s used alone, t h e con traction and rel a x a t i o n ph a s e s s h o u l d each last for 2 0 s . W h e n c o m b i n e d with r e s pi r a t i o n t h e s e p h a s e s s h o u l d coinci d e with t h e respira tory p ha s e s . G r a v i ty - i n d uced P I R is a m e thod of se l f trea t m e n t rig h t from t h e begi n n i ng. The e ffects o f tre a t m e n t c a n b e ascer t a i n e d n o t o n l y i n t h e m u s c l e tre a t e d , w h e r e t r i g g e r p o i n ts a nd t e n s i o n s ho u l d have d i s a pp e a re d b u t p a i n p o i n t s s i t u a ted m o s t freque n t l y w h e re t h e t e n d o n i s a t t a c h e d t o t h e perioste u m , w i l l a l s o h a v e d is appear ed . At t i m e s , t h ese p a i n poi n ts a re more l i ke l y to be d u e to r e fe r r ed p a i n i n w h ich case P I R i s a s e ffective a s loca l a naesth e s i a or n e e d l i n g . Th is m e t h o d i s h i g h l y specific i n f a n-s h a p e d m uscles whose fibres m us t be treated w h e re i n c reased t e n s i o n is fou n d . Th at i s u s u a l l y in t h e d i rection of p a i n fu l a tta c h m en t p o i n ts (e.g. p a i n p o i n t s on the ribs o w i n g to TrPs i n the pectora l is ) . H e n ce o n e reaso n f o r fa i l u re is i n s u f fi ci e n t s p e ci fi c i t y T h i s m e t h o d i s u s e l e ss w he re t he r e is no increased m uscl e t e n s i o n . T h e r a p e u t i c fai l u re m a y a lso be d u e to a n u n d e rl y ing c a use p rod u c i n g renewed m uscular tension, such as j oi o t b l ockag e o r v iscera l d isease i n t h e co rr e sp o n d i n g s e gme n t . Theoretically, S h er ri n g ton 's post-isometric ( me d u l l a ry ) i n h i b i t i o n c a n n o t e x p l a i n t h e e ffec t i ve n ess o f t h i s m e t h o d beca use o f th e l o ng l a t e n c y period. Com pared with the classic method o f Kabat ( 1 96 5 ) , n o t o n l y i s r e s i s t a n c e m u ch w e a k e r , b u t active s t r e t c h i s also avoided. Th e e x p l a n a t i o n o f t h e .

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exce l l e n t res u l ts fu rn ished b y t h i s m e t h o d m a y b e s oug h t i n t h e fa c t th a t (I ) d u r i n g resista n ce o f m i n i m a l force o n l y very f e w m uscle fi b res a r e a c t i v e , t h e o th e rs r e m a i n i n g i nactive, while (2) d u r i n g re l a x a t ion t h e s t r e t c h reflex i s avoided , (I r e fl e x w h i c h is brought a bout e v e n by passive a n d n o n p a i n f u l stretch . On t h e o t h e r h a n d t h e r e a r e s i t u a t io n s i n w h i c h t h e p a t i e n t e x pe r i e n ce s some p a i n d u ring P I R a n d yet goes o n re l a x i n g ( e . g . i n 'ligame n t p a i n ) . A fter t h e p roc e d u re , however, t he r e is a n a l g e s i a . Th is m e t hod d e m o n s t ra tes v e r y c l e a r l y t h e c l os e i n terre l a t i o n b e t w e e n t e nsion a n d p a i n a nd re l a x a t i o n a n d a n a l g e s ia This method i s co m p a ra b l e with the 'spray and st retch ' m e t h od o f Travell ( 1 976) b u t pl aces gre a t e r e m p has i s o n re l a x a t i o n . I n d e e d , s t re t c h i s n o t e s se n t i a L as l e n g t h e n i n g is m e re l y t he p roof of successf u l r e l a x a tion ( d eco n t r a ct i on ) In some of t h e gravi ty-i n d u ced t e c h n i q u e s a n d i n re l a x a t i o n o f t h e g l u t e i , n o s t r e t c h takes place. S t re t c h se e ms to b e req u i red o n l y w h e re t h ere i s t rue m u sc l e s h o r t e n i n g ( t a u tn es s ) d ue to c o n n e c t i v e t i ssue c h a n g e s c a l l i n g fo r soft t is s u e m a n i p U l a t i o n . To show the e ffec t i v e n e s s o f o u r m e t h o d , 3 5 1 pa i n ful m u s c l e g r o up s or m u s c l e a t t a c h m e n t s were treated i n 244 p a t i e n t s . There was i m m e d i a te a n a lgesia i n 330 i n s t a n ce s , w h e r e a s o n l y i n 2 1 w a s t h e r e no e ffect. R e ce n t l y using i n te r m i t te n t res i s t a n c e , we find i t ve r y useful t o comb i n e P l R w i t h c o n t ra c t i o n of t h e a n tago n i s t : i n the po s i t i on t he pa t i e n t h a s reached by P I R , s h e p re s s e s l ightly a g a i nst m o d e r a t e re s i s t a nce by t h e the r a p i s t i n t h e d i re c t i o n rea c h e d b y r el a x a t i o n . H e c h a n ge s t he counter- p ress u re r h y t h m ica l l y s e v e r a l t i m e s p e r sec o n d . Th e p a t i e n t m a y a l so m a k e a m a x i m u m m o v e m en t in t h e d i rection o f mobi l iza t i o n . ,

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Treat m ent o f i n d i vi d u a l m u sc l es a n d p o i nts of atta c h m ent T h e te c h n i q u e s

descr i bed here a re useful not fo r t herapy, b u t a lso for d i agnosis.

on ly

Tension i n the masti catory muscles Te n s ion

in the m a s t i c a t o r y m u s c l e s ( T r Ps) ca n b e p a l pated i n the te m p or a l r e g i o n ( t h e t e m p o ra l is), w h i l e fo r s c r e e n i ng p a l p a t ion t h rough t h e c h e e k s w i t h t h e m u scles relaxed shou l d reve a l a s y m m e t ry . A h e a l th y s ubj e c t s h o u l d be a b l e to i n s e r t t h re e k n uc k l e s betwee n the upper and lowe r i n c i sors. F o r accurate d i a g n os i s of TrPs, w h i ch a r e ofte n very tender, it i s n e cessa ry to p al p a t e th rough t h e o p e n m o u t h . If this procedure is pai nfu l , the tem poroma ndibu l a r joi n t w i l l also b e te n d e r o n pa l p a t i o n , e i t h e r owing to referred p a i n o r b e c a u s e t h e e x tern a l p t e r y go i d attaches to t h e m e n i sc u s of t h a t j o i n t The m a s s e t e r

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Therapelltic techn iques

21 1

( a) (a)

( b)

( b)

Figure 6.86 (a) P I R 01 t he m a sse t e rs, i n t e rn a l p t e rygo i d s a n d t h e t e m p o r a l m u scles: ( /J ) se l f- t re a t m e n t

t re a t m e n t

fro n t o f i t , a n d TrPs h e re s h o u l d be p a l p a ted p i n ce r gri p , w i t h one fi nge r i ns i d e the m o u t h and t h e o t h e r on t h e c h e e k . T h e i n t e r n a l p t e ryg o i d i s palpa ted with a s i m i l a r p i n c e r moveme n t , be h i n d t h e m a ssete r , a bo v e a n d be h i n d t h e l a s t m o l a r , t h e p a l p a t i n g fi n ge rs h o l d i ng t he ramus o f t h e mand i bl e . W i t h t h e exce p t i o n o f t he exte rn a l pte rygoi d , P I R of t h ese muscles is perfo r m e d by fi rst t a k i n g u p t h e s l a ck : t h e m o u t h is o pe n e d , t h e n closed aga i n s t isomet ric r e s i s t a nce w i t h t h e m i n i m u m o f force ; rel a x a ti o n c o m e s w i th o pe n i ng of t h e m o u t h . Fo r t h is m a n o e u v re to be e ffect i v e , res p i ratory sy n k i n e s i s i s esse n t i a l . T h e p a t i e n t is told to b re a t h e o u t a ft e r t h e s l a c k h a s bee n t a k e n u p by o p e n i n g h e r m o u t h , t h e n t o o p e n t h e m o u t h w i d e a s i n y a w n i n g , a n d ta ke a d e e p bre a t h (F i g u r e 6 .86a ) . I r t h e m u s c l e s i n q u e s t i o n a re the t e m pora l i s a n d/or t he i n t e rn a l p t erygo id , we m a y i n t roduce d e v i a ti o n to t h e side d u r i n g t h e re l a x a t i o n p h a s e , t o t h e opposite s i d e i n t h e tem por a l i s and to the same side i n the p terygo i d . Fo r s e l f- t re a t m e n t t h e pa t i e n t s i ts a t a ta b l e , o n e e l bow o n t h e t a b l e , w i t h t h e h a nd p r o p p i n g h e r for e h e a d : t h e fi n g e r s o f t h e o t h e r h a nd a re o n t h e lowe r i n c i sors. A ft e r o p e n i n g h e r m o u t h to t a k e u p

the slac k , s h e b re a t hes o u t ; d u r i n g i n h a l a t i o n s h e ope n s h e r m ou t h a s w i d e as poss i b l e . The h a n d o n t he forehead s h o u l d pre v e n t a n te flexion , w h ich w o u l d i n te r fere with m a x i m u m o pe n i n g o f t il e m o u t h ( F i g u r e 6.86b ) . T o t r e a t the e x t e r n a l pte rygoid t h e p a t i e n t i s s u p ine, h e r m o u t h s l i g h t l y o pe n . T h e t h e r a p i s t p l aces h is t h u m b s on the m a n d i ble from above; t h e p a ti e n t i s told t o p ress h e r ch i n forward a g a i n s t h i s t h u m bs , w h i le b r e a t h i n g i n ; s h e holds h e r brea t h , t h e n b r e a t h e s o u t , l e tting t h e ch i n d rop back. F o r se l f trea t m e n t she u s e s h e r o w n t h u m b s ( F i g u re 6 . 87 ) . The m a i n a n t a g o n i s t o f t h e mastica tory m u s c l e s i s t h e d i g a s t r i c u s w h i c h a t ta c h e s t o t h e hyo i d . Increased t e n s i o n is b e s t d i a g n o sed by s h i f t i n g t h e t h y roid c a rti l a ge f r o m s i d e to s i d e . I f t e n s i o n i s m a rked o n o n e s i d e , d e v i a ti o n o f t h e c a r t i l a ge to t h a t s i d e can e v e n be seen. Fo r PIR t h e p a t i e n t should be s u p i ne ; with o n e h a n d the t h e ra p i s t resi s ts t h e o pe n i n g of t h e mo u t h w h ile t h e t h u m b o f t h e o t h e r exerts m ini m a l p res sure o n t h e hyoid o n t h e side of i n c re a sed t e n s i o n ( d e v i a t i o n ) . T h e h y o i d i s pa l p a t e d a bo v e a n d l a t e r a l to t h e t h y roid ca rti lage. T h e p a t i e n t o p e n s h e r m o u t h

l i es i n

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Figure 6.87 (a)

P I R of t h e

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exte rn a l pte rygo ids: (/J) self

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Manipulative Therapy in Rehabilitalion of th e Locomotor System D u r i n g t h e resistance p h a s e s h e s l ig h t l y ope ns h e r m o u t h a n d b re a t hes i n , h o ld i ng h e r breat h a n d t h e n re l a x i n g w h i l e brea t h i n g o u t ; s h e c loses h e r m o u t h . w h i l e h e r t h u m b moves t h e h y o i d ve ry ge n t l y ( Fi g u re 6.88b) . I f the re is i ncreased te n s i o n (TrP) i n the m y l o h y oid m u s c l e i n the s u b m a n d i b u l a r region b e h i n d the c h i n , sel f- t re a t m e n t i s t h e only possi b l e a p p roach . The p a t i e n t p resses t h e tip of h e r tongue aga i nst t h e h a rd palate w h i le b r e a t h i n g i n , a n d lets the tongue drop back w h i l e b r e a t b i n g o u t .

Tension in the reg ion of the posterior a rc h of t h e atlas (Figure 6 . 89)

( a)

Te n s i o n a n d t e n d e rn e ss ( T r P s ) in t h i s regio n , i . e . of the short ex tensors o f the cra n iocervical j u nction , c a n be p a l p a ted o n l y w i t h tbe patient s u p i n e , h e r h e a d i n a n t e fl e x i o n . F o r t reatme n t tbe p a t i e n t s i ts on the t a b l e , with t h e therapist s t a n ding be h i n d her, and l e a n s aga i n s t h i s ches t . The therapist p l aces both t h u mbs o n t h e p a ti e n t's occ i p u t , with h i s fi n gers o n the m a l a r bones fro m a b o v e . T o t a k e u p t h e slack, t h e therapist ti l ts the head s l i g h t l y fo rward so as to d ra w t h e p a t ie n t ' s chin i n t o her neck . H e t h e n te l ls t h e p a t i e n t to look u p a n d breathe in s l o w l y wh ile resi s t i n g the patient's tende ncy to raise h e r h e a d : the patient is t h e n to l d to look down and breathe out slowly, le a n i n g back and bringing ber chin e v e n closer to t h e t h ro a t ( s h e m u s t n o t b e n d forwa rd) . This ma noe uvre i s repeated a b o u t t h ree ti mes. For s e lf-trea t m e n t . the patie n t ( Figu re 6 . 90) uses her o w n h a n d s , placing her fi ngers on t h e occiput a n d her t h umbs o n the ma l a r bone. I n order t o b r i n g the c h i n i n tow a rd s t h e t h roat d u ring relaxa t i o n , t h e p a t i e n t m us t l e a n backwards over a l o w cha ir-back. ,

Te n s i o n in the levator sca p u l a e ( Fi g u re 6 . 9 1 ) T h e typica l p a i n p o i n t s a re o n t h e lateral surface the spinous process o f C2 and o n the s u p e r i or border of t h e scap u l a . TrPs a re s i t u a te d ab ove t h e u p p e r m e d i a l a ngle o f th e sca p u l a o n t h e neck. For treatm e n t the patien t is s u p i ne w i t h her head at t h e end of the t a b l e a n d the e l bow o f t h e fl e x e d a rm raised above h e r h e a d . The therapist exerts p ressure on the sca p u la by p r e s s i n g in a caudal d i rection aga i n s t t h e e l bow, fl x i n g i t with h i s t h i g h . Us i n g both hands h e now bends the h e a d to t h e opposite s i d e , r a i s i n g a n d t u r n i n g i t v e r y s l ig h t l y i n t h e same d i rection u n t i J t h e s l ack i s taken u p . Th i s i s fe l t soon e r o n t h e s i d e o f i n creased tension t h a n on t h e o t h e r s i d e . The p a t i e n t t h e n l o o k s tow a rds the si d e t h a t is be i n g trea ted, a n d slowly breathes i n . w h i l e t h e therapist resists t h e a u to m a t ic tendency t o turn to tbat side. H e t h e n te l l s the patient t o 'let go' a nd brea t h e O Li t . D u ri ng t h e e n s u i ng re la x a t i o n t h e head is s l ig h t l y moved s i d e wa rds a n d fo rwards. H e may of

( b) Figure 6.88

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P I R of

the d igastricus: ( b ) se l f-treatment

a ga i n s t very s l ig h t resi s t a n c e and breathes in, hoJ d s h e r brea t h , a n d t h e n breathes o u t a n d re laxes. D u ring re laxatio n , t e n s i o n i n t h e d i gas t ricus w i l l a u t o m a t i c a l l y give u n d e r t h e therapist's th umb w h e re r e l ease i s fe l t ( F i g u r e 6.88a ) . F o r self-tre a tm e n t t h e p a t ie n t s i ts a t t h e t a b l e , ch i n i n o n e c u pped h a n d , w h i l e t h e t h u m b o f t h e o t h e r h a n d l i e s l a teral t o the h y o i d o n t h e tense s i d e .

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Th erapelltic techniques

( a)

( a)

(b)

( b)

Figure

6.89

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o f tensi on j u nction : (a)

PIR

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i n t h e s h o rt e x t e n s o rs o f t h e res i s t a n c e : (h) relaxa t i o n o f c r a n i o ce r v i c a l j u n c t i o n

Figure

6.90

Se l f� t re a t nl e n t of t e n s i o n i n t h e t he cra niocervica l j u n c t i o n

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Copyrighted Material

s h ort

213

214

I'vl aniplliative Th erapy in Rehabilitation of the LocomolOr System

Figure 6.91 Ex a m i n a t i o n a nd PIR o f te n s i o n in t h e

Figure 6.93 G ra v i t y - i n d u c e d P I R o f t h e l e v a t o r sca p u l a e

lev a t o r sca p u l a e ,

a n d t h e upper part of

t h e trapez i u s : l d t , w i t h s h o u l d e r s r i g ht. w i t h s h o u l d e r s l owered

w i t h fi x a t i o n o f the sca p u l a p u s h e d d o w n by t h e t h e ra p i s t p r e ss i n g his t h igh o n t h e patie n t 's e l bow

raised:

a l so t e l l t h e p a t i e n t t o p u ll o n e e l b o w u p s li g h t l y ,

tow a r d s t h e s i d e a w a y fro m w h ic h t h e h e a d i s b e n t .

u p t h e s l a c k . He then w h i l e h e r e s i s ts t h e m o v e m e n t , a fte r w h i c h h e a g a i n

asks

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the

resist i ng t h e p a t i e n t ' s a u t o m a t ic t e n d e n c y t o

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I f , h o w e v e r , t h e p a t i e nt c a n n o t r a i s e h e r a r m to

b r e a t h e out d u r i n g re l a x a ti on ; m e a n w h i Je t h e h e a d

t h e u t m o s t , th e t h e r a p i s t s t a n d s a t that side o f t h e t a b l e t o w h i c h re l a x a t i o n i s c a r r i e d o u t . H e p u s h e s

is m o v e d fu r t h e r t o t h e s i d e u n t i l t h e s l a c k h a s a g a i n b e e n t a k e n u p . R e s i s t a nce m a y a l s o be g i v e n aga i n s t

moves

the

head

sideways

and

fo r w a rd .

Th is

t o l d to bre a th e in d u r i ng this m a n oe u v r e . and to

r e p e a ted two o r three t i m es .

h e r s h o u l der d o w n w i t h o n e h a n d , w h il e t h e o t h e r

t h e s h o u l d e r , from abo v e ; i n t h i s c a s e t h e p a t i e n t i s

r o u n d t h e b a c k o f h e r occ i p u t a n d n e c k prod u ce s

t o l d to l i ft h e r s h o u l d e r a g a i n s t t h e res i s t a nce o f t h e

s i d e - b e n d i n g , s l ig h t l y fo rw a rd a n d i n to rota ti o n , s o

t h e ra p i s t , w i t h t h e l e a s t p o ss i b l e force : a f t e r a b o u t

a s to t a k e u p t h e s l a c k . Th e n P I R t a k e s p l a c e a s

1 0 s s h e s h o u l d ' le t g o ' . T h e t h e r a p i s t s h o u l d t h e n

described above.

b e n d t h e h e a d a n d n e c k s i d e w a y s a ga i n . to t a k e u p t h e s l a c k . I n b o t h c a s e s t h e proce d u re is re p e a t e d

Ten s i o n i n the upper p a rt of the trapezi u s m uscle ( F i g u re 6 . 92)

a b o u t t h re e t i m e s . T h e e ffe c t o f P I R o f t h e l e v a t o r sca p u l a e a n d t h e u p p e r t r a p e z i us c a n

be e n h a n c e d

by

il il t a go il is t

The u pp e r t r a p e z i u s s h o u l d b e t r e a t e d if te n d e r a n d

sti m u l a t i o n : the patient, with the head i n n e u t r a l

t a u t . T h e p a t i e n t i s s u p i n e , w h i l e t h e t h e ra p i s t fi x e s

p o s i t i o n , l e e1ll s a g a i n s t t h e h a n d o f t h e t h e r a p i s t

t h e s h o u l d e r f r o m a b o v e w i t h o n e h a n d , s id e - b e n d i ng

a n d r e s i sts s l i g h t pre s s u re f r o m t h e s i d e to w h i c h

t h e h e a d a n d n e c k w i t b t h e o t h e r h a n d so as to t a k e

re l a x a t i o n too k p l a c e ; t h i s p r e ss u re t h e t h e r a p i s t i n t e r m i t t e n t l y i n c re a ses a n d d e c re a se s .

Fo r s e l f- t re a t m e n t o f b o t h t h e u p p e r t r a p e z i us a n d t h e l e v a t o r sca p u l a e , gra v i ty- i n d u c e d P I R i s m o s t

e ffe c ti v e . T h e p a t i e n t sits aga i n s t

a

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post ure.

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she

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s h o u l d e rs w h i l e l oo k i ng u p a n d b r e a t h i n g i n ; a fter h o l d i n g h e r b re a t h she b r e a t h e s out s l ow l y w h i le l e t t i ng t h e s h o u l d e rs d ro p ( F i g u re 6 . 9 3 ) . No good re J a x a t i o n of t h e s e m u s c l e s c a n b e o b t a i n e d w i t h ro u n d e d s h o u l d e rs a n d t h e h e a d d ra w n fo rwa rd .

Tension i n the sca l e n e m u scles ( F i g u re s 6 . 94 a n d 6.95 ) I n m o s t cases t e n s i o n of t h e sca l e n u s d o e s n o t c a u s e F i g u r e 6.92 E x a m i n a t i o n a n d P I R o f t e n s i o n i n t h e u p p e r p a r t o f t h e t rapezi us

d i r e c t p a i n b u t i s o f g re a t c l i n i c a l s ign i fi c a n c e . A s a r u l e t h e s ca l e n e s a re t e n s e i f t h e o t h e r u p p e r fi x a tors

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'Th erapeulic techn iques

2 1 .'>

o f t h e s h o u l d e r g i rd l e a re t e n s e ; t h e y p l a y a d e c i s i v e role i n fa u lty r e s p i r a t i o n . ca u s i n g t h e p a t i e n t to l i ft h e r t h o ra x , a n d

in

t h e s y n d ro m e

o f the

upper

t h o r a c i c o u t l e t . T e n s i o n i n t b e pectora l e s a n d p a i n p o i n ts a t the s te r n ocosta l j u n c t i o n o f t h e u p p e r r i b s s e e m to be co n n ec ted w i t h t e n s i o n of t h e sca l e n e s . T h i s m a y e x p l a i n w h y t e n s i o n of t h e

t o p r od u ce

a

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patien ts,

w h o t h u s fe e l gre a t relief after P I R . D y s fu n c t i o n o f t h e fi rs t r i b goes h a n d i n h a n d w i t h T r P s of t h e s ca l e n u s o n t h e s a m e s i d e , c o r r e s p o n d i n g t o E rb ' s po i n t . T h e s e c a n be a b o l i s h e d by P l R o f t h e sca l e n u s . O n e x a m i n a t i o n , t e n s i o n i n t h e s c a l e n u s c a u se s res t r i c t i o n o f retro A e x i o n of t h e rot a ted h e a d to t h e o p p o s i t e s i d e . I f t h e r e i s m a rked c e r v i c a l l o rd o s i s . t e n s i o n o f t h e sca l e ne s m a y r e s t r i c t s i d e - be n d i ng o f sea ted , s i m u l a t i n g te n s i o n i n t h e u p p e r part of t h e t r a p ez i u s

t h e h e a d w i t h t h e p a ti e n t

.

For e x a m i n a t i o n . as fo r t r e a tm e n t , th e p a t i e n t s i ts o n the t a b l e , wh i l e t h e t h e r a p i s t s t a n d s be h i n d h e r a n d s u p p o r t s t h e s h o u l d e r o n t h e s i d e to be t r e a t e d

.

w i t h o n e h a n d fi x i n g t h e u p p e r r i b s of t h e s a m e s i d e

by press u re on t h e p a t i e n t s c h e s t . W i t h t h e o t h e r '

h a n d t h e t h e r a p i s t t u rns t h e p a t i e n t s h e a d to t h e o t h e r s i d e . b e n d i n g h e a d a n d neck backwards so as '

Figure 6.94 E X 8 lTI i n a t i o n a n d PI R of t h e sca l e n u s

to t a ke

u p t h e s l a c k . H e n o w t e l l s t h e p a t i e n t to l o o k

t o t h e s i d e o f t r e a t m e n t , resisting a u t o m a t i c m o v e m e n t w i t h m i n i m a l p ress u re o n t he pa t i e n t ' s t e m p l e

,

te l l i n g h e r to b re a t h e i n s l o w l y ; t h e t h e r a p i s t r e s i s t s t h i s i n h a la t i o n b y p re ss i n g t h e o t h e r h a n d a g a i n s t t h e pa t i e n t ' s c h e s t w i t h c o n s i d er a b l e fo rce . T o d o

t h i s h i s e l bo w s h o u l d be r a i s e d a n d b r o u g h t fo rw a r d . A ft e r fu l l i n h a l a ti o n t h e pa t i e n t i s t o l d to l o o k t o t h e breathe out. let t i ng the h e a d a n d n e c k d r o p i n to r e t r o A e x i o n ( h e m u s t n o t p u s h ! ) . T h i s p roced u r e i s repeated a b o u t t w o o r t h re e t i m e s . T h e r e i s p e r h a p s n o m u scle t h a t b e t t e r

s i d e o f re l a x a t i o n a n d to

l e n d s i ts e l f t o re l a x a t i o n t h a n the sc a l e n u s . F o r s e l f- t re a t m e n t , g r a v i t y i n d u c e d PIR i s dfe c t -

i v e . T h e p a t i e n t l i es o n h e r

s i d e , l i f t i ng h e r h e a d , s h e holds her brea t h t h e n s l o w l y s i n k s b a c k t o t h e t a b l e w h i l e bre a t h i n g o u t . T h i s is re p e a te d t h r e e t i m e s ( F i g u re 6 . 95 ) . I f , h ow e v e r , r e s p i ra t i o n is at f a u l t c o rrect i o n o f bre a t h i n g is t h e m e t hod o f c h o i ce . l oo k i n g u p a n d b r e a t h i n g i n ;

,

Te nsion i n t h e sternocleidom asto ids ( Figure 6.96) Th e r e i s f r e q u e n t l y a p a i n p o i n t a t t h e med i a l e n d o f t h e c l a v icl e a n d a t the transv e rs e proce ss of t h e a t l a s . T h e re are , h o w e v e r , n u m e ro u s t r igge r poi n ts to be fo u nd in t h e c o u rse of t h e m u s c l e ( t h e c l a v i c u

la r a s w e l l a s t h e stern a l d i v i s i o n ) pa rtic u l a rl y b e l o w t h e m a s t o i d p rocess, r e fe rri n g pain t o t h e fa ce a n d c ra n i u m . Te n s i o n i n t h e s t e r n oc l e i d o m a s t o i d m u s c l e ,

Figure 6.95 G t'a v i t y - i n cl u cecl P I R o f t h e sca le n i : a bove. with h e a cl r a i sed : below. with head l o w e red

m a y a l s o prod uce te n s i o n i n t h e s u b c l a v i c u l a r p a r t of t h e p e c t o r a l i s m u scle .

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21 6

Manipu/alive Therapy

in

Rehabililalion of th e

Loco m otor System

Figure 6,96 G r a v i t y - i n d u c e d P lR of t h e

Left : w i t h h e r h e a d of t h e t a b l e , t h e p a ti e n t b rea t h e s i n a n d looks u p . a u to m a t i c a l ly c o n trac t i n g t h e sternocl e i d o m a s t u i d a n d s l i g h t l y l i ft i n g h e r h e a d . R i g h t : s h e b r e a t h e s o u t a n d r e l a x e s , t h u s l e t t i ng t h e h e a d d ro p

s t e r n oc l e i d o m as t o i d m u s c l e .

t u r n e d to the s i d e over

For tr e a tm e n t of t h i s co ndition, gravity-induced P I R is t h e most effective m e t h o d . The p a t i e n t l ies s u p i n e , with h e r h e a d rotated a n d resti n g over t h e edge o f t h e t a b l e , t h e c h i n s u pp o r te d b y t h e e d ge of the t a b l e , a c t i n g a s a f u l c r u m . I f t h e l e ft sterno mastoid is to be treated, t h e h e a d is ro t a t e d to the r i g h t . I n t h i s pos i tion the p a t ien t is told to look u p a n d t o take a slow dee p bre a t h ; d u ri n g d e e p i n s p i r ation the sternomasto i d m u scle s l i gh t l y con tracts, lifti ng the h e a d , w h i c h is pivoted on t h e e d g e o f the ta ble . I n th is position s h e h o l d s h e r brea t h ; a fte r this she l o o k s to the c h i n a n d d u ring s l ow e x h a l a tion t h e p a t i e n t relaxes, t h e top of the head is lowered, and a slight s t re t c h i ng o f t h e sterno cleidomastoid ensues. This m a n o e u vre is re peate d about t h re e t i m e s . T h i s t e c h n i q u e gives exce l l e n t re sults i n t h e treat men t of a b l o c k e d a t l a n to-occ i pital j o i n t , a n d c a n be u s e d fo r self-tre a tment o f this j o i n t . I t h a s a m a rk e d ana lgesic e ffect on pai n ful or te n d e r trans v e rse processes of the a t l a s .

the

edge

t h e f u l l y abd ucted a r m a b o u t 2 cm, b re a t hing i n slowly a n d to h o l d h e r bre a t h . S h e t h e n r e l a x e s a n d breathes o u t s l o w l y , r e p e a t i ng t h is proce d u re a b o u t three t i m e s . She s h o u l d n o t re l a x s u d d e n ly, a s t h is w o u l d cause b r u s q u e s t r e tc h i n g . I f the sternoco s t a l p a r t of t h e p e c to r a l i s m u s c l e i s t e n s e t h e p a t i e n t t e n d s to be ro u n d s h o u l d e re d ; fu l l e l e v a t i o n o f t h e a r m i s re s t r i ct e d (Figure 6.98 ) , a n d t h e tendon i n t h e a x i l l a i s t a u t o n p a l p a t i on . a s well as t e n d e r . T r P s C il n be p a l p a te d by a p i n c e r m o v e m e n t w i t h t h e fi n g e rs b e t we e n t h e m u s c l e a n d t h e

r i b s , a n d t h e t h u m b on t h e s u rface o f t h e c h e s t . Fix a t i o n and treatm e n t a re s i m i l a r to t h a t p r e s c r i b e d for the u p p e r part o f the muscl e . O nce the p a t i e n t h a s u n d e rstood t h e c o r rect pos i t i o n a n d d i re c t i o n . grav i t y- i n d u ced P I R is c a r r i e d o u t by the p a t i e n t h e rs e l f .

Tensi o n i n the pectora l i s m aj o r I ncreased t e n s i o n (sho r t e n i ng) of t h e u p p e r (clavicu lar) p a r t o f the pectora l is ( Figure 6 . 97) res u l ts i n a forw a rd-drawn pos i tion of the s h o u lders. For both ex a m i n a t i o n and t r ea tm e n t, the p a t i e n t i s s u pin e , h e r arm abducted a t ri g h t a ngles . T h e t h e r a p ist sta nds a t t h e side of t h e a ffected m uscle ; w i t h h i s forearm h e fixes the pa t i e n t 's stern u m from a bove and palpates the tendon b e n e a t h the cl avicle with h i s fingers; i t should n o t b e tense even a t m a x i m u m abduction. T h e other arm brings t h e p a t i e n t ' s a rm i n to m a x i m u m a b d u c t i o n o v e r t h e side of the t a b l e , to t a k e up t h e s l a c k . F o r tre a t me n t the patient is t o l d to lift her arm aga i n s t the therapist's h a n d , using l ittle force , w h i le br e a t h i n g in slowly. Once t h e p a t i e n t h a s fo u n d t h e correct d i rection of abduction, t h e force of gravity is s u ffi c i e n t to hold i t , a n d t h e p a t i e n t i s rea d y for self-trea tme n t: she is told to l i ft

( a) Figure 6.97 ( a ) E x a m i n a t i o n a n d PI R of t b e c.Ia v i c u l a r p a r t o f t h e p e c t o r a l i s . ( b ) ( S e e o p p o s i t e ) G r a v i ty i n d uced p r R (se l f- t re a t m e n t ) 0 1 the c l a v i c u l a r part o f t h e p e c t o r a l i s : t o p . i n h a l a t i o n and s l i g h t r a i s i n g o f t h e a r m : b o t t o m . e x h a l a t i o n a n d r e l a xa t i o n l e t t i n g the a nn fa l l

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Th erap eutic techniq ues

Figure

217

6.97 (contin ued)

TrPs o f t h e pectora l i s ca n a l so b e b y s t i m u l a t ion o f t h e a n t a g o n i st the l a tissi m u s dors i . The p a t i e n t is s e a t e d , t h e therapist s ta n d i ng b e h i n d h e r ; s h e l i fts her a r m to Te n s i o n and

e ffec t i v e l y t r e a te d

,

the

level o f her

s h o u lder w i t h the

e lbow fl e x e d .

press u re w h i c h t h e therapist i s exerti n g aga i n s t h e r e l b o w from be h i n d S h e r e s i s t s the m o d e r a te i n t e r m ittent .

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21 8

l'vIan ip u /ilIive Therapy in Rehah ilita tioll

0/ the Locomotor

System

( a)

( b) Figllre 6.98 ( a ) E x a m i n a t i o n l1 n d P I R of t he ste rn a l part of the pectora l i s ma jor. ( h ) G ri l v i t y - i ncluce d PIR ( se l f- t r e a t me n t ) o f t h e a r m ; righ t . e x h a l a t i o n a n d rcia x a t i o n , l e t t i n g t h e a r m d ro p

o f t h e p e c t or a l is major: l e ft , i n h a l a tion a n d s l i g h t ra i s i n g

P a i n poi nts o n t h e ribs ( Figu re 6,99) T h e s e p o i n t s a re f o u n d m o s t freq u e n t l y i n t h e m i d

a x i l l a r y a n d mid-clavic u l a r tS

line,

a nd t h e i r tre a t m e n t

of p a r t i c u l a r i m p o r t a n c e . T h e s e p a i n p o i n t s are

the p o i n ts o f a t ta c h m e n t of

fi bres

of

the

pectorales

a n d se r r a t u s m u s c l e s w i t h i n c r e a s e d te n s i o n . Fo r t re a t m e n t o f p a i n p o i n t s i n t h e m i d -cl a v i cu l a r l i n e t h e p a t i e n t l i e s s u p i n e : t h e t h e r a p i s t l i fts t h e p a t i e n t ' s a r m t o pro d u c e t e n s i o n i n those fi. b r e s t h a t a r e d i re c te d t o w a r d s t h e p a i n poin t . Th is ca n b e pa l p a t ed w i t h the t h u mb a t t h e p a in p o i n t , and o f t e n i s v i s i b l e to t h e e y e . Once t h e c o r r e c t d i rec t i on h as b e e n e s t a b l i s h e d , t h e t h e r a p i s t t a kes up t h e s l a c k b y e l e v a t i o n o f t h e p a t i e n t 's a r m H e t h e n te l l s h e r t o press ge n t l y a g a i n s t t h e h a nd h o l d i n g t h e a r m u p a n d to b re a t h e i n a ga i n s t t h e t h u m b ( o r t h e n ar e m i n e n ce ) a ll t h e p a i n p o i n t . T h i s is fo l l o w e d b y e x h a l a t i o n a n d r e l a x a t i o n o f t h e < tr m i n t o f u r t h e r .

Figure 6.99 S pecific t re a t m e n t of p e c t o ra l i s fi b res a t t a c h ed to a p a i n p o i n t o n a rib

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Thaap elllic techniques

Figure 6.100

P I R o f the re l a x a t i o n

G ra v i t y - i n d u c e d

s h o u l d e r l o w e re d d u ri n g

p e c t o ra l i s m i n o r: l e ft , t h e s h o u l d e r

e l e v a t i o n , A ft e r t w o o r t h re e r e p e t i t i o n s t h e t h e r a p i s t fee l s t h a t the t e n s i o n h a s d i s a pp e a red , a n d t h is u s u a l l y m e a n s t h a t t h e t e n d e r n e s s at the p a i n p o i n t , t o o , h a s b e e n a bo l i s h e d .

M. pecto ra l i s minor

2 .1 9

over t h e edge o f t h e t a b l e , r a i s e d : r i g h t , t h e

Te n s i o n i n the serrat u s a nterior ( Fi g u re

6. 1 0 1 )

T h is m u s c l e a t t a c h e s a t t h e r i b s i n t h e a x i l l a r l i n e , a n d t h e re a re p a i n fu l t r i gger p o i n ts c l ose to a n d a t these a t t a c h m e n t poi n t s . F o r e x a m i n a t i o n t h e p a t i e n t

( Figu re 6 . 1 0 0 )

T h i s m u s c l e a t t a c h e s a t t h e c o r a c o i d p rocess a n d a t t h e t h i rd t o fi ft h r i b s , w h e re p a l p a t i o n c a n b e pa i n fu l . I n c re a sed t e n s i o n p r o d u ces fo rw a rd - d ra w n s h o u ld e rs a n d a c c o r ci i n g to H o n g a n d S i m o n s ca n be a c a u s e o f t h e u p p e r t ho r a c i c o u t l e t s y n d ro m e . Pa i n from TrPs close to the a t la c h m e n t p o i n t s at t he ribs re fe rs to t h e u l n a r aspect o f t h e u p pe r e x t re m i t y . F o r t re a t m e n t w e u s e g r a v i t y - i n d u c e d P I R . T h e p a t i e n t i s s u p i n e close t o t h e e dge o f t h e t a b l e wi t h h e r a r m h a n g i n g d o w n o v e r t h e e d ge : t h e sl a c k i s ta ke n up by t h e weig h t o f t h e a r m . S h e n ow raises h e r s h o u l d e r a n ci a r m w h i l e b r e M h i n g i n s l owl y , h o l d s h e r b r e a t h a n d t h e n l e ts t h e a r m d ro p , b re a t h i n g o u t a n d re l a x i n g .

l i e s o n h e r si d e , t h e l o w e r l e g ( o n t h e t a b l e ) s t re t c h e d o u t w h i l e t h e u p p e r i s b e n t a t t h e hi p : t h e k n e e o n the table s t a b i l izes h e r tru n k . The exa m i n e r raises t h e p a t i e n t ' s a r m so a s to c re a t e t e n s i o n a t t h e p ai n fu l a t t a c h m e n t p o i n t a t t h e r i b s . T h e tech n i q u e u s e d fo r r e l a x a t i o n i s s i m i l a r to t h a t s h o w n i n Fig u re 6 . 9 9 fo r t h e p e c t o r a l i s . For s e l f- t r e a t m e n t , gra v i ty i n d u c e d P I R i s u s e fu l . T h e p a t i e n t l i e s o n h e r s i d e i n the same position as d u ri n g exa m i n a ti o n ; she b r i n gs h e r a nn i n to a b d u c t i o n w i t h r e t ro fl e x i o n , u n t i l s h e h a s t a k e n u p t h e s l a ck . S h e t h e n bre a t he s i n w h i l e ra i s i n g t h e a r m s l i gh t l y ( F i g u r e 6 . 1 0 1 , a b o ve ) , h o l d s h e r b r e a t h , a n d t h e n le t s t h e a r m d ro p b a c k to t h e o r i g i n a l pos i t i o n , w h i l e s h e b r e a t h es o u t a n d re l ax e s ( F i g u re 6 . 1 0 1 . b e l o w ) .

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220

Manipulalive Therapy in Rehabililalion of

the

Locomotor

Figure 6.101 G r a v i t y - i n d u c e d P I R of t h e s e r r a t u s

Syslem

Figu(e 6.102 G ra v i t y - i n d uced rel a x a t i o n ot t h e

latissimus

a n terior

dors i : above t h e e l b ow s l i g h t l y ra ised . be l ow i t d rops

M u sc u l u s latissi m u s d o rsi ( Fi gure 6 . 1 02)

pronation i n order to t a k e u p the slack. T h e p a t i e n t i s t h e n told to s u pi n a te w i t h m i n i m a l fo r ce the the ra p i s t r e s i s t i n g f o r a b o u t 1 0 s , a ft e r wh ich h e te l l s t h e pa t i e n t t o ' l e t g o ' . W h e n re l a xa t i o n i s ach i e v e d , t h e t he r a pist b r i ng s the forearm fu rther i n to pro n a t i o n u n ti l the s l a ck has been t a k e n up once more. A fter t h ree to five re petitions there is u s u a l l y no d i ffe r e n ce be t w e e n the two sides, a n d p a i n should be reduce d . For self-trea t m e n t the p a t i e n t pe rforms t h e t h e rapist's m ove m e n t s w i t h h e r o w n h a nd s . I f t h e ex te n sor s a r e i n tensio n TrPs c a n eas i l y b e fo u n d a t t h e fore a r m ; t h e fl e x io n o f b o t h w r i s t a n d fingers i s restricted o n t h e side o f t h e ten s i o n . i . e . we c o m p a r e how fa r t he fi n ge rt i p s are from the forearm, on each side, a t m a x i m u m c o m b i n e d flexion of the wrist and fi n ge rs . F o r tre a t m e n t (Fi g u re 6. 104) t h e t her a p i s t places h i s p a l m on t h e b a c k o f t h e p a t i e n t ' s h a n d a n d h is fingers over h e r fl e x e d fingers, t a k i n g up t h e s l a c k i n to flex i o n o f t h e fi n g er s a n d h a n d . He then tells t h e p a t i e n t t o press her fingers s l i g h t l y i n to extension ; a ft e r r e s i st i ng this p ressu re for a b o u t 1 0 s the t h e ra pist te l l s th e pa t i e n t t o ' le t go ' , i ncreasing flex i o n of t h e w r i s t a n d fi n gers as fa r as re l a x a t i o n a Uows. The p roce d u re i s r e pe a t e d a b o u t five ti mes. For se lf- t r e a t m e n t t h e p a t i e n t p l a ces h e r t hen a r e m i n e n ce a n d t h u m b o v e r h er flexed fi ngers . ,

This m uscle l i n ks t h e s h o u lder gird l e to the pelvic g i rd l e ; i t a tt a c h e s a t the h u m e rus a n d t o g e t h e r w i t h t h e teres major a d d ucts a n d e x te n ds the a r m . Ther e c a n b e TrPs below the a x i l l a a n d f u r th e r d o w n t h e b a c k . Pain rad i a tes from t h e shoulder-blade down t h e u ln a r a s p e c t o f the arm. For t r e a t m e n t g r a v i ty i n d uced P I R is most p r a ct i c a l . T h e p a t i e n t l ies o n h e r s i d e , her back close t o t h e e d ge o f t he t a b l e ; above a n d b e h i n d her h e a d she p l a c es her a r m , be n t a t t h e e l bow w i t h the forearm h a n g i n g down. S h e n o w ra ises t h e e l b o w w h i l e s l ow l y b r e a th i n g i n ; a ft e r h o l d i n g h e r b r e a t h she J e ts the el bow drop a nd b re a t h es o u t . ,

P a i nfu l lateral h u m eral epicondyle In

a d d i tion to b l o c k a ge a t the e l bow t h e re is usually tension in the s u p i n a tor, i n t h e extensors of the h a n d a n d fi n gers, a n d i n the biceps. If t h e s u p i n a to r i s t e n s e ( Figure 6 . 1 03 ) there i s r e s tr i c ted p ro n a t i o n on t h e a ffected side. For t re a t me n t t h e p a t i e n t m a y b e s u p i n e or s e a t e d , w i t h the e l bow flexed and fixe d b y t h e t h e r a p i s t a ga i n st t h e p a t i e n t 's tru n k . He stands fa c i n g the p a t i e n t a n d b r i n g s h i s fore a r m i n t o

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( a) Figure 6. 103

( a)

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Exa m i n a t i o n a n d t r e a t m e n t of te n s i o n i n t h e s u p i n a tor. (b) S e l f- t re a t m e n t

( b)

Figure 6. 104 ( a l Exa m i n a ti o n a n d t re a t m e n t of t e n s ion i n t h e e x t e n sors of t h e h a n d a nd

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Man ip ulative Therapy in Rehab ilitlltion of t h e L o co m o {o r System

bri ngi ng h e r w r i s t i n to fl e x i o n . S h e t h e n co n t i n u e s s a m e m a n ne r as t h e thera pist. I f t h e b i c e ps i s i n te n s i o n , e x te n s i o n o f t h e e l b o w i s ( s l i gh t l y ) r e s t r i c t e d . For t r e a t m e n t (Figu r e 6 . 1 0 5 ) t h e thera pist exte nds the patient's e l b o w so as to

i n the

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up

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slack a nd

asks

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and

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with all

three m u scles i n volved in

pain

a t t h e l a t e r a l e p i co n d y l e . T h e p a t i e n t e x e rts m o d e r a te p r e ss u re i n t h e d i re c t i o n o f r e l a x a t i o n , a g a in s t

res i s ta nce by the t h e ra p i s t , i n c r e a s i n g a n d l o we r i n g i t .

ra p i d l y a n d r hy t h m i c a l l y

c o u n t e r- p re s s u r e fo r a b o u t 1 0 s , fo l l o w e d by re l a x

a t i o n i n to ex t e n s io n .

Th i s i s re p e a t e d t h re e t o fi v e s e l f-tre a t m e n t t h e p a t i e n t u s e s h e r o w n k n ee a s a fu l c r u m ; s h e may a l s o use g r a v i t y - i n d u ce d P I R by a l t e r n a te l y u ft i n g t b e fo r e a r m a b o u t 2 c m , h o ld i n g t h i s p o s i t i on fo r a b o u t 20 s , a n d t h e n times.

For

re l a x i n g i n to e x t e n s i o n fo r a n o t h e r 20 s .

P a i nfu l m e d i a l h u mera l epicondyle I n t h i s c o n d i t i o n t e n s i o n i s fe l t i n t h e fl e x o r s a t t h e t r e a t m e n t ( Figu re 6 . 1 06) t he p a t i e n t s i t s f a c i n g t h e t h e r a p i s t , w i t h h e r e l bow fl e x e d a n d fore a r m . For

t h e h a n d i n d o r s i fl e x i o n a t t h e w ri s t . T h e t h e r a p i s t

threads

his

fi n ge rs b e twe e n t h e p a t i e n t s '

thumb

and

fo r e fi n ge r , fro m t h e r a d i a l t o t h e u l n a r s i d e , w i t h h i s

t h u m b o n t h e d o r s a l s u rface o f t h e h a n d ac t i n g a s

a

f u l c r u m . He t h u s

takes u p t h e s l a c k i n t o pro n a t i o n by s l i g h t l y p r e s s i n g h i s li ng e r s a ga i n s t t h e u l n a r s i d e o f t h e p a t i e n t s p a l m . He t h e n t e l l s t h e p a t i e n t to r e s i s t t h i s m ov eme n t b y s l i g h t cou n t e r- p ress u re i n to s u p i n a t i o n. A ft e r a b o u t 1 0 s t h e p a ti e n t is to l d t o ' l e t go ' , i n c r e a s i n g p ro n a t i o n a n d d o r s i fl e x i o n d u r i n g re l a x a t i o n . Th i s p r oc e d u r e i s r e p e a t e d t h r e e to five tim es. '

F o r se l f- t re a t m e n t t h e p a ti e n t h o l d s t h e a ffe cted

h a n d in

the

h a nd she t reated , the dors a l

same way, but with h e r o t h e r

g r a s p s t h e u l n a r a s pect o f t h e h a n d b e i n g

on t h e p a l m a r s i d e , p l a c i n g h e r t h u m b on aspect a s a fu l c r u m s o as to t il k e u p t h e s l a c k i n to p ro

n a t i o n S h e t h e n r e p e a t s t h e t h e ra p i s t ' s m o v e me n t s . .

P a i n a rising i n t h e long head o f t h e biceps T h i s sh o u ld be

a rm a t

the

d i agnosed

b y ra ising t h e se m i - fl e x e d

s h o u l d e r , a ga i n s t re s i s t a n c e . To p a l p a t e

t e n d e r n ess o f t h e l on g t e n d o n o f t h e b i c e ps b e twee n

t h e t u b e r c l e s a n d t h e c r i s t a e of the h u m e r u s is v e ry mi s l e a d i n g , because t h e re a r e fre q u e n t l y pa i n fu l a ttach m e n t p oi n t s o f t h e s u bsca p u l a r i s a n d t h e i n f r a sp i n a t u s a t b o t h t he s e s t r u c t u r e s .

( b) Figure 6, 1 0 5

(a)

E x a m i n a t i on a n d t rea t m e n t o t t e n sion i n t h e b i c e p s brach i i . ( i» Se l f- t re a t m e n t

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Th erapetllic lecil niq w.l

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( b)

Figure 6. 1 06

(a)

Ex a m i n a t i o n a nd

Fo r t r e a t m e n t ( F i g u r e

t re a t l1l e n t

6. 1 07 )

o f te nsion i n t h e tl e x o rs of t h e h a n d a n d fi ngers. ( h ) Se l f- t rc a t m c n t

t he patie n t sits in

fro n t of t h e t h e ra p i s t w i t h h e r h a n d be h i n d h e r b a c k

Ten s i o n i n the s u p raspinatus m u scle

t h e d o r s a l a s pect o f t h i s h a n d p a ss i n g o v e r t h e

I n this co n d i ti o n , a b d u c t i o n a ga i n s t r e s i s t a nce i s

buttock on t h e opposi te s i d e . The therapist grasps

pa i n fu l a n d t h e re is a T r P i n t h e fo ssa s u p ra sp i n a t a .

stands

t h i s h a n d , b r i n g i ng i t i n t o p r o n a t i o n to t a k e u p t h e

For

s l a c k . I n this pos i t i o n t h e pa t i e n t i s t o l d to a p p ly

p a t i e n t s e a t e d o n t h e t a b l e ( F i g ure 6 . 1 09 ) a n d b r i n gs

s l i g h t c o u n t e r- p re ss u re ( i n t o s u p i n a t i o n ) , resisted for

t h e p a t i e n t' s tle x e d a r m i n t o a d d u c t i o n in fro n t o f

t re a t m e n t

the

t h e ra p i s t

be h i n d

the

a b o u t I Cl s b y t h e t h e r a p i s t . T h e p a t i e n t is t o l d to

h e r ches t . t o t a ke u p t h e s l a c k . I n t h i s pos i t i o n t h e

'Jet go' and re l a x i n t o !,ron a t i o n a n d s i m u l t a n e o u s e x t e n s i o n a t t h e e l b ow. T h i s i s r e p e a t e d t h ree t o fi v e

p a t i e n t i s t o l d t o e x e r t s l i g h t c o u n te r- p re s s u r e i n to a bd u c t i o n a n d to b re a t h e i n ; t h e t h e r a p i s t r e s i s t s t h i s

t i m e s . F o r s e l f- t r e a t m e n t t h e p a t i e n t d e a l s w i t h h e r

press u r e fo r a b o u t l Os , w h e n t h e p a t i e n t is told to

own h a n d i n e x a c t l y t h e s a m e w a y .

' l e t go' a n d b re a t h e o u t . D u ri ng this re l a x a t io n p h a s e t h e t h e r a p i s t bri ngs t h e a r m fu r t h e r i n t o a d d u ct i o n .

Pain arising i n the m . triceps

( Fig u re

This

6 . 108)

is

repeated

a bout

t hr e e

t i m es .

For

s e l f

t r e a t m e n t t h e p a t ie n t d oe s e x ac t l y t h e s a m e , u s i n g

TrPs in t h e t r iceps may c a u se e p i c o n d y l a r p a i n . A

her own h a n d .

TrP of t h e l o n g h e a d of t h e t r i c e p s , w h i c h a t t a c h e s to t h e sca p u l a , ca uses p a i n a t t h e a x i l l a ( K ro b o t , 1 99 4 ) . T h i s pa i n i s p r o v o k e d by p u s h i n g t h e a rm aga i n s t res i s t a n c e . Tre a t m e n t ( s e l f- t re a t m e n t ) is b y gra v i ty-i n d u ce d P I R :

the

p a t i e n t l i fts

h e r e l bo w

Tensi o n i n t h e i nfraspinatus m u scle I n t h i s c o n d i ti o n e x te rn a l r o t a t i o n aga i n s t res i s t a n ce is

pa inful

and

there

are

TrPs

in

the

fossa

a b ove h e r h e a d w i t h t h e Fo re a r m h o r i zo n t a l ; s h e n ow

i n fr a sp i n a t a .

s l ig h t ly ra i s e s h e r fore a r m for a b o u t 20

a ft e r t h a t

a d v a n t a ge o u s ( F i g u r e 6 . 1 1 0 ) . T h e p a t ie n t l ies s u p i n e

another 20 s.

w i t h h e r a rm i n a b d uc t i o n o v e r t h e s i de o f t h e ta b l e

she

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and

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R h y t h m i c i n te r m i t t e n t c o n t r a c t i o n o f t h e b i c e p s

a n d t h e e l b ow b e n t a t r i g h t a ng l e s , t h e fore a r m

a g a i n s t l i t t l e r e s i s t a nce w i l l e n h a n c e the e ffect o f

p o i n t i n g t o w a r d s t h e h i p . B y re l a x a t i o n t h e s l a c k i s

re l a x a t i o n .

t a k e n u p i n i n t e r n a l r o t a t i o n a t t he s h o u ld e T . T h e

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224

Manipulative Therapy in Rehabilitation of th e Locomotor System

( a)

( b)

Figure 6.107 ( a ) E x a mi n a t i o n a n d t re a t m e n t of t e ns i o n i n t h e biceps if t h e l o n g t e n d o n is p a i n fu l . ( b ) S e l f- t re a t m e n t

( a)

( b)

Figure 6.108 Grav i t y - in d uced P I R of t h e triceps: (a) the fore a r m r a i se d : ( b ) rela x a t ion

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Th erapeUlic techniques

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( b)

( a)

Figure 6. 109 ( 0 ) E x a m i n o t io n a n d t r e o t m e n t of te n s i o n i n t h e s u p ra s p i n a t u s . ( b ) Se lf- t re a t m e n t

Figure 6.110 Gra v i ty - i n d uced P I R of t h e i n fras p i n a t u s m u s c l e : t h e a r m i s h e l d o v e r

the

e d g e o f t h e t a b l e , i n i n t e rn a l ro t a t io n . Left : the a rm is slightly raised; righ t : it d ro p s , re l a x e d

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T h i s i s re p e a t e d a b o u t t h r e e t i m e s .

adduction

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b e t we e n t h e c h i n a n d t h e m a s t o i d p r o ce s s . I f t h e cervica l p a r t o f t h e m u s c l e is to be re l a x e d , t h e h e a d is o n l y v e r y s l i g h t l y l i ft e d , so t h a t t h e c e r v i c a l p a r t c o n t r a c t s : t h i s p os i t i on is h e l d f o r a w h i l e , t h e p a t i e n t s l o w l y b r e a t h i n g i n . T h e n s he re l a xe s , s l o w l y d r o p p i n g h e r h e a d . J [ t h e u p p e r t h o ra c i c p a r t of t h e m usc l e is to be t re a te el , t ile h e a d is r a is e el fu r t l 1 e r . u n t i l c o n t r a c t i o n is fe l t. A g a i n t h e p a t i e n t b r e a t h e s i n sl o w l y , w h i le eI u r i ng e x h a l a t i o n s h e r e l a xe s a n d d r o ps h e r h e a d o v e r t h e e d g e o f t h e t a b l e . Th i s is r e p e a ted a b o u t t h r e e t i m e s . The e r e c t or s p i n a e o f t h e ce r v i c o t h or a c i c j u n c t i o n a n d in t h e u p pe r t h o r a c i c r e g i o n is a ls o t r e a te d w i t h t h e p a t i e n t seateel i n fro n t o f t h e t h e ra p is t . Fo r t h e cervico t h o r a c i c r e g i o n ( F i g u r e 6 . 1 1 3 ) t h e t h e ra p i s t fi x e s t h e s h o u l d e r o n t h e s i d e o f t re a t m e n t w i t h o n e h a n el , w h i le t h e o t h e r p a s s e s r o u n d t h e patie n t 's h e a el t o bend i t forw a rd t o the s i d e a n d i n to ro t a t i o n a w a y f r o m t h e a ffe c te d s i d e , u n t i l h e h a s t a k e n u p t h e s l a c k . The p a t i e n t is t h e n t o l d to l oo k i n t h e

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t b e p a t i e n t to t h e s h o u l d e r o n the o p p o s i t e s i d e ( t he s i d e of tre a t m e n t ) , so as to o b t a i n a n t e A e x i o n , s i d e b e n d i n g a n d ro ta t io n . Th e s u m m i t o f t b e c u r v e t h u s obtai ned

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/v/anipuiative Therapy in Rehabilitation of the LOCOIIWlOr S vstCI I I

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6.1 16

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Therapell tic techniq ues

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( a)

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( b) PIR of t h e m i d d le t r a p e z i u s : t h e p a t i e n t l i e s on h e r s i d e w i t h t h e a r m o v e r t h e e d g e of t h e t a b l e . ( II ) S h e ra i ses h e r e l bow s l ig h t l y , t h u s c o n t ra c t i n g t h e m i d d l e trape z i u s , a n d b r e a t hes i n : ( b ) s h e l e t s t h e a rm d ro p , re l a xes a n d brea t h e s o u t Figure 6.118 G r a v i t y - i n d uced

the p a i n fu l a re a . S h e h o l d s h e r b re a t h , t h e n r e l a x e s a n d br e a t h e s o u t s l ow l y I n s e l f- t r e a t m e n t t h e p a t i e n t u s e s h e r o t h e r ha n d a g a i n s t h e r elbow, i n t h e same w a y a s the t h e ra p i s t . Grav ity- i n d uced PIR m a y be ev e n b e t t e r . The p a t ie n t l ie s on the no n - p a i n f u l s i d e a t the e d ge of t h e ta b le , h e r a r m h a n g i n g a l m o s t v e rtica l l y over t h e edge. S he n o w r a i s e s t h e e l bow s l i g h t l y , brea t h i n g in s l ow l y ; s h e holds her bre a t h a n d t h e n l e t s t h e a r m dro p w h i le b r e a t h i n g o u t s l o w l y (Figu re 6. 1 1 8 ) . .

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a b d o m i n a l m u sc l e : i n c r e a s e d te n s i o n i n t h e a bd o m i n a l w a l l is e a s i l y p a l p a t e d . It is a l so v e ry e a s y to p a l p a t e t h e t e n d e r a t t ach m e n t p o i n t s o n the upper aspect of the p u b i c s y m p h y s is a n d t h e l o w e r a s p ec t of the x i p h o i d p r o c e ss a n d t h e a dj a ce n t pa rts of t h e

lower ribs. F o r t re a t m e n t , g ra v i t y - i n d u c e d P I R i s m o s t e ffe c t i v e : t h e pa t i e n t is s u p i n e w i t h h e r b u t tocks a t t h e e n d o f t h e t a b l e , h e r le gs h a ng i n g o v e r t h e e d ge . A s t o o l i s p la c e d u n d e r t h e foot of t h e s i de w h ic h i s n o t be i n g t rea t e d : t h e p a t i e n t is t h c n t u r n e d to t h a t s i d e , s o t h a t a cu s h i o n c a n be i n se r t e d u n d e r t h e b u t to c k o f t h e s i d e to b e t r e a t e d , l i ft i n g t h i s s i d e o f t h e p e l v i s . I n t h i s posi t i o n t h e p a t i e n t r e l a x e s t o t a k e u p t h e s l a c k b y t h e w e ight of t h e h a n g i n g l e g . She t h e n l i fts t h e k n e e o f t h a t le g a b o u t 2 C ol . h o l d i n g i t s l igh t l y r a i s e d d u ri n g s l ow i n h a l a t i o n . A ft e r t h i s s h e h o l d s h e r b re a t h , b e fo r e l e t t i ng i t d r o p a n d b re a t h i n g o u t s l o w ly . T h i s m a noe u v re is re p e a t e d a b o u t t h ree t i mes ( F i g u r e 6. 1 20b ) . T h i s t e c h n i q u e a c t s m a i n l y o n the i n se rtions a t the s y m p h ysis: if we w i s h to act p r i m a r i l y o n t h e x i p h o i d p ro c e s s a n d t h e u p p e r p a r t o f t h e s t r a i g h t a b d o m i n a l m us c l e , i t i s better f o r t h e p a t ie n t t o r a i s e h e r h e a d a n d s h o u l d e rs a n d b re a t h e i n , t h e n l e t t h e h e a d a n d s h o u l d e rs d r o p w h i l e s l o w l y b r e a t h i n g o u t . T h i s e x e rc i se c a n b e used fo r s e l f t r e a t m e n t . t h e p a t i e n t p e rform i n g it t w o or t h ree t i m e s in s u ccess i o n .

20 s. S h e t h e n l e t s it d ro p i n to fl e x i o n a n d rel a x e s f o r a n o t h e r 20 s . Th i s i s r e pe a t e d a b o u t t h r e e t i mes ( F i gu r e 6. 1 2 1 ) ,

L u m bosacro i l i a c ' l i g a m e nt' p a i n W h e n l i ga m e n t p a i n i s t e s t e d , increa sed t e n s i o n i s u s u a l l y fo u n d o n t h e a ffe c te d s i d e , toge t h e r w i t h m o v e m e n t r e s t r i c t i o n i n to a d d u ction t h i s cond i t i o n P I R

is

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6. 1 22 ) : t h e p a t i e n t i s s u p i ne , t h e t h e r a p i s t a t t h e o p p o s i te s i d e o f t h e ta bl e to t h e l e g to be tre a t e d . T h e p a t ie n t l1 e x e s t h a t l e g a t t h e h i p a n d k n e e ; t h e t h e r a p i s t g r a s p s t h e k n ee, b r i n g i n g i t i n to a d d u c t i o n a n d fl e x i n g t h e h i p so a s to fi n d the pos i t i o n i n w h i c h t h e re is t h e g r e a t e s t resista n ce to a d d u c t i o n a n d t h e m o s t pro n o u n ced p a i n , w h e t h e r t h i s pa i n corresponds m o r e t o the i l i o l u m b a r o r to t h e s a c r o ili a c l iga m e n t . W h e n t h e t h e ra p i s t h as t a ke n u p t h e s l a c k i n to a d d u c t i on i n t h a t pos i t i o n , t h e p a t i e n t i s t o l d to res i s t the p r e s s u r e of h i s h a n d , s l i g h t l y , for a b o u t 1 0 S , a n d t h e n t o ' l e t go ' . D u r i n g re l ax a t i o n , a d d u c t i o n i s i n c r e a s e d ( t h i s m a y be p a i n fu l , b u t i f t h e p a t i e n t goes on re l a x

i n g i n s p i te o f i t , t he p a i n is n o t c l i n ic a l l y i m porta n t ) a n d w h e n t h e s l a c k h a s b e e n t a k e n u p a g a i n t he p r o c e d u re is r e p e a te d from the n ew l y ga i n ed position , t h re e t o five t i m e s . For self- tre a t m e n t t h e p a t i e n t u s e s h e r h a nds, o n e m a i n t a i n i n g fl e x i o n a t t h e h i p w h i l e t h e o t h e r m o v e s t h e k n e e i n to a d d u c t i o n .

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h e r t r u n k . S h e t h e n p r e s s e s t h e fo o t a ga i n s t t h e t a b l e - l eg i n t o e x t e rn a l r o ta t i o n . A ft e r a b o u t l O s s h e rel a x e s , i n c re a s i ng t r u n k r o t a t i o n b y b e n d i n g t h e k n e e o f t h e free l e g ( F i g u r e 6 . 1 27 ) .

Figllre 6 . 1 25 G I'� v i ty-i n d uc e d P I R o f the h a m s t r i n g s : the l i e s p r o n e , her l e gs d a ngl i n g o v e r t h e end of t h e t 8 b l e . t o u ch i ng t h e gro u n d . A b o v e , s h e ra i s e s o n e l e g for 20 s: b e l o w . she d ro ps the leg and re l a xes fo r 20 s p� t i e n t

A p a i n f u l g reater trocha nter (TrPs a t the a d d u ctors) T h i s i s d u e t o t e n s i o n , m a i n l y i n t h e t h i g h a b d u ctors. m o s t freq u e n tl y with TrPs

at

the t e n s o r fas c i a e l a ta e

b u t a lso i n t h e g l u te u s m e d i u s . TrPs o f t h e g l u t e u s m e d i u s a r e fo u n d b e l o w t h e pos t e r i o r a s p e c t o f t h e i l i a c c r e s t , w h e re a s TrPs o f t h e t e n s o r fa s c i a e l a t a e

a re b e l o w t h e s u p e r i o r i l i a c s p i n e a n d c l o s e to t h e g re a t e r troc h a n te r . I n a d d i t i o n , t h e t e n so r fasci a e l a t a e m a y c a u se p a i n a t t h e a t t a c h m e n t a t t h e u p p e r m a rg i n o f t h e p a t e l l a , a n d t h e fasc i a l a t a a n d t h e i l i ot i bia l tract c a n be tender al p a l p a t i o n . The most freq u e n t c a u s e o f p a i n a t t h e gre a t e r t roc h a n t e r is a p a i n f u l co n d i t i o n o f t he I l i p j o i n t . For e x a m i n a t i o n a n d PI R o f t h e a b d u c t o r s t h e fo l lo w i n g

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s i d e i s b r o u g h t i n to ma x i m u m a d d u c t i o n

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t h e u p p e r h a n g i n g ove r t h e e d ge o f t h e t a b l e . W h e n

i n to a b d u c t i o n , a ga i n for at l e a s t 20 s . T h e p ro ce d u re

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re p e a t e d t h ree to five t i m e s , a n d t h e w h o l e e x e rc i s e s h o u l d be p e r fo r m e d t w o or t h r e e t i m es a

t a k e n l i p b y t h e we i g h t o f t h e h a n g i n g l e g . T h e

p a t ie n t is t h e n t o l d to l i ft t h a t l eg a b o u t 2 e m a n d h o l d i t i n t h i s p os i t i o n f o r a b o u t 20 S , a n d the n t o l e t i t fa l l s l o w l y a n d re l a x fo r a n o t h e r 20 s . Th is p roce d u re is r e p e a t e d a b o u t t h re e t i m e s .

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foot a n d toes i n to m a x i m u m p l a n ta r fl e xi o n , to t a k e

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u p t h e s l a c k . The p a t i e n t i s t o l d to res i s t s l i g h t l y fo r

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t a b l e , i n to m a x i m u m a b d u c t i o n a n d e x t e n s i o n , t a k i n g u p the s l a c k . T h i s m o v e m e n t i s res i s t e d by t h e p a t i e n t fo r a b o u t 1 0 s , bef o re t h e p a t i e n t r e l a x e s , a n d t h e proce d u re i s re p e a te d t h re e to fi v e t i m e s . Te n s i o n i n t h e s h o r t a d d u c tors i s s h o w n b y a pos i t i ve P a t r i c k ' s t e s t . I f t he t e n s i o n is n o t d u e to s o m e u n d e r l y i ng fac t o r , we u s e grav i t y - i n d uced P I R . T h e p a t i e n t is a s d u r i n g P a t r i c k ' s test a n d re l a x e s

A p a i nful Ach i l l es t e n d o n T h i s i s a s i g n o f te nsi o n i n t h e s o l e u s m u s c l e . For t r e a t m e n t t h e p a ti e n t l i e s p ro n e , w i t h t h e knee o n l h e l e s i o n e d s i d e fl e x e d ( Fi g u r e 6 . 1 3 1 ) . T h e t h e r a p i s t p a l p a t es t h e ten d o n to m a k e s u re w h i c h s i d e o f i t i s p a i nfu l , a n d t h e n b ri ngs t h e foo t i n t o d o rs a l fl e x i o n

s o a s t o c re a te te n s i o n a t t h e p a i n fu l s i d e , w i t h t h e fo o t e i t h e r i ll p r o n a ti o n o r i n s u p i n a t i o n . A f t e r t h e

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Manip ulative Therapy

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Figure 6. 129

(a)

E x a m i n a t i o n a n d t r e a t m e n t of t e n s i o n i n

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s h o u ld i ncre ase n o t i cea b l y , a n d t h e p a t i e n t s h o u l d be encouraged t o cooperate to t h i s e n d . F o r s e l f t re a t m e n t t h e p a tie n t is s e a t e d , u s i n g b o t h h a n d s

(F i g u re 6 . 1 3 1 b ) .

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G r a v i t y- i n d uced P I R i s b e s t a c h i eved w i t h t h e p a t i e n t s t a n d i n g , h e r h a n d s o n t h e t a b l e ; t h e affe ct e d leg is sligh t ly i n fro n t of the other, a n d b o t h k n ees s l ig h t l y bent. B y b e n d i ng forw a rd s h e t a k e s up t he s la c k i n to d o rs i fl ex i o n ; s h e t h e n r e s i s t s i n t o p l a n ta r fl e x i o n fo r a b o u t 20 s , r e l a x i n g i n to d o r s i fl e x i o n

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toes, i n re l a t i o n t o t h e calcaneus. u n t i l te n s i o n i s fe l t i n t h e s a l e . The p a t i e n t i s t h e n told t o fl e x t h e extended toes, w i t h l i t t l e force, aga i n s t t h e the ra pist's resis t a n c e , m a k i n g (I S it were a ' hollow' foo t . This i s h e l d fo r a b o u t 1 0 s, t h e n the patient is told t o relax and t h e p roce d u re r e p e a t e d t h re e to five t i m e s . I t is most i m porta n t to a v o i d p l a n t a r fl e x i o n o f t h e fo o t . For se l f- t re a t m e n t t h e p a t ie n t i s s t a n d i n g, p u t t i ng some w e i g h t on t h e fo o t to be tre a te d ; s h e fi rs t a rc h e s t h e foo t . d ra w i n g i n h e r t o e s . A ft e r 2 0 s s h e re l axes t h is posi t i o n . fl a t te n i n g the p l a n t a r arch ( Fi g u r e 6 . L 32b ) .

R e m e d i a l exercise I n the prece d i n g p a r t of t h i s boo k , d ea l i ng w i t h se lf mob i l iza t i o n , post-iso m e tr i c re l a x a ti o n a n d soft tissue m a n i p u l a t i o n , t h e re is grea t e m p hasis o n self-trea t m e n t . T h e tech n i q ues prese n ted cou l d be regarded a s a form o f remed ia l e x e rcise, with w h i c h t he y certa i n l y have m u c h i n co m m o n .

T h e m a i n t a s k o f re m e d i a l exercise i n d i s t u rbed function o f the loco m o t o r system is to corr e c t fa u l t y moveme n t pa tterns ( s t e reotypes ) t h a t a re relevant t o t h e patie n t ' s compla i n ts , The most i m port a n t p a t h oge n i c m e c h a n i s m , t o b e t re a ted fl rs t , i s motor i m b ala nce between m uscl e gro u p s , m a n i fested b y fa u l t y move m e n t o r p o s t u r e . T o d o t h i s i t is esse n t i a l to u n d e rs ti1 n d w h i c h muscu l a r fu nctions a re a t fa u l t . a n d t h e i r m u t u a l corre l a t i o n : wea k n ess, i n h i b i t i o n , hyperactiv i t y , ta ut ness, hypo- o r h y p e r to n u s . Asym m e t ry must be ta k e n i n t o acco u n t . i n part icu l a r conce rn i n g m u s c l e tone. I f t he re is e x a gge ra t e d a c t i v i t y of certa i n m uscles, i t is l i k e l y that they c o m p e n s a t e the wea k n ess of other m u scle gro u p s . O n t h e o t iJ e r h a n el , m a r k e d t a u t n e s s ( s h o r te n i ng) o f a m u sc l e lll a y i n h i b i t i ts a n tagon ist. H owever, m otor function a n d elysfunction usually resu l t from a c h a i n react i o n and t h e re i s probably n o strict fo r m u l a w h i c h ca n be a p p l ied to e v e ry patie n t . Th i s i s w h y m e thods have been cl e v e loped i n rec e n t y e a rs wh ich ci a n o t a t t e m p t t o t r a i n speci fi c

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m u scles or m u s c l e g ro u ps

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t i o n c a n h e k e e p h i s b a l a n ce - c o ns e q u e n t l y s o m e

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t r a i n m o re c o m p l e x m o ve m e n ts l a te r . T h u s i t i s b e s t i f t h e p a t i e n t fi rst t r a i n s l y i n g o n t h e fl o o r , a n d o n l y

red u c e l u mb a r l o rd o s i s , For t h i s t h e p a t i e n t s h o u ld p l a c e b o t h forea r m s ( o r a c u s h i o n ) u n d e r t h e

l a te r u n d e r t h e i n fl ue n ce o f gra v i ty ; a ga i n , i t i s e a s i e r

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l e g v e r y slig h t l y s o a s n o t t o c o n t r a c t t h e l u m b a r

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e re c t o r s p i n a e a n d n o t t o b r i n g t h e l u m b a r s p i n e i n to l o rdosis. T h e p a t i e n t m a y b e t o l d t o ' l i ft h e r l e g a n d

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p os i t i o n o r i f s h e

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and s o f t t issu e m a n i p u l ; 1 1 t o t h e t re a t m e n t o r m u se u l :) r

H a v i n g l e arned I use b o t h t h e g l u t e i the pelvis (the T h e te c h n i q u e u s e d

Tra i n i n g wea k m u scles

t a u g h t to ( t i l t) o f fu n c t i o n ) . o f the

fo r s e l f-m o b i l i z a t i o n

l o w e r l u m b a r s pi n e into a n te - or re t r o fl e x i o n a p p r o p r i a te h e r e ( s e e F i g u re 6.57, p . 1 94) .

A s e xp l a i n ed a b o v e ( s e e p . 1 2 1 ) , t h e re i s n o t r u e p a r e s i s i n o u r p a t i e n t s . we a k n e s s be i n g t h e r e s u l t o f i n h i b i t i o n a n d d i s u s e . I t i s t h e re fo re u p t o t h e p a t i e n t

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to l e a r n h o w to u s e t h e s e w e a k e n e d m u s c l e s aga i n .

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To t e a c h t h e pa t i e n t we s h o u l d d i s t i n g u i s h fa c i l i t a t i o n a n d t ra i n i n g .

e ffe c t i v e : t h e p a t i e n t l i e s o n h e r s i d e , a n d a s t h c

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g l u te u s i s w e a k , s h e m a k e s a ' fa l se a b d u c t i o n ' a s described i n

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method

plays a p r o m i n e n t ro l e .

t h e ra p i s t p e r fo r m s and lets t h e leg

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repeats t h i s m a nocuvre,

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ce p t i ve s t i m u l a t i o n is is a l so i m porta n t , m ore i n m u s c u l a r n y p e rl o n u s , h o w e v e r : s i t t i ng i n a be n t p os i t io n c a u s e s h y pe r t o n us

she

is

t o l d to con tract the m uscle consciously, c h e c k i n g w i t h h e r fi ng e r s ( feed b a c k ) a n d t h u s

of most p os t u r a l m u s c l e s . S t r a i gh t e n i ng u p greil t l y

a c h i e v i n g c o r re c t a b d u cti o n , i . e . a b d u ctio n u s i n g

faci l i ta t e s r e l a x a t i o n . Before t ra i n i n g a m u s c l e i t i s .

s i m u l t a n e o u s l y b o t h t he g l u t e us m e d i us a ncl t he

o l' c o u rse , esse n t i a l t o t r e a t e v e r y TrP.

t e n s o r fasc i a e l a ta e .

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240

ManiplIlative Th erapy in

Rehabilitation of the Locomotor

The recti a b d o m i n is The test for t h i s muscle is fo r t h e p a t i e n t to s i t up from t h e s u pine positi o n , keeping the legs b e n t at t h e h i ps a n d kn ees. For coord i n a t e d con traction of the g l u t e i m a x i m i the p a t i e n t m a y p ress her h e e l s aga i n s t a h a rd c u s h i o n o r other obstac le; it i s a grave m i s t a k e to fix the foot from above. I f the p a t i e n t ca n n o t do t h i s , w i t h o u t h e r l u m b a r e r e c t o r s p i n a e bein g too short, the a bd o m i n a l muscles m a y be trained by the patient sitting w i t h bent knees, and lying d ow n slowly w i t h her spine i n ky phosis and her neck in a n te fl e x i o n , the contracted abdom i n a l m uscles a l l owing t h e v e rtebrae to touch t h e t a b l e one a fter t h e o t h e r (ecce n tric contracti o n ) (Figure 6 . 13 3 ) . The exercise m u s t be stopped the m o m e n t l u m b a r k y p h osis ca n n o t b e m a i n t a i n e d a n d i f t h e p a tien t 's fee t a re lifted from t h e tabl e . A fter a few days o r weeks of practice , the patie nt wi l l be able to li e down correc t l y i n t h i s w a y , and the n she w i l l al s o be able to sit u p by t he same method . I t m a y be e a s i e r for t h e p a t i e n t to start tra ining h e r abdomin a l m u scles j u s t b y lifting t h e pelvis w h i l e l y i n g s u p i n e A more difficult pos t u r a l exercise i s to contract t h e deep a b d o m i n a l m u scles i n B r U gger's relief position (see Figure 6 . l 44, p. 246 ) , c o n tracti ng the abd o m i na l muscles w i t h o u t ra i s i n g her thorax. I n ord e r to restore t h e pos t u ra l fu nction o f t h e abdom inal m uscles a n e ffe ctive m a n o e u v r e i s to b r i n g the ,

.

System

weight forwa r d a n d b a c k , a t the s a m e t i m e contract i n g the abd o m i n a l m uscles. U n t i l this becomes a u tomatic t h e patient ca n check by p a l p a t i o n . The fol lowing exercises also t r a i n coord ina ted contraction o f t h e gl u t e i m a x i m i a n d the ab d o m i n a l recti. Th e 'pelvic see-saw' (Figure 6. 1 34)

The pa tient is s u p ine with k ne e s b e n t and fee t o n t h e t a b l e . B y con t racting h e r erector spi nae she b r i ng s h e r l u mbar sp i n e i n to lordosis, a nd b r e a t h i ng quietly she relaxes the e rector s p i n a e w h i l e co n t r acting both t h e a bdom i n a l m u s c l es a nd t h e g l u te i maximi, bringing the l u m b a r s p i n e flat o n t h e table. O n c e s h e has m a stered t h i s p h ase the patie n t , w i t h h e r lumbar spine s t i l l fl a t o n t h e t a b l e , p u t s h e r k nees toget h e r and l i fts i n kyphosis fi rst the pelv is and then the l u mb a r spine, up to the low thoracic re gi o n i n caudocra n i a l order. The l u m b a r e rector s p i n a e m us t be kept relaxed, the recti abdo m i n i s a n d g l u t e i m a x i m i contracted a n d the k n ees toge ther. The pat i e n t t h e n l i es do w n ag a i n reve rs i n g t h e order of t h e e x e rcise, from t h e t h o racic s pine to the pelvis. ,

.

The 'cradle '

The patie n t l i es s u pi n e , d r a w i n g h e r knees to h e r chest w i t h h e r a r m s ; s h e t h e n p u s h e s t h e k nees again s t her c l asped h a n d s , t h us l i ft i n g her pelvis a n d l u m b a r sp i n e , a n d contracting the g l u t e a l m u sc l e s . A t t h e s a m e t i m e s h e l i fts h e r h e a d a n d chest. contracting the abdom i n a l m u scles. By rhythmic

( a)

( b) Figure 6.1 33 Tr a i n i n g t h e recti a b d o m i n i s b y l y i n g d o w n from a s i t t i n g p o s i t i o n , keeping t h e k n ees b e n t : (a) correct a n d ( b ) fa u l t y

Figure 6.134 T h e ' p e l v i c s e e -sa w ' : ( a ) b r i n g i n g t h e

l u m b a r s p i n e i n t o l o r d o s i s , su p i n e : ( b ) l i fting t h e p e l v is a n d l u m b a r s p i n e f r o m t h e t a b l e , in k y p h o s i s , a n d r e t u rn i n g i t to t h e p r e v i o u s pos i t i on

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Th erapelllic techn iques

24 1

nose w i t h t h e o t h e r h a n d a n d i n h a l e . A fter t h i s resisted in h a l a t io n , i t is e a s y fo r h e r to d raw i n t h e a n a l regi o n . O n ce t h e patient has learned th is, she can d o i t without i n h alation. She then l e a rns this m a n oe uvre w h ile s i t t i n g and s t a n d i ng. She s h o u l d n e v e r press t h e b u t tocks toge t h e r . This i s a n exercise w o m e n s h o u l d pe rform a s a routi n e after d e livery, j ust as t h e y s h o u l d tra i n t h e abdo m i n a l m uscles.

The lower part of the trapezius muscle

Fi g ure 6.135 T h e ' c ra d l e ' : a b o v e , t h e k n ees a re d ra w n to t h e h i ps a re e x t e n d e d aga i ns t res i s t a n c e b y the arms, and the t r u n k l i ft e d

t h e c h es t : b e l ow ,

press ure o f h e r knees aga i n s t her hands she swings herse l f i n to a s i t t i n g pos i t i o n , before d ro p p i n g back to the fi rst ( Figu re 6. 1 35 ) . A t a l a t e r stage the patie n t may d o this e x e rcise w i t h o u t t h e h e l p of h e r h a nds, which a re s t re tched fo rward . S t ronger gluteal and abdom i n a l m u scles, and the i r i mproved coord i nation , can b e ach ieved i n t h i s way.

T h i s m u scle h a s a key role i n t h e corr e c t fi x a tion o f the s h o u l d e r . T h e fo llow i n g e x e rcise s h o u l d be carried out to fac i l i ta t e contraction (Figure 6. 1 3 6 ) : the p a t i e n t sits o n h er he e l s a nd b e n d s forward t o r e s t h e r forehead o n t h e t a b l e i n fro n t o f h e r ; t h e arms ca n be a l on g t h e t r u n k , re l ax e d . I n t h i s position t h e m ed i a l bord e r o f the shou l d er-blade d ive rges from t he spi n a l c o l u m n in a ca u d a l d i recti o n . The t h e rapist t e l l s the p a t i e n t to draw her s h o u l d e r-blade i n a c a u d a l d i rectio n , by con tracting the lower part o f the trapezius. Correctly performed , t h i s move m e n t brings the me d i a l border o f t h e shoulder-blade parallel with the s p i n a l colu m n , the lower a ngle be i n g p u l led in a c a u d a l - m e d i a l d i rection. O nce the the rapist h a s p a lpated good contraction o f t h e lower part of the trapezi u s , the patient should a lso palpate i t with t h e t h u m b o r i n dex fi nger o f h e r own fu rthermost hand (feed back ) . The s h o u l d er-b l ades m u s t not be drawn together. O n ce th e p at i e n t has mastered this proce d u r e , she le a r n s to d o i t lying p r o n e , flat o n the ta ble , check i ng the contraction with h e r fi nger. S h e c a n t h e n con tract both the low e r t rapezi i , l y i n g w i th both arms by h e r sides i n i n te r n a l rota t i o n . S h e s l i g h tly l i fts both a rms, t h e n her head a n d neck, k e e pi ng the neck i n line w i th the thoracic spine, the m a n d i bles a t r i g h t angles to t h e neck. I f the lower trapez i i are contracted , the upper trapez i i remain rel axed ow i n g

The pelvic d i a p h ra g m The importance o f t h e pelvic d ia p h ragm c a n be compared to t h a t of the abdom i n a l muscles: both fo rm t h e w a l ls of the abdom i n a l cavity , playing a vital role in postu re a n d respira t i o n . U n l i ke the abdomi n a l wall, t h e pelvic d i a p h ragm is hidden a n d therefore rem a i n s u n notice d . When e l i c i t i n g t h e ' S ' reflex (see p. 99) we find a TrP i n the m . coccygeu s . A n i n d i rect sign i s hypertonus o f t h e a d d u ctors . For tre a t m e n t i t is a d v i sable first to relax the adductors and flexors of the h i p . To make the patient u n d e rstand how to tra i n the w e a k p e l v ic d i a p hragm, i t is usefu l for her to l e a rn to ' d raw i n ' h e r navel, c hecki ng t h a t moveme n t w i t h h e r fi n ge rs . O n ce s h e has u n d e rstood t h i s , she lies o n her side w i t h h e r fi n gers flat o v e r h e r a n u s a n d tries to draw i t i n . This is not easy a t fi rst; t h e re fore she should hold h e r

Fi gure 6.136 Squatting o n h e r heels, tr u n k b e n t over t h ighs, th e p a t i e n t contracts t h e l o w e r part of t h e trapezius

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Manipula tive Therapy il1 Rehabilitation of th e Locomotor S vstem

Figure 6.138 O n hands and k n e e s w i t h

a book on the

o c c i p u t - c o rr e c t p o s i t i o n

t h e t rapezi i rem a i n i ng re l a xed and the recti abdom i n is con t racted . Th e back a n d neck s h o u l d be as fl a t as a board .

The deep flexors of the neck

Figure 6. 1 37 T h e p a t i e n t o n h a n d s a n d k n ee s fo r e x a m i n a t i o n a n d t r a i n i n g of t h e s e r ra t u s l a t e r a l i s : ( a ) fi rst pos i t i o n ; (b) arms b e n t (corre c t ) : ( e ) fa u l t y po s i t i o n w i t h a rms be n t

to re flex i n h i b i t i o n . Th e patie n t fi r s t relaxes t h e n e c k , t h e n t h e a r m s a n d lastly the s h o u l d e r - b l a d e s . O nce t h e p a t i e n t has learned to con tract the l o w e r part o f t h e t r a pezius w h i l e p r o n e , s h e can d o t h e same upright (sitting o r sta n d i n g ) , aga i n fi rst check ing up o n t he contraction w i t h her fi ngers.

The s i m p lest exercise is head a n teflexion aga i nst resistance: the patie n t is sea t e d , her c h i n sup ported from below by the c u p ped h a nds, givi n g res ista nce to head a n t e fle x i o n ( i s o m e t r i c a s w e l l as isoto n i c resis t a n ce m a y be us e d ) . A v e r y e ffec t i v e exercise consists o f d ra w i ng t h e c h i n i n t o t h e n eck w h i l e s i t t i ng, w i t h the t h oracic spine b e n t backwards over t h e low back of a ch il i r (Figure 6. 1 39) , repeating t h e movem e n t severa l t i mes.

Tra i n i n g for s o m e of the m o st i m p o rta nt stereotypes ( m ovement patte r n s )

Sta n d i n g on both feet

The serratus l atera l i s T o t r a i n t h is m us c l e ( Figu re 6 . 1 3 7 ) , t h e p a t i e n t is o n h a n d s a n d k nees, w i t h h e r weight m a i n l y on the h a n d s , w h ich (I re i n i n ter n a l rota t i o n , the fi n ge rs poin t i ng a t e a c h o t h e r . The s h o u l d e r-blades m u s t b e k e p t we l l a p a r t a n d t h e t h o racic s p i n e h e l d i n a stra ight I i n e . The patie n t i s t h e n told to bend h e r arms a t t h e e l bows. Correct fi x a t i o n o f t he tr u n k a n d shou l d e r g i rd l e i s m o s t i m porta n t : t h e s h o u l d e r blades m ust be k e p t a p a r t (by the serra t i ) a n d fixed from below by t h e lowe r p a r t o f t h e tra pezii. T h e n e c k is h e l d straight. i n pro longa t i o n of t h e thoracic spine. Contraction of t h e a b d o m i n a l m usc les i s necessary to keep t h e tru n k s tra igh t : t h i s is m a d e easier i f t h e p a t i e n t breathes o u t w h i l e b e n d i n g h e r a rm s . O n h a n d s a n d knees ( Figure 6. 1 3 8) w i t h a b o o k resting o n t h e occ i p u t has a s i m i l a r e ffe ct, t ra i n i n g correct fi x a t i o n o f the s h o u l d e r g i rd l e by con t raction o f t h e serrati la terales a n d t he lower part of t h e tra pezi i , a s w e l l as by coord i n ated contraction of t h e neck e x te nso rs a n d d e e p flexors, t h e upper part of

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An i m port a n t c r i t e r i o n fo r sta n d i n g pos t ur e is t h a t i t s h o u l d be stable, w i t h t h e m i n i m u m of m uscu l a r

Figure 6. 1 39 Tra i n i n g t h e d e e p n e c k flexors h y d r a w i n g t h e c h i n i n w i t h t h e t h o r a c i c s p i ne b e n t h a c k w a rd s o v e , t he l o w b a c k of a c h a i r

Th erapelltic techniq l l es

243

T h i s is p a r t i c u l a r l y true for the t r u n k : t h ere a lw ay s s o m e a ct i v i t y at th e level of the l e gs t h u s i m p l y i n g t h a t the fee t a re d e c i s i v e . This is n o t a m e r e coi n c i d e nc e : toge t h e r w i t h t h e h a n d s a n d the m o u t h t h e y a re re l a t e d to t h e l a r ge s t a rea o f the c e r e b r a l cortex a nd a re richest in se n s o r y rece ptors. For t h i s r e a s o n t h e a c t i v e role of t h e fe e t i n s t a n d i n g c a n h a r d l y be o v e re st i m a t e d . I t i s , h o w e v e r , j e o p a r d i z e d s e r i o u s l y by w e a r i n g s h oe s , c a u s i n g w h a t c o u l d be a c t i v i ty . is

,

c a l l e d ' c h r o n i c s e n s o r y d e p ri v a t i o n ' .

The key t o t r a i n i n g p h y s i o l o g i ca l s t a n d i n g l i e s i n activa t i o n o f t h e fe e t . I n C h i n e se g y m n a s t i cs t h e subject s t a n d s w i t h h i s f e e t s l i g h t l y a p a rt a n d i n i n w a rd rot a t i o n w i th s l i g h t l y b e n t k n ee s . This p o s i t i o n g r ea t l y f a c i l i t a t e s t h e ac t i v i ty of t h e toe fl e x o r s : the p a t i e n t g r i p s t h e I� o o r . O b v i o u s l y t h i s is e a s i e r to d o w i t h o u t s ho e s . T h e s ta b i l i ty of t h is type o f s ta n d i ng ca n be t e s t e d ve ry s i m p l y : t h e e x a m i n e r g i v e s a s l i g h t u n e x p e c te d p u s h to t h e p Cll i e n t ' s t r u n k from i n fro n t or b e h i n d : i f s h e s t a n d s t h e u s u a l w a y w i t h fe e t i n o u t wa r d rota t i o n , s h e is l i k e l y t o lose h e r b a l a nce. S t a n d i n g w i t h fee t i n s l ig h t i n w a rd r o ta t i o n a n d be n t k n e es, sta b i l i t y i s g re a t l y e n h a nced . T h i s , h o we v e r i s not the only e ffe c t : t h e pe l v i s w i l l a u t o m a t i c a l l y be in a n e u t r a l p o s i t i o n , t h u s g re a t l y i m p ro v i n g b o d y statics, i . e . t h e pos t u re o f the t r u n k . head and n e c k . '

'

,

Sta n d i n g o n o n e leg, o r wa l k i n g B e i ng a n asym m e t r i c a l F u n c t i o n t h i s i s u s e f u l t o correct a s y m m e t ry S t a nd i ng o n o n e l e g i s related t o w a l k i n g , w h i c h e n ta i l s a l t e r n a te s t a n d i n g o n e a c h l e g. Some a s y m m e t ry is f r e q u en t a n d a s a rule we c a n d i s t i n g u i s h t h e s u p p o r t i n g l e g , t h e one on w h i c h the subj e c t p u ts m o re w e i g h t w h e n s t a n d i n g a t e a s e . T h e a s y m m e t r y s h o u l d n o t be too m a rk e d , however. B o t h when s t a n d i n g on o n e l e g a nd i n w a lk i ng , i t is e sse n t i a l to a c t ivate the fee t a n d t o es . When s t a n d i ng t h e k n ee should s l i gh t l y bend and t h e toes s h o u l d grip t h e �l o o r : w h e n wa l k i n g t h e heel s h o u l d touch t h e fl o o r fi r s t a n d t h e n the t o e s be u s e d fo r p r o p u l s i o n

Figure 6 . 1 4 0 A l t e r n a t e for w a r d a n d b a c k w a r d s h i ft i n g o f t h e legs, s u p i n e

.

.

.

A ltern a te forward a n d backward sh ifting o f the legs, supine (Figure 6. I 40) The pa ti e n t is

asked to s h i ft her s l i g h t l y a b d ucted t h e d i rec t i o n o f i ts long a x is . The re i s co n t r a c t i o n o f th e g l u t e u s me d i u s a n d a t t h e same t i m e t h e re i s a l te rn a t i n g c o n t ra c t i o n o f t h e i n te rn a l a n d e x t e rn a l r o t a tors o f t h e h i p . T h e a b d o m i n a l a n d g l u t e a l m uscu l a t ur e p r o v i d e s fixa t i o n o f t h e p e l v i s a n d l u m b a r spi n e . I n t h i s way t h e pa t i e n t l ea rn s to fix h e r p e l v i s a n d t r u n k d u r i n g l e g r o t a t i o n . leg ' i n t o t h e d i s t a n c e ' i n

Rota tion of the h ip with th e leg in abductio n

d i s t a n ce ' . T h e

i s p u l l e d u p by t h e q u a d ra t u s pe l v ic o bl i q u i t y . T h e g l u t e u s m e d i u s of t h e a b d u c t e d l e g is c o n t r a c t e d w h i l e t h e a b d o m i n a l a n d g l u t e a l m u s c u l a t u re fi x e s t h e pe l vi s . I n t h i s pos i t i o n t h e p a t i e n t r o t a t e s t h e foo t a n d t h e l e g ( see F i g u r e 6 . 1 40) . other

Flexion a n d extension of th e upper leg, lying o n th e side ( F i g u re 6 . 1 4 1 )

p a t i e n t i s i n t h e s a m e position a s for t h e p r e ce d i n g exercise; she l i ft s ( a b d u c ts ) t h e stre t c h e d u pp e r l eg. D u r i n g le g fl e x i o n a t a l l j o i n ts ( d o rs a l fl e x i o n of t h e a n k l e , b e n d i n g h i p a n d k n e e ) t h ere i s a l s o s l ight k y p hosis o f t h e lumbar s p i n e a n d d u r i n g e x t e n s i o n wi th a l l t h e e x t e l1sors a c t i v e , t h e l u m b a r s p i n e m o v e s i n to s l i g h t l o r d o s i s . C o r r e c t c o n t raction of t h e a b d o m i n a l m u sc l e s a n d t h e g l u t e i s ho u l d p re v e n t h y p e r l o r d o s i s d u r i n g extension . T h e t h e rap i s t ca n h e l p t h e p a ti e n t by g i v i n g some r e s i s t a n ce ( d u r i n g flex i o n ) to the k n e e or t h e b i g t o e ; a n d d u r i n g e x t e n s i o n , to t h e h ee l , or to t h e b i g toe from b e l ow These exercises teach the p a t i e n t c o o r d i n a t i o n d u r i n g wa l k i n g

The

,

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l eg

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.

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244

IVianipuLa t i ve Therapy in Rehab ilitation of the

Figu re 6.141

(a)

Fl e x i o n a n d

(b)

Locomotor System

e x t e n s i o n of the u p pe r leg, w i t h the p a t i e n t on h e r side

Sta n ding on one leg ( s e e Figure 4 . 7 5 , p . correct fixation o f th e pelvis a n d trunk

136) :

The

p a ti e n t fi rst sta n d s on b o t h l egs, a n d then p u ts h e r w e i g h t on o n e l e g . S h e now has to fi x both h i p a n d p e l v is. S h e t h e n l i fts t h e o t h e r l e g b y b e n d i n g the h i p a n d k n e e a l m o s t a t ri gh t angles. S h e s h o u l d b e able to kee p her p e l v i s h o rizon t a l wi t h o u t losing h e r b a l a nce. Correct fi x a t io n of the pelvi s and tr u n k a re r e q u i r e d , fo r w h i c h t h e k e y m u scle is the gl uteus m e d i u s ; t h e p a t i e n t should p a l p a t e i t on the side o f t h e s u p p o rting leg. I f s h e fe e l s t his contraction s h e s h o u l d c h e c k u p w i t h both h a nds o n t h e crest o f the i l i a , to m a k e s ur e that the pelvis is horizon tal.

S itt i n g (see Figure

4.68,

p. 133)

Sitting erect o n th e floor, fo r trun k ro ta tion

( Fi g u re

6 . 1 42)

p a ti e n t s i ts on h e r i sc h i a l tuberos i t i e s , the legs p a ra l l e l and s l i g h tl y bent, h e r h a n d s cl asped on t h e occi p u t . By coord i n a te d contraction of t h e t r u n k m uscu l a t u re , t h e s p i n a l co l u m n i s h e l d e rect; correct fi x a t i o n of t h e s h o u l d e r- b l ades is also essenti a l . From t h i s p o s i t i o n the p at ie n t c a rries o u t a x i a l rotation , be n d i n g n e i t h e r backwards, for w a r ds n o r s i d e w ay s . G o o d faci l i t a t i o n c a n b e o b t a i ned if s h e l oo k s to t h e s i d e of rotation a n d u pw a r ds, b re a t h i n g i n d u ri n g rota t i o n to t h e s i d e a n d breathing o u t d uring rotation b a c k t o n e u tra l posi t i o n . ( I n t h e kyp h o t ic p o s i t i o n i t is t h e re v e r s e : b re a t h i n g o u t fac i l ita tes rota t i o n ) A l l t h a t h o l d s for trun k r ota t i o n w h i l e s e at e d c a n be a ppl i e d d u ri n g t r u n k rotation standing, w i th l e gs a pa r t . The

Figure 6.142 ( a ) S i t t i n g erect o n t h e fl o o r . ( b ) Tru n k rotation

L a te ra l m o ve m e n t o f th e th o rax, sitting

( F i g ur e 6. 1 4 3 )

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a re h e l d h o r i z o n t a l l y . S h e d oe s t h is of h e r t r u n k m uscu l a t u re , c h i e A y the a b d o mi n a l m u s c l es, kee p i n g t h e t r u n k s t ra ig h t a n d a v o i d i ng a croo ked pos i t i o n . T h e t h e r a p is t c a n faci l i t ate t h i s exercise b y e f fe c t i n g r es i s ta n c e a g a i n s t t h e p a t i e n t ' s ri b s , fi r s t from o ne and t h e n fro m t h e o t h e r si d e . U p r i gh t posture is a l so fac i l i ta te d b y b re a t h i n g out o n m o v i n g to the s i d e a n d in w h i l e re tu r n i n g t o n e u t r a l pos i t i o n ; t h i s is d u e t o c o n t r a c t i o n of the obli q u e abdo m i n a l m u s c l e s . the

arms,

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by correct c o n t r o l

Con trolling th e pelvis wh ile s ea te d The p a t i e n t s i ts o n a s too l , fa c i n g a m i r r o r ( s e e Figure 4 . 6 8 , p . 1 3 3 ) . S he fi r s t i n t e n t i o n a l l y re l a xe s her a b d o m i n a l a n d g l ut e a l m u s c l e s , b r i n g i n g th e l u m b a r s p i n e i n to l o rd o s i s . S h e t h e n s l ow l y c o n t racts the g l u t e a l a n d a b d o m i n a l m us c l es t o c a u s e l u mb a r

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correct

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B r u gger's re l i ef position

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p o i n ts o u t t h e p os i t i o n , ove r l o a d i n g t h e i n te rv e r t e b r a l d i s c s , p re s s i n g on the ste r n u m and the p ub i c sy m p h ys i s a n d c a u s i n g a forw a rd - d ra w n neck, w i t h h y perl ordosi s of the cran i o In

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he h a s t h e p a t ie n t a d op t t h e po s i t io n : seated o n the ed g e of a stool wi t h t h e k n e e s a p a r t a n d o u t wa rd rota ted fee t , res t i n g h e r w e i g h t o n h e r le gs , she c o mp l e t e ly re l axes t h e g l ut e a l a n d a b d o m i na l m u s c le s ; th e p e l vis i s ti lt ed fo rward , c r e a ti n g consid era b l e l u m b o s a c r a l l o r d o s is w i t h t h e a b d o m e n p r o tr u d i n g . Once th e p a t i e n t h a s fo u n d t h is p o s i ti o n , t h e u p p e r l u m bar, t h o racic a n d ce rv i c a l s p i n e straighten u p . a n d a l l t h e p os t u r a l m u s c u l a t u r e r e l a x e s ; t h e e n t i re s p i n a l co l u m n i s app arently i n b a l a nce. For m a x i m u m r e l i e f

fo l l o w i n g

Copyrighted Material

246

IVlanipulalive Therapy

in Rehabililalion of the L O C0l1 1 0 l O r Syslel1l

� 8 o o o

o o o

( a)

Figure 6.144 ( a ) B r ugge r ' s re l i e f p o s i t i o n . ( b ) T h e u s u a l k y p h o t i c p o s i t i o n ( s h a d i n g ) a n d t h e re l i e f pos i t i o n ( b l a c k )

( b)

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m ,ln o e u v r e : wh i l e i n t h e u s u a l k y p ho t i c p os i t i o n

i n t h e l ow b a c k . I n t h e a u t h o r ' s o p i n i o n t h e y a re most

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w h e re a s i n t h e re l i e f p o s i t i o n i t i s p a i n les s. a n d e v e n

u s e t h i s ch a i r e x c l u s iv e l y . b u t m a y c h a n g e h e r s i t t i n g

a s t h e t h e r a p i st p a l p a t e s t h e m a l l o f t h ese m u sc l e s

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t e ns e . I t is u s eful to p r o fi t fro m t h is p o s i t i o n for p a t i e n t s w h o seem to be a b l e t o re l a x in t h is w a y . e v e n i f o n l y t e m pora r i l y . I n t e re s t i n g l y . t h e p o s i t i o n g re a t l y fa c i l i t a te s n o r m a l r e s p i ra t i o n .

Stoo p i n g Prepara tio n: u n c u rling fro m sitting on th e heels (Fig ure 6. 1 4 5)

S p e ci a l ch a i rs a re n o w m a d e . s l i g h t l y t i l te d fo rwa rd

T h i s is a u s e fu l p r e p a r a tory e x e rc i s e . T h e p a t i e n t s i ts

wi t h a s u p port for t h e knees, s o t h a t t h i s p o s i t i o n ca n

on h e r h e e l s . re l a x e d . a n d b re a t h i n g q u ie t l y . w i t h h e r

e a s i l y be m a i n ta i n e d . T h e y a re r e co m m e n d e d fo r

h a n d s on t h e fl o o r i n fro n t o f h e r k n e e s : s h e i s i n

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Th erapell tic techlliq lles

Figure 6. 1 45 U n c u rl i n g from s i t t i ng on t h e

heels: (a ) with hands

l o r d o t i c pos i t i o n w i t h t h e pe l v i s t i l t e d fo rward . B y contraction o f t h e g l u te a l a n d a b d o m i n a l m us c l e s t h e p e l v i s is t i l te d b a c k a n d t h e l u m b a r s p i n e bro ug h t i n to k y p h o s i s . B y co o rd i n a ted con tract i o n o f t h e a b d o m i n a l a n d b a c k m u s c u l a t u re , a n d fi x a t i o n o f t h e pe l v i s by the g l u t e i t h e pa t i e n t l i fts h e r a rm s fro m t he g r ou n d w h i l e the l u m ba r a nd t h o r a c i c s p i n e c u r l u p i n success i o n . .

A n te- an d retro flexion of th e spinal column while s tanding

floor:

(b) s t raighten i n g

up

bre a t h e

o u t aga i n s t resista nce, o r m a y press h e r t he floor. This fo rces t h e a b dom i n a l m u scles t o c o n t r a c t , a n d t h i s con tracti on s h ould b e m a i n ta i n e d as the p a t i e n t s t r a i g h t e n s u p , k ee p i n g h e r c h e s t as close as possi ble to th e t h i g h s o r pelvis, t o a v o i d l e ve r a ge by t h e t r u n k . The p a t i e n t m a y c heck u p on h e r abdo m i na l m u scles by p a l p a t i n g w i t h o n e h a n d ( feedback ) . T h e p a ti e n t s h o u l d m a k e a h a b i t of p u tt i n g o n e foot fo rward w h e n s h e has to s t oo p , e v e n s l i g h t l y ( e . g . a t t h e k i tch e n s i n k p e e r i n g i n to t h e b a t h r o o m mirro r , or in fron t of a c u p b o a r d ) , le a n i n g h e r s l i g h t ly b e n t k n e e and th i g h aga i n s t i t . fi n g e rs

to

,

A n o t h e r p r e p a ra t o ry e x e rc i s e ['o r s t oop i n g c o n s i s t s of t rai n i n g c o r r e c t c u r l i n g u p o f t h e s p i n a l col u m n . Sta n d i ng e re c t . t h e p a t i e n t con t racts her a b d o m i n a l a n d g l u t e a l m u s c u l a t u re t o fi x t h e pe l v i s , a n d a n te tl e x i o n begi n s w i t h t h e h e a d a n d n e c k fo l lowed by t he t h o rax and a b d o m e n , t h e p e l v i s r e m a i n i n g i n the o r i g i n a l pos i t i o n . T h e pa t i e n t ca n no t usua l l y re ach furthe r t h a n to h e r k n e e s , w i t h h e r h a n d s . F r o m t h i s pos i t i on s h e s t r a i g h t e n s u p . begi n n i n g w i t h the l u m b a r s p i n e '

on the

247

'

Retrofl ex i o n As o u r e y e s a n d h a n d s a re i n fro n t o f LI S , most o f o u r w o r k . w h e th e r s i t t i ng o r s t a n d i n g , occu rs i n a fo rwa rd- b e n t pos i ti o n . H e n c e , as a co m pe n s a t i o n , ba c k - b e n d i n g is fre q u e n tl y a v a l u a b l e e x e rc ise B a c k b e n d i n g of t h e l u m b a r s p i ne i n i ts m ost spe c i fi c for m has b e e n described as se l f- m o b i l i za t i o n ( s e e Figure 6,58). A less s p e c i fi c b u t very e ffe c t i v e e x e r c i s e is to p u t bot h palms o n t h e b u t t o c k s w h e r e t h e y form a fu l c r u m , a n d to b e n d b a c k . It c a n be e v e n m o r e a d v a n t a g e o u s for t h e p a tie n t to l i ft h e rse l f o n bot h a r m s i n t o re tr o fl e x io n ( s e e F i g u re 4 . 5 6 ) u p t o [0 t i m e s . R e t r o tl e x i o n c a n be e n ha n ced i f the p a t i e n t e x h a l e s de ep l y a t m a x i m u m retro fl e x i o n , Accord i n g t o McKe nzie t h is is effective i n m a n y types o f back p a i n i n c l u d i ng d i s c l e s io n ; t h i s e x e rcise should be performed 10 t i m es and r e p e a ted 10 t i mes a d a y e v e n i f i t c a u ses some p a i n , s o lon g as t h e p a i n d o e s not ra d i a t e i n t o t h e l e g s . ,

-

,

Lifting a n object from th e gro u n d (see Fig ure 4. 70, p. 134)

The p a t i e n t p u t s one foot fo rward a n cl b e n d s t ru n k a n d k n ees s i m u l t a ne o u s l y . [ n t h i s way the l o a d i s e v en l y d i s t r i b u ted b e t we e n leg, p e l v ic and tr u n k m u s c u l a t u re . T o r e t u r n t o a n e rect posi t i o n , b o t h knees a re s t r e t c h e d wh i l e the g l u t e a l m us c l e s s t ra i g h t e n t h e p e l v i s a n d t h e abdo m i n a l m u scles co n t ro l t h e u n c u rl i n g of t h e s p i n a l colu m n . To fa c i l i t a t e t h e a b d o m i n a l m u s c l e s , the p a t i e n t m a y

Copyrighted Material

248

Manipulalive

Therapy in

Rehabilillilion of Ihe

LocOl1l otor S VSINII

Lift i n g the a r m s

Raising a n d lo werin g the shoulders ( Fi g u re 6 1 47 )

h e re i s to i m prove fixa t i o n o f t h e t h e lower fi x a tors o f t h e s h o u l d e r b l ad e ( s e r r a t u s a n te r i o r a n d t h e lo w e r tra pez i i ) a n d

The

t o r e l a x t h e u p p e r fi x a t o rs w h i c h a re a ttached a t t h e

fi x a to r s , res i s t e d b y t h e th e ra pi s t T h e p a t i e n t re la x e s

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.

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o t h e r s h o u l d e r cl ow n , by t h e l owe r fi x a t o r s . T h i s

Mo ving t h e a rms forward, prone ( F i g u r e 6 . 1 46 ) T h e p a t i e n t i s pro n e , b o t h arms s t r e t c h e d o u t , p a l m s d o w n w a r d s , a n d the fore h e a d o n t h e fl o o r . T h e p e l v i s i s fi x ed b y t h e g l u te a l l a t u re . T h e t h e ra p i s t b r i ngs

e x e rc i s e s h o u l d b e c a r r i e d o u t fi rs t o n o n e s i d e , a n d t b e n o n b o t h s i d e s toge t h e r . I t t e a c h es t h e p a t i e n t c o n t ro l o f c o n t r a ct i o n a n d re l a x a t i o n o f t h e re l e v a n t m uscles.

a n d abdom i n a l m us c u the s h o u l d e r- b l a d e i n t o

L ifting both arms, s ittin g

correct p osi t i o n by c o n t r a c t i o n o f t h e l o w e r p a r t o f

the tr a p e z i u s

.

T h e p a l m s a re

n o w fl a t o n t h e fl o o r. fi x e d , t h e p a t i e n t

T h e pa t i e n t s i t s e re c t on a s t oo l , b e fo r e

K e e p i n g t h e s h o u l d e r- b la d e w e l l

r a ises h e r h e a d s l igh t l y , m ov i n g h e r o u ts t r e t c h e d

i n s u c h a w a y a s to t u r n t h e p a l m s fo rwa rds w h i l e k e e p i n g t h e u l n a r s u r face o f t h e hands o n t h e fl o o r . T h e lower fixa t o rs o f t h e s h o u ld e r- bl a d e re m a i n c o n t racted, w h i l e t h e u p p e r fi x a t ors a re r e l a x e d .

a r ms fo rward

Figure 6.146 M ov i n g rhe a rm s forwa rd, prone:

m i rror.

u p p e r fi x a t o rs , i . e . a t fi rst o n l y li p t o 9 0 d e g r e e s a n d fi n a l l y t o 1 80 degre e s . T h i s fi x a t ion m a i n t a i n e d w h e n l ow e r i ng the

(II) fi rst p h �se; (b)

Copyrighted Material

a

the s h o u l d e r- b l a d e s from be l ow, as fi r m l y as s h e ca n , t o avoid a c t i v a t i n g the u p p e r fi x a t o r s . M a i n ta i n i n g t h is fi x a t i o n , s h e s l o w l y raises h e r arms a s fa r a s she can w i t h o u t a c t i va t i n g t h e She now fi x e s

second

phase; (e)

t h ird

p h ase;

s h o u l d a l so

a rms.

(d) fa u l ry

be

Th erapeu tic tech n iq u e.)

Figure 6.148 Li ft i n g the arms over t h e h e a d : a n d (b) fa u l t y

(a)

249

correct

Breat h i n g

Figme 6. 1 47 R a i s i n g a n d l o w e r i n g t h e s h o u l d e rs to t ra i n ( a c t i v e ) re l a x a t i o n o f t h e ( u p p e r ) t r a pe z i u s : (iI) re l a x e d A rs t a n d e n d - p os i t i o n : ( ll ) s h o u l d e rs raised

T h e m o s t s e r i o u s fa u l t h e r e i s l i ft i n g t h e t h o r a x d u ri n g i n h a l a t i o n . D u r i n g e x a m i n a t i o n , w i t h h i s h a n d s o n b o t h s i d e s o f t h e p a ti e n t ' s t h or a x , t h e t h e r a p i s t may e n co u rage t h e pa t i e n t by e x e r t i n g s o m e p r e ss u re d u r i n g e x h a l a t i o n a n d by

re l e a s i n g t h i s p r e ss u re

d u r i ng i n h a l a t i o n to p ro d u ce w i d e n i n g or n a rr o w i n g

L ifting th e a rms abo ve th e head

(Figure 6. 1 48 )

o f t h e t h o r a x . U s u a l l y , t h i s d o e s n o t s u ffi c e .

T h e p a t i e n t s i t s e re c t o n a s t oo l , ra i s i n g h e r a rm s

t h e sca l e n e s , w h e re t h e y h a v e b e e n fo u n d s h o r t e n e d

The fi r s t ste p i n t r e a t m e n t s h o u l d b e r e l a x a t i o n o f

a b ove t h e h e a d a s s h e d o e s , fo r i n s t a n c e , w h e n

( se e p . 2 1 3 , F ig u r e 6 . 90 ) . I n s e v e r e c a s e s t h e m a n

com b i n g h e r h a i r . C a re m u s t b e t a k e n t o fi x t h e

o e u v re d e s c r i b e d b y S a c h s e a n d S a c h s e ( 1 975) i s

s h o u l d e r- b l a d e c o r r e c t l y , t o re l a x t h e u pp e r fi x a tors

a d v i s e d : t h e p a t i e n t , s e a t e d o r s u p i n e , i s a s k e d to

a n d t o co n t ro l t h e pos i t i o n of t h e h e a d .

p re s s h e r fl e xed e l bows d o w n w a r d s aga i nst r e s i s t a n c e , w h i l e b re a t h i n g i n d e e p l y . For se l f- t r e a t me n t s h e m a y p re s s h e r e l b o w s d o w n o n t h e a rm s o f a n

Sitting e rect, turning t h e h e a d ( s e e F i g u r e 4 . 7 3 ,

a rm c h a i r .

p. 1 35) T h e pa t i e n t si ts e re c t o n a stoo l , t u r n i n g

her

head.

I f t h e p a t i e n t lifts h e r t h o r a x m o r e o n o n e s i d e t h a n t h e o t h e r , t h i s us u a l l y rev e a l s wea k n es s o f t h e

The re s h o u l d b e a x i a l r o t a t i o n o f t h e cervi c a l a n d

l owe r t r a pe z i u s o n

t h o r a c i c s p i n e , t h e s h o u l d e r - b l a d e s fi x e d f r o m b e l ow ,

w h i c h m u s t b e t r e a t e d se p a r a t e l y .

t h e u p pe r fi x a tors re l a x e d . I n t h i s w a y coord i n a te d

t h e s i d e o f i n c r e a s e d l i ft i n g ,

W e t h e n t r y to m a k e c o r r e c t b re a t h i n g a u t o m a t i c ,

by t h e m e t h o d o f G a y m a n s ( 1 980) : t h e p a ti e n t s i t s

h e a d rota t i o n i s a c h i e v e d .

e re c t o n a s t o o l , b o t h fe e t o n t he gro u n d ( h i g h h e e l s

Correct wei ght carry i n g

(see Figure

a re p ro h i b i te d l ) . T h e h e a d i s e re c t , i . e . t h e e y e s l o o k

4.74,

a t a n o bj ec t p l a ce d a t e ye l e v e l , w h i l e t h e t i p o f t h e

p . 1 36 ) For correct w e i g h t ca rry i n g , t h e p r o p e r fi x a t i o n o f

t o n g u e p re s s e s a g a i n s t t h e h a rd p a l a t e a bo u t o n e fi n g e r ' s b r e a d t h b e h i n d t h e t e e t h . T h e h a n d s l ie i n

t h e s h o u l d e r- b l a d e i s esse n t i a l , a s d ur i n g l i ft i n g o f

t h e l a p , c l a s p e d i n s u p i n a t i o n , t h e fi n ge r t i p s e x e r t i n g

t h e a r m s . H e r e , h o w e v e r , i t i s a l so i m p o r t a n t t o re l a x

s l ig h t press u re o n t h e b a c k o f t h e h a n d s , o r w i t h t h e

t h e s u bc l a v i c u l a r p a rt o f t h e p e c t o r a l i s t o m o v e t h e

fi n ge rs o v e r t h e th u m b i n s u pi n a t i o n i n fro n t o f t h e

h e a d a n d sho u l d e r b a c k , i n re l a t i o n t o t h e s p i n a l

a b d o me n ; i n n o c a s e m a y t h e s h o u l d e rs b e r a i se d .

co l u m n . Coord i n a ted c o n t r a c t i o n o f t h e i n te rsc a p u l a r

T o faci l i ta te i n h a l a t i o n t h e p a t ie n t m a y l i ft h e r t o e s ,

m u scl e s i s t h e re fo re necessa ry . T h e m o m e n t t h e

w h i l e t o fa c i l i t a te e x h a l a t i o n s h e p re s s e s h e r toes

p a t i e n t succeeds i n b r a c i n g h e r s h o u l d e rs b a c k , t h e

against

w e i g h t s h e c a rr i e s ceases t o a ffe c t t h e c e r v i c a l s p i n e

p e r fo r m e d i n fro n t o f a m i rr o r , t o m a k e s u re t h e c l a v i c l e s d o n o t m o v e u p a n d d o w n . A n a l t e r n at i v e i s B ru gge r ' s re l i e f p os i t i o n ( s e e F i g ure 6 . 1 44, p . 246 ) ,

a n d t h e u p p e r fi x a t o rs o f t h e s h o u l d e r g i rd l e r e m a i n re l a xed . N o t o n l y i s t h e re r e l a x a t i o n o f t h e s h o u ld e r g i rd l e , b u t a l so h o l d i n g a n o t t o o h e a v y w e i g h t , l i ke

the

fl o o r .

T h is

e xercise

should

fi rst

be

a b r i e f-case , beco m e s possi b l e w i t h a l m o s t r e l a x e d

a n d poss i b l e c o m b i n a t i o n s . O nce t h e p a t i e n t h a s m a s t e red correct respi ra t io n ,

hands.

s h e g e t s a fee l i n g fo r t h e r i g h t w a y to b re a t h e , i . e .

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250

Manipulative Th erapy in Rehab iliwtivn o{ the Locomotor Systcm

how to broaden t h e t horax fro m t h e waist u pw a rd s w i t h o ut these fac i l i t a t i n g m a n o e u v res, so t h a t s h e c a n b re a t h e correctly d u ring her d a i l y a c t i v i ties. A ccord i n g to G a y m a n s ( 1 980) , high heels constitute a serious i m pe d i m e n t to correct respira t i o n . Abdom inal resp i ra t i o n must be practised w i t h t h e pa t i e n t supine. I f t h e pa tie n t is u n a b l e to b re a t h e i n to t h e thoracic s p i n e while p ro n e , t h e same faci l i t a t i n g position should be a dopted as for self-mob i l i za t i on o f the t horacic spine i n to fl e x i o n (see Figure 6 . 62 , p . 1 97 ) . I t i s a l so i m p o r t a n t for t h e p a tie n t t o re l a x h e r fa cia l m u scles a n d t h e m us c l e s contro l l ing t h e tongue a n d j a w . S u c h is the i m por l a n c e o f correct r es p i r a tion that a ny gross fa u l t is bound to jeopard ize the rest of the motor p a t terns and even t h w a r t the e ffec t of mobil iza t i o n tech n i q ues. T h e hands. thei r pos i t i o n a n d e v e n to n u s h a ve a m a rk e d i n fl ue nce on re s p ir a tio n . This can be q u i t e i m porta n t i f a p a t i e n t ca n n o t rel a x h is h a n d s .

Figllre 6. 1 49 R h y t h m i c l i ft i n g o f t h e k n e e by n e x i o n o f t h e t o e s a ncl t h e a n k l e . wi t h t h e p a t i e n t s e a te d

metacarpa l s ; or by r o t a t or y move m e n t s a t t h e i n te r p h a l a nge a l J o i n t s .

The feet T h e fee t a re a k e y region of t h e motor s y s te m . U n l i ke the h a n d s t h e y a re rarely u nsho d . S hoes n o t o n l y m o d i fy t he i r mobi l i ty, t h e y a l so d e p rive t h e m o f m o s t o f the n o r m a l s e n sory i n pu t s . I t i s t h e refore i m porta n t to advise p a t i e n ts to w a l k b a r e fo o t whenever there is a reaso n a b l e opport u n i ty. Because of this se nsory deprivation stroking p l ays a p 3 1·ticu l a rty i m po r ta n t role i n the t re a t m e n t o f fe e t - both if the p a t i en t ove r-reacts a n d even m o re so i f s h e d o e s not r e a c t a t a l l ( ' d e a d fee t ' ) . W h e n w a l k i n g i t is i m po r t an t for the fee t to p l a y a n a c t i v e ro l e . parti c u l a rly i n t h e act o f p r op u l sion . w he n t he toes s h o u l d be a c t i v e . So as to tra i n a c t i v i ty o f t h e toes, t h e pa tient s h o u ld grasp objects on t h e floor such as penci l s . P repa ration for usi n g the t o e s fo r p ropu l s i o n w h e n wa l k i ng is fo r t h e s e a t e d p a t i e n t rh y t h m ica l ly to l i ft h e r knee by b e n d i n g t h e toes a n d exten d i n g t h e a n k l e ( Figure 6 . 1 4 9 ) . In t h e s w i n g p h a s e . t o o , t h e fee t s h o u l d p l a y a n a c t i v e ro l e : fl e x io n o f t h e l e g s h o u l d be i n i t i ated by e x t e n s i o n of t h e b i g toe. R u n n i ng i n d e e p s a n d is i d e a l . Patients w i t h a h a l l u x v a l g u s s h o u l d t ra i n a b d u c t i o n o f t h e b i g toe . T h i s req u i res conce n t ration a t fi rs t ; t h e patient m a y s t a r t by moving the toe pass i ve l y a nd o n l y grad u a l l y try active m o v e m e n t . S h e s h o u l d stim u l a te t h e a b d uctor po l l icis b revis b y s t ro k i n g i t on t h e m e d i a l s u rface of the foot. T h i s exe rcise is not o n l y prev e n t i v e , i t a l so re l ieves p a i n a t the ha l lu x v a lgus.

The h a n ds There is fre q u e n t l y hypertonus - 'crampe d ' h a nds. P l a y i ng w i t h a soft b a l l or rice is a d v i sa b l e . Stro k i ng a n d massage of t h e h a n d s is r e co m m end e d : t h is m a y b e ca rr i e d o u t along t h e a x i s of t h e fi n ge rs a n d

S u p p o rts So fa r J h a v e d e a l t m a i n l y w i t h tech n i q u es t h a t restore or correct m o b i l ity; i t is beyond t h e scope o f t h i s b o o k to dea l w i t h i m m o b i l iza t i o n tech n i q u e s . I t i s u s e fu l , however. t o reco m m e n d s i m ple s u p ports t h a t can be made by p a t i e n t s at h o m e . O n e i s a soft c e r v i c a l co l l a r o f l a t e x fo a m ( F i g u r e 6 . 1 5 0 ) . fi tted to t he s h ape or t h e n e c k . T h e soft materia l . pl a ced round t h e n e c k t o fo rm a t u be . becomes a s o ft a n d y e t su fficient support fo r t h e cervica l s p i n e ; cove red i n some s o ft m a t eria l , i t can be secu red by t a pe and protects t h e p a t i e n t from j o l t i n g in p u b l i c t r a nsport v e h i c l e s . Hypermobile p a t i e n ts w i t h m a rked l u m b a r kypho sis w h e n seated s h o u l d ca rr y a n in fl a t a b l e cush ion w i t h them to use when t hey lean a g a i n s t a cha i r b a c k . e tc . ( Figure n. 1 5 1 ) . The c u s h i o n s h o u l d be o n l y s l ig h t l y i n fl a te d . a n d fi t ted to the top of t h e k y p h o s i s . fi x e d by braces o r a b e l t . T h i s is of p a r t i c u l a r va l u e fo r ca r d rivers; i t i s n o t o n l y e a s i l y a d a p ted t o each i n d i v i d u a l case, but a lso a d a p t s i t se l f to the p a ti e n t ' s move m e n ts . Hypermob i l e p a t i e n ts w h o freq u e n t l y s u ffe r from low-back pa i n in bed ( ' l i ga m e n t ' p a i n ) may profit from a fi r m pelvic b e l t . fixed between t he pe l v i c c r e s t s a n d t he gre a t e r t roc h a n lers. I t s h o u l d be suffficiently b r o a d . a n d l i ned with a m a t e r i a l t h a t does not i rritate t h e s k i n . I t m ust be fa s t e n e d fi r m l y ( Figu re 6 . 1 5 2 ) . The e ffect is noticeable o n l y a ft e r i t h a s b e e n worn fo r a fe w wee k s . Pa ti e n t s w i t h fla bby abdom i n a l m uscles, o ften acco m p a n i e d by obes i t y , should wear a fi rm belt o r ( i n t h e c a s e o f wo m e n p a t i e n ts ) fi r m e l a s t i c p a n t i es.

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Th erapeutic techn iques

Figure

Figure 6. 150 Soft s u p p o r t i n g col l a r

6. 152 Pelvic belt ( A ft e r

cri b e d h e r e . P r o b a b l y

25 1

Cyri a x , ( 977)

T h e re a re i n n u m e ra b l e m e t h od s e m p l oy i n g r e fl e x

t h e m e t h od most p o p u l a r w i t h d octors i s loca l a n a e s t he s i a . A s s h o w n i n C h a p t e r 5 , t h e re s e e m s to be l i t t l e d i ffe re n ce b e t w e e n t h e e ffect o f l o c a l a n aesthesia and d r y n e e d l i n g , p r o v i d e d t h a t t h e r i g h t t e c h n i q u e i s e m ployed. This is i n good a g r e e m e n t w i t h the r e s u l t s of Frost el £11. ( 1 980 ) , w h o fo u n d i n a d o u b l e - b l i n d test t h a t p h y s i o l o g i c a l s a l i n e sol u ti o n w a s , i f a n y t h ing, m o r e e ffective t h a n loca l a n a e s th e t i c . The c r u c i
m e c h a n i s ms ( s e e

with here.

Figure 6. 1 5 1 I n fl a t a b l e support i n g c Ll s h i o n fo r l u m b a r l a t e ra l v i c w : (h) back v i e w

k y p h os i s : ( a )

H i nts o n reflex t h e r a p y Chapter 5 ) which

c a n n o t b e des-

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7 Clinical aspects of disturbed function of the locomotor system

[n this c h a pter the gen era l principles of t h eor y ,

re.levance assessed, bu t o n ce th i s has been d o n e we

d iagn o sis and t he ra py w i l l be app lied to specific

n e ed t h e diagnosi s of disturbed function fo r t h e vast

c l inica l enti ties or s yn dro m es, in which disturbed

m ajo ri ty of patien ts 'withou t any speci fi c di a g nos is '

9).

As these conditions form the s u bj e c t of

fun c ti on of t h e locomotor system and of the s p in a l

( see

column in par ticu l a r has a si gn ifican t ro l e . It s h ould

all c l assic textb ooks of rheum a t o logy or ort hopae d ics ,

p.

be re m e m bered tha t fami l ia r c l i nic a l pictures suc h

however, we may pass them by and devote ou r

as b a ck p a in, low- b a ck pain, s h oulder p ain

attent ion to our main su bj e ct .

,

head

a c h e, etc., have rarely been considered from this

For a n a mn e sis , refe r to the begin n i ng of C ha pt er

poin t of vi ew ; there is, therefore, l i tt l e on the sub j ec t to be found in the literature ( M enne l l 1952; BrUgger,

4. H e re, too, a part is p l a yed not onl y by the fac t o rs acting upon the mechanical fun c tio ni n g of the sp in a l

,

1977; Cyr iax, 1977; Tr a ve l l and Simons, 1983, 1993; M a i gne , 1996). Nevertheless, this ap proa c h must b e used t o s h ow t h e p r a c ti ca l app lication o f a l l . been put forward in the pr e c e ding c h a p ters . It is of grea t c o n s e q u e n ce for medical t h e ory that t h is new appr oac h h a s reve a .l ed un susp ec ted features in t h es e fa miliar clin ical entitie s. This h as been made possi b l e bec a use t h e t h era p e utic m e as u res we use are h ighl y spe c i fic ; neverth e less , th e y can only be call ed upon a n d ap p l ied to the best a dva nt age if the c l inical d i a gn o sis h as be e n draw n u p acc u ra t e l y . As t h e nu mber of pr ofess iona l s w o rk ing in this field rapidl y in c re a ses , the b ody of c l inic al data grows apac e .

column, but also by those th a t a ffect the (a uto

n o m i c ) ne r v o u s syste m - the weill h e r, c o l d or heat, i nfection, h o rmo na l c han g e s (including menstru a tio n ), and last but not l east , p syc ho l ogic a l fa c tors . For p recise c l inica l ana l y sis, back pain is far too i l l -defi ned, and i t is necessary to treat the various sections of the spin a l colu mn ( t h e back) one by o n e . The first subj ect i s low - ba c k pain.

Low-back pain The de r m a t o me chart shows that in t h is region

a

great n um be r of seg m e n t s c onverg e , fro m th e t hora co l umb a r j un cti o n to the sacral segme nts (se e Figure

4.2,

pp .

90-93),

with the possibi lity of referred pain

from the whole o f th i s vast region.

Furthermore, the most p o w e rfu l forces (m u scle s ) act here, where the

Backache

trunk

[n backache, at le as t , the signific a nt ro l e of the spin a l column i s b e y ond doubt. However, the p ro ble m i s t rad i tional l y treilte d main ly or even ex c l usi ve l y morphological ly, which gives t h e im pr e ssion that a l l w e h a v e t o d o i s t o find t he under l y ing inflamma tory, degenerative, meta b ol i c or neoplastic diseas e , or ma l forma ti on , or at l eas t a gross mec h a nical obs t a c l e

has

its

mo v eme nt

of

greatest mobility and

the

lower

e x tre m i ties

where the must

be

transferred to the tfunk . All of t h is e x p l a ins the great

v ulner a b il i t y of the region and is a p ointe r to

the

many possi bl e pathoge ni c factors that have to be b o rne in min d , a nd the r e l e vance of w hich must be assessed in every c ase . The most important disturb

the

an c e s of fun c tion causing certain types or low-back pain and their resp ec t ive therapies are now re v iewed .

diagnosi s of d isturbed function, such traditional disorders undou bted l y have to be e xc l ud ed , or their

It may be useful to add t hat tile term ' low-back pain' i nc l ucles pain radia t i ng to both sides, tow a rds the

such

as

disc herniation.

Before turning t o

252

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Clinical aspects hips, huttocks or groin,

and

that this pain is usualh

of distllrhed

01

.1

system, e.g. the spine.

vstCI1I

253

the cervical

Thera py

Low-back pain due to ligamental and muscular overstrain

If exogenic strain is the main cause, we should try to correct posture and faulty movement patterns at

In this type of low-back pain. not only need there

work; If thc underlying cause is faulty statics and

be no morphological lesion, but the spinal column

muscular imbalance. correction of statics and/or

as such may he functioning normally. at least at the

remedial exercise are indicated. In the hypermobile a support during static loading is important, particu

outset As this first category is not homogeneous, some further definition is required: the cause of strain may be

cxogenic

like

physical labour. or more I under conditions posture or bad movem\'nl

excessively heavy performed faulty

even. this overstrain

larly in public transport vehicles. Where obesity is a relevant factor. weight reduction is essential. of muscle

For immediate

tension, of triggcI

Ii(.�ntly.

ion points is mosl

[lilei/or

antagonist inhibition.

movement patterns

Finally, it is

such as difference in lelY

imbalance may

rosis, muscular imbalmlcc,

the craniocervical

etc. the common denlJrninl\\or

which must not

ligamental overstrain.

back pain.

S y m pt o m s Discomfort and pain are usually the consequence of activity, postural even more than dynamic, and they Increase as activity continues. Often it is postural strain that is more disagreeable than movement. Thus. any position that has to be held for any length of time is registered as a strain, patients feeling the [n cases need to change position, which is there is pain (stiffness) gradually overcome,

11\l"r by

pain as a sign of fatigue.

Clinical signs and in :111:1 lysed

:I

in each case. The typical imbalance region

This condition may accompany the preceding one. It

must

not

be

is

between

the

111

the lumbo

gluteal

and

the

thought

to

be

identical

to

coccygodynia: it is low-back pain due to a tender coccyx of which the patient is often unaware. In an earlier paper I showed that onlv one-fifth of the patients with a godynia: the pain. On the 01 'coccygeal pain'

painful

sacroiliac dysfuncl

·reilex or even

to a painful ischial I

These consist of changes faulty movement patte!!1" sacral

A tender coccyx

frequent cause: cases. and rarely

1rl

lower

injmy the most olle·fifth of the tenderness of

the coccyx. PsycilOloglcal tension and anxiety are frequent.

abdominal musculature on the one hand. and the hip Acxors and the back muscles on the other. This is

S y m pt o m s

frequently made worse by hypermobility, which

Low-back pain, particularly when sitting; there may

results in what is called 'ligament pain' (p.

101).

The

be constipation anel even dyspareunia. Pain may be

hvperactive erector spinae as well as the iliopsoas can be tender. The most typical tender periosteal

referred to the groin and hips, but this is not very characteristic,

points arc the spinous processes, in particular the last two and the spinel

. If

Clinical signs

there is marked asymmetry

The diagnostic

the iliac crest and the

the coccyx which

imbalanced scoliosis

touch; this is

lumborum.

dorsal aspect. A�

Baastrup-',

rosis of the spinous

which makes

thought to play a pan.

important sign

Ip;lInful) tip of

I. he slightest iatlta than the is kyphotic, Another

of the spinous processes.

of the gluteus

is usually found in hypennol.lIle younget patients

piriformis. There rnay be a pOSitive straight leg

without osteochondrosis. and where there are typ

raising test. Patrick's sign and spasm in the iliaci, and

ical X-ray changes no pain or tenderness is found on

there is often an HAZ visible on the sacrum in the

the spinous processes. Quite frequently we have to

form of a fat cushion. TrPs are found in the levator

look for the cause in other regions of the motor

ani (per rectum).

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Clinical aspects of disturbed junction of

Table 7.1 Clinical signs uf bluckage of the

joints of the

lumbar spine

and

of

the

sacroiliac

Sign

the locomotor system

255

joints

Segment

Lilck of pelvic rotary syn kinesis Straight leg raising: hamstrings spasm Femoral nerve stretch test: spasm of rectlls fe mor is Spasm of thoracolumbur erector spinae Spasm of quadratus lumborulll Spasm of psoas Spasm of lumbar erector spinae Piriformis spasm

TIL

LJI4

++

+

L415

L51S1

Sacroiliac

+

+

++

+

+

+

+

+

++ ++ ++ ++ +

++

lIiiicus spasm

Painful iliac c rest

+

+

P,linful gre,-ilcr trochanter

+

Painful posterior

superior il ia c spine L4 segment (hyperalgesia) Pain nldiating in L5 segment (hyperalgesia) Pain radiating in S I segment (hyperalgesia) Patrick's sign (ildductlll' spasm) Tenderness of the symphysis Tenderness at the ends or sacroiliac joint

+

P,lin radiating in

+

+

+

+

+

+

+

+

+ ++

+

+

the hip joint. It is therefore the most e ffect i ve type of conservative treatment.

Allhough self-treMment is difficult, o n ce the patient has learned what to do du r i n g the iso metric phase, and how to re l ax, the role of the therapist is negligible. Any relative or fr iend can help the pa tient, regularly, once a day if po s si b l e , for about 5 minutes. If there is i m b a la n c e of t h e muscles of the pelvic gir d l e, most frequ en t l y weakness of the glutei, particularly of the a b duc t o r s , with hyper activity in t h e hip flexors and adductors, it is important to rel a x the taut m u s cle s and train the weak ones. In coxarthrosis a well-planned regimen is e ssen tial, sett i ng down how much w a l k in g the p ati e n t is

+

+

+

+

+

++

Blockage of the joints of the lumbar spine and of the sacroiliac joints Low-back pa in due to blockage of a p op h ysea l j oints and to bloc k a ge of the s a cro i li a c joints sha res a

com mon therapeutic approac h and t h e s e conditions also have some clinical features in com mon.

Symptoms If th e state is acute there is severe mo v e men t res t r i ct ion, and stra i ghtening up usuall y presents more diffi culty than s too p i n g; there may be pa in on sn eez ing or cough i ng . In more chronic cases there is usu all y stiffness after rest lying down or s i tting, w h ich im prove s on movem e n t . B a ck - b ending is more fre quently rest rict ed than stooping, and the most char

a l lowed to do. p re fer a bly on soft g rou n d with t h i ck

acteristic com pla i nt is d i f fi cu l ty in straightening LIp

crepe rubber soles and c ar ryi ng a stic k on t h e side not affec ted - regular e x erc is e in t h e supi ne position should be performed. and sw im ming and cycling are to be encouraged. Loads should be carri ed on the affected side.

after stoo p i n g. Side-bending can be restricted and

P. J. (1911) fell Oil the I. i g,h t hip, and felt sharp pain down and in the groin. as well as in the low back. She walked with a stick. ,\Ie found a positive Patrick's sign: the femoral head was painful and so was active abduction of the right lower leg. Internal rotation was n ot painful. Immediate relief was obr,lined by traction along the axis of the rig ht leg. Two months later there was no pain, and t hi s state persisted for many years.

the leg

painful, at least to on e s i d e , a nd typi c a l l y t here is no rota t ion of the pel vis on side-bending. Pain is usua l l y a sym me tr i ca l and may radiate to t he h ips , buttocks, lower abdomen, groin, lower extremiti es, and towards the thoracic spine.

Clinical signs Typical s i gns of b lo c k ag e are found in all the j oints affected, including tenderness and resistance to springing ( see p. 102). The more s pec i fic s i gns a re given in Table 7. I; t h e thora colu m b ar junction

IS

formed by the segm e nts TIO-U; seg m en t

is

L2/3

affected only in exce ptio n a l ca se s .

This patient illustrates an acute l esion of t he hip joint without cox arthros is.

NOle: A posi t ive stra i g ht l e g ra ising t est is due to

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256

Manipulative Therapy in Rehabilitation of the Locom%

s p a sm of the h a m strin gs while the stre tch test is po s it ive in s p a s m of the j ust as Patrick's sign is c a used by a d d u c t ors. The c h aracteri stic m u scle

r System

femoral nerve

rec tus fe m o ris , spasm of the s p a s m s ( TrPs)

for each segment are very im portant features of the clinical p i c ture of e a c h type of b l ock age: s p a s m of t he p s oa s [o r t he a b d o m in al pain in t h o racolumbar l e sio n s ; spa s m of t he rectus femoris for pain from t he thigh to the knee in lesions of L3/4; p i r ifo rmis spasm for p a i n in the b uttocks i n L4/S lesions; an d iliacus spasm for pse u dogy n a e co l o g i cal symptoms ( a lgomen o rrh oe a ) in lesions of LS-S1. Low-back pain due to disc lesion

T h e c ases gr o u p ed under this head i n g are those In which there is n o radic u l a r s y nd ro m e It is essenti a l to k n o w when a disc l e s ion should be s u s p ec ted in lum b a g o even without signs of root compression. If t h i s is the case, we have to d ea l with a lesion n o t o nl y of function but ( a ls o ) of stru ctu re.

Figure 7 1 Typical posture in acute elisc lesion (,sciatic ..

scoliosis')

.

Symptoms

spi n e if b l oc k a g e is absent or if it persists after b loc k a ge has been treated. [f man u al lumb a r tr ac t ion gives relief, this is a g o o d diag n ostic test.

Unless acute, the co urse is as a r u l e m ore severe tha n in the cond itio ns alre a d y d e alt with, that is to

Therapy

say, artacks la st l o nge r and the condition has a te n d e n c y to r e l a pse. Pain at c o u ghing, etc. is more p r o mi n en t. The post ure th a t is p arti c ul arly harmful is th a t of s ligh t l y b e n din g forward, as o v e r a wash basin while sh a v i n g , where c o n tr a ct i o n of the erec t o r s pi n a e is at its m a xi mu m a nd t he r e is therefore maximum pressure on t he disc. Another c h ar a cter i s tic co m p l a i n t is of p a i n w he n tu rn in g over in bed and w h e n ris i n g from t h e recumb e n t a n d s i t ti n g positions.

rest in the relief position is (by hand) in this p o s itio n because it may pro c ure immediate r e lie f (se e Fi gu r e 6.2S, p. 175). If pain continues in the rel ie C p os iti o n , e p i d ural inflltration with l oc al a n aesthe t i c may bring a b o u t immediate relief. The met h od of str a i n and cou nter st r a i n (see p. 2(2) c a n be very u sefu l even at this s tag e if the exagge r a te d relief p o s i t i o n is well tolerated This may, and s houl d , be co m b ine d with the usual ph arm ac o ther a py as p i ri n (u n le ss c o n t rain d i ca ted ) remaining one of the most e ffect ive drugs. In the more chronic cases, t rac ti o n is again very im p o rta nt as l o n g as it gives relief. I f t h ere is s eg m e n t a l movement restrictioll this sho u l d also be treated b y moblization and/or manipulation: so ft tissue l e sions, of t h e fasciae in p a rt i cula r , should be given d u e attention. A ls o ch a n ges in ot h e r parts or the motor s y s tem if c o nsi d er e d rel evant, mllst be tr ea t ed . The McKenzie method, in particular his ex t e n si o n tech n iq ue s if tole rated, are very eff ec t ive ( l is t e n ing to the p a t ien t s sy m pt o m s ) see p. 247. Most i mpo r ta n t here is t h e establishment or a suit a ble reg i me n av o i d i n g the most dangerous ca uses of strain sllch as th e forward-bent p o s i ti o n j o lt i n g in ve hicl e s , etc., combined with judicious remedial exercises; the lumbar region should also be well p r o te c ted a g a i nst c h i l l . Comp l ete rest should not be e nco urage d l o ng e r tha n it is absolutely necessary. In acute cases c om pl et e

recommended; traction may be attempted ,

,

,

Clinical signs In a c ute cases we s ee the cha ra c te r isti c a n t a l ges i c po si t i o n a d o p te d in ac u te root lesion (Figure 7.1), i.e. k y ph o sis a nd lu m b ar sc o lio s i s , m o s t freq ue n tl y towards the s i d e of the le s i o n ( s e e Figure 3.8, p . 44). S t oop ing is s e v erely l i m ite d and the straight leg rais i n g test marke d l y p o sit ive (except in l e sio ns at th e L3/4 s e gm en t where the femoral nerve stretch test is p o si tive) All movement di s tu r bin g the a nalgesi c posture is severely rest ri cte d . If t h e patient is c a p a b le of lying prone, s p ri n g ing of th e lumbar spine is very painful, p a r tic ul a rl y at the site of the les i o n . Nevertheless, if bl ockage of individual seg m e n t s is examined this m a y be a bs e n t In the m ore c h ro nic cases it is s t o o pi n g that is usually most im p a ire d while the pa tie n t is sta n d ing but with the pa ti e n t se a te d a n te flexion m a y be n o r m a l . Another d i a gn o s tic sign is the p a i nf u l a r c ( C y ria x, 1977) (see p. 102). The strai ght leg r a isin g test, a n d the fe m o ra l nerve stretch test in L3/4 lesi o ns may be m ar ke d ly positive, much more so than when th ere is only joint b l oc k a ge . A most useful d ia gn ostic sign is pain on s p rin g ing the lumbar .

.

,

,

,

,

'

'

,

,

o. F. (71) seen 22 December 1986, complained of low-hack pain worsening all standing or walking. particularly when going down stairs, jolting. carrying loads, or turning over

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Clinical in bed, on coughing or

both

legs dorsally. more on I after excessive effort (liI:,nl' The patient gave a history of headache. eprcondylar pain. and (since omy

1979.

j 977) occasional low-back pain. Cholecystect

At examination there was 3ntalgesic kyphotic posture. back-bending restriction and side-bending restriction. yet stooping was normal and the straight

leg raising test was

aspects of disturbed

Iystem

operator adducts

257

on the side until the

where the anterl()r slack is taken up:

patient to press

against his hand into abduction, This is resisted for about 10 s, the patient slowly breathing in, and relaxing while the therapist increases adduction, producing inward rotation of the innominate. On the side where the anterior spine is more prominent and

negative. There was severe pain on springing the lumbar

medial (inflare) the therapist o btains outward rota

spine with the patient prone, but there were no signs of

tion against resistance, using the thigh as a lever.

segmental movement restriction (blockage) in the I.umbar

spmc. During the tirst months deteriorated. standing

condition

imel

1(,:1singly only

difficult. and lumbar tr,UIOII comfortable position w;", I

c\amin-

ation there was hypertrophIC spine and a narrow spined

of silcroiliflC

b1ockflge. which in our

experience, ho�cvcr The clinical back pain freqllcnrh cases of failed is most important

At CT a massive prolap" The patient was

According to Greenman, this manoeuvre is carried out on the side

hOSI'1

complete recovery with I

eXercise,

at first only in the rccumbent postltOn.

P ioUl

The patient S.

1\hrch 2nd

..

complained about

1.1\\

1994,

rlll.klting into the

grom and thigh on both sides. There was intense pain on

from low-back pain j 7, after a fall on her buttocks. Her periods were irregular [rom the menarche on, and during her first delivery in 1966 birth pains were felt in her low back. A coughing or sneezing, She had suffered

Severe pain on jolting, turning over in bed, coughing and sneezing and especially on springing without segmental blockage were typical for lum bago with some pseudoradicular pain, caused by disc prolapse in a narrow spinal canal.

since the age of

second

delivery

miscarriage. In was

was

before

term

1969 pain radiated

and

year and she was

Pelvic distortion (sec

improved until

this

19

in the fell of

1971.

She was

into the left

1991. This time she her condition is

condition is always e corre-

highly characteristic sponds to the lesion,

must be distortion

treated. If treatment subsides spontaneously, a

one

leg: for this pain

Even if the case is

lar, however, it is

had

first operated for disc herniation in the spring of 1970. pain recurred Within a

After operation she felt well, but

Figures 3.12, 3.13, p.

she

into her left leg and she

particu-

hint that there IS a leSIOn

craniocervical junction

that

requires

III

the

treatment.

invalid since

1983.

in early December with nallsea and At examination

the right. her

any trunk

trunk deviating to mobillty. There was

marked tenderness at the groin.

Straight leg raising was greatly restricted. Dorsiflexion of

Adolescent girls with pelvic distortion frequently

the left big toe was weak. There was blockage at

suffer from algomenorrhoea. This may be related to

sacroiliac joint.

iliac spasm which is most frequently due to con comitent lumbosacral movement restriction.

the right A tender point was found laterally at her

buttocks, and on pressure at the sacroiliac ligament. The coccyx. too, was tender on palpation. Therapy: first pressure was applied to tbe sacrotuherous ligament (m. coccygeus) after which the coccyx was no

Innominate shear dysfunction (Greenman)

longer tender. The sacroiliac joint was also mobilized. This.

Greenman (1 986) descnh:d change of the pelvis

witb hypotonus of I

plhll:ional

however, gave little relief Outfbrr of the anterior spina

II

shear dysfunction'. and

then noted. Reposition

There can be a shill

carried oul.

After

principal finding is, however

symptoms had

riar superior iliac spines

(troin and leg.

to be flatter and more

point in the

is more prominent muscular tone on the Side

the same side,

and inflare with

of

the more prominent

spina and hypotonus on the opposite side is the rule ill the lower abdomen. For treatment very simple reposition manoeuvres 3re used: using the patient's thigh as a lever, the

The coccyx was also tender. Pressure at the sacrotuberous ligament was therefore repeated and the gluteals were relaxed. She was re-examined on March 23rd. She had deteriorated again after i\'larch 18th, with pain in her legs and groin on both sides. Her pelvis was shifted to the

Copyrighted Material

side and again

25S

A1anipli/alive Therapy in

there

Re/wiJilillllio/l of Ihe LocomOlOr SY.INIJ/

was innominate shear dysfunction.

repeated after which

hospital.

she

stood

straight

was leave the

Reposition

and could

I n n o m i n ate s he a r d ys fu n c t i o n pr o v e d to be the most relev a n t les i o n i n this p ati ent .

l i t t l e or no abdominal respiration. Attachment points

of the straight abdominal muscles

are

tender at

palpation in particular at the symphysis. At the same time there is h y p er t o ll u s of the gluteal muscles, at least on Olle side, and Oil that side th e re is increased

r e s i st a n c e a ga i n s t c r a n ial s h i ft of the gluteal muscles

(a

pathological barrier ) . On thc sidc of hypcrtollus

the ischial tuberosity appears to be lower. There is

Dysfunction of the abdominal and gluteal muscles with a forward-drawn position and

an apparent shift o n the symphysis, too, at pa l p a t i o n . Forward-clrawn position (owing to te ns ion in the

symphyseal shift

a bcl o m i na l muscles ) necessarily causes tension in the

There is yet a n ot h e r (apparent) shift a t t h e pu b i c

whole of the back and dorsal neck musculature.

symphysis a n d the isc h i a l tuberosity (see Chapter 4 ,

o n o n e side ) ; t h e abdomen is drawn in and there is

An elegant diagnostic test follows from this: if we find forward-clrawn posi t ion with i n cr e a s e cl tension in t he back ancl neck muscles when the pillient loo k s at an obj ect at eye level, we seat the patient. If tension i n the back and neck m us c l e s then dis appears, we can conclude that ten s i o n even at the neck has its origin in the pelvic girdle.

(a)

(b)

pp.

98-99)

w h ich goes hand i n h a nd w i t h muscular

spasm: i n coordi n a t i o n of the glu te a l a n d abd ominal

musculature

pos i t i o n

and

a

( Figure 7.2).

c h a racte risti c

forward-drawn

TrPs are found re gu l a r l y in the

straight a b dom i na l m usc l es whic h are t e n s e

Figure 7.2 Typical

forward-drawn position

( at

least

of the entire

body including the head

pressure on the gluteal muscles

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(a) before and (I))

after treatment by

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Clinical nspecis region, T h e rapy mllst be its very favour able efkcl pos it i o n (se e Figure 6, I

For relief type

o f pain d escribed h y Maign e ( 1 964) as dorsalgie inicrscaj!ulllire in which the spinolls processes of T5 or T6 are very te n d e r on palpation and i n which nndtl1gs In the thoracic re g i o n are otherwise n egative: the prima r y lesion i s, accord i ng to Maign e , i n t h e lower cervical spine, Pain of this locali?cltion can be due t o a thoracic TrP causIIlg the S re flex which is related to a TrP in the m, coccygeus, [t can also be caus e d by trigger mid thoracic points in t he erector region, and it is h ere [11,,[ However, on examinat rolling it under our anee can be felt in th;ll upper I umbar re gion restriction of trunk roLdlOIl d y sfu n ction ) There are, of course llUiHCiOUS ullier rnuscIcs w i th trigger points causing pain in the thoracic regi o n , i n particulcrr the pectoralis mcrjor and min or, the serratus and the Icrtissimus d orsi ( see Chapter 6), It is p arti c ularl y i mp orta n t to poi n t out the su b s capu laris, whi ch is a very frequent source of pain in the upper part of the t hor a x o n either s i d e, because it is so hidden that it causes no local but o n ly referred pam, so that i t IS ad visabl e to examine it routi nely in cases of thorac i c Clilse, It may even cause movellle nl o n ly Blockage in the thOl:lcic the interverte bral the joints between the the same typ e of pain, acute, pain m ay be WOl this is, of cour s e , more where it is uselul to know 111 or ou t causcs the gre a test pain, The imp ort a nce exact d iffere ntial d iagnosis as against ple urisy is obvious, Both for d iag n osis and for therapy the t e chniques described in Chapters 4 and 6, respective ly, are essential and n eed n ot be re pecrted here. M uscle s pasm of the ere ctor s pincre i s freque n tly founcl in the thoraci c spine even without blockage or crfter hlockage has been treated, and in such cas e s P IR of the thoracic ercc:tol rewarding (see Figures 6,112-6,1 i i). Just as th ere is acute there can be (though of pain in the thorax segme nt or, more can be eve n more neck, because the pat respircrtio n. As mere :11 [Ilc; pain ful. first aid is more likely to be local anaesthesia, which IS n ot difficult as the trans versocostal joint is easy to reach, Eve n here there i s the danger o f diagn ostic error: a similar crcut e pain '

'-

,

,

,

,

of disfllrbed

oj'

Sl'stem

26 1

at r e sp i r a t io n

can pneumonia before the typica I More rcrrely in tense pain which they localtze below th e I r ribs (upper abdo m e n), Pain is us ucrlly provoked by deep rcspiration crnd forceful move men t of the upper ext r emit y on the painful side, These patients have usually u n d ergone man y visceral exam i n at i ons which are all ncgative, In these p a tien ts we d i agnose the syn dro m e o f the sl i p ped rib', described (amon g o thers) by Cyriax, The rib a t fa ult is usually the tenth, Once we think of t h i s possibility the d iagn osis is easy: we our fingers stand b e hind the abdominal round the last rib, the fingers cavity a n d e xert the patie n t crgai n st our thenar experie nces sharp I n a fres h ccrse mobilize the r i b pain, If that with our hooked d oes n ot bring diagnos t ic) to treat the rib by local anacslllcsia at its in ner margin, If reJicf by t he s e conservative measur e s is not per manent and pilin keeps recurring, surgical removal of the rib is ind i cated , Fincrlly, a s men t i oned above, restrict e d trunk rotatio n , widely believed t o be due to thorac olumbar d y sfun c t i on, is o n e of t he most frequen t causes of low-hack pain, and can also cause in terscapular pain because of spasm of the erector spinae, It is also a of psoas frequent cause of u nctio n of spasm, and of pam in the the last two r i b s quadra tus lumbpi exceptional for at its own site, Palll secondary to a but more frequGl tly muscles, '

Neck pain

Unlike low-back pain, n e ck pain is clinically simpler, although t he 'cervical syndrome' is even more compJex than the clinical pictures of lesions of the lumbar s pine and pelvis, Here, too, wc can d istin guish between pain cause d or due t o o n ly b y overstrain (either by faulty muscular imbaI:HlC<') s ta t ics, The comrnonrst overstrain of the neck is caused head bent to faulty statics F i g ure 3,36, p, i n the region of ! Chapter 4 (p. 1

described in

Sym ptoms

First d iscomfort and then pain caused by overstrain usually after workin g i n a sitting position, Another

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262

/V/allipllimivc

complaint buses, tractOis asymmetrical and/or ahoulder'

j{,:hu/J!iilatiOI1 of Ihe Locomolor SYS!{l1l The most frequent cause C213, in exceptio nal cases , important to realize that

by jolting in Pain is usually towards the head

usually illvolved. most frequently another C'l/6 the cervicothoracic ju n ct i o n or sometimes the occiput/atlas. These segments rcquire treatment, but arc better diagnosed after treatmcnt or C213. because acute pain and spasm make di a gnos is difficult. The typical pain point is the lateral aspect of the spin ous process of C2 on the convex sid e. A p a i n point between the upper medial edge or the sGlpula and the spinous processes to which the middle part of th e 2!t2chcs should be l o oked for: tlus IS by a cervicobrachial or ,

Clinical signs

Signs typical of muscular imbalance (if present); faulty posture which must be examined in a relaxed sitting position without a support, and standing. Fault y breathing by lifting the thorax should nol b e overloo ked. The mos t typical periosteal pain points are the lilteral edge of the spinous process of C2 (more on the right) ;md the upper edge of the Important muscular I rapezius, the levator trigger points scapulae and t ( Any spi nous, articular o r I l1Iay, of course, be tend er on cases restricted mobility 01 impor tant Therap y

First. reversible changes in function (TrPs, segmental movement restrictions and soft tissue lesio ns) are t reated. The patients have to avoid head anteflexion; remedial exercise must include correction of faulty posture and breathing patterns. A supporting c ollar is useful in jolting vehicles ( see Figurc 6.150). PIR of muscles with trigger points and painful insertions is effective. ft is important to provide correct back support when h.151). Whenever articular dysfunction is movemen t manipulation. found , this It must the cause of neck pain can b e region. In that case treatment und erlying cause. Acute wry neck.

One of the most frequent causes of neck pain is, of c ourse, blockage of mobile segments o f the cervical spine; this has t o be diagnosed by the methods give n in Chapter 4. Blockage w i th severe muscular spasm is also the mos t freque n t cause of what is cailed acute wry neck.

,

Therap y The

[rilction with the p atien t 6.51. p. 189), which and at the same time should the n t re a t the fr e es o ther segme n ts which are usually involve d. Residual muscle spasm, most frequently III the trapezius. is trcated by PIR. There is a possible diagn ostic pitrilll in relilpsing acute wry neck - the i nitial stage or a spasmodic torticollis. In such cases, although pain hecomes less at e ach relapse, rotation and inclin8tion o[ the bead become w orse and we see the lypical spasm of the stern,xleidom3stoid on o n e sicle ancl tbe sple nius o n the be co mcs less and Ir ng concerns m eninge a l use acute pa in in t b e 'nation. however. there rciiL\ion (meningeal signs) h loc kage III which blockage is not acute rorms of the cervical syn d rome, as described later in this c ha p t er. It is unusual if neck pain is not combllle d with pain in the regio n of the shoulder. i.e. clermatome C4. 10 which pain radiates from about as many slructures as in the low-back region. In adclitio n 10 the large C4 d ermatome, there is a characteristiC hyperalgesic zone in blockage of the craniocervical junction below and posterior to the mastoid process. .

S y m pt o m s

Th e condit b e d with times aftel again after complains side of the

In:qlhntly after rest in position, some windo w open, or neck: the patient usually only on one towards one

Clinical signs

other pain motor function extremities of what I have a lrea cly p ai n in Chapter 2 (p. 31). of block8ge of lumbar mobile segme nts. the segmen t of r a d i a tin g i.e. pseud oradicular, pain was includ ed. C l inic al experi ence shows that, as in true radicular syndromes. we e n counter pseudoradicular syndromes only in .

Not only is the head held very stiffly, it is usually also rotated and i nclined. Rotation and bending t o the opposite side i s most res tricted, b u t anteflexio n

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pa i n , too, ca ll re s u l t from a ffec t i o n s of t h e h e a r t , g a l l

p a t te rn ' , w h i c h res t r i c ts p r i m a r i l y e x t e r n a l r o t a t i o n

bladder a n d the stomac h .

a n d a b d u c t i o n . Rece n t l y , howe ver, S a c hse ( 1 996) u s i n g his t e c h n i q u e o f e x a m i n a t i o n , s h ow e d t h a t it i s a b d u c t i o n w h i c h i s A rs t a n d m o s t re s t r i c te d . In

Pa i n or i g i nati n g i n t h e u p p e r r i b s

s e v e re c a s e s t h e re i s m u sc l e a t ro p h y i n the d e l t o i d ,

The A rs t fo u r r i bs p r o d uce p a i n ra d i a t i n g i n to t h e

t h e s u p r a - a n d i n fra s p i n a t u s m u sc l e s , a n d t h e r e c a n

s h o u l d e r . I n l e s i o n s o f t h e s e c o n d t o fo u r t h r i b ,

be s e v e re v as o m o t o r d i s t u rb a n ce i n t h e w h o l e o f t h e

s h o u l d e r- b l a d e .

u pp e r e x t re m i t y w i t h cya n o s i s , o e d e m a a n d e v e n

In l e s i o n s of t h e A r s t r i b ( s e e F i g u re 4 . 2 7 , p . 1 08 ) s h o u l d e r pa i n m a y be t h e o n l y c o m p l a i n t . A t e x a m

glossy s k i n o n t h e fi n gers ( , s h o u l d e r-a r m sy n d rome ' )

p a t i e n ts

a l so

fe e l

pain

in

the

a

,

fre q u e n t m a n i fe s t a t i o n o f a l god y s t r o p h y .

i n a t i o n t h e re i s u s u a l ly t e n d e rness a t t h e v e r t e b r a l m a r g i n of t h e sca p u l a in l e s i o n s o f t h e s e c o n d to

T h e ra p y

fo u r t h r i b , a n d te n d e rn e ss of t h e ( u n d e r l y i n g ) a n g l e

i n t h e a c u te s t il ge w e h a ve to c o m b a t pai n , u s i n g t h e

o f t h e r i b i s · fo u n d o n l y a ft e r sc a p u l a a bd u c t i o n .

c l assic a n a l ge s i c s b u t a v o i d i n g n a rc o t i c s i f poss i b l e .

Te n d e rn e ss o f t h e tl rst ri b c a n b e p a l p a ted a t i ts

i t i s a l s o i m po r t a n t t o c o m b a t p a i n i n d i re c t l y , b y

attach ment

the

t re a t in g a l l c o n c o mi ta n t d i s t u r b a nces o f t h e c e rv i c a l

c l a v i c l e . H e r e , t o o , m o v e m e n t r e s t ri c t i o n i s t h e m o s t

s p i n e d own t o T h 3 a n d a n y m u s c l e s p a s m in t h e

fre q u e n t c a u s e o f p a i n a n d t h e refore t h e p ri n c i p a l

s h o u l d e r. T h e u s u a l m o b i l iza t i o n a n d m a n i p u l a t i o n

to

the

m a n u b r i um

sterni

below

t e c h n i q u e s a re u s e l e s s i n d e a l i n g w i t h t h e s h o u l d e r

obj e c t o f t h e r a py .

j o i n t i ts e l f, b u t t h e re i s o n e tech n i q u e t h a t m a y g i v e re l i e f a t a n y s t a g e o f t h e d i s e a s e - traction u s i n g P I R

T h e sc a p u l o h u m er a l j o i nt

( see F i g u r e 6 . 1 0 , p . 1 66 ) , T h e m o s t spe c i fi c t r e a t

T h e c l i n i c a l p i c t u r e of i n v o l v e m e n t o f t h i s j o i n t

m e n t , w h i c h s h o u l d a l w a ys b e g i v e n a t r i a l , i s g r a v i t y

h a s b e e n d e s c r i b e d i n c l a s s i c t e r m s b y Cy r i a x ( 1 97 7 ) .

i n d uced P I R o r i n A l t r a t i o n o f t h e s u bsca p u l a r i s , T h i s

I t corresponds t o t h e ' frozen s h o u l d e r ' w h i c h is

i s i n d i c a t e d w h e n e v e r we d i agnose a trigger poi n t i n

u n i q u e in a r t h ro l ogy b e u l U s e it is ca u se d by c o n

t h i s m u sc l e (see C h a p t e r 6 , Fi g u re 6 . 1

t r a c t u r e o f t h e j o i n t capsule ( D e Seze , 1 960, 1 96 1 ;

s h o u l d be t r i e d ( o r s ub s t a nces w i t h s i m i l a r e ffe c t .

C y r i a x , 1 97 7 ) .

s u c h a s tri a mc i n o l o n e ) a s a n i n t r a - a r t i c u l a r i nj ec t i o n ,

I 1 a) .

Cort i s o n e

b u t s h o u l d be re p e a ted o n l y a fe w t i m e s a n d o n l y i f i t a l l e v i a te s t h e p a i n . I t i s a d v i s a b l e fo r t h e p a ti e n t

S y m pt o m s In p a t i e n ts o f 4 5 -6 5 yea rs of a ge , m o re u s u a l l y

t o w e a r h e r a r m i n a s l i n g d u r i n g t h e a c u te s t a g e a n d

wo m e n , pa i n

t o perfo r m o n l y i s o m e t r i c e x e r c i s e s . M o re a c t i v e

o f s e v e re i n te n s i t y s e t s i n ,

fe l t i n

t h e s h o u l d e r , ra d i a t i n g d o w n t h e a r m e v e n t o t h e

e x e rc i s e c a n be u nd e r t a k e n i n t h e s e c o n d s t a ge ,

wri s t . a n d b e i n g w o r s t a t n i g h t ( i n bed ) , o r w h e n t h e a rm h a n gs d ow n , c a r r y i n g a w e i g h t , or on m o v i n g

w h e n p a i n h a s s u bs i d e d , b u t i t s ho u l d n e v e r b e s u c h a s t o p r o v o k e t h e p a i n a ga i n .

t h e s h o u l d e r. A t A rs t t h e re i s o n l y s l i g h t res t r i c t i o n o f m o v e m e n t , b u t i n t h e c o u rse o f a fe w w e e k s t h i s d e t e r i o r a t e s . I t is poss i b l e t o d i s t i n g u i s h t h re e stages

(as

Cyri a x

p o i n ts

out),

each

Pa i n p r o v o k e d b y a r m a b d u ct i o n

l a s t i n g 3-4

Pa i n d u r i ng a b d uction o f t h e a r m i s m o r e c o m m o n

m o n t h s : d u r i n g t h e fir s t s t a ge p a i n i s i n te n s e a n d

t h a n t h e c a p s u l a r p a t te r n . I t is ca u s e d b y d i s t ur b a n ce

t h e s y m p t o m s e x a ce r b a te ; d u r i n g t h e s e c o n d s t a ge

of t h e m e c h a n i s m by w h i c h t he h e a d of t h e h u m e r us

p a i n s u b s i d e s a l t h o u g h m ov e m e n t is s t i l l res t r i c t e d ;

s l i ps t h ro u g h u n d e r the

and

d u r i n g a b d u c t i o n . T h i s m o v e m e n t i s l u b r ica t e d by

during the

t h i rd

' thaws', so t h a t

in

stage

about

the

I

frozen

year the

shoulder pa t i e n t

is

c o r a c o h u m e ra l

l i ga m e n t

t h e b u r s a s u b d e l t o a c ro m i a l i s , a n d i f the m ec h a n is m

s y m p t o m - fre e .

i s i m p a i red X - r a y s o m e t i m es reve a l s c a l c i fi ca t i o n s .

C l i n i ca l s i g n s

t h e ro t a t o r c u f f ( , i m p i n ge m e n t s y n d r o m e ' ) .

I t c a n a l so be c a u se d by i m p i n ge m e n t o f t i s s u e s o f A t e x a m i n a t i o n w e fi n d t h e t y p ical c a ps u l a r p a t te r n ( Cy r i a x , 1 97 7 , sec Fi gure 4 . 3 9 , p , 1 1 6 ; S a c h s e , 1 996,

S y m pt o m s

Figure 4 . 6 1 ) . I t i s worth n o t i n g t h a t j o i n t p l a y ( s e e

T h e re m a y b e p a i n p r o v o k e d b y il b d u c t i o n o f t h e

Figure 4 .40, p .

a r m , o r e v e n m e r e l y m o v e m e n t res t r i ct i o n , o r t h e re

1 1 6)

re m a i n s u n a ffe c t e d a s l o n g a s

a b d u c t i o n o f t h e a r m i s poss i b l e to a b o u t 9 0 d e g r e e s ,

m a y e v e n be s e v e re s po n t a n e o u s pa i n . Two t y p e s o f

w h i c h i s fu r t h e r p r o o f t h a t i t i s o n l y t h e c a ps u l e t h a t

i m p a i re d m o ve m e n t m a y b e p r e se n t :

restricts m o b i l i t y . The t y p i c a l pa i n p o i n t i s a t t h e a ttach m e n t o f t h e d e l t o i d m uscle t e n d o n a n d t h e

1 . T h e p a t i e nt a b d u c t s t h e a r m t o t h e p o i n t a t w h i c h

s u bsc a p u l a r i s m u s c l e . T h i s m u s c l e m i g h t be c a l l e d t h e ' m uscle o f t h e froze n s h o u l d e r ' , a n d s p a s m h e re

t h e h u m e r a l h e a d beco m e s e n gaged u n d e r t h e l iga m e n t a n d a t t h i s p o i n t t h e p a t i e n t fee l s p a i n ,

is p a r t i c u l a r l y i m po r t a n t i n t h e e a r l y stages of t h i s

b u t o n c e h e ove rco m e s t h i s ' o b s t ac l e ' , a b d u c t i o n

synd rome

m a y co n t i n u e to 1 80 d e g r e e s w i t h o u t s y m p t o m s .

-

it

is

respon s i b l e

for

t he

' c a ps u l a r

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Clin ical aspeCis

re m e m b e r t h a t t h e

c o n ci i ti o n fa i l u re i n treatme n t is d u e to pil t i e n t' s h a b i ts ra t h e r t h a n to i n e f fe c t i v e m e t h o d s of t re a t m c n t . Fi m l i l y , i f t h e re a re s o ft t i s s u e c h a nges, soft t issue m a n i pu l a t i o n i s i n d i c a t e d ( s e e Figu re 0 . 7 0 ) . Restri ctio n is u s u a l l y fou n d w h e n m o v i n g t h e soft tissues a ga i n s t the u n d e r l y i n g b o n e at the e l bow and com p a r i ng t h e two s i d e s . S tro k i ng ( e x te ro c e p t i v e s t i m u l a ti o n ) c a n b e v e ry e ffec t i v e e v e n i n severe cases. i s a cramped w a y o f

of disturbed

t h ese a re t h e t h o ra c i c - o u t l e t

Iyslem

and

267 the

The carpal-tun nel syndrome

T h i s c o n d i t i o n is a ttrib u ted t o c o m p ressi o n o f t h e m e d i a n n e rve i n the t u n n e l for m e d b y t h e c a r p a l b o n e s and crossed by t h e l ig a m e n t u m c a r p i t r a n s v e rs u m , compress i o n fi rs t a ffec t i n g t h e vesse l s s u p p l y i n g t h e n e rv e . S y m pto m s

Medial epicondylar Sy m pt o m s

Pain at the medial C l inical signs

Te n s i o n i n t h e fl e x o rs a nd i m p a i re d s p r i n g i n g 0 1 d i re c t i o n . Li ft i n g w i t h t h e a r m I n s u p i n a tion i s pa i n ful (gol fe r 's e l bo w ) .

The p a t ie n t c o m even pain, in waking u p i n the h i m up in the n ight stage p i n s and needles and the day, pa rticu l a rl y o n 1 I. S o b t a i n e d when the arms the hands fe l t a t t h e i m proves t h e b l o o d w r i s t a n d m a y rad i a t e u p t h e a r m . S t ra i n o n t h e h a n d s exace r b a te s t h e s y m p t o m s . C l inical signs

Th e rapy

R e l a x a t i o n 0 1 t h e finger and h a n d flexors, m a n i p u l a t i o n o f t h e e l bo w i n a m ed i a l d i re c ti o n , s o ft t i s s u e tec h n i q ues. a n d i C n ecessa ry, loca l a n aest hes i a . Usc o f cort i s o n e s h o u l d he the e x ce p t i o n . S t ro k i ng the skin can be ve ry e ffec t i v e . Pain at t h e w rist

The st ructure most frell I is t h e s t y l o i d process 0 1 t h e cl ose l y l i n ke d w i t h l a tc LI i spri n g i n g o f t h e e l bow pp. 1 64- 1 65 ) . A n o t h e r r a i n fu l ( w i t h o r w i t h o u t a r t h ro S I S ) I S t h e fi r s t c a rpometaca r p a l j o i n t . I n b o t h t h e s e c o n d i t i o n s t h e symptoms a r e l oca l , gen e ra ll y ge t t i n g w o rs e w i t h stra i n . T h e m o s t s i gn i fic a n t s i g n i n a pa i n fu l s t y l o i d process, b e s i d e s l oc a l te n d e rness, i s restricted rad i a l A e x i o n o f t he h a n d . T h e rapy s h o u l d be m a i n l y d i rected to t h e u IlCl e r l y i n g d i s t u r b a n c e of fu n c t i o n a t t h e e l bo w c a u s i n g i m p a i r m e n t o f pro n a ti o n s u p i n a t i o n w h i c h a re esse n t i a l fo r rad i a l ( a n d a ls o 11 I I De u l n ar) fl e x i o n ( s e e Q u e rva i n 's t e n d o v a g llll l co n d i t i o n . Joi n t m o b i l see for l e s i o n o f t h e fi rsl Fig ure 6.2 ( p . 162) . I n rare cases there o n e ca use be i n g b l oc k age t r i q u e tr u m . This ca n

t h e i n i t i a l s tages w e h ave t o provoke t h e s y m p t o m s f o r e x a m i n a t i o n ; t h e s i m p l e s t m e t h od i s r a i s i ng t h e a rms whil e t h e p a t i e n t is s u p i n e . Press u re o n t h e m e d i a n n e r v e a bo v e the w r i s t m a y e l ic i t a s h a r p t i n g l i n g p a i n (Ti n e l 's s ig n). I n t h e m o re a d v a n c e d stage I h e re 1 0 the a re a w e a k ness w i t h s u p p l ie d by t h e rnusc l e m ust a t ro p h y o f t h e stage of a l wa y s be teste cl . t h e d isease d o w e O n e o f t he m o s t s i gn i fic a n t j o i n t p l a y between 1 64 ) . In

T h e ra py

I f j o i n t p l a y is i m p a i red i t m u s t fi rs t b e restored by m o b i l i z a t i o n ( s e e Figu res 6.5 and 6.6, p . 164) and t h e pa t i e n t m us t be t a u ght s e l f- m o b il i za t i o n ( s e e Figure 6 . 7 1 ) . T n t h e few cases in w h i c h j o i n t p la y i s not i m p a i re d , o r if m o b il i z a t i o n b r i n gs n o re l i e f, l oc a l a n aest h e t i c s h o u l d b e a pp l i e d i n t h e c a rp a l t u n n e l . I f t h e re i s t i g h t ness o f t h e ligame n t u m t ra n sver s u m this should be i o n a ] cases s h o u l d local a p p l i c a t i o n o f a t t e m pted. In t h e a d v a nced atrophy and typical EMG c h a n ges , o pe r a t i o n h i n d e r the s u ccess is ind icated. The thoracic-outlet

( ,scalenus

syndrome ')

Entrapm en t syn d r o m es

The re a re two i m po r t a n t a ffect i o n s i n t h e u p p e r e x t re m i ty t h a t a re q u i t e oft e n fou n d i n combi n a ti o n :

T h i s is a tt r i b u te d t o c o m p re ss i o n of t h e b r ac h i a l p l e x u s m a i n l y a t t h e g a p b e t w e e n t h e a n terio r a n d m i d d l e sca l e n u s a n d i t s a t ta ch m e n t a t t h e first ( o r

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Man ip ulalive Th erap v

in Rehabililmion of the Locomotor System

cerv ical) r i b , a l so between t h e clavic le a nd t h e fi rs t r i b , c a u s i n g n u m bness a n d t i n g l i n g p a i n i n the upper extremity, t h i s b e i n g most i n te n s e i n the h a nds a n d fi ngers. T h u s , i t i s not u n l i ke t h e carpal- t u n nel syn d rome. I n fa ct, at the time the s y n d rome was d i s tinguished, many cases a t prese n t d i agnosed as carpa l - t u n n e l syn dromes w e re a t t r i b u t e d to t h e sca l e n u s s y n d r o m e . The thoracic-o utlet syn d rome i s a p p a re n t ly t h e res u l t o f a com p l e x o f lesions i n s tr u c t u re s form i n g t h e t h o racic o u t l e t , e a c h req u i r i n g separate d i agnosis a n d p ro d u ci n g its speci fic sy m p to m s . T h ese a r e i n creased tension of t h e sca l e n u s (see Figure 6 . 94 ) ; i n creased t e n s i o n of the o t h e r u pper fi x a t ors o f t h e shou l d e r g i r d l e a n d the pectora l i s m inor; move m e n t restriction i n t h e lowe r cervica l a n d u p p e r thoracic s pi n e ; and m o ve m e n t restriction o f t h e u p per ribs, i n partic u l a r o f the fi rs t r i b . It i s n o w o n d e r, i n view o f this complexity, t h a t doctors u n fa m i l i a r with t h e d i agnosis of these d i s t u r b a nces o f fu nct i o n i n d i cated o p e ra tion instead o f conservative t r e a t m e n t o f t h e u n d e rl y i n g cause o f the con d it i o n . T h i s s y n d ro m e w a rra nts ope r a t i o n o n l y i n exce p tiona l cases w here m a r k e d n e u ro l ogical s i g n s are present a n d m y e l o p a t h y can be e x c l u d e d . Sym ptoms

P r i n c i p a l l y dysaesth esi a - i . e . n u m b ness a n d p i n s a n d n e e d l e s - w i t h pa i n i n t h e u p pe r extre m i t y , m o re o n t h e u l n a r aspect, i n c l u d i ng the h a n d s , w h i c h gets worse w h e n heavy ca rry i n g has to be done. The s y m ptoms v a ry acco r d i n g to w h i c h structure (l esion) plays t h e p r i n c i p a l ro l e . C l i n i c a l signs The fo l l ow i n g tests a re useful: Adson's m a n o e u v r e , i . c . weake n i ng (d i s a p p e a r i ng) p u l se a t the rad i a l artery on be n d i ng t h e h e a d b a c k a n d t u r n i ng i t t o t h e s a m e s i d e ; raising t h e a b d ucted a r m be n t a t the e l bow a n d obse rving the rad i a l pulse; or p u l l i n g the a r m down ( a s i f ca rryi ng a heavy case) a n d obse rv i n g t h e p u l s e . A J I these tests show concom i t a n t com pres s i on of the s u b c l a v i a n artery. More i m porta nt, h ow ever, i s d i agnosis of d is t urbance of the struct ures form i n g t h e t h o racic outlet. I n view o f the ro le of t he sca l e n i a n d the upper fi x a tors o f t h e s h o u lder blade i t is obvious that d i s t u rba nce o f b re a t h i n g by l i fti n g the t h orax i s fre q u e n t l y decisive. O n l y in exce ptio n a l cases a re true n e u rologica l signs fou n d ( a t ro p h y o f m uscles o f the h a n d ) ; ce rvical myelo p a t h y m us t then be ruled o u t . Therapy d e p e n d s on the a n a lysis o f c l i n i ca l find i n gs a n d their re l e v a n c e , a n d i s l ess a tec h n i c a l q uest i o n t h a n one o f p a t hoge n i c c o n s i d e r a t i o n s .

Combined lesions A s w i t h l o w - b a c k p a i n , pa i n i n t h e u p p e r e x t re m i t ies is usua l l y a tt r i b u t a b l e n o t to one speci fic l es i o n but

to a co m b i n a t i on of severa l . As we have seen in the thoracic-o u t l e t syndrome, w h i c h is d u e to a com p l e x o f i n t e rco n n ected lesions, a l l t h e s y n d romes affecting t h e u p per e x trem i t ies form c h a i n s , as described i n Ta b l e 4.3 ( p p . 1 42- 1 43 ) . A key role i s t h a t of m u scular i m b a l a nce a t t h e s h o u l d e r girdle, prod u c i n g tension o f t h e u p pe r fi x a tors, a n d o f fa u l t y respiration w i t h l i fti n g of t h e t h o ra x a n d i ncreased tension in t h e sca l en e s . T h i s i ncreased tension is tra n s m i tted to t h e m uscles of the uppe r arm and fore a r m and i n fl u ences t h e epicond y l es. Secondary movem e n t restriction of t h e spi n a l a n d e x t re m i t y j oi n ts s o o n fo l l ows, w h i c h i ncreases m uscle s pa s m . We c a n t h u s s e e combi na tions not o n l y i n space, s o t o s p e a k , b u t a lso i n t i m e : p a i n radia t i n g from t h e neck into t h e shoulders may be fo l l owed by p a i n i n the e p icondyles, t h e styloid process, a n d then by a ca r p a l - t u n n e l s y n d rome fo l l owed b y dysaesthesia d u e t o b l ock age o f the fi rs t r i b . The p r i m a ry lesion n ee d not be in the spinal col u m n or the trunk, b u t may eq u a l l y we l l be i n t h e l i m bs . A ffere n t stimu l a ti o n i s decisive a n d t h e re a re a b u n d a n t rece ptors i n t h e peri p h e ry. A l l t h i s h a s to be considere d a n cl weighed up in ord e r to i n d i c a te t h e prope r pl ace and the prope r time for spec i fic trea t m e n t , n o r s h o u l d t h e poss i b i l i t y o f v isce ra l involvem e n t or a T r p a t t h e d i a p h ragm be fo rgo t te n .

The cervicocran ial sy n d rome Th i s sy n d rome covers headache of ce rvica l origin a s well as oth e r d i s t urba nces m a i n l y o f e q u i l i b r i u m , i n c l u d i ng m i n o r n e u rological disorders such a s cervica l nystagm u s . The u nd e rl y i n g d i s t u rbance o f t h e cervical spine ca n be t h e sa m e as i n s i m p l e n e c k p a i n . I t is, o f cour s e , true t h a t the cause i s more fre q u e n t l y a lesion in t h e u pper cerv ical s p i n e , i n pa rticular a t t h e cervicocra n i a l j u n ction, j u s t a s t h e lower cervical s p i n e is more l i k ely to produce p a i n i n t h e u p per e x tre m it y , b u t t h e re a re freq u e n t excep t i o n s . T h i s i s u n d erst a n d a b l e i f we consider t h e m usc u l a t u re : long m u scles l i k e t h e sternocleido mastoid, t h e sca lenes, trapez i i , and l e v a t ores scapu lae, with t h e i r fr e q u e n t spasms a n d trigge r poi nts, cover al l o f t h e cerv ica l regi o n and may react to lesions a t any segm e n t o f t h e cervica l spine. Appare n t l y , t h e re action of the n e rvous sys t e m d e te r m i n es w he t h e r t h e pa t i e n t w i l l s u ffe r o n l y fro m p a i n i n the n e c k , or i n t he s h o u l d e r or a r m , or m a i n l y fro m headache, a l though t he s a me d i s t u rba nce o f fu n c t i o n may u n d e r l i e t he m a l l .

Headache o f cervical origin This is a n e x t re m e l y freq u e n t co n d i t ion a n d is in m y o p i n i o n t h e commonest s i n g l e t y p e o f h e adache . I t i n c l u d e s ' tension heada c h e ' w h i c h w a s t h o u g h t t o be m a i n l y psyc ho logica l : increased m u sc l e tensi o n , as

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f o r v e r t e b ro ge n i c disorders 83-84) is t r u e fo r head ache of ce r v i c a l origi n . I w a n t to i n s i s t p a r t i c u l ar l y on t h e pos i t i o n o f t h e h e a d , i . e . h e a d a c h e d u e to h e a d a n te fle xion fo r l o n g p e rio d s at wor k ,
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r e gi o n . E v e n p a i n ( b u t not t ypica l t r i ge m i n a l n e u r a l g i a I ) c a n be o f cerv i c a l origi n . This i s l e ss surpr i s i n g t h a n it m a y see m : T r a ve l l ( 1 98 1 ) s t u d i e d referred p a i n fro m tri g ge r poin ts i n t h e ste rno c l e id o m a stoid : this was f re q uen t l. y l oca l ized in the fa c e . ra d i a t i n g i n to t h e face

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i mporta n t a re , o f cou rse , the signs o f disturbed cervical functio n , w h ich a re c o m m o n to n e c k p a i n , a n d i n c l u d e sig ns o f m u scu l a r i m b a l a nce, sp a s m , fa u l ty res p i r a t i on a n d s e gm e n t a l lesions, p a rt i c u l a rly of t h e c r a n iocerv i c a l j u n ction . The m os t i mpo rt a n t p a i n points a re o n the lateral s u rface o f t h e sp i n o u s process of t h e a xis ( m o re fr e q u e n t l y o n t h e r i g h t) , a t t b e posterior arch o f the a t l a s ( i n the s h ort e x t e n so rs) , a t t he transverse p r oce ss of the a t l as and in the sternocleidomasto i d . The fre q u e n t p a i n points on t h e occi p u t i tse l f a re usu a l l y secon d a ry , a n d t h e re may sometim es be odd p a i n poi n ts o f a t ypical loca l i za t i o n on t h e s k u l l . There i s a n i m port a n t p a i n p o i n t a t the temple i n the t e m po ra l i s m u sc le ( not to be con fused with a pa i n f u l temporal a rte ry ! ) : o t h e r m ast ic a t o ry muscles m a y a lso ca use h e a d a c h e , a n d s h o u l d b e exa m i n e d fo r tri g ge r poi n ts e v e n t h ro u g h t h e open mou t h . Even t h e p a i n p o i n t c o r resp on d i ng to t h e notch o f t h e fi rs t d i v i s i o n of t h e t rige mi n a l n e rve at t h e orbit can be o f cervical or igin . Ty pical h ype ra l g e s i c s k i n zo nes are fou n d m e d i a l l y be low t h e m astoid p r oc es s e s , a t t h e temples a n d e y e bro ws a n d a t t h e fore h e a d a bove t h e eyebrows a n d o n bot h sides o f the n ose . W h a t may be ca l led t h e ' t y p ic a l ' s o ft tissu e l e sion i s rest ricted mob i l i ty of t h e scalp a g a i n s t t h e sk u l l . This can re a d i l y be p a l p a ted a n d t h e two sides c o m p a r e d . I t i s o ft e n a v e r y re leva n t lesion a n d i s e a s y to tre a t ( s e e Cha p ter 6 , p . 206 ) . I t i s fre q u e n t l y l i n k e d to s i m i l a r c h a n ges of t he c e rv ica l fasciae. T h e most

T h e ra py s a m e r u l e s as for a n y o the r cerv i c a l reg i o n . It m a y be wort h s tress i n g t h a t h e re the si g n i fi ca n ce of m o v e m e n t restriction at t h e cr a n i oc e rvi ca l j u nc t i o n is so gre at t h a t it is good po l ic y to tre a t this first, as m u s c u l a r i m b a l a n ce ca n n o t be i m p roved u n ti l t h i s obstacle h a s b e en remove d . Move m e n t restric tion b e t w e e n atlas a n d occi p u t m u s t b e e x am i n ed in all d i rections. I f p a i n regu l a r l y be g i ns o n w a k i ng, we must e n q u i re a bout t h e s l ee p i n g position of t h e pat i e n t . W hile t r i gg e r poi n ts i n t h e m uscles a n d at peri os te a l points o f a tta c h m e n t a re best treated by P I R , p a i n points o n t h e s k u l l a r e b e s t t re a ted b y soft tissue tech n i q u e o r needling. A t e n d e r te mpor a l i s m u scle ca n be t reated by P I R (together w i t h t h e m a ss e te r ) or b y m ere press u re or local a n aest h e t i cs. The h ypera l gesic zones on the fo re h e a d , te mples a n d round the nos e

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,

Th e mandibulocranial s yndrome

T h a t t h i s s y n d rom e is i m p o r t a n t is c l e a r n o t o n l y from i ts f r e q u e n t occurrence b u t b e c a u s e i t p rod uces a l m os t the same s y m p t o m s as t h e cervi cocra n i a l syndrome a n d is o fte n fo u n d i n c o m b i n a t i o n w i t h i t . Th is i s true n o t o n l y fo r p a i n ( h e a d a c h e ) b u t a l s o for d i s t u r b a n ce s of e q u i l i br i u m i n c l u d ing ve r t i go I n d e e d , i t fo rms c h a i n reactions w i th the cervical s p i ne a n d the cerv i ca l m u s cle s ( s e e C h a p t e r 4, p. 143). C h a n g e s i n the orofa c i a l s y s t e m w i t h fa c i a l a s y m me tr y a re oft e n l i n ke d w i t h s c o l i o s i s

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I n a d d i tion t o symptoms t y p i c a l for t h e ce r v i c o c ra n i a l s y n d r o m e t h e re m a y be bruxis m , p a i n i n t h e region of t h e e a r ( t h e tem porom a n d i b u .l a r j o i n t ) a n d t h e face m a y be ve ry p r o m i n e n t , a s we l l as d ysphagia due to t r i g g e r p oi n t s i n t h e d i g a s t r i c u s .

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Post-i s o m e t r i c re l a x a ti o n ( P I R ) o f t h e re l e v a n t m u scles i s the t re a t m e n t o f c h o i c e , fo l l ow e d b y se l f tre a t m e n t ( s e e C h a p t e r 6 ) . I r t h e j oi nt i s i n v o l v e d , i s o m e t r i c tra c t i o n i s a u s e f u l a d d i t i o n . H o w e v e r , w h e re t h e re is m a l occl u s i o n , p r o s t h e t ics a n d/or o r t h o d o n t i cs a re esse n t i a l I n m o s t cases, d i s t ur b a n ce o f f u nc t i o n i n t h e o r o f a c i a l s y s t e m is bou nd u p w i t h c h a n ge s e l s e w h e re i n t h e l oc o m o t o r s y st e m , p a r t i c u l a r l y i n t h e c e rv i c a l s p i n e , a n d t h e p r i m a r y t a s k is to d is c o v e r i n a j ud icious m a n n e r t h e m o s t re l e v a n t l i n k i n t h e c h a i n .

Cli n i cal s i g n s

There m a y b e rest ricted o p e n i ng of t h e m o u t h ( i t i s n o r m a l l y p o s s i b le t o i n s e r t t h ree k n u c k l e s b e t w e e n t h e upper a n d t h e lower i n c i s o rs ) . D u ring o p e n i n g and clos i n g of t h e m o u t h t h e re m a y be d e v i a t i o n o f the c h i n to o n e side a n d t h e re may be a " popping' sound a t t h e j o i n t . There m a y be tenderne ss a t the temporo m a n d i b u l a r j o i n t . T h e fo l l ow i n g t r i gge r p o i n t s should be loo k e d fo r : a t the te m po r a I m u s c l e a t the tem p l e , b e h i n d a n d b e low the j a w - b o n e fo r s c r e e n i ngs; t h e masset e r a n d the i n t e rn a l p t e rygo i d m u s c l es a r e b e t t e r p a l p a t e d t h ro u g h t h e o p e n mouth. I t is i n t e r e s t i n g t h a t w h i l e t h e p a t i e n t i s u s u a ll y aware of p a i n in t h e tem p l e s , trigge r p o i n ts in the other m a s ti c a t o r y m uscles - more p a i n f u l O il p a l p a t i on - are observed o n l y at exa m i n a t i o n . P a l p a t i o n of t r i g g e r p o i n t s i n t h e d i g a s t ric u s ( b e h i n d t h e a n g l e of t h e m a n d i bl e a n d t h e c h i n ) is more d i ffi c u l t a n d l e s s rew a r d i n g . The s i m p l e s t w a y to d i a g n o s e i n creased te n s i o n is to move t h e t h yr o i d ca rti l age a n d/or the h yo i d from s i d e to s i d e . I ncreased resistance here is c h a r a ct er i s t i c a n d e a s i l y a ssesse d . There is a l so t e n d e rness a t t h e l a te r a l e d g e o f the hyoid on t h e s i d e of i n c r e a s e d ten s i o n . W i t h m a r k e d i n cre a s e o f t e ns i o n o f t h e d i ga s t ri c m u s c l e o n o n e side, the t h y r o i d cart i l age can b e see n t o ,

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C l i n i ca l signs O n l y i f it is poss i bl e to e x a m i ne t h e p a t i e n t d ur i n g a classic a t t a c k of t r u e v e r t i go c a n w e obs e rve t h e typic a l s i g n s o f l a b y r i n t hin e disorder, s u c h a s n y s t ag m u s to the ri g h t w i t h d e v i a t ion to t h e l e ft , a n d d e v i a t i o n to t h e s i d e of t h e w e a k e r la b y ri n th - i . e . d u r in g R o m b e rg's t e s t , s ta n d i n g w i t h eyes closed with t h e h e a d i n n e u tral posi t i o n , t he re is d e v i a t i o n to t b e s i d e ; w i t h t h e head t u rned to t h e s i d e o f t h e w e a k e r l a byrin t h t h e t ru n k mo v es backwa rds, w h i l e i t m o v e s fO lw a r d i f t h e h e a d i s t u r n e d to t h e oppos i t e s i d e . I f, however, we e x a m i ne the pa t i e n t i n b e t w e e n a t t a c k s , a n d t h e re a r e n o pathologic a l neurological fi n d i ngs, t h e re i s l i t t l e to observe u n less we carry o u t H a u ta n t ' s t e s t a s descr i b e d i n C h a p t e r 4 ( p. 1 1 9) . U s i n g t h i s a s a rou ti n e e x a m i n a t i o n m e th o d a c h a racte ristic p a ttern emerges i f t h e r e is a cervi c a l fa ctor, rega r d l e s s o f t h e t y p e of d i s t u r bance o f e q u i l i b r i u m . 1 n 7 2 exa m i n a tions of 69 p a t i e n t s I fo u n d t h e m os t con s t a n t p h e n o m e n o n was i ncreased d e v i a t i o n o f t h e fo r w a r d - s t r e t c hed arms a t head retroA e x i o n and a t rota t i o n o f the head in the o p posi te d i rection to that o f d e v i a t i o n , and less or n o d e v i a t i o n o f the a rm s at head rotation in t h e d i rection o f d e v i a tion , o r a t a n t e A e x i o n . I n 6 9 cases t h e re w er e on l y t wo excep t i o n s , and in n e ither o f t h ese d i d the ce rvica l s p i ne p l a y a n y p a r t . I n w h a t m i gh t be c a l l e d ' t y p i c a l cases ' , d e v i a t i o n i nc r e a s e d i f t h e ' p a t hoge n ic ' head pos i ti o n coincide d with the d i rection o f moveme n t restri c t io n , as was t h e c a s e i n 5 0 e xa m i na tions (70 p e r ce n t ) . I n m a ny cases s i d e devia t i o n is prov o k e d o n l y if t h e head i s rota t ed a n d /o r be n t bac k , but d e v i a t i o n of the arms is i n t h e o p p o s i t e d i rection to t h a t o f h e a d rota t i o n . I t i s a lso sign i fi c a n t that d ev i a ti o n d is a ppe a rs a fter tre a t m e n t o f moveme n t rest rict i o n , or a t least becomes m u c h less m a r k e d , t h e effect being v i s i b l e a fe w m i n u tes a fter treatment. The same a p p l i e s to d i s t u rbed f u n c t i o n o f t h e orofa c i a l muscles i n c l u d i n g t h e d i gastricu s . I t i s i m p orta n t t o stres s h e re t h a t a cervical fa ctor may be p rese n t i n all forms o f v e r t igo a n d d izzi n e ss; this was as t r u e in a group o f typica l vert igo patie n ts ( 5 4 p a t i e n ts ) as in 70 p a t i e n t s w i t h cervica l. a n d m ix e d - type v ertigo, t h e res u l ts of t re a t m e n t s ho w i n g l i t t l e d i fference ( t h e figu re fo r i m p rov e m e n t i n b o t h was 90 pe r ce n t ) . The t y p e o f vert i go t h a t reacts least t o t re a t m e n t o f the ce rvica l sp i n e a p p e a rs to b e po si tio n a l v e r t i g o ; t h i s is a less freq u e n t for m . Disturbed a ud i tio n , t o o , i s a ffecte d by m a n i p u la t i o n o n l y i n a few c a s e s . D i s t u rb e d cervical fu nction i s u s u a l l y fo u n d i n a l l forms, m o s t fr e q u e n t l y i n t h e cran ioce rvical j u nc t i o n , i n c l u d ing C2/3 . I n C h a p t e r 2 I s e t o u t some of t h e t h e o re t ica l reasons for the i m p o r t a n ce of t h e s p i n al co l u m n a n d i n particu l a r of t h e c ra n i ocerv ica l j un c t i o n . C l i n i ca l evid e n ce corroborates t h is : t he p a t t e r n d esc r i b e d a bove , i n w h ic h movi n g t h e h e a d i n t h e d irec t i o n o f movement restriction aggra v a tes d e v i a t i o n , a n d t h e

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fact t h a t t h e nystagm u s ch a nges ( N oITe e l al. , 1 976), in the r h y t h m provi d e a d d l l, I O Ii;,l l role of rece p to rs i n j o i n ts a n d m uscles I n t h e m a i n te n a nc e o r d i s t u rb a n ce o f eq u i l ib r i u m . I n two o f m y cases t h e re w a s o n l y s p a s m o f t h e short e x t e n sors a t t h e cra nio cervica l j u nc t i o n , and by s i m p l e PIR o f these m uscles d e v i a t i o n was a bo l i s h e d . N o l ess i mp o r t a n t a re t he m a s ti c a tory m us c l e s . I t i s i m portan t to n o t e t h a t d is t u r ba nce o f e q u i l i b r i u m , w i t h a d i ffere nce o f more t h a n 4 kg i n w e i g h t d i s t r i b u t i on o n t w o sca l e s , a n d t h e c e r v i c a l p a t t e r n s h o w n by o m I I a ma n t 's test, i s m u c h more fre q u e n t v e r t igo. T h e forme r s i gns a re t h e d i s t u rbed craniocervica l m uscle functi o n , They poi n t to w h e t h er I h e c ra n i ocervical o n t h e post u r a l j u n c t i o n , i.e, m uscles. A s Il l wa y s d i sa p p e a rs dysfuncti o n , t h i s type of d is t ur b a nce o f e q u i li bri u m w i t h o u t d izzi n e ss c a n no t be of l a by r i n t h i n e ori g i n . I t i s n o t o n l y by a ffe re n t s ti m u l i f r o m j o i n ts a n d m uscl e s t h a t t h e ce rvical s p i n e m a y c a use d is t u rb a nce of e q u i li b ri u m , however; i t can a ffect i n tracra n i a l s t r u c t u res, i nc l u d i n g t h e l a b y r i n t h , by i m pi n g i n g o n t h e v e r t e b r a l artery . I n fact, t h e re i s a ten d e n cy t o ascribe m o s t disturba nces o f e q u i l i b r i u m o f cervical origi n to S (Hll t of a rtery, w h i c h i n my v I e w I S I t i s t h e re i n w h i c h cases o f d i s t urbed o f the v e r te b r a l a il e ry l.

I n p a ti e n ts a re o t h e r (ce r v i c a l syncope ) . 2. If t h e re 3 . I f b a c k - be n d i n g o f t b e h e a d cou p l e d w i th rot a t i on h a s a m ar k e d e ffec t on d izzi n ess, p a r t ic u l a rly i n t h e absence o f m o ve m e n t restriction , o r i f d izzi ness persists a ft e r m a n i p u l,l t i o n ; a posi tive d e K l e y n ' s test i s a l so s uggest i v e , 4. Ce r ta i n X - r a y fi n d i ngs - re t r o l i s t h e s i s , i n particu Iil r i f o b l i que p i c t u res o f the cervica l s p i n e i n head retroflex i o n show a n a rrowed i n terve rte bral foramen (see Fi"me 1 '"}1 , p . Ii 1 ) d i fference i n t h e obli q u i t y o f a po p h y se a l j o i n ts at one p . 82) o r m a rked m d i rect signs, the ; I r l e riogra p h y o r b y o n l y proof Dopp l e r a re certainl y Cerv ica l syncopes proo f o f i sc h a e m i a a n d a re most fre q ue n t ly pro v o k e d by s u s t a i n e d h e a d retroflexion d ur i ng w o r k . If cere bra l i sc h a e m i a i s m a r ke d , e v e n e p i leptic seizures c a n occu r . T h e i m po r t a nce of ce rvi c a l

syncope u nd e rra t e d , as i t i s ce rta i n l y t h a n the AdamsStokes So fa r i t mig h l see m o n l y d q uest i o n o f d i ffere n t i a l d i agnosis, w h i c h i n i tse l f i s a d i ffic u l t m a t te r i ll d i s t u r b a nces o f t h e e q u i l i b r i u m . Howe v e r , i n t h c l a rge m aj o ri t y o f cases w i t h i nvol veme n t o f t h e vertebral a rt e r y t h e re is a l so i n v o l v em e n t o f t he cervical s p i n e . Th i s is not j ust coi n c i d e nce : t h e re i s n o t o n l y a dose a n a to m i c a l re l a t i o n s h i p , w h i l e t he a v erage age o f p a t i e n t s suggests a degree o f a rt e r i o scl e rosis, but a sclerotic a r t e ry i s i tse l f much more i r r i t a t i o n than i s a normal susce pl complications a t a r t e riovesse l . graplw in cases w i t h arteriosderosis i n t u m o u r p a t i e n ts. A " p i n e w i l l t h e re fore b e p:l t i e n t w i t h a sderotic ; i pa tie n t w i t h n o r m a l a rten e". The g r e a t a t p d ti e n t s wi t h v e r t e bra l a r t e ry i n v o l v e m e n t a lso s u ffe r from d i s t u rba n ces o f t h e cervica l s p i n e , a s i s borne o u t by c l i n i c a l experie nce a n d b y t h e l i terat ure ( Ba rr e . 1 926; B a r tschi - Rocha i x , 1 949). Both a u t h o rs describe a comb i n a ti o n o f ce rv i c a l h e a dache a n d d is t u r b a nce o f e q u i l i b r i u m due to verte b r a l a rtery i nvolve m e n t e v e n w i t h poss i b l e m in o r n e u ro l ogica l sy m p toms, V ite k ( 1 970) m a d e t h e poi n t t h a t h e a d a c h e i n a rk r i osclerosis is as a rule patienh c a u se d i n v o l ve m e n t of the cervica l rel a ti o n s h i ps becau se consequence s i n volved . e ffect of m e c h a n ica l verte bra l artery by d i s t u r b a nce In ;; kes a d e q u a te t re a t m e n t N e v e r t h eless t h is i s of t h e s p m :iI t h e s u bj e c t o f con s i d e ra b l e con t roversy because o f poss i b l e com p li c a t ions d u e to d a mage t o t h e v e rt e b r a l a rtery b y m a n i pu l a t i o n ( s e e p. 1 49). C l e a r l y , such complications are not t h e res u l t o f m a n i p u l a tion as such, b u t o f gmve tec h n ical m istakes. Leav i ng d is t ur b ed fu n c t i o n unt reill e d is t a n ta m ou n t t o l e av i ng mechan ica l i rr i t a t i o n free to e n ci a nger the v e r t e bral a rtery u nc h e c k e d . A ga i n , i n the gre a t m aj o r i t y o f ('nsf'S t h e d i st mba nce i s a t t he cra n i o i m port a n t because t h i s i s cervica l I II regul a r l y gives rel i e f. the s; n o r m a l fu nctio n i n g o f t h e loops o f t h e verte b ra l h e a d rot a t i o n w i t h o u t a rl e ry; a n d ( 2 ) i f h e a d h a s to t a k e p lace be low rota t i o n C2 , i . c . �Htery runs t h rough i ts c a n a l , ex posed to s h e a r i n g forces i f rota t i o n t a kes p l ac e , Th i s i s borne out by c l i n ical p ract ice. I n a group o f 7 0 patie n ts w i t h d i zzi n ess, v e r t igo o r bot h , 2 1

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s h o wed t h e s i g n s g i v e n a rt e ry i n volve m e n t : a r t e r i a l i n v o l ve m e n t ( t h e res u l ts w e r e s i m i l a r to t h os e i n t h e l a rge r gro u p a l ready q u o t e d ) , i n t h e gro u p w i t h i n vo l v e m e n t o f t h e v e rt e b r a l a r t e r y t h e re w e re 2 8 . 5 % f a i l u re s , b u t 38';;, e x ce l le n t a n d 3 3 .5% good re s u l t s . The l e s i o n t r e a t e d was. for t h e m o s t p a r t , a t t h e c r a n i o c e r v i c a l j U ll c t io n . These resu l t s a r e a l s o s i gn i fi c a n t for d i a g n o s i s . I f n o i m p rov e m e n l o f t h e c on d i t i o n fo l l ows o n n o r m a l iza t i on o f t he f u n c t i o n o f t h e c e r v i c a l s p i n e , I lI v o i vc m e n t i t c a n be s u r m i s e d t h a [ ! o f t h e v e r t e bra l a rt e r v or by gross d e for m i ty i n t h , m a y req u i re s u r g i c a l not 1 972). Ade q u a t e no o n l y g i v e s s a t i s factory o t h e r n o n - s u rgica l b ut e n ab l e s us t o s i n g l e p u t a rt e riog r a p h y i s i n d i c a t e d w i th a v i e w to s u r g i c a l treat m e n t . P . F.. ( 1 93 4 ) . li rsl secn 2 1 A u g u s t 1 98 6 . c o m p l a i n e d o f v e rt i go w h i c h w a s w o r s e w h e n s h e l a y d o w n . g i v i ng a

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Mlln ipulative

Therapy

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i n vo l ve m e n t of t h i s g a n g l i o n , b u t t h is is a q u i te u n fo u n ded assu m p tion . Howev e r , n o t o n l y is t h e cerv ica l s pi n e a f u nc t i o n a l u n i t , b u t i t p rese n t s ty pica l c h a i n r e a c t i o n s ( s e e Ta b l e 4.3 ) , w h ic h e x p l a i n s w h y e v e n i f p a t ie n ts fort u n a te l y d o n o t s u ffer from a l l p o s s i b l e sym ptoms o f c e r v i c a l origi n at o n e a n d t h e s a m e t i m e , they m a y n e ve r t h e l e s s e x peri e n ce q u i t e a fe w of t h e m i f t he d isease ta kes i ts typica l c h ro n ic i n te r m i t t e n t course. I t i s m uscl e te n s i o n i n particu l a r, i n v o l v i n g t h e l o n g m us c l e s o f t h e n ec k , t h a t is l i ke l y t o pr o d uce sym ptoms over a l a rge area . T h e re is a lso a n i n tere s t i n g p h e n o m e n o n ofte n observed d ur i n g trea t me n t of cervica l l e s i o n s : t h e i r t e n d ency t o d e sc e n d . Fo r i ns t a n ce , we fre q ue n t l y fi n d t h a t a fte r t r e a t i n g the cra n i o ce r v ica l j u n ctio n i n a p a tient w i t h cervica l headache, she wi l l a rrive a t t h e next sessi o n w i t h move m e n t restri c t i o n i n t h e m i d ce r v i c a l regi o n , c o m p l a i n i n g o f n e c k pai n : a t t h e t h i rd session she w il l b e s u ffer i n g i n t h e lower c e r v i c a l re gi o n with symptoms i n t h e s h o u l d e r , u n t i l w e h n a I J y get h e r s y m p t o m - free after tr e a t i n g t h e u p p e r t horacic s p i n e o r r i bs f o r p a i n ro u n d t h e s h o u l d e r - b l a d e or i n t h e u p p e r t h or a x . So fa r we have dealt almost exclusive l y w i t h c h a nge s o f fu ncti o n , excep t w h e n discuss i n g v e r t e b r a l a rtery i n volveme n t . causing v e rtigo: we will now d e a l with p a t h o l ogica l conditions i n w h i c h d y s fu n c t i o n c a n p l a y a v e r y i m port a n t ro l e . ,

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w h e n t h e t o n g u e w a s e x t r u d e d it d e v i a te d to t h e l e f t . T h e p a t i e n t h <1 d a v e r y s h ort n e c k w i t h l i m i t e d i n c l i n a t i o n a n d r ot a t i o n t o e i t h e r s i d e . I n t h e u p p e r e x t re m i t i e s . l i ga m e n t and p e r i o s t e a l r e fl e x e s were m o r e m a r k e d o n t h e l e f t : H o ffm a n ' s s i g n w a s p o s i t i v e o n b o t h s i d e s . T h e re w e re e x a gge r a t e d t e n don re ft e x e s i n t h e legs w i t h p os i t i v e s i g n s of

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two a n o m a l i e s have i n c o m m o n t h e a b i l i t y to c o m p r e ss ion t h e fo r m e r o f the med u l l a , t h e l a tte r o f t h e cervical cord a n d pa r t icu l a r l y o f t h e i n t u mesce nce . They a l s o s h a re a t e n d e n cy fo r s y m p to m s to a pp e a r i n t h e h i gh e r age gro u p s , a l t h o u gh t h e u n d e r l yi n g a no m a l i e s a r e c o n ge n i t a l . A process o f d e ge n e ra ti v e c h a n g es a n d fu nction a l d e co m p e n sa t i o n ca n th e refore be assumed. I n b o t h co n d i t i o n s , as l o n g as su rge ry i s n o t p r op o se d 1 h a v e fou n d m a n i p U l ative tre a t m e n t v e r y u s e fu l . I n b as i l a r i m press i on t h e re a re fre q u e n t l y n o signs o f struc t u r a l n e u ro l ogica l d a mage. t h e on l y s y m p t o m s b e i n g h e a d a c h e , d izzi n ess, o r b o t h , a n d i n s u c h c as e s t h e t r e a t m e n t i s t he s a m e a s fo r p a t i e n t s w h o d o n o t p r e s e n t t h e a n o m a l y . E v e n p a t i e n ts w i t h some signs of com press i o n . however, may i m p r o ve a fter m a n i p u l a t i o n , or e ven a ft e r t ra c t i o n . The same is true pa r t i cu l a r ly o f pa i n in t h e upper e x t re m i t i e s i n pati e n ts with cer v i ca l m y e l op a t h y w i t h a n a rrow s p i n a l c a n a l (and s p o n d y l os i s ! ) , and t h e re may e v e n be s o m e i m p r o ve m e n t i n l oco m o t o r fu n c t i o n . For s i m i l a r re a s o n s pa i n i n s y rin go m ye l i a i m p ro v e s a fter ma n i p u l a t ive treat men t of the c e rv i c a l s p i n e . This is n o t w i t h o u t i m p or t a n ce fo r the p a t i e n t , as surge ry i s n o t a l w a y s sllccessful a n d a n y i m p r ove m e n t a c h ieved by n o n-s u rg i c a l m e t h od s i s to b e v a l u e d . cause

,

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( 1 893)

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needles in t h e fi rs t . t h i r d a n d 1 050. T h e h a n d w a s so

l i t t l e fi n ge r o f t h e righ t h a n d i )1

a f fe c t e d t h a t· h e c o u l d n o t s h a v e . and

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i nc l u d e d a t ro p h y o f t h e i n t e ross e i a n d t h e a dd u c t o r po l l i c i s o n t h e rig h t . r e s t r i c t e d extension o f t h e fi n ge rs, a n d e x a ggerMed re fl e x e s o f t h e t e n d o n s a t C5�7 . X - r a y s h ow e d o n l y s l i g h t cerv i c a l s p o n d y l o s i s . A i r P M G s h o w e d d i sc p ro t r u s i o n a t C � -4 a n d C S --{) , a n d s t i g h t h y p e ra l b u m i n o s i s . T h e a t r op h y c o r r e s p o n d e d t o t h e seg m e n t C8 w h e r e t h e re was a l s o d i sc r e t e h y p a e s t h e s i a . A t r a c t i o n t e s t i m p r o v e d s e n s a t i o n i n t he r i g h t h a n d a n d t h e p a t i e n t cou l d a ga i n s h a v e h i mse l f. M a n i p u l a t i o n t r e a t m e n t c o n t i n u e d a n d b ro u g h t pe r m a n e n t i m p rove m e n t i n t h i s Fi n d i n gs

case o f ce rv i c a l m ye l opa t h y .

S. M.

( 1 905)

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278

Manipuiarive Therapy in Rehab iliwrion of rhe L o com o r o r Sysrem

It is i m p o r t a n t t o p o i n t o u t t h a t m o v e m e n t r e s t r i c t i o n a n d a n t a l ge s i c p os t u re i n root s y n d ro m e s a r e n o t d u e t o b l oc k a g e i n i n d i v i d u a l m o bi J e s e g me n ts , a n d t h a t i n d e e d such b l oc k a ge m a y be a bse n t w h e n the p a t i e n t i s e x a m i n e d ( s e e F i g u res 4 . 1 6 Cl n d 4 . 1 7 , p p . 1 03 a n d 1 04 ) . A n o t h e r fe a t u r e o f root s y n d r o m e s i s t h e pos i tive s t ra i g h t l e g rais i n g t e s t w h i c h , i n t y p i c a l c a s e s , m a y b e v e ry ma r k e d . Th ere c a n b e

a t y p i c a l s t r a i g h t l e g r a i sing t e s t s : ( 1 ) a pa i n f u l a rc (Cy r i a x , 1 97 7 ) , p a i n fe l t e a r l y on i n t h e t e s t b u t p a ss i n g a t fu r t h e r r a i s i n g ; ( 2 ) a l t h o u g h p a i n i s fe l t fro m a c e r ta i n po i n t , i t i s s ti l l possi b l e t o r a i s e t h e p a t i e n t ' s l e g fu r t h e r . I t i s a ls o m a n d a tory t o e x a m i n e t h e ' fe m o r a l s t re tch t e s t ' w h i c h i s c h a r a c t e r i s t i c fo r t h e L4 roo t , a n d in w h i c h t h e s t r a i g h t leg ra i s i n g test c a n be n e ga t i v e , a re a s o n w h y the d i a g n o s i s o f L4 root com pression i s freq u e n t l y m i s s e d .

a ffe cted b y t h i s sy n d ro m e . H y p a e s t h e s i a is fo u n d i n t h e L 5 d e r m a to m e . A v e ry v a l u a b l e s i g n i s re s t r icted s k i n s t r e tc h , freq u e n tl y w i t h hype r a l g e s i a o f t h e s k i n b e t w e e n t h e fi rst ( big) a n d sec o n d toes, a n d b e t w e e n t h e seco n d a n d t h i r d , a s w e l l a s i n c re a s e d re s i s t a nce w h e n m o v i n g the fi rs t m e t a ta rs a l bo n e aga i n st t h e seco n d , a n d t h e s e c o n d a g a i n s t t h e t h i rd . 5 ] 1'0 0 1 syn drome - Pa i n r a d i a t e s o n t h e do rsa l a s p e c t of t h e t h i g h a n d l e g , t o w a r d s t h e he e l a n d o v e r t h e l a te r a l a s p e c t o f t h e foo t t o t h e f o u r t h a n el fi ft h t o e s . M u sc l e we a k n e ss m a y be fo u n d in t h e g l u tea l m u s c l e s , pa rtic u l a r l y i n t he g l u te u s m a x i m u s , a n d i n t h e t ri c e p s s u ra e a n d t h e fl e x ors o f t h e toes. In very s l i g h t root l e s i o n t h e fi rs t sign o f m o t o r i m p a i rm e n t i s t h a t w h e n t h e p a t i e n t i s tolel to l e a n fo r w a r d w i t h o u t l i ft i n g h i s h e e ls f r o m t h e gro u n d t h e re i s n o t o e fl e x i o n o n t h e side o f t h e l e s i o n . I f

O f m a j o r s i g n i fic a n c e a re n e u ro lo g i c a l s i g n s o f root i n vo l ve m e n t , s u c h a s m o t o r d e fi c i t a n d by p

m o t o r i mp a i r m e n t i s m a rk e d t h e p a t i e n t ca n n o t w a l k o n h i s t o e s o n t h e a ffec t e d s i d e . T h e A c h i l le s t e n d o n

aes t h e s i a , w i t h o u t w h i c h t h e d i agn o s i s o f t r u e r o o t sy n d ro m e i s i n c o n c l u s i v e beca use o ( the a l t e r n a t i v e possi ble d i a g n o s i s o f re flex (pseudora d i c u l a r ) referred p a i n . F o r t h is reason the s l i g h te s t i n d i c a t i o n of m o t o r o r s e n s o ry d e fi c i t is h i g h l y sign i fic a n t . T h e s pe c i fi c s i g n s a n d s y m p t o m s a re n o w g i v e n f o r e a c h r e l e v a n t roo t . O n l y t h ree a re i m p orta n t : L4 , L 5

r e fl e x i s w e a k e n e d o r a h o l i s h e d . Th e r e is h y p a e s t h e s i a a t t h e d or s a l a sp e c t of t h e t h i gh a n d leg, t h e

and 5 l .

L 4 roo t syndro m e - Pa i n r a d i a te s ove r t h e v e n t r a l a s p e c t o f t h e th i g h t o t h e k n ee a n d ca n r a d i a te fu r t h e r o n t h e a n terom e d i a l a s p e c t of t h e leg d o w n to t h e m e d i a l a n k l e a n d e v e n t o t h e m e d i a l a s p e c t o f t h e b i g t o e : i n t h i s s y n d rome a posi t i v e fe m o r a l n e rve s t re t c h test i s v e ry m a r k e d . T h e r e i s we a k n e s s of t h e q u a d r i ceps a n d of t h e hip fl e x ors ( o f t e n n eglected a t e x a m i n a t i on ! ) a n d e v e n o f t h e ad d uctors. T h e p a te l l a r re fl e x i s w e a k e n e d o r a bs e n t and s o , at t i m e s , i s t h a t of the a d d u c t o r s . Th e re i s h y p a e s t h e s i a ma i n ly o n t h e a n te r i o r a s p e c t of t h e thigh i n the L 4 d e rm a to m e . O w i n g to wea k n e ss o f the k n e e e x te n sors a n d h i p fl e x o r s , w a l k i n g m a y be d i ffic u l t , pa r t i c u l a r l y o n sta i rs . L5 roo t syndrome - P a i n r a d i a te s o n t he l a t e ra l aspect o f t h e t h igh a n d l e g t o t h e lateral a n k l e a n d o v e r the i n s t e p t o t h e b i g t o e a n d t o t h e s e c o n d a n d t h i rd toe s . T h e re i s we a k n ess o f t h e foot a n d toe e x t e nsors, t h e m u s c l e s most a ffe c t e d b e i n g t h e e x t e n s o r s o f t h e b i g t o e a n d t h e e x t e n sor d i g i t o r u m b r e v i s . V e r y sl i g h t i m pairmen t i n t h e L 5 r o o t c a n t h e re fo r e be d e t e c t e d by c o m pa r i n g t h e fo rce o f e x te n sion o f t h e b i g t o e on e a c h foo t , a n d b y p a l p a t i o n o f the d i g i t o r u m b re v i s m u s c l e a b ove a n d i n fro n t o f t h e l a t e r a l a n k l e , a n d t e s t i n g t b e to n u s o f t h e e x tensors a t t h e shi n , p a ra l l e l to t h e t i b i a . I f there is m a r k e d w e a k n ess the p a t i e n t cannot w a l k on h i s h e e l s a n d in the m o s t s e v e re c a s e s t h e re i s t y p i c a l d ro p foo t . I t i s i m p o r t a n t to r e m e m b e r t h a t d ro p fo o t is o n l y e x ce p t i o n a ll y d u e to p a r e s i s o f t h e p e ro n e a l n e rv e , a n d i s fa r m ore o f t e n d u e to s e v e re L5 n e rv e roo t c o m p ressi o n . Te n d o n r e fl e x e s a re u s u a l l y l i tt l e

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l a t eral a s p e c t o f t h e fo ot a n d t h e Fo u r t h and fi ft h toe . H e r e , too, we fi n d rest r i c t e d s k i n s t re tc h w i t h pos s i b l e h y p e r a l g e s i a b e t w e e n t h e t h i rd to fi ft h toe s . a n d res t r i c t e d m o v a b i l i t y b e t w e e n t h e t h i rd a n d fo u rt h , a n d fou r t h a n d H ft h m e t a t a rsa l s , c o m p a red w i t h the o t h e r s i d e .

T h e ra p y In t h e a c u t e stage t h e most i m p o r t il n t s i n g l e m e a s u re is a b so l u te rest i n h e d . i f possi ble i n a p o s i t i o n t h a t g i v e s m a x i m u m r e l i e f; i t i s esse n t i a l t o i m provise p i l l ows to s u p po r t t h e p a ti e n t in this pos i t i o n . I f t r a c t i o n c a n b e c a r r i e d o u t i n t h e r e l i e f p os i t i o n ( s e e Figu re 6 . 2 8 , p . 1 7 5 ) i t s h o u l d be a t t e m pted . I f t h e r e is bl ockage a n d s o m e o f t h e ge n t le m o b i l i za t i o n te c h n i q u e s a re p r a c t i c a b l e , t h e y c a n g i v e s u b s t a n t i a l re l i e f. T re a t m e n t o f l es i o n s i n t h e cra n i oce rv i c a l a n d t h o r a c o l u m b a r j u n c t i o n s , i f fo u n d , c a n a l so be h e l p fu l . I f rel i e f c a n n o t b e o b t a i ned e i t h e r b y posi t i o n i n g of t h e p a t i e n t or by t ra c t i o n , a n d m a n i p u l a t i o n is r u l e d out b e c a u s e o f a c u t e pa i n , t h e n root i nfi l t r a t i o n or a n e p i d u ra l a p p l i c a t i o n o f l oca l a n a e s t h e t i cs is t h e trea t m e n t of c h o i c e . I f t h e re i s a ve ry t e n d e r pa i n p o i n t - for e x a m p l e a t t h e fi b u l a r head, i n t h e p r o x i m i ty o f the a n k l e , o r a v e ry te n d e r i n t e rd i g i t a l fo l d - n e e d l i n g o r i n fi l t r a t i o n m a y give re l i e f. The s a me goes fo r a t e n d e r scar. in p a r t ic u l a r on t h e l o w e r a b cl o m e n , t h e h i ps or l e g s , especia l l y i f t h e p a i n d ur i n g n e ed l i n g i s fe l t v e r y i n t e n se l y . T h e ' n o n i n v a s i v e ' s o ft t i s s u e te c h n i q u e s , g i v i n g m y o fasc i a l rel ease . s e e m e v e n p re fe ra bl e : s k i n s t r e t c h i n g a t t h e i n t e r d i g i t a l fol d ; myofasci a l re l e a se b e t w e e n t h e m e ta t a rs a l s : fo l d i n g sca r t i s s u e ; P I R o f t h e b i ce ps fe m o ri s o f t h e sol e u s ; o r fo l d i n g s o ft tissue b e n e a t h t h e A c h i l les t e n d o n ( s e e C h a p t e r 6, p . 206 ) . A n a lge s i cs h a v e a n i m p o r ta n t s u p p o rt i n g ro l e , best a p p l i e d by i n t ra v e n o u s i n fu s i o n , b u t a re o f t e n i n s u fficie n t i n t h e mse l v e s . I f, h o w e v e r . c o m p l e te r e s t a l o n e b r i n gs

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Clin ical aspects

rotation t o the side of the lesion, i . e . moveme n ts t h a t cause na rrow i n g of t h e i n te rverte bral fo ra m i n a , even if there is no segme n ta l b l o c k age , i . e . even a fter manipulation. There a re a l so cases, however. i n wh ich h e a d a n d n e c k a n te fl e x i o n is p a i nful ( Fry kho l m , 1 969) . This depends o n whether the root i n v o l v e d has a desce n d i n g cou rse inside the spi n a l c a n a l : s u c h roots s t re tch a t h e a d a n te fl e x i o n , causing p a i n (Adams a n d Log u e , 1 97 1 ) , whereas the m ove ment otherwise tends rather to give rel ief, a s it widens the i n te rvertebral fora m i n a . As in the lower extremities, t here may be i m pa ired stre tch and hyperalgesia o f the s k i n between the fi ngers, a n d i ncreased re sista nce w h e n m o v i n g one metacarp a l bone agai nst the n e x t i n a d o r s opa l ma r d i rect i o n . Individual root syndromes

C S , C6, C7 and C8 a re of practical i m portance. C 5 roo / syn drome - This is rare. P a i n i s fe l t a t

the s h o u lder, m a i n l y i n the region of the d e l toid m uscle, which is wea k . The biceps a n d t h e biceps reflex a re wea k. T h e re is hy paesthesia ove r the del toid, not u n li k e i n paresis of the axillar nerve . C6 ro o / syndrome - Pa i n r a d i a tes over the rad i a l (latera l ) aspect o f t h e a r m to t h e t h u m b a n d fore fi nger, and here hypaesthesia may be fo u n d . There is wea k ness o f p ro n a t i o n a n d i n some cases a n a l a r scap u l a can be o bse rved . T h i s is best tested b y t he p a t i e n t stretc h i n g b o t h a r m s forwa rd, w h i le seated, and m a i n t a i n i ng this position for a while. Vite k ( 1 949) has described a reflex that is specific: with the patient's arm flexed a t the elbow i n s e m i - p ro n a ti o n , t h e e x a m i n e r taps the radius a bove the wrist, from the palmar aspect, and obtains a pro n a tory j e r k . (Th e usual t a p p i n g o n the s tyloid p rocess produces flexion a t the e l bow, corres p o n d i n g more to segm e n t CS . ) C 7 ro ot syndrome - P a i n rad i a tes over the pos terior aspect of the a r m towa rds the second to fou rt h fi ngers , with d ysaesthe s i a ; hypaesthesia m a y also be fou nd i n t h i s are a . T h e re is typical w e a k n ess a nd even w a s t i n g o f t h e triceps, and the t r i c e p s reflex is weak o r abse n t . (Th e n a r atrophy is sometimes given as a sign of C7 involvement; t h i s c a n be m i s l e a d i n g , as t h e n a r a t rophy is m a i n l y a sign of the carpa l-tunnel syndrome.) There may be restricted skin stretch with h y peralgesia of t he s k i n between t h e second to fourth fi ngers and move m e n t restriction be twee n the seco nd a nd t h i rd metacarpal bones a nd between t h e t h i rd a n d fo u r t h . C 8 roo/ syndrome - Pa i n rad i a tes o v e r the u ln a r (med i a l) aspect of t he a r m to the fo u rth and fi fth fi ngers, with dysaesthes i a ; hypaesthesia m a y b e fo u n d i n this a re a . There is weakness of fi n g e r fl e x i o n and the flexor re flex is i m p a i r e d . (Th is is elicited by tapp i n g o n the tendons o f the fing e r flexors j u st prox i mal to t h e carpal t u n n e l , wi th the fingers in a s e m i - flexed positio n . ) There can b e

of disturbed function of the locomotor system

281

wasti n g of interosseal m uscles and o f the hypo thenar, with weakness of abduction of the l i t tle fi n ger, but care m u s t be t a k e n to d iffere n tiate this fro m p a r esi s of the u l n a r n erve a n d from cervica l m y e l o p a th y . I n this segmen t , too, t h e re m a y be i n c reased resista nce to skin stre tch between the fourth and fifth fi ngers, a n d to disp lace m e n t of the fourth a n d fift h m e t a c a r p a l s i n a dorso-palmar d i recti o n . G e n e ra l t h e r a p y

A l t h o u g h , i n t h e u pp e r extre m i ty , true root s y n dromes p rese n t a m o r e se rious disturba nce t h a n pseudoradic u l a r p a i n , t r e a t m e n t fo l lows t h e same pri nciples; g re a t e r e m phasis i s l a i d , howeve r, on traction a n d re flex therapy, i n pa rticu lar the use of soft tissue tech n i q u e s . I h a v e a l ready mentioned the tre a t m e n t of Erb's point and the fre q u e n t pain point med i a l to t h e upper bord e r o f the scapu la by PIR. W hatever the i n te r p re ta t i o n , i n fi ltration o f the s te l l a te ganglion by l o c a l anaesthetic ca n be u se f u l . I n t h e u pper extremity, a s i n t h e lower, fa i l u re o f conservative therapy is a n i n d ication for s u rge ry; however, this is rare. S . J . ( 1 92 6 ) i n 1 95 4 s u ffe r e d f r o m p a i n ra d i a t i n g f r o m t h e n a p e o f t h e neck over t h e l e ft s h o u l d e r a n d d o w n t o t h e

t h a t s h e h a d n o t t h e fu l l use o f t h a t a r m . w r on g pos i t i o n ' i n bed . S ince 1 955 a l s o p a ul i n t h e l u m b a r reg io n . M i gra i ne from t h e a g e of 1 2 . At e x a m i n a t i o n in A p r i l 1957 r o t a t i o n o f t h e h e a d to t h e l e ft w a s p a i n fu l , a s w a s b e n d i n g forw a r d . The re w a s a p a i n f u l E r b ' s p o i n t o n t h e left, a w e a k trice ps e l b o w , fe e l i n g

T h i s occurred s u d d e n l y a ft e r ' l y i n g i n t h e

brach i i on t h e l e ft , and a weak triceps r e fle x ; h y p a e s t h e s i a i n t h e C7 d e r m a t o m e . Tra c t i o n p r o d u c e d gre a t e r s t re ng t h in the

triceps (EM G ) ;

t h e tri ce ps r e fl ex was th e n n o rm a l .

s a c r o i l i a c j u n c t i o n w a s t re a t e d b y m a n i p u l a t i o n . T h e e a r l ie r s y m pto m s h a d d is a p pe a r e d , a n d a l t h o u g h the p a t i e n t s u f fered f r o m vario u s a U e rg i e s , h e r Later

the

p a i nful

m igra i n e i m prove d .

B . L. ( 1 907 ) , w o u n d ed i n t h e a r m b y g u n s h o t i n 1 920, w a s n e c k by a h o r s e . I n 1 9 6 0 s e v e r e

b i t te n o n the n a p e o f t h e

p h y s i c a l s t r a ill w a s fo Uowed b y pa i n i n the n e c k r a d i a t i n g down

left

th e

left a r m t o t h e t h u m b a n d fore fi ng e r of t h e

h a n d . Tra c t i o n , m a n i p u l a ti o n a n d i nj e c t i o n s proved

ine ffect i v e . E v e n w h e n m a n i p u la t i o n a p p e a red to be suc

cessfu l . b l o c k a g e soon recurre d . The pa t i e n t h e l d his h ea d forw a rd

and

sligh t l y

to

the r i g h t . A n te fle x i o n , b a c k

b e n d i n g a n d r o t a t i o n were a l l re s t ricte d . There w a s s pasm

C6 the l e ft . Hypaes t h es i a was fo u n d

of t h e left t rapezi u s ; the l e f t t r i c e ps was h yp o t on i c : the r e fl e x w a s a b o l i s h e d o n

in t h e C6 a n d C7 d e r m a to m es o n t h e l e ft . P l a i n X - r a y s h o w e d s i g n s o f d e ge n e ra t io n o f the C5-6 d i s c . P M G s h owe d i n te r r u p t i o n o f th e a i r co l u m n o n t h e v e n t ra l a s p e c t of t h e s pi n a l cord a t C6-7 . A t o p e ra t i o n d i sc he r n i a t i o n w a s fo u n d a t C5-6( 1 ) a n d t h e p a t i e n t m a d e a r a p i d reco v e r y .

Vertebrovi scera l c o r r e l a t i o n s The poss i b l e corre l a t i o n o f structures belonging to the same segm e n t, the poss i b i lity of referred p a i n

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fVlanipl1i iii I e

H" liohlillatiol1 of Ihc Locomotor Systil)l

a n d s o m e 01 I !Jllve already been d iscussed consi d e r t h e practica l c l i n ica l a s pects T h e fo l l ow l Ilg poss l b l i l ltes s h o u l d bc e n v i sa ged : l.

2. 3.

4.

5.

T h e v e r te b ra l c ol u m n ( l ocomotor sys t e m ) i s ca u s i n g sym ptoms t h a t a re mista k e n for v i sce r a l d isease. Visceral d i s t u rbance i s causing s y m p t o m s si m u l a t i n g affe c t i o n of s o m e p a r t o f t h e locom o t o r syste m . V i sce ral d isease i s c a u s i n g a retlex ( p s e udo radicu l a r ) s e g m e n t , i nclud i ng b l o c k age 111 0bi l e s e gm e n t of the vertehral V iscer a l callsed segme n ta l m o ve m e n t s u hs i d e d . b u t b l ockage re m a i ns. Si m u l a t i ng v i scera l d isease I ( Co nj e c t t h e l ocomotor segm e n t l � causwg v i sceral d isease. I t m a y , h o w e v e r , p r o v o k e a l a t e n t affect.io n .

T h e first two poi n ts show t h a t o u r fi rs t concern i s d iffe re n t i a l d i agnosis. T h e s p i n a l col u m n w i t h i t s m o b i l e segm e n ts c a n p roduce s y m p toms i n e a c h body segm e n t t h a t m a y i m it a t e t h ose a r i s i n g i n t h e v i scera a nd a re fre q ue n tl y ascribed to t h e m b o t h b y l a y m e n a n d by m e d i ca l practi t i o n e rs. a s we sha l l s e e below. T h i s m a n i p u l a tors are d i sease ( a n d b e l i e v e b e l i e v e d to I h a t some d oc t o rs a nd use t h e ignore this te rm ' fu n c t i o n a l ' p a t h ologica! o rga n s , ' f u lici psyc h o l og i o l [ I o u h l c , a doctor treats a s y rn p loms thought to be o f v i sceral origin and fin d s no p a t h o logical c h anges t o correspond t o t h e m , b efore o p t i n g for a ' psycho l ogica l ' origin he o r s h e s h ou l d fi rs t l oo k for c h a nges in the segm e n t ( se e p p . 30-3 1 ) . The p e j o r a t i v e use o f t h e word ' functiona l' is c h a racteristic o f t h e u n d e re st i m a t i o n o f t h e s i g n i fi c a n ce of d i s t u rb e d fu ncti o n . i n p a r t i c u l a r o f t h e locomo t o r syste m . I t i s t h i s u n d e re s ti m a t i o n , c o m b i n e d w i t h i g n o r a nce, t h a t gives the tlie o p p o r t u n i ty t o claim it is put in point The other t lie' l a pi s t concerned ( 2 ) . i s a fa i r with p a i n i n t h a t t he re m a y be hind t h i s pain. be o rga n i c Particu l a r l y typical signs of I C lH.l e ncy to re l a pse, segme n t a l d i n t h e c o r re t h e ca use ony s p o n d i n g segment. E r r o r i n p o i n t ( 1 ) is c om m o n ; e rror i n poi n t ( 2 ) c a n be fra u g h t w i t h d a nger. Poi n t ( 3 ) i s of gre a t t h eo r e t i c a l s i g n i fica nce, e x p l a i n i n g w h y o n e of t h e poss i b l e c a u se s of segme n t a l

movernt: n l v isce ra l d i sease . In fac t . c l inicdl I us t h a t d isease o f i nd i v i d uri l a speci fic p a t t e rn o f rea c t i o n s III v a n o u s segm e n t s : t hese patterns a re o f consid e r a b l e d iagnostic i m porta ncc a n d a re des c r i be d here. T h e regularity i s so stri ki n g t h a t i f a ft e r trea t m e n t of segm e n ta l d isorders ( b lockage . muscle spasm . pain p oi n ts , etc.) w e fi n d a tende ncy to r e l a pse, we h a v e to con c l u d e t h a t v i sceral d i se a se is e i t h e r s t i l l active, o r h a s a ls o re l a ps e d . T h i s shows that w e have an i m porta n t poi n t e r not only for d i agnosis but a l so for prognosis. lrolll I h is : i f v iscera l d i sease Po m l has t h e cha nges in t h e p i> la i n most s a t i s factory the s uccess of t h e a n d t h e ra p ists tend because seco n d a ry c h a nges in t h e segm e n t . a ft e r g i v e n to t he t h e rapist i n terrul I w h o lrealed l h e m . On t h e o t h e r h a n d . re l a pse o f d i s t u rbed fu n c t i o n i n t h e segm c nt i s often t he fi rs t sign o f recurri n g i n t e rn a l d i sease . Poi n t (5) is one most c h erished b y l a y m a n i p u l a t o r s , i n t h e past, a n d i t is s t i ll co n t roversial toda y . I t w o u l d s e e m to be fa i rl y w e l l est a b l ished l h a t lesions i n t h e mobi l e segm e n t of t h e v e r t e b r a l co l u m n a fiec t s o m e functions o f i n t e r n a l o rga n s : t h i s is bome out by vasoconstriction i n the w h o l e segme n t affected by a Wil l: . I n such cases we can soon a s we t re a t the con d i t io n s h a ve been w i t h t h e cra n i ocervica l o f eq u i l ib ri u m : s t i l l s o m e d is t u r b ances o f c h a n ges, a n d i n m e n observe v i sceral d i sease m a ll l p u l a l ion. o r recur i f blockage occu rs , t h i s is no proof as it m a y j u s t be a l a te n t lesion provoked by t he segm e n t a l dysfunction ( V ecan a n d Lew i t, 1 980) . 1 s ha l l now d i scuss our e x p e rience in t r e a t i n g i n d i v i d u a l con d i t i o n s . O n e m us t cons i d e r c u m u l a t i o n o f v a r i o u s factors : n o t o n l y m a y t h e re be a l e s i o n i n t h e locomot o r s y s t e m a n d i n a v i sce ra l o rga n s i m u l tane o u s l y . b u l a lso t h e re m a y be some factor w h ich a ffects the orga n i s ill w h o ic- , ,: IIlL:nstruCl t i o n . i n fectious d isease, s uc h c h a nge may b e c l i n ic a l l y u l il ti o n o f s t i m u l i m a y make s·). Ton sil litis

Ta k i n g t p a t ie n ts w i t h vertebroge n i c s t r u c k by t h e high i ncide nce o f c h ro n i c relapsing t o n s i l l i t i s t h a t I took a r a n d o m sa m p l e o f 1 00 c a s e s from m y fi l e s a n d fou n d t h a t 56 h a d a hist ory o f c h ro n i c rel a psi ng t o n s i l l i t i s o r tonsi l lectomy for t h a t reason, w h i l e o n l y

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Clinical aspects of disturbed most o f 44 hac! no or o n l y t h ese p a t i e n t s b l och!,,; T h i s lec! t o a of 76 ch i l d re n w i t h c h ro n i c t o ns i l l it i s u nd e r t h e ca re o f a n otorh i n ol a r y n go l og i s t ( Lewit a n d Abra h amovic. 1 976). The most s t r i k i n g a n d consta n t c l i n ic a l fi nd i ng w a s m o v e m e n t restri c t i o n a t t h e cra n i ocervica l j u nc t i o n . i n t h e grea t m aj o r i ty be tween occi p u t a n d a tl a s ( 70 cases. o r 92% ) . Twe n ty-eight p a t i e n ts u nd e rwe n t opera t i o n . w i t h o u t h a v i n g b e e n m a n ipu l a tec!; 25 s u ffered from move me n t rest rict i o n prior was t o o p e ra t i o n . and i n : 9 nf t hese l a te r . u naffected by 3 - 6 m o n t h s a ft e r o p , ' r;11 Thi rty-se v e n c h i I Li !c ! l we re given m a n i p u l
A s o u r a t t e n t i o n was drawn t o t h e rol e of resp i r a t i o n i n correct f u n c t i o n i ng o f t h e l oc o m o t o r system . t h e re l a t i o n b e t w e e n t h e l u ngs a n d t h e fu n c t i o n o f t h e thorax became c l earer. Pa i n d u e t o rib les i o n s m u st he d i ffe r e n t i a ted from p l e u r a l p a i n a n d e v e n from pneumonia. move m e n t Severe i n co o rd i n il l l Ol1 m a y produce d y s p n orcIl, e m physe m a wi l l produce resp i ratory d isease i n h a s been s t u d i e d d i s e a s e ( Steg l ic h , 1 972 1 975 ; Sachse . 1 ,:)7 5 ) . mechi li ll u e n ces anisms by w h i c h d is t u rhed respi ra t i o n i n a s t h m a t ics: ngi d i ty o f the t h orax w a l l fu r t h e r i ncreases re sistance d u r i ng resp i r a t i o n a n d t h e i ns p i r a tory pos i tion o f t h e t h o r a x i n a s t h m a tics i s wors e ned by fur t h e r l i ft i n g o f the t horax d u ring i n ha l a t i o n . w h i c h i s t y p i c a l fo r t h a t d isease.

system

283

I n addition I fou n d b lo c kage fou n d a t a u t a gro u p of 30 <.l s l tra pezi us i n 23 p a t ie n ts . a ta u t pectora l i s i n I S a n d a w e a k l o w e r t r a p e z i u s i n I S . I ncreased t e n s i o n i n t h e sca l e ne m uscle i s t h e m o s t const a n t c h a n ge i n m uscu l a r a c t i v i t y d i re c t l y connected w i t h l i ft i n g o f th e t h orax d u ri ng i n ha l a t i o n . T h e m o b i l i za ti o n o f t h e r i b s a n d o f b l ocked seg m e n ts of the t h o ra c i c spine. and t ra i n i ng of correct b re a t h i ng p a t t e rn s , w i l l thus be the logical t r e a t m en t for p a t i e n ts w i t h d i s o r d e rs, p a rt i c u l a r l y d i ,;case. those w i t h ObSl.!UCl ivc T h e h eart

between the ) h a s rece i v e d t h e i m portm o s t a tte n t i o n m l e o f pai n i n a n c e of t h e t h e l a rgest g ro u p of p a t i e n ts, i . e . i n t h os e w i t h ischa e m i c h e a r t d i s e a s e , pa i n b e i n g o f course t h e p r i nc i pa l m a n i fe s t a t i o n of d i s t u rbance o f s p i n a l a n d t h o racic f u n ct i o n . Pai n o f c a r d i a c o r i g i n i s l oca l i/.ed m a i n l y in t h e s t r u c tu re s o f the l oc o m o t o r syste m . i nclud i ng t h e (le ft) s h o u l d e r a n d t h e arm . The fo l lowing p a t t e r n of d is t u r b a n ce of t h e locomotor system seems c h a racter i s t i c o f isch a e m i c h e a r t disease: b l o c kage ilffe c t i n g t h e thoracic spi n e between T4 and T5. from T 3 t o T5. m o v e men t res t r i c t i o n l1 0 1 1 c e a b l e t o t h e and of the l e ft . a n d a t t h e i s m us c u l a r t h i rd t o fi ft h r i h erector s p i n a e s p a s m (i n creased o n t h e l e ft: between T4 a n d spasm of t h e p o i n ts in t h e serra t u s l a te r a l i s i n t h e a x i l lary l i ne m a i n ly o n t he t h i rd t o fi f t h ri b . O f si m i l a r i m p o r t a n ce i s spasm o f t h e s ubscap u l a ri s : t h i s i s u n fo r t u n atel y less o b v i o u s a n d m us t h e soug h t . T h e re i s a l so i ncreased ten s i o n w i t h t r i gg e r p o i n ts i n t h e u p p e r p a r t o f th e t ra pezi u s . I ncreased tension in t h e sca l e n u s i s con n ected with pain p o i n ts a t t h e sternocost a l j o i n ts o n b o t h sid e s a n d is l i n k e d t o fa u l ty respi ra t i o n . prod uci n g t h e fee l i n g o f op pression t h a t i s a l s o c h a ra ct e r i s t i c o f a n g i n a . l i n k ed w i t h a Ten s i o n i n t h e l e s i o n o f t h e fi rs l po i n t o n t h e If i t i s o n the l a te r a l a s p e c t o f l e ft s i d e i t m a y t h e p a t ie n t a s com in g from It is obviously d is t i n g u i s h p rod u c i n g t h i s b e t w e e n ischaerY11 c p a t t e rn a n d t h e l oc o m o t o r system o f a S I m I l a r p a t t e r n ( th e ve r t e b roca rd i a l s y n d r o m e ) . R yc h l ik o v a ( I 975b ) showed t h a t t h e m o re complete t h i s p a t t e r n , i . e . t h e more severe t h e ( re fl e x ) c h a n ges i n t h e l ocomotor sys te m , t h e m o re l i ke l y i t i s t o b e s e co n d a ry to h e a r t d isease .

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284

Rclwh iil tation of the L ocom oto r Syslem

Mani[! lIiillil l'

I mporta n t effect o f p h ys ic a l susceptib i l it y to effort s u c h n i t roglyce r i n e c h aracteristic o f t r u e i sc h a e m i a . O n t h e oth e r h a nd, p a i n provoked by c e r t a i n pos i t i o n s of the body i s m o re c h a racteristic o f locomotor d is t u r b an c e . T h e painful a ttacks a re s h o r t e r i n t r u e a n gi n a t h a n i n t h e vertebroca rdi a l sy n d ro m e . T h e cou rse of t h e d i se ase i s sign i fi c a n t : i f d e s p i te specifi c t r e a t m e n t of l ocom o tor lesions these re l a pse o r a re aggravated, the cause m us t be p r i m a ry h e a r t d isease ; t h e t h e r a p i s t s h o u l d i n s i s t on thorough c a r d i o logica l investigat i o n even if rou t i n e ECG fi n d i ngs a rc o f t h e locomotor system i n t h e i s b o rn e o u t b y w i t h m yoca rd i a l t h e fact t h a t ( 1 97 S b ) d i d n o t i n fa rc t i o n t h e l ocomotor fi n d a n y syste m . As t h e p a l l c m distu rba nce described s i m i l a r to those a bove will presen t of isch a e m i c h e a r t d isc:ase, they have t o b e t re a t e d accord i n g t o t h e principles l a i d down here, w h e t h e r t h e y a re p ri m a ry o r seco n d a ry . M o re o ft e n t h a n not, m o b i lization of m ov e m e n t rest r i c t i o n and m uscle re l a x a t i o n w i l l h a ve to b e fol lowed b y t h e tra i n i ng o f correct b r e a t h i n g patterns a n d correct posture, i f t h e res u l ts ach ieved a re t o b e m or e t h a n temporary. I t i s i mporta n t here to warn r e a d e rs o f t h e complex ity of this prob l e m , a nd the m a n y p i tfa l l s to be o f t hese p a t i e n ts e n co u n tered: b y a ca rd i o logist ischa e m i c h e a rt Tak i n g a s d isease i n locomotor d is t u rb ance, the i n h e a r t d isease o n e co n d i ti o n . l a tt e r assumption seems we l l tachycardia w i t h n o o rga n i c h e a r t l e s i o n . lI e r e t h e e h a n ges fou n d i n t h e spi n a l c o l u mn a r e l in k e d w i t h tachycard i a i n s u c h a w a y t h a t w h e n w e n o r malize t h e f u n c t i o n o f t h e s pi n a l co l u m n , h e a r t rhy t h m a l so becomes n o rm a l a n d rem a i ns so a s l o n g a s t h e re i s n o r e lapse i n the s pi n a l col u m n . A lthough d i rect evidence o f d i s t u rbed motor fun c t i o n causing organ i c heart d isease is lac k i ng , it wo u l d seem reas o n a b l e to grant it t h e role of a poss i b l e risk factor. The prime i re' a t m e n t o f loeo motor d isturba n ce l ie s in the r e l i e f of p a i n , w h i c h re h a b i li t a t i o n o f t hese p a t i e n ts, J . K . ( 1 898) s p a ( ba t h )

neck pain rad i a t i n g

into the head.

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m o b i l i z e d t h e n e c k a n d c a r r i e d o u t t h r u s t m a n i p u l a t i o n of T h 4 ·S a n d LS-S l . S o m e 6 w e e k s l a t e r t h e p a t i e n t fe l t i m prove m e n t i n t h e l u m b a r spi n e . X - r a y s h ow e d m a r k e d

the spine, but with the I vp i c i l o f h y pe ro s t o t i c s p o n d y

l 1;i l l ,1 11 1 c o u l d w a l k for 4 h o u rs

w i t h o u t fa t i g u e . Ivl a n i jJ u i a l i o ll of C l -2 a n d c e r v i c a l m a n i p u l a ti o n w e re re p e a t e d . S i x w e e k s l a t e r s t e n o c a rd i ac a n d

l u m b a r s y m p t o ms rec u r r e d . A ft e r h o s p i t a l i za t i o n t h e h e a r t

s y m p t o m s d i s a p p e a r e d , LS-Sl w a s t re a t e d [ o r l u m b a r p a i n . S tenoca r d i a c s y m p t o m s d i d n o t rec u r t h ro u g h o u t t h e 1 2 y e a r s h e re m a i n e d o u r p a t i e n t , u n t i l b i s d e a t h from c a n ce r ( 1 973 ) . I t a p p e a r s t h a t t h e i s c h a e m i c h e a r t d i s e a se had healed

during

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c h a n ge s . h c c, d c: c h e a n d a b u r n i ng s e n sa appendectomy i n

1 980.

o r m e d i n O c t o b e r 1 980.

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I %9 s h e w a s h o s p i t a l i z e d fo r [ il d i a t i ng i n t o t h e l e ft a r m . t d i n t . Exa m i n a t i o n show e d

.2 a n d Th4-5 . w i t h spasm o f the sca l e n i and

t h e s u bs ca p u l a r i s o n t h e l e lt . S h e w a s

t re a t e d b y m o b i l iza t i o n o f Th l -2 a n d 4-5 , a n d b y P I R o f t h e s c a l e n i a n d t h e l e f t s u bscap u l a ri s A t c o n t ro l e x a m i n

a t i o n o n 4 J a n u a r y 1 990 s h e h a d b e e n w e l l o v e r t h e C h rist

mas h ol i d a ys but a ga i n fe l t fa i n t d u n n g the n ig h t o f J

J a n u a r y . fol l o w e d by p a i n i n t h e l e ft t h o r a x n e x t d a y . T h e

o n l y fi n d i ng w a s a t r i gg e r p o i n t i n t h e s u b s ca p u l a ri s : a ft e r re l a x a t i o n b y grav i t y - i n d u c e d P I R t h i s p a i n s u b s i d e d .

In

fi rs t the typical 'cardiac pain therapy: a t control sil it a i ned only by spasm

Stomach

As ill c o n d i t i o n s in t hese orga n s a rc most LO produce reAex cha n ges in t h e locomo t o r system ; for t h i s reaso n , c l i n ica l experien c e of vertebrovisce r a l corre l a tion is greatest in t h ese cond i t io n s . Th e data given be low are based o n a group of 79 a d olescen t s s u ffering from d u o d e n a l a n d/or g a s t r i c u l c e r (Lewi t a n d Rych l fkova, 1 975 ; Rych l ikova a n d Lewi t , 1 976). The fol lo w i n g pattern was cha racteristic of distu rb a n ce in the l ocomotor syste m : b lockage o f th oracic segm e n ts T4 a n d T7 w i t h a cle a r maxi m u m w i t h a con t rol grou p o f b lockage in the the most s t ri k i ng c h ange compared with 44.4% was i ncreased m uscle erector spinae i n t h e the maximum a t TS/6, h y pera lgesic skin zo nes, and the i ncidence o f the l atter being about h a l f that of i ncreased m uscle tensi o n . I t is i n te resting that t h ese c h a nges w e re a lmost symme trica l , with a s l ig h t prepon d e r a n ce o n t h e right; t h ere was h a rd l y a n y

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Clin ical asp ects of disturb ed fune/ion d i ffe r e n c e

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I n t h i s g r o u p t h e i n t e n s i t y o f re A e x c h a nges w a s c l e a r l y corre l a ted to p a i n ; w h e re t h e re w a s n o p a i n ,

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process i n t h e which was treated

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4 y e a rs , d u r i n g w h i c h n o

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a s i n s o m e cases a fte r o pe r a t i o n , t h e p a t t e r n d i d n o t prese n t i tse l f I t m u s t be a d d e d t h a t t h i s pa ttern w a s fo u n d i n y o u n g p a t i e n ts ( 1 5-22 y e a r s o l d ) ; i n o l d e r

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d i s e a s e d k i d n e y , p a i n i n t h e l u m b a r regi o n ( b a c k

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d i re c t l y

associ ated

p a i n ) i s a l s o fo u n d i n t h i s co n d i t i o n .

A

with

a

thorough

a n a ly s i s of r e A e x c h a n g e s i n t h e l o c o m o t o r system

o f t h e d i s e a s e , a n d i f we fi n d t h is p a t t e r n i n p a t i e n ts

in k i d n e y d is e a s e h a s been m a d e b y M e tz

w h o do n o t com p l a i n of abd o m i n a l s y m p t o m s , t h e

( 1 98 0 ) and M e t z ( 1 986 ) . I n 206 c a s e s of c h r o n i c

el

al.

s t o m a c h a n d d u od e n u m s h o u l d be e x a m i n e d . T h i s

k i d n e y d i s e a s e ( p ye lon e p h r i ti s , gIo m e r u l o n e p h ri t i s )

i s p a r t ic u l a r l y s u s p e c t i f t h e p a t i e n t w a k e s a t n i g h t

t h ey fou n d t h e fol l o w i n g pa tter n : m o v e m en t r e s t r i c t

w i t h pai n b e t w e e n t h e s h o u l d e r - b l a d e s ( h u ng e r p a i n

i o n a t t h e t h o ra co l u m b a r j u n c t i o n (Tl O-L l ) , a n d a t

i n d u o d e n a l u l ce r ) ,

t h e l o w e s t r i b s ; p e l v ic d i s t o rtio n ; i nc r e a s e d t e n s i o n in

the

t h o r a co l u m b a r e r e c t o r s p i n a e , t h e p s o a s ,

q u a d ra t u s , t h e t h i g h a d d u ctors a n d t h e p i r i fo r m i s ;

Liver a n d gall bladder

a n d A a b b i n e s s o f t h e a b d o m i n a l m us c l e s a n d t h e

A s pa i n h a s a p ro m i n e n t r o l e i n a ffe c t i o n s o f t h e

g l u te i . T h e re w a s acco m p a n y i n g l i ga m e n t p a i n a nd

l iver

d i s t u rbed s t a t ic s . T h e s e c h a n g e s w e re n o t v e ry res

and

especi a l l y

of

the

ga l l

bladder,

re A e x

c h a n ge s m u s t be e x p e c te d . Accord i n g to Ryc h l f k o V 3

p o n s i v e t o t h e ra p y a s long a s the u nd e r l y i n g k i d n e y

( 1 974) t h e segme n ts m o s t fre q u e n t l y a ffe cted a re

d i s e a s e w a s s t i l l active .

T6-T8 , Freq u e n t r il d i a t i o n of p a i n i n to the s h o u l d e r

In a g ro u p of 40 ( m a i n l y wo m e n ) p a t i e n ts w i t h

i s b o r n e o u t by a n H A Z i n t h e C 4 d e r m a tome a n d

n e p hroptosis a n d a n o t h e r 40 p a t i e n t s a ft e r n e p h ro

i n creased t e n s i o n i n t h e u p p e r p il r t o f t h e t ra p e z i u s

p e x y , t h e re w a s m a rk e d h y p e r m o b i l i t y , i n p a r t i c u l a r

o n t h e r i g h t . Th e re i s a l so i n c r e a s e d t e n s i o n i n t h e

a t t h e L5/S 1 s e g m e n t w h i c h s h o w e d a h i g h p ro m o n

t h o ra c i c e rector s p i n a e , m o r e o n t h e r i g h t t h a n o n

t o r y ; t h e re A e x c h a nges w e re si m i l a r , w i t h m a r k e d

t h e l e f t . F o r d i ffe re n t i a l d i a g n o s i s w i t h p s o a s spa s m ,

m u s c u l a r i m b a l a n c e , fa u l ty s t a t i cs a n d l ig a m e n t p a i n .

see b e l o w . On t h e o t h e r h a n d , T i l s c h e r el a l . ( 1 977) ,

In

s t u d y i n g 30 p a t i e n ts w i t h h e p a t i t i s , fo u n d m o v e m e n t

loco m o t o r f u n c t i o n p r o v e d t o b e t h e d e ci s i v e c a u s e

r e s t r i c t i o n i n t h e s e g m e n ts T8-Tl O i n 2 0 c a s e s a n d

of t h e s y m p t o m s , a n d t r e a t m e n t o f d i s t u rb e d l oco

these

cases,

however,

d i s t u rb a n c e

of

the

( i n t e r e st i n g l y ) res t r i c ted r o t a t i o n o f t h e right h ip

motor fu n c t i o n b ro u g h t re l i ef, w h e r e a s n e p h r o p e x y

in 15.

p r o v e d i n e f fe c t i v e .

A b dom i n a l v i sc e r a c a n h a v e a ve ry d e t r i m e n t a l e ffec t o n p a i n s y n d ro m e s i n t h e u p p e r e x t r e m i t i e s , via t h e p h r e n i c n e r v e ( Zboj a n , 1 98 8 ) a n d t h e d i a p h ra g m , p a r t i c u l a r l y

in

c o n d i t i o n s w i t h o u t gro s s

T h e psoas a n d t h e a b d o m i n a l m u sc l e s As the psoas is located i n t h e a b d o m in a l cavity, in

p a t h o l ogy, su ch a s ' i n d i ge s t i o n ' c a u s e d b y fa u l ty d i e t

many

o r b a d e a t i n g h a b i ts ( e a t i n g t o o fast, c o l d d r i n ks

d i ffere n t i a l d i a g n o s i s i s t h e re fo r e v e r y i m po r t a n t . A s

ways

it

behaves

l i ke

an

e a r l y i n t h e m o r n i n g , i r regu l a r m e a l s , e t c , ) , w h ich

w e h a v e s e e n , t e n s i o n i n t h e p s o a s m a y b e seco n d a ry

may cause n o m aj o r d is e a s e but o n l y dysfu n c t i o n of

to k i d n ey d i s e a s e ; i t is m o s t fre q u en t l y a s s o c i a t e d

orga n ;

t h e v i scera , T h i s may s u ffice to p r o v o k e r e fe r r e d p a i n

with

a n d t r igge r p o i n t s i n t h e u p p e r e x t re m i t i e s , s h o u l d e r

j u n c t i o n ; b u t i t c a n a l s o be a s i g n o f m o t o r i m b a l

g i r d l e , head and neck. I mproved eating h a bits and

a n c e , v e ry often a s a r e s u l t o f fa u l ty a t h l e t i c t ra i n i n g .

a h o t ( b u t n o t t o o h o t ) d r i n k a t a p p r o p r i a te t i m e s

For e x a m i n a ti o n , s e e F i g u r e 4 . 52 , p . 1 25 . P a l p a t i o n

may grea t l y a l l e v i a te s u c h c o n d i t i o n s .

m a y be d i ffic u l t i f p a i n i s i n te ns e , b e c a u s e t e n s i o n i n

L. O . ( 1 906) s u ffe red from t h e a g e o f 50 from c h r o n i c l u m b a r pa i n rad i a t i n g t o b o t h l egs, p a i n b e t w e e n t h e

i n c r e a se d , a s i n any o t h e r p a i nfu l a b d o m i n a l co n

s h o u l de r- b l a d es a n d res t r i c t e d move m e n t o f t h e h e a d . We fo u n d p e l v i c d i s t o r t io n , w h i c h was t re a te d , and

muscle i m b a l a n ce w h i c h req u i re d re m e d i a l e x e rc i s e . S o m e y e a rs l a t e r t h e p a t i e n t w a s t re a ted fo r g a l l b l a d d e r t ro u b l e ; h i s l u m b a r p a i n i n c r e a s e d a ft e r s p a t re a t m e n t . f o r e xa m i n a t i o n

When he came

h e w a s s u fferi n g fro m a n a c u te ga l l b l a d d e r

so t h a t r e m ed i a l e x e rc i s e was o u t o f t h e q u es t i o n . There was a h r o a d H A Z on t h e r i g h t c h e s t w a l l , w h i c h we a t t a ck ,

the

m o v e m e n t r e s t r i c t i o n a t the

i n t e rn a l

m uscles of the abdominal

t h o r a co l u m b a r

wa U wiII

a l s o be

d i t i o n . I n s u c h c a s e s t h e a b d o m i n a l w a l l s o f t e n s a ft e r p r o p e r t r e a t m e n t of t h e p s o a s . P s o a s s p a s m is u s u a l l y a s s o c i a ted w i t h s p a s m o f t h e t h o racol u m b a r e r e c t o r s p i n a e a n d t h e q u a d ra t u s l u mbor u m , a n d r e l a x a t i o n o f o n e m uscle i n d uces r e l a x a t i o n o f t h e o t h e r . T h e m o s t fre q u e n t c l i n i c a l m a n i fe s t a t i o n o f psoas s pa s m i s the ' p o s t - c h o lecystectomy s y n d ro m e ' , or p a in s i mu la t i n g ga l l - b l a d d e r d is e a s e after the o rga n

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286

ManiplI!u!!\'{'

Rr-i;uhililalion of the

Loco/n %

h a s bee n I 01 II bloc k e d t hora e ffective. I t i s col u m ba r p a t t e r n of true g a l l i n te re s tin g to b l a d d e r d i sease d o e s n o t regu l a rly i n c l ude psoas spasm . Because of i ts size and s i te , the psoas ca n i m i ta t e a l m ost a n y v i scera l d i s t u r b a n ce : d u o d e n u m , a p pe n d i x , p a n c re a s o r k i d n e ys. N o t o n l y i s t h e pain Imitat ed , hut so a re t h e concomita n t d i sord ers of the a u to n o m i c n e rvous system s u c h a s loss o f a p p e t i t e . t h e fee l i n g o f ind iges t i on , etc. I n d ia gn osis o f ' fu n c t i on il l d is t u r b a n c e ' o f a n a b d om i n a l orga n . t h e re fore, e x a m i n a tion o f t h e psoas s h o u l d n c v e r b e omitted, as b e m o re e ffectively relieved p s o a s spasm. Te n s i o n I m uscles w i t h t n gger poi n t s m a y ra a b d o m i n a l pa i n , e . g . t h e p s o a s . Eve n visce ral p a l to m o re freq u e n t l y t h e a bdom in a l m uscles a re i ncoord i n a t i o n w i t h fo rw a rd - d r a w n I n c re ased t e n s io n i n t he g l u t e i fre q u e n t l y l i n ked to d ysfu n c t i o n o f t h e l o we r e x t r e m i t i e s w i t h spasm o f t h e h a m s tr i ngs (scc Fig u re 7.2) . P a l p a t i o n i s n o t easy; it c a n best be pcrfor m e d b y a p i n ce r m o v e m e n t o f t h e t w o h a n d s , a v o i d i n g pressu re fro m above. T h e m ost r e l i a h l e s i g n s a re p a i n fu l i ns e rt i o n s a t t h e u p p e r aspect of t h e p u h i c s y m ph y s i s a n d a t t h e x i ph o i d p rocess, Pain p o i n t s a t t h e sy m p h ysis re fer pai n t o t h e l o w b a c k , w h ich i s i n k e e p i n g w i t h a fo rwa rd-d r a w n pos t u re a nd restricted b a c k - be n d i n : . -

.

r SysfC1Jl

In

pregna n t w o m e n ( Lew i t a n a nlll (�stic m e n s t ru a l p a i n i n d i s t o r t i o n or lumbosacral m o v e m e ll t rest rict l o ll . fi n d i n gs in t h e l u mbo s acra l spi nal co l u m n a n d t h e pelvis w e r e norma l o n l y i n 1 0 . Moreover, me n s t ru a l p a i n w i t h out les i on a t t h e l u m bosacral s pin e or p e l v is w a s fe l t m a i n l y in t h e h y pog a s t ric re g i o n w h i l e i n p a t i e n t s w i th d i st u rbed f u n c t i o n o f t h e l u m bosacral r egi o n . p a i n w a s u s u a l l y fe l t a l s o i n t h e low hilCk. I n a n o t h e r gro u p o f 7 0 women w i t h me n s t ru a l p a i n a n d nega tive g y n a ecologica l fi n d i ngs t rea t m e n t of the In a n i p u l a t i o n g a v e exce l l e n t in / 3 , a n d fa i l e d i n 1 4 . d i s t u rbed fu nction o f t h e freq uen t l y fee l l a b o u r pa i n s d e l i ve r y is norma l i n other I conc l ud e t h a t : al. 4 8 ; in el

,

,

,

I,

Low b a c k p a Ul m a y b..: prec i p i t a t e d by gyn aeco l o gi c a l con d i t i o n s such a s pregn a n cy. p a r t u r i t i on g y n aec o l ogic a l d i sease o r o p e r at i o n . 2 . I n a very la rge n u m b e r o f p a t ie n t s l o w -hac k p a i n o f l o com o tor origin i s m i s ta k e n l y ascribed t o g y n a ecol ogica l d is t u rba nces. O n e r c a s o n for t h i s m a y be spasm o f t h e i l i a cus w h i c h i s p a l pa ted a s a s i t e o f lender re s i s t a n ce 1 11 t h e h y p og a s t ric .

h e rw i se n o r m a l g y n ae when locil lize d in of vertebrog en ic origi n fll q manife station o f l u m hosacral reg i o n . La b o u r In a n otherwise norm al pointer. wi t h

'

Gynaeco l o g ical pain

and l ow-back

b een t rad i t i o n i1 ll d t h i s i s ce rtai n ly n o m e re s i gn i fica n t c l i n i cal i nc l udes l e s i o n s o f corre l a t io n s . t h e l u mbosacra l j u n c t i o n , t h e s a c ro i l i a c j o i n t ( i n y o u n g w o m e n fre q u e n t l y pe l v ic distort io n ) , a te n d e r coccyx , s p a s m of t h e i l iacus, musc u l a r imbala nce o r t h e p e l v i c m u s c l e s , a n d l iga m e n t p a i n . Novot ny a n d D v o ra k ( 1 972) m a d e a s u r v e y o f a l most 600 p a t i e n t s s h o w i n g t h e ver t e brogyn aeco l ogica l re l a ti o n s . There was menstrual pa i n ( a lgo menorrhoe a ) w i th re g u l ar gy naecol o gical fi n ci i n gs w i t h t ypica l o n se t felt also i n l o w hack, a t t he me n ; u ra r e l y d e t e r i o r a t es c h i l d b i rt h An ot h e r a n d v e ry o tten symptoms d u ri n g pregi m po r t a n t n a ncy a n d iI p e r i o d o f i n c r e a s e d strain and of t h e l u m b a r s p i n e an d h d r k pa i n fo l l owed gy n aeculogic a l a ffe c t i o ns , upon o r grou p o f p a ti e n ts w e re w o m e n s u ffe r i n g from l ow - b a c k p a i n d u e t o d is t u rhed fu n c t i o n o f t h e s p i n a l col u m n , i n whom gyn a ecological e x a m i n a t i o n was carried o u t as a rou t i n e d ia gn o s ti c p r o ced u re w i t h nega t i v e fi n d i n gs . ,

,

IrOll 1 I l c ;l c];; c h e s from t h e a g e o f 1 2 ,

B. B. (

a n d s u bs e q u e n t l y from m e t ro rr h ag i cl

cl n d

a l go m c n o r d l O e a ,

We fo u n d ( 1 95 R ) p e l v i c d i s to rt i o n to t h e Iel t ; t h e l e ft s p i n a i l i aca post e r io r s u pe r i o r a n d M e n n e l l " s l e st were p a i n fu l

C 1 -2 ,r n d t o t h e l u m b o s a c r a l j u n c t i o n T h r e e m o n t h s l a te r t h e p il t i e n t

o n t h e l e ft . M a n i p u l a t i o n w a s a p p l i e d I II .

r e po r t e d

menstruation

u n c h a n ge d

,

much

i m p roved

but

h e a d a c he s

M a n i p u l a t i o n of t h e l u m b o s a c r a l a n d c e r v i co

t h o ra c i c j u n c t i o n w a s rep e a t e d . Two

wee ks l a t e r m e n s t r u

a t io n t i m e h a d d e c r e a s e d f r o m t w o w e e k s to o n e , a n d t h e h e a d a c h es were m i l d e r. Thev never d i s a p pe a re d c o m p l e t e l y but dealt

.

t ro u b l e w a s successfu l l y

the l u m b o s a c r a l j u n c t i o n

,

symptoms,

.

,

(l t

In

ev id e n ce t h M w i t h n egao r i gi n a t t ribu t a b le to pe l v i c tive prese n t ed stat istica l l y highly ;l l i e r adeq u a t e m a n u a l tre a t m e n t i n a controlled t r i a l S i nce t h e fi nd i ngs o f H e a d ( 1 893/4) a n d l a t e r H a n s e n a n d Sch l i ac k ( 1 962), q u i t e a n i m p o r tan t b od y o f l i t e r a t u re has b u i l t u p co n ce m i n g segme nta l

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Clinical

aspects of dislLlrbed fUl1ctiol1 of /he

IOCOnl OlOr sys/em

2P,7

c h a n ge s in t h e s k i n , s u b c u t a n e o u s t i s s u e s a nd m u sc l e

T h i s i s a l so b o r n e o u t b y a u t o ps y fi n d i n gs : i n a l l 20

s p a s m i n visce ra l d i sease ( K u n e r t , 1 97 5 ) . L i t t l e

c a s e s of d e a t h a f t e r h e a d i nj u r y , L e i c h s e nri n g ( 1 964 )

w r i tte n

be e n

has

re s tri c t i o n

a b o u t se g m e n t a l m ov e m e n t

fo u n d s e r i o u s d a m a g e to t he c e rv i ca l s p i n e .

a n d c h a n g es i n m u sc u l a r p a t t e r n i n t h ese co n d i tions,

I n a g ro u p o f 6 5 o f m y p a t i e n t s a ft e r c o n c u s s i o n

h o we v e r , a n d for t h i s reason I h ave i n cl u d e d i m p o r t

( w i th loss o f c o n s c i o u s n ess) , c l i n i c a l fi n d i n gs i n

a n t d a t a on t h e s e s i g n i fi c a n t c h a nges i n loc o m o t o r

c e rv ic a l s p i n e w e re n o rm a l o n l y i n s i x .

The

the

re s u l ts

fu n c t i o n , a n d t h e i r c l i n i c a l re l e v a nce i n ve r t e b r o

of m a ni p u l a t i v e t re a tme n t w e re s i m i l a r to t h os e i n

v i scera l corr e l a ti o n s .

o th e r cases o f h e a d a c h e a n d v e r t igo o f c e r v i c a l o r i gi n

Post-trau matic states Th e i m p o r t a n ce of t r a u m a

(37

'exce l l e n t ' ,

1 0 fa i l ur e s ) .

a n d a n te fle x i o n h e a d a c h e ; t h e most freq u e n t s i te o f b l o c k a g e w a s betwe e n a t l a s a n d a x i s .

as a

I n t h e l i g h t o f t h i s e x p e r i e n ce , m a n i p u l a t i v e treat

c a u se o f d i s t ur bed

fu n c t i o n o f the s p i n a l c o l u mn w a s p o i n te d out in

ment give n

Chapter 2 (p.

d u ri n g

17).

1 8 ' fa i r ' a n d

Fa i l ur e w a s m o s t freq u e n t l y d u e to l i g a m e n t p a i n

This i s e s pe c i a l l y true o f

tr a u m a

the

( i n hospi ta l ) for

p re ve n t i v e p u r p o s e s .

fi rs t

c o n c u ss i o n ,

d a ys

a fter

seemed

i n c h i l d h o o d . H ow e v e r , c l i n i c a l m a n i fe s t a t i o n s m a y b e l o n g de layed b e c a u s e o f d e c o m p e n s a t i o n , w h i c h i n i tse l f c a n ca u s e seco n d a ry c h a n ge s . I n t h i s w a y a

j u s t i fi e d . A l l t h e p a t i e n ts w e re f u l l y

t e rr a i n is p repa r e d w h i c h is

s p i n e . In 24 o u t o f 32 ca se s a n y p a i n t h e y fe l l c e a s e d

to

i nj u r y

furt her

deco m p e n s a t i o n .

-

much

and

in

a pp a

Eve n

m o re s usce p t i b l e turn

re n t l y

no s u s p i ci o n o f i n t r a c ra n i a l h a e m o rr h a ge , a n d w i t h n e ga t i v e X - r a y fi n d i n gs i n t h e s k u l l a n d cerv i c a l

to

furt h e r

immediately

t r i vi a l

t ra u m a

p u b l is hed

a ft e r

a l most

t r e a t m e n t . B a r t e l ( 1 980) h a s res u l t s : i n 5 0 c a s e s

iden tical

m il y s e t

I t s h o u l d b e re m e m b e r e d

e x a m i n e d i m m e d i a t e l y a ft e r

t h il t

t h e s p i n a l co l u m n a re s u c h

bl o c k a ge

th is i n m o t i o n . the ror c e s
t h il t e v e n p r od uce

a

rash

u n co o rd i n a t e d

sudd e n

a

moveme n t may

a mo u n ti ng

loa d

to

s e v e ra l

h u ndre d k il ogr a m s .

B eca u s e

i nj u r y m a y b e c o m e m a n i fe s t o n l y a fte r

conscious. with

in

all

bu t two,

h ead

the

i n j u r y t h e re w a s

lesion

be i n g

m e n t w a s s u ffic i e n t ( fo r t h e m o s t p a r t t h i s w a s m o b i l i z a t i o n ) , while i n s i x c a s e s t re a t m e n t w a s re p e a t e d o n c e . F o r t y o f the c a s e s w e re t h e n s y m p t o m - f re e ; s i x

( se c o n d a r y ) d eco m pe ns a t i o n , i t is n o t s u r p r i s i n g t h a t

w e r e i m p ro v e d ; t h e re w e r e t w o fa i l u r e s .

there m a y b e a v e ry l o n g l a t e n c y p e ri o d a n d t h a t t h e cou rse o f t h e d i s e a s e c a n b e progressiv e . T ra u m a t o l o g i s ts a re freq u e n t l y u n aw a re t h a t a n y tra u m a

t r a u m a t i c n e u ro s i s m u s t b e p u t d o w n

a f fe c t i n g t h e l i m bs , t h e t r u n k a n d a b o v e a l l t h e h e a d ,

most

fre q u e n tl y l o c a t e d a t C l -2 . I n 40 c a s e s o n e t r e a t

[ n v i e w of t h e s e r e s u l t s , t h e h i g h i nc i d e n c e o f m i s m a n a ge m e n t ;

in

the

vast

maj o r i t y

mainly to of

cases

is a l so l i k e l y t o i nj u re t h e s p i n a l co l u m n - s u c h i nj u ry

w i t h o u t g ross n e u ro l og i c a l fi n d i ngs , d oc t o rs n o t t r a i n e d i n t h e m a n u a l d i a g n os i s o f m o v e me n t

is t h u s o ft e n m i ssed in the fi rs t ( r e l a t i v e l y l a te n t )

r e s t r i c t i o n a n d s e gm e n t a l r e fl e x c h a nge c o rn e t o t h e

p e ri o d . T h i s i s a l l t h e m or e so be c a u se i n t h e a c u t e s t age a ft e r t ra u m a , t h e d i rect i nj u ry to l i m b s , e tc .

d i s a s t r o u s c o n c l u s io n

(s u ch

as

a

frac t u re )

o v e r s h a d ows

the

d a m a g e to t h e s p i n e , so t h a t t h e p a t i e n t not a w a re

i n d ir e c t

h i mse l f is

or i t .

H e a d i nj u ry , i n c l ud i n g c o n c ll ss i o n , i s a s i g n i fic a n t

e x a m p l e . I t s t a n d s to re ;) s o n t h a t a n y force

a c t i ng

on

that

t h e re

a re

' n o o rg a n i c

fi n d i n g s ' a n d he nce d i s m i s s the tro u b l e as ' fu n c t i o n a l ' ,

i . e . p s y c h o l og i c a l d is t u r b a n c e . T h e p a ti e n t t h u s h a s ins u l t a d d e d t o i nj u ry , r ec e i v e s n o a d e q u a te t r e a t m e n t a n d i s fo rc e d i n to a n e u r o t i c r e a c ti o n w h i c h i s t a k e n a s c o n fir m a t io n o f t h e origi n a l m i s t a k e n d i a g n os i s . T h e re c a n h a rd l y b e a b e t t e r i l l u s t ra t i o n

t h e h e a d m u s t a l so a ffe ct t h e c e r v i c a l s p i n e . w h i l e i t

o f h o w c l o s e l y p ro p h y l a x i s a n d correct m a n a ge m e n t

i s o bv i o u s t h a t t h e l a r ge , fi rm s k u l l i s less fragi l e

o f t h e p a t i e n t a re b o u n d t o g e t h e r .

th e s e v e n

v e r te b r a e a n d ( v i t a l )

so ft

than

tissues of the

m o b i l e c e r v i c a l s p i n e . [ n fa c t . w h a t i s ca l l e d t he post co n c uss i o n s y n d r o m e w i t h h e a d ac h e a n d v e r t i g o can scarce l y be d i s t i n g u i s h e d sy n d r o m e . I n de e d .

from the c e rv i c o c r a n i a l B ii rtsc h i - Roc h a i x ( 1 949) d e sc r i b

ing ' m i gra i n e c e r v i ca l e '

fo u n d

that

most

of

his

p a t i e n ts h a d s u ffe re d h e a d i nj u r y . To rres a n d S h a p i ro ( 1 96 1 ) c o m p a re d 45 c a s e s a ft e r c o n c u s s i o n w i t h 45 cases after

whi plash

i n j u ry to t h e c e r v i ca l s p i n e : t h e y

fo u n d l i t t l e d i ffe rence i n sy m p t o m s o r n e u ro l og i c a l

fi n d i ngs . o r eve n E E G , t h e

o n l y s i g n i fi ca n t o bs e rv h i g h e r i n c i d e n c e of n e c k a n d u p p e r p a i n i n w h i p la s h i nj u r y . J u n g h a n n s wrote

a t i o n be i n g a

e x t re m i t y

as e a rl y as J 952 t h a t , ' r e c e n t e x pe r i e n c e s u ggested

T. M . ( 1 94 9 ) w a s t re a t e d a t t h e

age of 10 for persist e n t

h e a d a c h e . S i x m o n t h s p rev i o u s l y s h e h a d rece i v e d a b l o w

of t h e neck. from a sc h o o l b a g . S h e v o m i le d and fe l t s h a r p p a i n a t t h e s i t e o f t he i n j u ry . P a i n i n t h e h e a d p e rsisled fo r 3 w e e k s , a n d w a s s t i l l m a r k e d . N e u ro

o n the nape

l o g i c a l t e s t s were n e g a t i v e . X - r a y s h o wed d e x t ro r o t a l i o n

C 2 . M a n i p u l a t i o n w a s s u ccess f u l : t he re w a s re l i e f for 5 C2 w a s s u ccess fu l l y repea t e d . T h e b l ow b y a s c h oo l b a g h a d s i m u l a t ed post concllssion s y nd rom e with h e a d a c h e a nd v o m i t i n g .

of

m o n t h s . a ft e r w h i c h m a n i p u l a t i o n of

K . E . ( 1 94 / ) s l i p p e d a n d fe l l ( 1 95 8 ) w i t h o u t l o s s o f and headache . N e u ro l ogi c a l fi n d i ngs t h e s a m e d a y w e re n e ga t i ve , b u t t h e

consciousness, b u t with s u b s e q u e n t vom i ti n g

t h a t s y m p t o m s u s u a l l y a t t r i b u ted to c o n c u ss i o n were

a t l a s w a s p a i n fu l o n pa l p a t i o n . S y m p t o m s d i s a p p e a r e d

in r e a l i t y ca used by c o n t u s i o n o f the c e r v i ca l s p i n e ' .

i m m e d i a te l y a ft e r m a n i p u l a t i o n .

Copyrighted Material

2118

Manipulative Therapy in Rehabilitation of th e

Locomotor S vslem

K . J. ( 1 9 10 ) , bric k l a y e r , fe l l 2 m e tres and was u nconsc i o u s fo r a s h o r t t i me . The n e x t d ay h e compla i ne d o f p a i n i n the te m ples. R o t a t i o n o f t h e h e a d was re s t r i c t e d . M a n i p u l a t i o n o f C 1 -2 fre e d mo b i l i t y a n d t h e pa in c e a se d . n o t t o re t u r n .

t h e a m b u l a n c e . A t t h e h o s p i t a l h e com p l a i n e d o f d i zz i n e s s a n d h e a d a c h e . Ha u t a n t ' s t e s t s h o w e d d e v i a t i o n to t h e righ t w i t h e n d - po s it i o n n y s t a g m u s to t h e l e ft .

M a n ip u l a t i o n

was

h a d i n t e n d e d t o s i t fo r a n b u t w a s h o s p i t a l i z e d for v e r t igo t h e sa m e

n o t successfu l . T h e p a t i e n t

e ve n i ng. Ma n i p u la t i o n ( t ra c t i o n w i t h ro ta t i o n to t h e l e f t )

t h e pa t i e n t r e t u r n e d . w i t h a l o w e r ed cor n e a l re fl e x o n t h e l e f t , e n d pos i t i o n n y s t a g m u s t o t h e righ t a n d h y pe r m e t r i a of t h e l e ft a rm . X - r a y s h o we d as y m m e t r y i n t h e pos i t ion of C 3 . was a ga i n

fa st m o t i o n ; s l o w m o v e m e n t , e y e s

a n d h e a d fo l l o w i n g a p e n d u l u m : p a s s i v e m o v e m e n t ) r e v e a l s c o n s t a n t a n d h i g h l y c h a ra c t e r i s t i c p a t t e r n s w h i c h i t wo u l d be i mposs i b l e

to s i m u late.

T h e s y n d r o m e m a y be p r e se n t o n l y i n t h e a c u t e

V . B . ( 1 922) col l i d e d w i t h a ca r i n 1 95 8 w h ile r i d i n g a mo t o r b i k e . For a w b i l e h e w a s i n s h oc k . a n d fe l t s i c k i n

ex a m i n a t i o n .

s i m ulta n e o u s l y :

u n s u ccessfu l . Th ree w e e k s l a t e r

M a n i p u l a t ion

o f C3

abolished

the

pos t - t ra u m a t i c s t age . b u t m a y a l s o h a v e

c h ron ic

a

co u rse . W h a t is t r u e fo r h e a d i n j u r y is e q u a l l y v a l i d for

ot h e r p a r ts o f the l ocomotor fa U s on a h a n d m a y

s u f fe r

sy s t e m :

a

p a ti e n t w h o

f r o m i n d i rect i nj ur y to t h e

c e r v i c a l s p i n e i n a d d i ti o n t o fra c t u re o f t h e

ra d i us,

w h i l e o n e w h o fa l l s o n h i s fe e t o r b u t t o c k s m a y a lso s u s t a i n i n j u r y to t h e l u m b a r s p i n e . T h e r e a re t y p i c a l l e s i o n s i n t h e e x t re m i ty j o i n t s after inj ur y . A p a t i e n t w h o fa l l s o n h is h a n d , w h e t h e r

t h e r a d i u s is fra c t u re d or n o t , p u s h e s it u p w a rd s a t

the

t h e e l b o w , block i n g t h e e l bo w j o i n t . T h e cl i n i c a l

c o n t r o v e rs i a l ,

d u e to b l o c k a ge a t t h e e l bow , a n d t he a bsence o f

nystagmus

and

a t a x i a , a n d t h e p a t l e n t rem a in e d w i t h o u t s y m p t o m s .

co n se q u e n c e i s p a i n a t t h e s t y l o i d p rocess a ft e r t h e r e m ov a l o f the p l a s t e r . w i t h i m p a i red r a d i a l fl e x i o n

A

speci a l ,

and

sti l l

somew hat

s u bj e c t i s ' w h i p l a s h i n j u ry ' . T h e re m a y seem t o h a v e

ra d i a l s p r i n g i n g ( a s i n a p a i n f u l r a d i a l e p ico n d y l e .

b e e n n o m o r e t h a n a j e rk o f t h e h e a d , u s u a l l y ca u sed

s e e Figure 6 . 8 , p.

by r e a r-e n d c o l l i s i o n , a n d yet after a fe w h o u rs or d a ys s y m p to m s set in w h i c h c o n t i n u e for m o n t h s

s u bs i d e a ft e r

a n d ev e n y e a rs . T h i s i nj ury i s p a r t i cu l a r l y s e r i o u s

freq u e n t l y a b l o c k e d a c r o m i o c l a v i c u l a r j o i n t o r a

i f t h e h e a d w a s r o t a ted a t t h e m o m e n t o f i m p a c t . R e a r-e n d c o l l i s i o n is n o t t h e o n l y pos s i b l e m e c h a n i s m : a fa l l o n t h e s h o u l d e r w h i l e s k i i ng m a y

w i th o r w i t h o u t frac t u re . w e u s u a l l y fi nd b l oc k e d

p r o d u c e a si m i l a r e f fe c t . A n u n d e r l y i n g m e ch a n i s m

b l o c k a ge a t t h e a n k l e j o i n t i n m a n y c a s e s ; a ft e r k n e e

1 65 ) . I n s u c h c a s e s t r e a t m e n t o f t h e el b o w g i v e s i m m ed i a te re l i e f. I f p a i n d oes n o t a

fa l l o n t h e s h o u l d e r t h e

ca use i s

fi rs t r i b , or a g a i n a c e r v i c a l l e s i o n . A ft e r foot t a rs o m e t a t a r s a l o r t a rs a l j o i n ts , or b o t h ,

is

as

i nj u ry . wel l a s

i n t h i s i nj u ry m a y b e t h e t e a r i n g o f l i g a m e n t s , a

i nj u ry

t o r n a l a r l iga me n t i n p a r t i c u l a r (Dvora k , 1 98 8 ) . Thi s

Tr e a t m e n t o f t h e s e j o i n ts i n v a r i a b l y g i v e s i m med i a t e

t h e re

o fte n

a

blocked

fi b u l a r

h e il d .

is i m porta n t , b e c a u s e i n t h e e a r ly s t a ge s m a n i p u

re l i e f, w h i c h i s o ft e n p e rm a n e n t . A g a i n t h e q u e s t i o n

l a ti v e tre a t m e n t i s m o re o ft e n t h a n n o t o u t o f p l a c e ,

a r ises a s t o w h e t h e r o r n o t we s h o u l d t re a t t h e s e

and

l e s i o n s i m m e d i a te l y a ft e r i nj ur y . T h i s is a

s u p p o r ts

a n d/or

i mmobilization

should

be

p r e fe r re d .

question

of d i a g n osis: i f w e c a n r u l e o u t fract u r e , h a e m a t o m a

A n i m p o rt a n t c o m p l i c a t i o n of i nj ur y to t h e h e a d a n d n e c k , and o f whip l a s h i nj u r y in p a r t i c u l a r , h a s

a n d h y p e rm o b i l i ty , t h e s oo n e r t re a t m e n t i s g i v e n t h e b e tter, t o p r e ve n t l a t e r s e q u e l a e .

rece n t ly b e e n d e scri b e d b y B erge r ( 1 990) u n d e r t h e d e s i gn a tion ' s t i ff o r frozen n e c k s y n d r o m e ' . H e g i v e s

t h e fol l o w i n g c h a r a c t e r is tic fe a t ur e s , b a s e d o n a n a l y sis o f 20 cases: m o ve m e n t i s re s t r i c t e d , slow a n d

T h e c l i n i c a l p i ct u r e of m ovem e nt rest r i ct i o n at i m p o rta nt j o i nts

j e r k y ; i n v o l u n t a ry m o v e m e n t i s l e s s r e s t r i c t e d t h a n v o l u n ta r y ; s l ow mov e m e n t h a s a g r e a t e r r a n ge t h a n

T h i s c h a p t e r h a s b e e n d e v o t e d to t h e c l i n ic a l p i c t u r e

fa s t m o v e m e n t ; active r o t a t i o n i s l e ss rest r i c t e d t h a n

of d i s e a s e ca used by d i s t u rbed t u n c t i o n of t h e m o t o r

s u p i n e ( w i t h C 7 fi x e d ) i s l e s s restricted t h a n ro t a t i o n in t h e si t t i n g p o s i ti o n . T h e r e

syste m , i n p a r t i c u l a r o f t h e s p i n a l c o l u m n . T h e mos t

p a ss i v e ;

r ota t i o n

frequ e n t s y m p t o m i s p a i n a n d t h e s t r uc t u re w h i c h

i s m a r k e d hyp e rto n u s i n m u sc l e s a n d s o f t t i s s u e s ,

m o s t freq u en t l y e x p resses p a i n i s t h e m u sc l e w i th i ts

a n d t h e re a re e x te ns i v e h y p e ra l g e s i c zo n e s . P a t i e n ts

t r i gge r p o i n ts a n d p a i n f u l a t t a c h m e n ts . I t is the g r e a t

c o m pl a i n of s e v e re h e a d a n d n eck p a i n r a d i a t i n g to

m e r i t of T r a v e ll a n d S i m o n s ( 1 98 3 ) to h a v e des

t h e s h o u l d e rs , a r m s a n d c h e s t , o fte n acco m pa n i e d

c r i b e d syste m a t i ca l l y t h e c l i n ica l p i c t u r e c a u sed by

b y d i z z i n es s , n a us e a a n d b l u r r e d v i s i o n .

m uscles h a rb o u r i n g t r i gger p o i n ts (TrP) . Seco n d to

M o s t t y p e s o f p h y s i c a l t he ra py , mo b i l i za t i o n , e x er

m u scu l a r TrP as a c a u s e of p a i n comes j o i n t move

cise a n d m a ssage are n o t w e l l tolera t e d , and t h e

m e n t r e s t r i c t i o n . and it i s n o less i m p o r t a n t to gi v e

p a t i e n t ' s c o n d i t i o n i m proves o n l y w i t h res t , a soft

a c o n c i s e o v e r v i e w of t h e

s u p p o r t i n g co l l a r , and som e t i m es w i t h cry o t h e r a p y .

l es i o n s w i t h t h e i r s y m p t o m s . Howe v e r , b y t h e t i m e

m o s t i m po r t a n t j o i n t

T h e s y m p t o m s a r e o fte n c o m b i n e d w i t h d e p res

t h a t j o i n t d y s fu n c t i o n is c l i n i ca l l y m a n i fe s t , s y m p t o m s

s i o n , re s u l t i n g i n t h e se p a ti e n ts b e i n g c o n s id e re d

a r e ca used n o t o n ly by t h e j o i n t b u t i n v a r i a b l y a l so

psychologica l c a s e s . H o w e ve r , c e rv i c o m o togra p h y

b y the c o n co m i ta n t m u sc u l a r TrPs. For e x a m i n a t i o n .

( re g i s t r a t i o n o f h e a d m o v e m e n ts i n t h re e p l a n e s

w h i c h i s n o t d e a l t w i t h here, see

Copyrighted Material

C h a p t e rs 4 a n d 6 .

Clinical aspects of dislllrbed r o t a t i o n restrict i o n d irection a s t h a t o f

The t e m p o ro m an d i b u lar

of t he T h e main s y m p tom is a ffected J o i n t , p a i n radia ti n g s t r o n g l y i n to t h e e a r a n d face. There is frequ e n t l y a h i s tory o f m issi ng tee t h , b a d l y fi t t i ng fa lse tee t h , o r some o t h e r CCl use of m aloccl usion , p ri m a ri l y a ffec t i n g the j o i n t. How ever, pain may be caused by dysfu nc t i o n of the mastica tory m u scles d u e to i ncoo rd i n a ti o n a nd/or psychologica l tension as in b r u x i s m ( w h ich s h o u l d a lways be a s k e d a b o u t ) . The c l i nical pict u re i s t h e n usua l l y d o m i n at e d bv TrPs of thc m a s t ica tory m uscle, the d i gastricus 1 1 m of t h e c r a n iocervica l j u ne: I o n ) TMJ (and prese n ts c l in i c a l pictures c r a n ioee rvica l bound u p w i t h ) those j unct ion, i n c l u d i n g

'yslem III

2R9

the same

Segment C2-3

T h i s i s t h e segm e n t o f t h e a c u t e wry neck , y e t i t i s n o t usu a l l y t h e o n l y segmen t a ffected by t h a t con d i t i o n . A ga i n , t h e m o s t p r o m i n e n t t rigger p o i n ts are fo u n d in t b e s t e r n o m astoid, the l e v a t o r sca p u l a e and a l so i n the t r a pezi u s ; p a i n may t h e re fo r e r a d i a t e not only t o t h e h e a d b u t a ls o a s fa r a s to t h e s h o u l d e r . T h e re i s a p a i n the of t h e tip of t h e spi n o u s o f rot a t i o n a nd o f side - be n d i n g frequ e n t to t h e r i g h t , w h i le p a i rl a lso u s u a l l y o n t h e rig h t . S e g m ents C3-4

T h e cran i ocervical

This i n c l u de s segm e n ts CO-I , C l -2 and C2-3 , t h e la ttcr being a n a to m i c a l ly a cervical j o i n t w i t h a d isc a l th ough c l i n ica l l y it b e h aves l i k e t h e first two motor segm e n ts . In t h e c l i n ica l p i ct u re p resen ted h e re t h e com m o n d e n o m i n a tor i s headache; i t m a y o r m a y n o t rad i a te t o t h e face, u s u a l ly b e i n g fe l t mainly a t t h e occ i p u t , t h e t e m p l e s a n d t h e e y e b a l l s , a n d m a i n l y one-s i d e d . T h e o t h e r fre q u e nt fac t o r i s disturba nce of e q u i l i b r i u m w i t h o r w i t h o u t vf:rtigo, ca used by i ncoord i n a t i o n o f the T h is is , a ffectwhy we refe r to t h i s i n g t h e w h o l e o f the Segment CO- l

v e r t ig o ; Symptoms a re m a i n l y a nd/or t h e re is as a r u l e ch rollle tonsil lectomy, and meso t i t i s . Ty pica l l y , pain i s w o rse on w a k i ng in the m o rn i ng, a n d m a y waken t h e p a t ie n t d u ri n g t h e n i g h t . T h e re a r e typica l trigger poi n t s i n t h e s h o r t e xtensors o f t h e c r a n i ocervica l j u nction a n d a t t h e upper e n d o f t h e s t e r n o m asto i d . I f moveme n t restriction i s s l i g h t , i t a ffects a n te a nd/or retroflex i o n a n d j o i n t p l a y . If rot a t i o n a n d side-bending is a lso restricted, t h is is m u c h m o re often restricte d to t h e l e ft t h a n to t h e righ t: freq u e n t l y i t i s restricted t o b o t h sides. Segment C 1-2

This is t he segm e n t most tra u m a . A l though h e a d ache neck pain is a lso frequ e n t . poin t a t t h e l a te ra l surface o f C2; muscular t rigger poi n ts a re m o s t p rom i n e n t in t h e sternomastoid a n d t h e l e v a to r sca p u lae a n d trape zius. Rotation restriction is m o re frequen t to the rig h t , whereas side-be n d i ng i s more often restricted to the l e ft . T h i s is t h e only cervical segme n t i n wh i c h

A l though headache pil i ll rad i a t i n g to the arm is t h e pred o m i n a n t symptom, in partic u l a r e p i co n d y l a r p a i n a t t h e e l b o w . m o re fre q u e n tly o n t h e l a t e r a l a s p e c t , someti m e s c o m b i n e d w i t h p a i n a t t h e styloid p rocess. Typica l trigger poi n ts a re fou n d in the d e e p l a y e r of t h e pa raspina l muscles, t b e u p p e r trapezius a n d t h e m u sc l e s i n v o l ve d w i t h e pi co n d y l a r p a i n - t h e s u p i n a to r , t h e fi nger e x t e n sors a n d t h e biceps. The cervicot h o ra c i c T h 2-3 )

to

but pain rad i a ti ng t o t h e t I l t h e s h o u ld e r pred o m i n a t es . e v e n m o re s o , t h u s b e i nv o l v e d . i n c re ased particu l a rl y t h e tension in most m usc l e s of t h e s h o u l d er gird l e , w i t h t rigger p o i n t s i n t h e s te rn o m a s t o i d , t h e u pper a n d m i d d l e t r apezi u s , t h e sca len i , t h e i n frasp i n a t u s a n d s u bsca p u l a ri s . T h e sca l e n i w i t h a b l o c k c d fi rst r i b a n d t h e pectora l i s m i n o r produce t h e syn d ro m e o f t h e t h oracic o u t l e t : t h is is usually l i n ked t o t h e c a r p a l t u n ne l syndrom e . I n g e n e r a l , m o v e m e n t res t r i c t i o n is more fre q u e n t to the righ t t h a n t o t h e l e ft . T h e t h o raci c

Th9- 1 0 )

pse u d o v i scBecause sympt o llis e ra l , d i ffere n ti a l S y mptoms o n t he l e ft s i m u l a t e d uo d e n u m , . d uo d e n u m , p a n cre as; o n the to v isceral l u ng, stomach. d isease, d ysfu nc t i o n i s usua l l y seconda ry t o dysfu nctIOn e i th e r o f t h e cervical o r of the l u m ba r spine, i n c l u d i n g t h e t h o r a c o l u m b a r and l u m b o p e lv ic j u nc t i o n s - except i n t h e case of severe t h oracic j uv e n ile osteochondrosis. A painful spinous process a t Th5 o r Th6 w i t h o u t m oveme n t r estriction

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8 Prophylaxis

Importance of the problem

symptoms go to see a doctor, having found out by

As the decisive role of impaired function has been

they learn to live with the ir symptoms, in this way

demonstrated in the theoretical part of this book, it

escapi ng

would be inconsistent not to discuss prophylaxis.

impressive.

experience that conventional treatment is ineffective: Even

registration.

so,

the

figures

are

Not only do we apply some preventive pri n ci ples in

Mindful of all these difficulties, Wood and Badley

our therapy (see p. 150), but the very principles of

(1980) give the following figures for morbidity per

rehabilitation are to a large extent i dentical to those

1000 persons in the USA and Great Britain

of prophylaxis; indeed, it is one of the main goals of

latter

rehabi l itation to prevent relapses and complications. Before going into detail, let us consider for a

in pa re n thes e s) :

(30 'arthropathies');

(the arthritis and rheumatism, 79

b ac k or spine p ro bl ems , 47.

52 (34);

heart trouble , 29; high blood pressure ,

moment the importance and, at the same time, the

The total visits per year for back troubles, in Great

magnitude of the task , bearing in mind that patients

B ritai n, amounted to 3401 000 to general practition

with disturbed function of the locomotor system

ers, 1819 000 to orthopaedic surgeons, 637 000 to

form the vas t maj ority of those suffering from back

osteopaths and 361000 to chiropractors .

pain and associa ted problems. The statistical data

Table 8.1 gives official data from Czechoslovakia:

illustrating thi s are neces sarily inexact, the true

these give a good overview and are significant

incidence of these conditions being much higher. The reason is that a large number of our patients

economically ; they cover only patients who missed work because of their symptoms.

are registered under quite different headings, such

Obviously, among the cases designated 'soft-tissue

as headache, ver tigo, pain in the chest or pelvic

rheumatism' there will be many pa tients sufferin g

region, etc. Not all patients who suffer from these

mainly from disturbed

locomotor function.

It is

Table 8.1 Number of cases of conditions causing absenteeism per 100000 inhabitants of Czechoslovakia

A verage dura/ion of working incapacity

Year

Complaint 7968

1973

7979

1984

1989

(days)

Disease of the locomotor system

7897

9451

10432

11724

21.9

Soft-tissue rheumatism

2138

1975

1 622

1839

20.6

Vertebrogenic disease

3763

4895

6406

7338

19.9

3114

3324

3335

39.7

1403

1276 961

1229

32.0

1087

940

29.6

36538

44562

40263

9.4

Circulatory disease Psychiatric disease Neurological disease Respiratory infection

4623

292

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1989

Profihylaxis respiratory

certainly striking that infections are a more than locomotor distu lbanccs

(lbSI'flteeism vt: ric hrogc I I Ie dis-

incidence of

293

a constant

tendency to rise Instead of Wcd

sit or stand

ease. If we take into account vertebrogenic disease

in vehicles in which we are jolted or slumped; most

alone we come almost to the figure of

work in offices and even in factories is carried out

15000000 lost 15 000 000.

working days in a total population of

in a more or less fixed (static) position, frequently

With

stooping or sitting. As agriculture becomes more

110 frcsh applications for invalidity pensions per 100000 inhabitants annually, diseases of the locomotor system (J 9% of applications in 1989) take first place (after 1989 no such exact data are available) .

However impressive from reflecting the lrllc

mechanized, work in the fields is not much better in this respect than work in mines or offices. Indeed, the unfavourable trend begins as soon as the child first goes to school and is forced to sit most of the day. Young and he rebels at times, and c!ldnce); as he rushes about

tions, for working

grows he soon

criterion: it is mainly

the TV.

rIlilIOr bike and

lower extremities that

attention

and here the type of

is so narrowly

pollution

There are, however, (bra

that the harm

changes in

symptoms due to distlillwd

There are

directly. The 'cervic;d

two logical

vertigo, frequently related to trauma, and what is called the 'repetitive strain syndrome' at the upper

conditions: one is to

extremity are formidable problems as well.

As most of our work is done seated,

In his classic 'Munkfors Investigation', covering

1200

static overstrain as far as

possihle; the other is to seek to compensate it.

workers in various trades, Hult ( 1954a, b)

51 % and 60%, either

a

correct

sitting posJtion is of great importance (see Figures 4.68 and 4.69, p. 133). This, however, depends on the

found symptoms due to cervical lesion in

chair used: the height of the chair is correct if the

symptoms due to lumbosacral lesion in

in t he patient's history or at examination. J n a

thighs are horizontal and the whole of the foot rests on the floor. even if the knees are bent at slightly

found that

more than right anglt's. Tht' hack should be supported

country district near Pra!':ut'. Uttl

61

(1964)

of a representative

had

suffered from vertebrogemc To this it must be associated complaints

region of the against the chall

maximum work capaci

the work-table

quently time conSumiII1' and physical therapy).

of the table should arm hang natur;i1ly

tom is pain, there is

which (sitting!)

at the summit 01 is more often

and

the thoracic elbows on , the height the upper elbows on nor table

the table (sitting

frustration PIS well. Even if loss of working capacity

offer support, the seat should slope upwards towards

can be registered, the factors of reduced efficiency

the back, tilting the pelvis forward and preventing lumbar kyphosis. Another way of avoiding the

and psychological implications cannot be.

unfavourable effects of kyphotic sitting posture of long duration is for the patient to learn BrUgger's

Principles of prophylaxis

relief position (see Figure

6.144).

Chairs are now

manufactured with the seat tilted forward and a As disturbed locomotor function plays a highly

knee-rest: this position enforces lumbar lordosis and

Important role in the pathogenesis of back pain, conditions prevention must be

thus automaticallv achieves this 'relief position'. Used judiciously. great help, over-strain in particularly for

under which this mosl analysis that imbalanc;

Imd on

the cervical and

faulty movement patterns

forward-drawn

This is largely due to

in the postural

industrialized civilizatIon

causing faulty

our eating habits, pol

pain may find

endangers us with tm:ie

time, but using

for a limited may bring

radiation; it changes our locomotor habits most radically. To

increased pain. It IS therefore Wlse to recommend its

put it briefly: while reducing movement it increases

use, but to warn patients to change when they begin

static overstrain, hence producing the typical im

to feel discomfort. Indeed, there are (hypermobile)

balance between mainly postural and mainly phasic

patients who will get pain if they hold any position for a long period. In such a case it is helpful if the

muscles (Janda,

1975).

This is also a reason why the

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Prophv/{lxis pillows with

a

hole for the nose, enabl ing the pa tient

to lie prone with his neck straight. U sing such

a

295

are instantly aware that the answer is not sim ple. Not only do the various forms of sport affect our

support , however, he must take care not to lift the

bodies in very different ways, but they c a n even be

head into retroflexion. The most suitable compromise

positi ve ly harm ful. It is essenti al to anal yse each

for those who cannot drop this habit is to pl ace a

type of sport care fully , bea ring in mind the consti

p ill ow under the shoulder and chest on the side to which the head is turned, thus lessening head and

Then there is the questi on of competitive sports: in

tution of the person asking our pro fessional advice.

neck rot a tion. The habi t of lying prone usua l ly dates

view of the extreme and ever-increasing demands

from early childhood, when the posi ti on has much

made by com petitive sports on their devotees, their

to recommend it:

later

in life, un for tun a tely ,

it

becomes less and less well tolerated.

usefulness for pre vention of disturbances, or for the maintenance

of

normal

good

health,

is

most

Even when ly i ng s upine, most o l der peopl e need

questi onable . In fact, as I shall be showi ng later,

a head s uppor t : many become round shouldered and

most of those who compete in sports must be

stiff, and if the head is not supported it falls into

considered among the most threatened popu lation

retroflexion. This is not only unfavourable for the

groups.

cervical spine but can be positi vely dangerous in

s u bjec t s with

some

degree

of cere bra l

arterio

It cannot fall within t he scope of this book to give a comprehensive picture of the effect of various

sclerosis, since it favours ischaem ia , pa rticu l arly of

types of sport on the locomotor system.

structures supplied by the vertebral arteries. This is

It

may be

root syndromes with

useful, however, to give a few examp les of how to approach the quest ion . Take swimmi ng, for e xample,

severe pain at night, because s o m e degree of cervical

considered by most people to be a particularly

kyphosis is necessary

' healthy ' sport: a l l the muscles are brought in to play, the body we igh t does not act on the spinal column

i mportan t

too,

in cervica l

to keep the

intervertebral

foramina wide open. Such patients often prefer to s l ee p in an armchair.

and there is very little risk of inj ury . On further

To co ncl ude : it is most i mportant to find out wh ich

analysis, h owever , we find that the breast stroke and

con di tions preci pitate symptoms, and to detect faults

even the crawl make the pectoralis muscle overactive

or correct ed in order to prevent relapse. In fact,

shouldered. On the other hand, the breast stroke

there is pro ba bly no more etfective way of helping

and e ven more so the ' butt e rfl y ' produce lum ba r

in the pa ti ent ' s daily habits that should be avoided

and taut, so tha t most swimmers become round

these pa tients than by j udicious advice about their

hy pe rlordosis anel hype rmobil ity . In the older age

habits of working , si tti ng or sleeping. Fu rthermore ,

groups most people hold their head out of the wate r

our best therapeuti c measur e s will fail if we do not

while

discover the fau l ty positi on a typist maintains at her

hype rlordos is . This having been s a id , I do no t w a nt

swimming,

keeping

the

cervical

spine

in

work, an unsui table driver's seat, a wrong position

to suggest that swi mming is a ltogether ha rmful ;

during sleep. It is theretore a grave omission on our

advis ing a round-shouldered pati ent or one wi th a

part if, after learning that symptoms occur in the

hy permobi l e low back ,

mo rn i ng, we do not ask the patient what position he

swims on his back , and I would expl ain that the crawl

I would suggest that he

usually s lee ps in - or if we learn that symptoms are

is better than the breast stroke for a hypermob ile

precipitated by lifting objects and do not inves t igate

low back. [ would warn e lde rly patients with signs

the way the pa tien t stoops to lift things. Indeed, one

of arteriosclerosis not to swim with the breast strok e

of the main purposes of taking a case history is to

for long stretches , causing cervical lordosis, but to

i nvest ig a te these ma t ters e xact l y. This shows th a t

use the side stroke, or to swim on the back; this does

prophy l ax i s and correct management of patients

not invite the risk of ver te bral artery insuffficiency. Doctors should be aware of the d a nge rs of volley

c a nnot be separ a ted.

ball for the locomotor system: those who p lay at the ne t must, as they leap up and drop back to the

Sports

ground, keep the lumba r s pi ne in hy periordosis so as not to touch the net: this is most unphysiological

The other

approach

to

preven tion of disturbed

and a danger to the low lumbar discs. Diving is a

locomotor function , as [ poi nted out at the beginning

dange rous

of this chapter. is to seek ways to compensa te for

mechanism, spondylolisthesis being significantly more

sport

by the operation

civilization's ills du ring our leisure time. If we have

freq uen t among divers than

too little movement at wor k, for instance, we may

pop U lati on .

in

of a similar

the rest of

the

G ymnastics as usually taugh t make

make up for it in our free ti me. This, as everyone

muscular imbalance even worse, pa rt icularly in e xer

knows, ought to be the main reason for taking up

cises in which the trunk and legs are held straight

gymnastics and sports, and we are often asked by

and at r ight angles to each other. In order to achieve

patients which sport or other phys ical activity we

this, the action of the abdom i nal muscl es n a turally

would recommend them to take up for prophylactic

approaching the stern um to the pubic symph ysis

reasons. The question seems s traightforward, but we

must be overcompensated and inhibited by

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the

296

Manipui!lfiVC

Relw!)!lilatio/1 of the

erector spinae provoke the

Locom%

the best way to syndrome'

137-138).

(see pp.

r Systen;

There

of curling up

the lumbar spine

expose our bodies to

and to the ail,.

to the question. what

discarded and instead there is

might be called the mechanical side; tight corseting

leverage at the lumbosacral junction, with deleterious effect on the discs. Gymnastics on apparatus tend to

there are other hazards - hair and cap styles that

is no longer a menace to the modern woman, but

make the upper fixators of the shoulder girdle

force a forward and upward tilt of the head. bags

overactive. The emphasis on swift movement in

slung from one shoulder and, of course. shoes. High

gymnastics makes safe control of the body difficult,

heels not only change the gait but also the body

and It is not easy to avoid a movement that may be

statics: they produce forward pelvic tilt with its

harmful. For this reason some types of yoga exercise

unfavourable effect on muscle function (imbalance),

(but not those resembling acrobaticsl) and Tai-chi

affecting spinal curvature and even the position of

are probably

the head.

There should be

than traditional fast jerky activity is in

angles with

tioning

balance with

Anot of pantihose is harm

musc.le, wearing crepe the most physio

less for

h strong muscles. but

logical form of locomotion. Simiiady, cross-country

for the muscles - especially

skiing has much in its favour; it also makes use of

pregnancies - a firm belt is most desirable. Obese

all four limbs, and the snow provides a soft terrain. We should not forget that dancing is among the oldest forms of movement that people have enjoyed.

elderly men, too, with poor abdomin8! muscles. should wear a broad belt. On the other hand, care

Because, unlike gymnastics, it can be carried on for

the abdomen. A suitable brassiere is also extremely

hours at a time, it is as effective as exercise; with few exceptions

it

is

harmless,

and

it

must be taken to see that the belt does not cut into important for women w ith heavy breasts. Only too

be

often do we see women patients liftmg their breasts

show the need

with brassieres that are too small. with narrow flesh of the shoulders.

can

also

recommended to combat obesity. These

after

with weak abdominal operation or several

a preventive of spine, or to correct

warn against over·

mistake not to point out in this respect: women should be advised most This is one of the

Clothing

should not remove Although posture

as a routlll e; the examiner should

mOl ernent, and their cor

rection, naturally play the principal part in preventing

insert a finger under the brassiere straps of a heavy

disturbed locomotor function and its sequelae, there

breasted patient (standing or sitting) to assess the

are other

strain on her shoulders.

important

factors such

as

food

and

clothing. It is notoriously well known that regions

There are men who do not tolerate a tight trouser

highly susceptible to pain, like the neck and the low back, are sensitive to cold and draughts. and those

belt and should wear suspenders. Men with pro

who suffer from pain in these areas will try to protect

truding bellies due to weak musculaturc causing faulty postur e should wear a broad abdominal belt. It is only too o bvious that the campaign against

them. This is fully justified by experience. but we should not the necessary protect-

obesity

ion and desirahle although we

relevanl systelll,

hardening. Thus that we know

are apt to

try to harden

the body as

forget that the lik.e the low back

susceptibility is usually

and that after hardening may be

successful undertaken,

t

purposes of wearing

clothes is to protect the body from the cold, but this

fields of medicine is very functioning of the locomotor c;lsily set up. in which h faulty statics mani·

obesitv

the patient is reluctant

fests

and gets even fatter. 1 cannot but it relevanl

of combating obesity. In

whether obesity is a case of locomotor

should be judicious to maintain thermoregulation or

disturbance. We should remember that increased weight will seriously affect the lower extremities,

resistance to heat and cold at an optimum. Besides clothing, this also applies to the question of when

slight relevance to the cervical spine. There are

less so the pelvis and the lumbar spine, but is of only

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Prophylaxis

297

subjects with very little fat on the trunk but obese

important where surgical treatment has been needed,

buttocks and thighs; this may be practically irrele

because then operation trauma has been added to

vant for the spinal column and body statics. The

the internal lesion. It is, indeed, rather the exception

physical type of the patient is important; the pyknic

if such patients do not suffer from complications

tolerates obesity much better than the asthenic. A

due to disturbed

heavily built subject who weighs about 80 kg at 20

gall bladder or gynaecological operations). General

years and 90 or even 100 kg at 50 years may suffer

anaesthetic with intubation frequently causes cervi

very little, whereas an asthenic subject who weighs

cal lesions which it is imperative to treat.

50 or 60 kg at 20 years and 80 or 90 kg at 50 years will

be

advising

Whether

preventive

manipulation

after

could

be

envisaged for those engaged in some particularly

reduction we must have good reason to think that

demanding professions is doubtful; in fact, as we have

a

When

(e.g.

weight

obesity is

decompensated.

locomotor function

seen, most occupations in modern society are carried

potential cause of the symptoms.

on in conditions that are harmful. However, there is one group that is at such risk that manipulative

Manipulation as a prophylactic measure

treatment for preventive purposes is justified, and even to some extent carried out: this group is that of competitive sportsmen and sportswomen, a fact which

Having discussed some of the basic principles of

throws light on the effects of competitive sport.

prevention, we now come to the question of prevent

There is another possible approach to the pre

ive correction of specific disturbances. As T pointed

vention of locomotor disturbance in particularly

out on p. 150, we not only indicate treatment of

demanding professions: the choice of employment,

those lesions that manifest themselves by causing

taking into account the individual's constitution.

pain, but we also treat lesions in key positions

Here we are most concerned with hypermobility; it

although they may still be latent, because we

are

is the hypermobile subject who suffers most from

convinced that they are a potential source of trouble.

static overstrain and is most susceptible to the conse

We are therefore justified in asking whether, and

quences of a long-lasting confined sitting position,

under what conditions, we should treat clinically

stooping, head anteflexion and jolting.

latent lesions in persons without symptoms. This is

It would of course be very misleading to give the

particularly to the point in joint or segmental

impression that the only therapeutic measure to be

movement restriction (blockage) which is potenti

applied for prevention was manipulation. The import

ally harmful, and at the same time can be quickly

ance of this method, and its possible application,

and safely diagnosed as well as treated. This may

have been dwelt upon because it is the subject of

also apply to latent TrPs in 'key muscles'.

this

Having discussed the usefulness of manipulation

book,

and has

proved

both

effective

and

practicable in prevention.

as prophylaxis we must now turn to its practical

The classic therapeutic measure is, of course,

possibilities. It is certainly not possible, and probably

remedial exercise, and this has been given its due

not even useful, to suggest prophylactic manipu

importance in Chapter 6. I should add that it is

lative treatment for the whole population, but it may

effective only if the principles laid down in that

be reasonable to envisage such medical supervision

chapter are consistently followed, i.e. if the type of

for pre-school and schoolchildren. Our experience

muscular imbalance and faulty locomotor pattern is

suggests that a check-up once a year or even every

accurately analysed and the therapeutic plan worked

other year would be sufficient, and carried out by

out accordingly. It can readily be seen, however, that

experts this would not even be time consuming, as

remedial exercise is much more demanding as a

it is usually the craniocervical junction and the pelvis

form of prevention than is manipulation, and it is

that are affected. This would present an effective

therefore not easy to determine its practicability.

way of dealing with disturbed locomotor function at

Remedial

exercise

has always

been used for

children with bad posture, but there are few children

the very outset. There are some groups of patients for whom

who can really profit from it. A more effective

preventive manipulation is of great importance. The

approach would be to introduce elements of remedial

first are patients recovering from injury; trauma was

exercise into normal physical training in schools:

listed among the chief causes of blockage in Chapter

teaching correct respiration, stooping, weight carry

2, and indeed after any type of mechanical injury

ing, standing and sitting. It would be possible to

there is likely to be movement restriction which can

devise different types of exercise for hypermobile

complicate recovery. This is particularly true of the

children and for stiff and very muscular children. I

spinal column (see Chapter 7, p. 287

have pointed out the great shortcomings of trad

el seq.).

Another important group comprises patients who

itional European physical training on pp. 295-296,

have suffered from internal disease giving rise to

but the greatest misfortune is the attitude of many,

segmental movement restriction (see p. 282

et

seq.,

Vertebrovisceral correlations). This is particularly

if not most, physical training instructors. Like sports trainers,

they are primarily interested in those

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/

ih

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9 Problems of expertise

Expertise poses considerable problems in patients

much changed with the introduction of new imaging

suffering from pain originating in the locomotor

techniques (CT and MRI) because

even

system, among whom those with back pain form the

techniques

morphological

most numerous group. Although their lives are not

changes cannot be determined, e.g. irrelevant disc

endangered, they may nevertheless not be fit for the work they are expected to perform, temporarily or

permanently,

and in some cases they are even

the

relevance

of

the

by

these

herniations. There are psychological

factors at work, too,

something like public opinion working to the same

tbreatened with invalidity. In addition, tbe question

end: the patient himself is informed, more often

traceable to tbe type of work tbey do,

than not, of the changes found in his X-rays and

of d a m a ge

and particularly to occupational injury, bas often to

presented to him as the cause of his pain, with

be sell led by litigation requiring expert opinion.

the inevitable psychological consequences. It is the

Any decision taken in so complex and responsible

patient so

'informed'

who

becomes

a

hopeless

a matter must be the outcome of scientifically based

problem for further management, and invalidity is

assessment of pathogenesis and prognosis, as well

then not the consequence of the disease but of

as management of the patient. From all that has

been written he r e it is evident that opinions differ ,

widely, yet if disturbed function is accepted as

of

one

tbe most significant factors in pain deriving from

the locomotor system, this must necessarily find expression in our expertise.

The di fflcul ties are

obvious.

misguided

'expert

opinion'. On the other hand,

young patients with serious symptoms including true disc herniation are considered malingerers because their plain X-rays show 'no changes', i.e. no degener ative changes. It is thus important to give some indication here of how expert opinion can and should be expressed

In the first place, in most of the cases where our

with regard to disturbed fUllction. We cannot deal

expertise is called for. the patient has received

with aII types of pain caused by locomotor disturb

An

ance, but back pain and root syndromes are discussed.

even greater obstacle is that most doctors are not

neither adequate therapy nor rehabilitation.

To present a problem for expertise, pain must have

taught detailed diagnosis and analysis of locomotor

had

function and its disturbance, so that even significant

cases. It has to be assumed, too. that pathological

a

chronic course: we therefore exclude acute

lesions pass unnoticed. This is particularly serious in

conditions such as ankylosing spondylitis, tubercu

view of the principal symptom, i.e. pain: the doctor

losis, osteoporosis, etc., have been ruled out.

who does not recognize changes in muscle and tissue

In chronic cases without

pathological

findings

tension brought about by pain will have to rely

there is decompensation as

(reluctantly) on what he is told by the patient, or

cular lesions, faulty statics and muscular imbalance.

a

consequence of arti

else simply refuse to believe him. The unfortunate

Our chief concern will be to correct these, so

consequence is that the expert, in order to find

as to achieve compensation, but at the same time we

'objective' criteria, feels bound to base his decision

have to assess to what extent the work the patient

on the morphological findings, i.e. mainly

on

X-rays.

is expected to perform contributes to decompen

This is also easier to 'prove '; changes in function are

sation or even causes relapses.

far more difficult

assessed specifically for each case, in view of the

to

show. This has, indeed, not

This

has to be

299

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30t)

Manipuiarive Therapy in Rehabifiration

of rhe

LocomOlOr Sysrem

effect of different types of work on the locomotor system.

For instance, if the patient gets backache whenever

which has nothing to do with his real job and gives him no chance to readapt to it.

Pain in the low back and the lower extremities is

he has to sit for a longer period we shall have to

certainly a more frequent cause of working incapac

him to walk, if he reacts favourably. First, however,

extremities, even if the pain is equally intense,

not due to an unsuitable chair, a table at the wrong

same effect on movement. If pain in the low back

weight carrying causes symptoms, we must first find

cannot get to his feet, whereas pain in the shoulder

forbid him to do sedentary work but may encourage we must make sure that the bad effect of sitting is height, etc. Similarly,

if lifting and stooping or

ity than pain in the neck, shoulders and upper because the latter type of pain does not have the

and lower limbs is sufficiently severe, the patient

out whether the patient's movement patterns are at

or headache are often the same whether he goes to

techniques - but not allow him to return to this type

interferes directly with his work, as shoulder pain

As one of the frequent factors involved is movement

to his own resources at home.

fault - in which case he must be taught correct of work before making sure it will not cause relapse. restriction,

we

should

be

reluctant

to

forbid

movement as long as it is well tolerated; it is one of

work or stays at home.

Indeed, unless the pain

may do, the patient may suffer less at work than left One important exception which causes absentee

ism, and may even necessitate a change of employ

the principles of the management and rehabilitation

ment, is repetitive strain, i.e. pain in the

appropriate movement - despite public opinion

apparently little strength, usually in a rigid position.

enjoying country walks or even moving about on

in the muscles of the neck and upper extremity, is

of such patients to improve locomotor function by shocked by the sight of a patient not fit for work

upper

extremity caused by fast repetitive movement of Adequate clinical examination, in particular of TrPs

skis' Sometimes the trouble lies not in the work

essential to establish the diagnosis.

from work, particularly if jolting in public vehicles

trauma, it may be appropriate to say a few words

performed by the patient, but in how he gets to and is not well tolerated. Here

again there

is

an important distinction

between back pain with or without pseudoradicular

(i.e. referred) pain in the lower extremities, and true

radicular syndromes. In the former, movement is

Before turning to the much-discussed question of

about

occupational

'damage'.

In

the

preceding

chapter we saw that Western civilization has altered living conditions in such a way as to make the large

majority of professions unfavourable to a healthy

locomotor system. There are occupations that are

usually well tolerated and should be encouraged,

particularly undesirable from this point of view:

radicular signs are very acute - which may be for

as in

while in the latter it can be harmful as long as the

some time. A special problem can be root claudication

which has to be diagnosed and yet clinical findings

at rest may be minimal. Another condition in which

drivers, particularly those exposed to severe jolting a

tractor, and jobs involving extreme static

overstrain, like that of the dentist or the seamstress.

Yet it seems exaggerated to regard back pain as an

occupational

disease

in

such

cases.

Frequently,

walking is not well tolerated and where we must be

patients get worse at a job for which they are clearly

involvement of the lower extremities. Here walking

expertise

cautious about allowing it is pain due to articular

on hard ground (paved streets) is particularly harmful. There is

a

specific problem in the case of patients

who have been unfit for work for a long period, such

as several months; this is often the case with radicu

lar syndromes of the lower extremities, particularly where operation has been necessary. These people are out of training. If a young footballer, for example,

has to lie in bed for several weeks, nobody expects

him to play in a match the day he recovers his health. Working people,

however physically

demanding

their job, do not enjoy the same consideration,

physically unsuited; this is due to a lack of medical in

eliminating

individuals

from

work

detrimental to their physical constitution. This is

most marked when workers are forced to change

jobs at an age when adaptation is no longer easy.

They then rightly claim that symptoms appeared or got much worse because of their new job - but the

real fault lies in lack of prevention.

The role of trauma As injury, and particularly injury at work, gives the

although it should be obvious that some readaptation

patient the right to claim compensation, it is

patient shoilld work for a time under somewhat

The questions put to the doctor in such cases are

is necessary. If we do not want to risk relapse, the

easier conditions, i.e. either not full time, or omitting

a

frequent subject of litigation requiring expert opinion. whether there was trauma at all, and

(2)

(1)

whether

some of the more demanding operations involved,

and to what degree trauma is responsible for the

sometimes an attempt in this direction, giving the

questions may cause considerable controversy, parti

until he fully recovers his former strength. There is patient

'easier

work';

alas,

this

usually

means

transfer to office work or to that of a doorman,

patient's condition.

The

answers

to both these

cularly if the injury has affected the spinal column.

I therefore deal mainly with that issue here.

Copyrighted Material

expertise or as malingerers.

The infliction of it a heavy object falb

'lcture,

patien t feels leadi ng to

30J

is that the conflict ensues justifies the

nobody would question that the fracture was due to

diagnosis which began as a grave error and which

inj ury When s too ping to lift a heavy object. the force of contraction of the erector spinae may

could have been avoided.

.

amount to several hundred k ilograms

,

If in such a

situation a man's foot slips, or if two men are lifting

The effect of trauma

a weight and one of them unexpectedly drops it. a sudden force of several hundred kilograms is brought

Where trauma has been admitted as such, the question to be answered is whether the patient's symptoms

to bear on the lumbosacral junction. It would be illogical not to regard the sudden, lInexpected effect

question in some circumstances. e.g. if symptoms do

of such a force as an

ITll'dn that llonslltutes an

the lifting of a he avy injury, even if the forcc

not follow symptom-free

if there is a

months. 'We know,

i n deed considerable: activity that within limlt.s

are indeed the result of that trauma. This is a difficult

q

the unforeseen, incomdinatecl.

is an

cause disturbed

movement

It is

restriction; this

that

time and m ay bCCOlllc'

latent for some the result of

should be reco gn i zed

addition al

A further point is thaI injury column is more often than not mdirect, as I pomted out in Chapter 7 (see p. 287). If, therefore, symptoms pointing to spinal involvement occur after a fall on the extremities, buttocks or shoulders, they should be considered as caused or exacerbated by the trauma even if the pat ien t himself does not realize the connection. The greater the d amage to the structure directly mjured, the more easily sp in al involvement is overlooked. Immediately after fracture of the arm aUention or pelvis, local pain i, to the major trauma, the spinal column is re gion, this is often fracture heals and the svmptoms 11(1 I hl..lrefore attributable to that unrecognized injury up, Finally, and should be clearly although by now whiplash lIlJury lS a f amiliar lraum ,HIC e nti ty its seriollsness and the relatively un favourable prognosis are not sufficiently admitted. The fact that whiplash injury need not be caused e xc lusively by rear-end collisions but also by similar mechanisms brought into play by a falL for example (Berger and Gerstenbrand, 1981), is still not sufficiently recognized. The most seriOus aspect, as I have pointed out in Chapter 7, is that ttlll after function, trauma are frequenlly whereas only relatively a bility to recognize and as,(',(, more difficult than the can be that of hypenno!\l injury, resulting lab without blockage. This situation only too frequently ends with patien ts who have suffered injury - whose pain typically persists because of disturbed function being diagnosed as having no objective signs of illness; they are then treated as 'psychological' cases

infection. Anotilci

,

stram,

cold,

or

of

whether the

trduma affects a structure that was completely intact, or whcther the structure now affected h as previously been injured. This question is frequently put in cases of elderly patients in whom degenerative changes are no surprise. At first glance it would seem logical to aSSllme that trauma that does not (yet) cause serious morphological damage such as fracture or torn ligaments, but only disturbs function in the form of blockage or hypermobility in an intact terrain, will have than if the struCl me case there is treated adequately sequelae. In the previous

even if our pat to injury, he w a, and that trauma

til

compensation decompen-

s ation, which may be (and frequently is) a much more seriOlls condition. What usua lly happens is that expert opinion arrives at more or less the opposite conclusion: the argument then is that in view of the changes (i.e. degenerative, morphological) that can be proved, the patient would sooner or later have suffered from the same symptoms, and therefore the tr auma did not cause the symptoms but merely precipitated what would hllh

A s this type

of argument is

not discuss it

here

.

or is not t he Th e quest io n cases of disc cause of symptoms llmes. A gain herniation the argument affects an vcrtebra is more intact spin al colunl)!. likely to result than disc prolapse, If, however, disc degene ration is already present, prolapse with its clinical consequences would have occurred anyway, so that again the trauma would have been no more than the precipitating factoL

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302

Manipllfdille

Taking this

Ndwhli;!atiol1 of the LocomolOr Systeli! by point, it is

'inevitable' disc pro-

important to

even probably produced is also unjustifiable,

1. There are conditIOns under which a disc may rupture even if intact; this occurs in lordosis or hyperJordosis and is known from those tragic cases in which a diver strikes his head on the bottom of a pool and sudden quadriplegia results. There may be no vertebral fracture at all, because what happened was due to an acutely prolapsed disc causing cervical-cord compression. 2. Disc degeneration is a very frequent condition; over 50

because the young vicurn of mjury with a perfectly intact locomotor system would thcn be given maxi mum

compensation after injur y , while the victim

who showed no symptoms because his changes were well compensated but who becomes decompensated would get next to nothing, although he will have much greater difficulty in recovering from his injury thrlT1 his younger colleague. The crucial question now is: by what criteria can rnatter of changes in thorough clinical examin-

root syndromes. may be asympto-

3. matic who never 1956). At present.

n round in subjects ',vllClromes

(McRae,

and MRI we find

('11111((111) Ilf":,,vant disc herni ations bearing no correlation with the patient's increasingly

symptoms. Even if a patient with disc prolapse recovers without operation, the prolapse may still be found, although without clinical manifestations. To sum up: it is an untenable argument that in view of certain morphological (mainly degenerative) changes we must expect a certain type of syndrome. either as a

of rhese changes or,

ation (2) tlltl

changes in function and, are the direct sign or

clinical tion). only be

(nociceptive stimula-

III'

trauma can be decided dllamnestic data. IF it can

to the given criteria al1cl (2) the patient was trauma symptom-free before the incriminilted trauma, then the trauma must be recognized as having caused the symptoms. On the other hand, if the patient has had symptoms previously that took the typical course of pain-free intervals alternating with relapses then the trauma was at best a precipitating cause, or even irrelevant. As most employed persons are registered with a doctor who has to confirm sick leave, it is not usually diff\cul! 10 Ihe true state of affairs.

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10 The place of manipulative therapy and its future

There

arc

two aspects to manipulation. First, it

di agnostic tools. Manipulation, rightly compared to

causes marked reAex effects in many types of pai n.

surgery in this respect, req u ires absolu tely accurate

a

feat u r e that it shares with many other methods of physical the ra py such as massage. electric stimula

diagnosis. The criteria necessary for mani pulation

tion and local anaesthesia. The other aspect is th a t

patterns, statics, and reAex

tissue) changes. It

thus became possible to obtain the necessary diag

locomotor [unction, i.e. of reversible j oi n t movement

nost i c data for a judicious anal ysis of the clinical

r es tri ction

picture , and to plan rational therapy , i.e. to choose

is

a

form of

(so ft

treatment of impaired

it

specific

have since been consistently applied to movement

or blockage. This aspect became crucial

for further clinical development and applica t ion.

(1)

It soon became clear that treatment of restri cted joint mov ement had m obi lity

its limits and that

passive

t h e structure w h e re treatment is most urgent and

promising, and

(2)

the most adequate method of

treatment.

in i ts el f involves not only joints but also

Preoccupation with active, i.e. muscular, function

muscles. This close relationship between joints and

was n ot without consequences for the develop m ent

muscles

became

the

starting point for further was to turn our attention muscle function and its typical impairment

advances; the logical step to a ctiv e

of manipulative techniques. In recent years we have tended to make use of the pat i e n t's own muscles to restore impaired joint movement, i . e. we have learned

in patients with pain due to disturbed function of

increasingly

the locomotor system. in particular in verteb r ogenic

inherent forces, rather th a n t hose o f the thera p ist.

lesions. This was muscular imbalance due to faulty

Indeed, by involving muscular physiology we have

mo t o r pat t e rn s.

how

to make use of the

patient's

i ncreas i n gly engaged the patient's own activity:

No less i m portant than movement is posture, or

ori g i n ally pas s ive manipulative techniques became

stat ic s, because of contemporary conditions of static

semi-active, until finally the p a tien t began to lea rn

strain and overstrain. I nte g r ation of various aspe cts

self-treatment

of disturbed function of the locomotor system shed

these techniq u es are very effective in producing

some l i ght on the no man's land b et we e n neurology,

muscular relaxation, they can also be used to t reat

inde p e nde n t

of the therapist.

As

o r thopae dics and rheumatology that is the home of

muscular spasm, tr i g ger points and even referred

the vast ma j ority of patien ts with pain deriving from

pain. In this way these semi-active and ultimately

the locomotor system, in whom no definite patho

active methods of se l f - t rea tmen t take an inc re a s ingly

morphological changes can be found. We suggest

evident

'functional pathology of the locomotor system' as

reha b i l i tation

the

name

for this no man's la n d . The most freque nt

symptom of impaired locomotor function is pain.

share

in

remedial

gymnastics

and

in

medicine.

This is un d e rs t andab l e,

for as the

locomotor

system is the organ of voluntary movement, it should

rcAected clinically by refkx changes such as muscle

be efficiently controlled by the patient. It is then no

spasm, trigger points. hy p era l ges i c skin zo n es, pe ri

coincidence

osteal points. and other soft tissue lesions.

that

the

a i ms

of

rehabilitation

(to

res tore lost function) us i n g active cooperation on the

Manipulation owe s its pioneering role in this field

part of the patient converge with those of modern

not only to the two aspects already discussed, but

ma n ipulativ e techn i q u es which use m u sc u l ar/ n e ur o

also to the fact that it has furnishe d the necessary

muscular techniques . Rehabilitation medicine is not

303

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(l ml Join t

T.

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P h a rm a c o l ogy

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4(

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osteokhon dro z e

(Theore t i c a l

p o z vol1 ochn ika.

of reh C1 h i ! i l � l i o n i n o,:cocli o n d rosi,

1 5 9- 1 63 and Badley. E. M. (

Wood, P

E p i d e m i o l o gv

of b a c k p a i n . I n The Lumbar Sp ine and Back 2nd e d n , p . 29. Ed. J a y s o n , M. I . V. Lon d o n : Pi t m a n

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a

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kompc n s i e r t e r

und

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B e w e gll fl g\c i n

Orllwpiidie

ih re

Gren zgebie/e. 97, 2 1 8 B e w,.· r; n n gsa n a l ys c n

R b n tge n o l o gische

H a l sw i r h l s z.i ll l e b e i gC\llI n d c n

K i n d e r r' ll n d J u g tl n d h· h � n . Fo rls-elmllc allJ dem

t h e a t l a ntlXi x i a l j oi n t . RadIOlogy , 90, ( 1 962)

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87

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( 1 960)

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I

( l 970) M a n u e l l e Th e r a p i t'

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Zich�,

94 W y k e , B . D . ( 1 97 5 ) M o r p h o l o g i c a l a n d fu n c t i o n a l fe a t u re s Morph%

.

T h e a c t i v it y o f i n d : l i d u a l t r l l n k m us c l e s d u r i n £

v i s n a l d i s t u rb a n ce 2 n d i t s m a n i p u l
1 9, 78 Wyke, B .

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Copyrighted Material

Index

Abdominal muscle tension, 258-9.

Articulation and blockage, 13-14 Asthma, 283

286 Absenteeism, 292-3 Achilles tendon pain, 206, 235-6, 264 Acromioclavicular joint, 116,166-7,

trauma, 17

Asymmetry, 35, 36, 51, 58, 72, 74, 80, 84, 85, 120,243, 269 Atlas - occiput junc t ion : mobility examination, 113-14

266 Acupuncture. 152-3

mobilization, 190-1

Acute wry nec k . 21, 145, 262

self-mobilization, 198, 200

Ad hesions, 86

reflex sp asm, 17-18

Atlas position, 71-2

Body

st atics,

10

Brain tumours, 145 Brassieres. 296 Breathing, 27-9, 137. 249 during manipulation, 160-1 side-bending, 27 Breathing e x erci s es . 249-50

Adson's manoeuvre, 268

Atlas tension, 212

BrUgger's relief position. 245-6

Age. diagnostic relevance. 84

Atlas tilting, 62-3, 65

Bruxism, 119, 270

Ageing and disc degeneration , 8

Autonomic nervous system, 84, 156,

Bursa subdelto-acromialis. 266

Aktualitatsdiagnose. 3 Alar scapula, 123, 281 Algomenorrhoea . 21, 257, 286

252 Axis, odontoid, 58, 59, 62-5, 109, C5, C6, C7 and C8 root syndromes.

110-14

281

Anaesthesia. 152. 251

Calcaneal spur pain. 206, 236, 238,

Analgesics, 156

263-4

Anamnesis. 83-4

Babies, postural neck reflexes, 22

Ankle j oin t , 118. 170

Back-bending,

An ky losing spo n dylitis . 11, 144, 147,

Back pain , 252-61, 286-7

Carpal bones,

Balance:

Car p al tunnel syndrome . 23, 117,

274

see

Retroflexion

C a psu l ar pattern, 115

sel f - mobilization,

200

267-8

Antagonis t inhibition, 160

coronal vs sagittal, 38

Antalgesic position/posture, 12, 256,

craniocervical j unc ti on, 19-20

Carpometacarpal thumb j oint, 162

spi n al column, 19-20

Carrying, 27, 135. 249

277

Balance disturbances, 20, 272-5

Case history, 83-4

cervical spine. 62-3, 65, 76. 109, 129

Bala n ce testing, 119-20

Causalgia, 151

lumbar

Barrier p henomenon, 11-12, 86

Centre of gravity . 38. 136

pain during . 102

Basilar impression, 79, 276

Cervical collars . 250

t h o racic spine , 104--5, 129

Belt supports, 250-1

Cervical h eadac he, 21, 269-71

Anteflexion:

spine,

101-2. 103. 128

Anteflexion headache, 271

Berger's tes t , 119

Cervical myelopa t hy. 80, 276

Apophyseal j o i nts , 255-6

Biceps brachii, 222-3, 266

Cervical spine , 60-1, 77, 79

Arch of the foot, 94

Bice ps femoris, 233-4

anteflexion. 62-3, 65, 76, 109, 129

Arm abductio n pai n . 265-6

Binding, 11

atlas-occiput j unction:

Arm li fti n g, 27

Blockage, 11

mobility examination. 113-14

examination, 135

articulation. 13-14

mobilization. 190-1

exercises, 248-9

causes of, 16-18, 24

self-mobilization. 198, 200

Articular process, 49, 57, 61, 67, 73, 81, 108

faulty movement patterns, 16-17

axis rotation, 72-3

meniscoid entrapment, 14--15

c a n a l narro wing, 79, 276

341

Copyrighted Material

Index

342

Complications. 149, 274, 297

Electromyography, 33

degeneration, 79-82

Concussion, 287

End-position resistance, 93

forward-drawn position, 67, 7 J

Congenital disc hypoplasia, 49, 51

Engaging the barrier. 159

mobility evaluation, 73-6, 108-111

Connective tissue examination. 86

Enthesopathy,89

mobility range, 129

Connective tissue stretching, 151,

Entrapment syndromes. 267-8

Cervical spine, COII/.

mobilization, 188-91

Epicondylar pain, 116, 207. 220-2.

203

odontoid anomalies, 79

Corticoids, 156

retroflexion, 62-3, 65, 76, 109, 129

Coxarthrosis. 255

rotation, 62, 109-11,129

Cradle exercise, 240-1

self-mobilization, 197-8

Craniocervical junction, 61-2, 79 289

266-7 Epidural anaesthesia. 32, 278 Equilibrium. see BlIlance headings ..

Erb's point, 215. 280

shifting, 11 1-13

balance, 19-20

Erector spinile. 125-6. 225, 227-S

side-bending, 62, 73-6, 109, 110,

basilar impression. 79

Europe, development of

J29 thrusting, J91-3 traction, 188 transitional cervicothoracic vertebrae. 79

blockage in children, 22

Exercise, physical, 295--6

tension, 212

Exercise. remedial.

Cross-country skiing, 296

15:1-5. 238-50.

297-8

Cushion supports, 250

Exteroceptive stimulation, 151,

vertebral coalescence, 77, 79

Cyriax. J., 5

X-rays, 57-60, 65, 67-76

Czechoslovakia, development of

Cervical syncope, 274

manipulative therapy, 5-7

hypermobility, 76

208-9

manipulative therapy. 6

Cervical vertigo, 272

self-treatment, 208-9 Eye movements and manipulation, 160-1

Cervicocranial syndrome, 268-9 Cervicomotogram, 1 J 1

Dancing, 296

Cervicothoracic junction, 20, 55-6,

de Kleyn's test, 120

289 manipulation, 190

Facilitation. 12,26.27.141;, lSI, 11;9.

190, 19K. 209. 239, 304

Deep pressure, 203-4 Degeneratioo, 8-9, 23, 79-82, 302

Fascia shifting, 86. 15 1 , 204-6

rotation. 1 J 1

Depression, 3. 145, 156

self-mobilization, 197

Dermatome charts, 90-3

Feedback. 138. 153

shifting, 113

Diaphragm. 28

Feet, 20, 250

side-bending, 110

Differential diagnosis, 144--{)

self-treatment, 208

arch examination. 94

Cervicovertigogram, 120

Digastricus, 211-12

examination. 94. II R

Chain reactions, 139-41, 142-3.

Disc degeneration, 8-9,23, 302

injuries, 288

156--7 Chair design, 246, 293 Children, 21-3

Disc hypoplasia, 49. 51

manipulation. loS-70

Disc lesions and back pain, 256-7

pain, 203-4

Disc prolapse, 8-9, 23, 32. 302

sensibility chilnges, 208. 209

acute wry neck, 21

Disc thickness, lumbar spine, 49

Femoral head, 254

craniocervical junction blockage,

Disseminated sclerosis, 21

Femoral nerve stretch test, 255. 263.

22 headaches, 21, 269, 271

Diving, 295

27R

Dizziness, 272, 273

Fibromyalgia, 145

lumbago, 21

Dorsalgie inlerscapulaire, 261

Fibular head pain. 233-4. 263

migraine, 2J

Drop attacks, 274

FIMM (International Federation of

minimal brain dysfunction, 21

Drop foot, 278, 279

pelvic distortion, 21-2

Drug therapy, 4, 156

remedia I exercise, 297-8

Duodenal ulcer, 284-5

tonsillitis, 22,283

Dysaesthesia, 33, 267. 268 277, 281

examination. 108

Chiropractic schools, 5

Dysfunction, 32

lesions, 10K, 265

Chiropractors, 5

Dysmenorrhoeil (algomenorrhoea).

mobilization, 188

Chopmt's joint, 168-9 Claudication, 280 Clavicle (collar bone), 1 15, 137,215, 268

Manual Medicine). 6-7 Finger joints. 16 1-2, 200-1 First rib: ,

21,257, 286 Dysphagia, 118, 270 Dyspnoea, 283 Dystrophic changes, 31

Click, 14, 170

Fixation, 158 Flabby posture, 43. 85 Flat spines. 43. 57. 85

Clothing, 296 Coccyx tenderness, 253-4, 290-1

self-mobilization, 197 thrusting, 188

Focus of disturbance, 3 Elbow joint, 116, 164-5

Foot, see Feet

diagnosis, 99-100, 253

mobility range, 129

Forward-bending, see Anteflexion

symptoms, 253

self-mobilization, 200

Forward-drawn position. 67, 71,85,

treatment, 180,231-2,254

Elbow pain, 266--7

140. 258

Collar bone, see Clavicle

Elderly. disc degeneration, 8

Frozen neck syndrome. 281l

Compensation, 10,23, 155, 277,301

Electrical stimulation, 152

Frozen shoulder, I 15. 225, 265

Copyrighted Material

Copyrighted Material

344

Index

Manipulation, indirect, 20i mobilization normalization

Muscle training, 239-42

rcspiration, 29,137

Muscle weakness, 121-4,239-42

disease, 21 symptoms, 84

Muscles: fUllcllOn, 10

post-treatment advice, ISO, 161

Paroxysmal tachycardia, 284

phasic, 25,29, 121 postural, 25,29,121

Pasty hypotoous, 88

Muscular trigger points, 87-8

prophylaxis, ISO, 297-8

Patella, 118, 171-2, 263

record keeping, 161

Mylohyoid muscle, 212

Pathological barrier, 93

reflex effect, 16

Myofascial pain, 31

Patrick's sign, 98, I 17, 235, 253, 254,

repositioning theory, 9

Myofascial trigger points, 87-8

respiration, 160-1

Myorelaxants, 156

263 Pectoralis major. 216-17

table height, 158

Pectoralis minor, 219

taking up the slack, 159

Pedicle, 49,51, 65, 73 Naegeli, 0., 5

theories, 9-10 Massage, 151-,'

Narrow spinal canal,

Masseter, 210-1.1

250-1 see

Spindl

narrowing

Masticatory

Neck extensors, 126

Medial humeral

Neck flexors: testing, 123-4

222,267 Meniere's synclrome,

phenomenon, 95-6

training, 242

<)5

Meniscoid enft3pnh:nt,

Neck pain, 261-2

lindlllgs, 48

Mennell, j,A_,

Neck soft tissue manipulation, self-treatment, 208

Menstrual pain, 21, 257,286 Mental disorders and motor dysfunction, 20-1 Meralgia paresthetica nocturna, 264 Metacarpophalangeal joints:

Needling, 152,251

Pelvic examination, 94---6

Neural control and motor

Pelvic obliquity, 39-41, 95,155

dysfunction, 20-1 Neuromuscular techniques, 159-61,

manipulation, 161-2

303 Neurosis and blockage, 20-1

mobility range, 129

dyr,ll!l1ction ('S' reflex), 99, 140-1, 259-60

Pelvic palpation, 94--5 Pelvic see-saw, 240 Pelvic types, 44---5,46, 47 Periosteal points, 88-9,207

Metatarsophalangeal joints, 168

Newborns, postural neck reflexes, 22

Pes anserinus pain, 235

Microspasticitv, 21, 29

Nociceptive stimulation, 1, 2, 30 2,

Pharmacotherapy, 4, 156

Migraine, 21,

33

Minimal brain

25

Nystagmus, 120

Mobility examination, Mobility ranges, Mobilization,

Obesity, 296-7

self-treatment,

Obliquity, 39-41,95, 155 145

Occipital condyle, 58, 62,65.

Motor segment,

vertigo, 120, 272, 275

Occipital foramen (foramen

173 Movement:

magnum), 57,65,67, 81-2 Occupational environment, 29,

active, 93, 101,108 concentric, 93

293-4, 299-300

Post-cholecystectomy syndrome, 286 Post-isometric relaxation, 151, 159-60,209-10

eccentric, 93

Odontoid anomalies, 79

Post-traumatic states, 287-8

passive, 93, 97, 108-9

Organic disease, 2R2-7

Post-treatment advice, 150,161

Orofacial system, 143,270

Posterior atlas arch. 108,140,269,

Movement patterns, 23-9 causing blockage, 16-17

Osteopathic schools, 4---6

examination, 13 1 , 133-7

Osteopaths,S

Postural muscles, 25

permancnt changes, 2

Osteophyte formation, 23

Posture:

psychological

Osteoporosis, 11, 147

training, 242-50

Overtake phenomenon:

Movement restriction,

271

84-6, 133

pelvic distortion, 95-6

Blockage

ribs, 107

Multiple (disscn1ll13!cd) Muscle hyperactivity, Muscle imbalance, 137-8, 156,

Pain, 30-4, 145

I,

268, 269, 285,293, 295, 297 Muscle inhibition, 24---5

Painful arc, 102, 115, 266 Palmer, D,D, (Palmer College of Chiropractic), 5

Pseudoradicular pain, 31,262-3. 264---8

Muscle tension and pain, 30-1

Palpation, 86-9

Pseudoradicular syndromes, 263

Muscle testing, 120-6

Palpatory illusion, 99

Pseudospondylolist hesis, 52-3

Copyrighted Material

Index

cervical spine,

Psoas spasm, 285-6 Psychological factors, 3, 145

lC'dmination, 108 ic"ons, 108, 265 Shoulder:

Pterygoids, 211

mobilization, 188

Pubic symphysis, 41, 45, 231, 245

self-mobilization, 197

examination, 115-16

th usting, 188

manipulation, 165-8

r

mobiJiza tion, 185--6

mobility range, 129-31

Quadratus lumborum, 126, 229-30

overtake phenomenon, 107

painful arc, 115

Quadriceps, 278

pain, 265

Radicular claudication, 280

345

self -mobilizatio n , 201

pain point treatmen t, 218--1 9

Shou lder -arm sy ndrome, 264, 265

retroflexion, 107

Shoulder-blade, 168

self-mobilization, 197

Shoulder girdle, 27, 56, 62, 109, 135, 268, 296

rib,261

Radicular syndromes, 32 :;

186--8

Radiocarpal joint, 116--17, I Radiog r aph y , see X-rays

109, 110,

Radioulnar joi nt, 164 Range of movement, 126--1 Receptors, 1, 2, 3, 13,19,

C7 and e8, 281

110

L5, 278

33,274 Record keeping, 161 Rectus abdominis:

t horaCIC spine, 105--6, 129

Rotation:

Singing problems, 259

tension, 230--1

cervica.1 spine, 62, 109-11, 129

testing, 122, 240

cervicothoracic junction, 111

Sitting, exercises while, 244--5

training, 240

lumbar spine,51

Sitting posture, 133, 245-6, 293-4

Rectus femoris, 231 Referred pain, 33, 260, 264, 281, 303

thoracic spine, 104, 106--7, 128 Rotator cuff pain , 266

Skiing, 296 Skin drag, 86

Rellex spasm, 17-18

Skin stretching, 151, 203

Reflex syndrome, 31

Slack, taking up, 159

Reflex therapy, 1,4, 151-3, 251 Regimen, 156, 255 Rehabilitation, 3, 6, 7, 1 292, 299, 303-5 Relapse, 144, 150, 154, 292 Release, 31, 153 Remedial exercise, 153-5, 297-8

's' reflex (pelvic dysfunction), 99,

Sleeping position, 294-5

259-60 151, 202-10

syndrome , 278 joint, 45, 47, 290 97-8, 255--6 C\;mlln;ltion,97--8 marllpuiation,178-9 mobilization, 193 97-8 Spillal canal narrowing:

Repetitive mobilization, 15, 160, 177

Sacrum, 45, 47

Repositioning theory, 9

Scalenus syndrome, 268

cervical spine, 79, 276

Respiration, 27-9, 137, 249

Scalenus tension, 214-15

lumbar spine, 49

during man ipulation, 160--1

Scalp mobility, 86, 206

paradoxical, 29, 137

Scaphoid, 116, 163

side-bending, 27

Scapulohumeral joint, 265

Respiration exercises, 249-50

mobility range, 130--1

radicular claudication, 280 Spinal column, 19-20 Spinal curvature, 43 Spinal mobility range, 127-9

Respiratory disease, 283

Scar treatment, 153

Spinous process tenderness, 207

Respiratory synkinesis, 28, 160, 210

School headache, 21, 271

Spondylolisthesis, 52-3

Restric tive barrier, 11 Retroflexion: cervical spine, 62-3, 65, 129 lumbar spine, 101, 102--" .I ribs, 107 thoracic spine, 104, 129 Retroflexion exercises, Retroflexion headache, 271

22,35,36, 39, 41, 43,51, 148, 253, 256, 277 facilitation, 12 Sell-1Tlolliltzation, 193-201 -6, 243, 244

I reatment: shifting, 208 mobilization, 193-201

1.'5

tissue manipulation, 207-8 stroking, 20R--9

Slatie overstrain, 10

Rhythmic muscle pull, 160

Sensibi l ity changes, 208, 209

Stereotypes ,

Ribs, 56

Sensory motor facilitation, 239

Steril ity, 287

blockage, 290

Serratus anterior, 123, 219

Sternoclavicul ar joint, 116, 167-8,

examination, 107-8

Serratus lateralis training, 242

Copyrighted Material

266

see

Movement patterns

Index Sternockidomastoids, 215-16

pain,260-1

Trunk rotation, 128, 133

Sternosymphyseal syndrome, 141

retroflexion, 104, 129

Twitch sign, 88

Stiff neck syndrome, 2RR

rotation,104, 106--7, J2R

Typing, 294

Andrew, 4

self-nwbilization, 196--7

Stoddard, A., 5

"de,hending, 105-6, 1)l)

Stooping, 133, 247

Storung.l!eld,

Uncifonn

[04

disease, 281-5 3

Straight leg raising test,89, 98, 124,

Upper crossed syndrome, 138

X-rays, 57

Upper quarter syndrome, 275-6 USA,development of manipulative

Thoracolumbar junction,20, 55,

J39, 140, 232,253, 255, 263,

60

thrustmg, 183-5

therapy, 4-5

290 183

Straightening up from lIi-7,133

Thor'lX

and counterstt"!'"

Tho>

ValsalvCt

28

Stratification syndrome, 138 Stroking, 151,208-9 self-treatment, 208-9 Subaracbnoid haemorrha?,e, 145 Subclavian artery

mtll10tlUVre, 28

Vasomotor headache, 269

widening during

Vertebral arch, 43, 49, 57, 113

Thrusting, 16, 148-9, 161

Vertebral artery, 61

Thumb, 162,200-1

Vertebral artery insufficiency, 120,

Tibial pain, 235

268

Suhscapularis muscle,

274-5

joint, 118, 170-1

Vertebral coalescence, 77, 79

267

Vertebrogenic lesions, 3, 33

joint, 169-

Vertebro\iscetel correlations,

Supinator, 220

Toe exercises,250

Vertigo, 120,272, 273-5

Supports, 155-6, 250-J

Toe extensors, 235

Visceral disease, 282-7

Supraspinatus muscle,223

Toe joints, 168-9

Volleyball, 295

Surgery, [56

Tonic neck reflex, 19, 22, 57 Tonsillitis, 22,283

Swimming,295 Symphyseal shift,%-G,

258-9

Tonn, Traction,

gait, Weight carrymg, 27,135,249

TransitIOnal cervicothoraclc

Taking up the slack, 159

vertebrae,79

Weight lifting, 26--7

Transitional lumbosacral vertebrae,

Tarsal bone joints, 168-9 Tarsometatarsal joints, 168-9 'rc,mporomandibulat

as

establishments,

1 Tachycardia,284

208, 209 50-1

Working environment,29, 293-4,

44--5, 49 process, 65, 10:),

[(j-19,

Whiplash, 288, 301

10,

29')

191,215

289 points, 88

Writers'

'rcndomyosis, 31 testing, 122-3

Tennis elbow, 266 Tension and pain, 30-[

training,241-2

Tension headache, 269

middle, 228-9 upper, 214

Tensor fasciae latae, 122, 125, 137 lborr'ric-outlet syndrome,

206

Wry neck, 21,145,262

1

,

X-rays, 35--{)

84, 287-8, 31l(l-;'

neurosis, 287

spine, 54-f"

cerV'Gti lumbar

r1l11eAexion, 104-5"

Trenclelenburg's sign, 136

pelVIC

breathing, 107

Triceps brachii, 223

thoraCic spine, 57

curvature, 57

Triceps surae testing,124

flat, 57

Trigger points, 87-8

mobility evaluation, 104-7

Trochanter major pain, 234--5

mohility range, 12R- <)

Tnmk

mobilization, 180-3

using a plumb-line,36-8 Xiphoid process, 23],286

shifting, 205-6

,l'll-toeatment,208

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