This book is dedicated to my wife and to those of my pupils from whom I have learnt most of all.
For Elsevier Publisher: Sarena Wolfaard Development Editor: Sally Davies Project Managers: Anne Dickie and Sukanthi Sukumar Designer: Kirsteen Wright Translators: Elaine Richards and David Beattie Illustration Manager: Bruce Hogarth Illustrators: Gerda Istlerová, Prague, Henriette Rintelen and Velbert Photographs: Jitka Fabianová, Prague
First edition published in English © 2010, Elsevier Limited. All rights reserved. First published in Czech (original Czech title Manipulacˇní lécˇba v myoskeletální medicíneˇ) and subsequent other editions in Swedish, Dutch, Bulgarian, Polish, English (under the title Manipulative Therapy in Rehabilitation of the Locomotor System, 1985), Italian, Spanish, Russian, German and Japanese Eighth Edition published in German under the title Manuelle Medizin 8. Auflage © 2007 Elsevier GmBH, Urban & Fischer Urban & Fischer is an imprint of Elsevier GmBH No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail:
[email protected]. You may also complete your request online via the Elsevier website at http://www.elsevier.com/permissions. ISBN: 978-0-7020-3056-7 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notice Neither the Publisher nor the Author assume any responsibility for any loss or injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method of application for the patient. The Publisher
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Foreword My professional life has been enormously enhanced by Karel Lewit’s teaching and I am so pleased that he has continued to enhance his book, for this latest edition, by adding his further distillation of how recent research should refine our management of locomotor pain. If you liked a previous edition, you will definitely want this one. Although many would consider this a textbook, Professor Lewit has said that it is not one; he has always wanted to make us think, and to enable us to work out our puzzles and problems with the aid of the principles and approaches which he outlines in this book. I can remember, as a medical student, how my teachers gave me the impression that I was learning, at that hospital, all that could be learnt about humankind’s suffering, illnesses and diseases. How wrong they were! Karel Lewit’s teaching has certainly ‘shone light where there was darkness’ on my understanding of musculoskeletal pain. Even after many years it remains a source of pleasure and even excitement that our ‘clinical experience in the use of manipulation for diagnosis and treatment constantly reaffirms, in countless patients, the principle that treatment, if technically successful, brings normalization of restricted mobility in the joint or motion segment. Normalization of function also brings relief of pain.’ But we must take it further than being proud of technique. ‘It is as important – and still more difficult – to adjust our thinking to the functional approach as to master the technical aspect of manual medicine.’ Following this statement Lewit gives important differences between the usual, pathomorphological understanding and the functional approach. The fourteenth of these is, ‘When treating dysfunction, the practitioner is lost – or
rather his patient is – if he treats it at the point where pain is felt’. I can remember being so confused when Philip Greenman said this same thing. This book helps us understand more deeply about how the motor system works and how dysfunction causes pain, and why that statement is true: compared to doctors with our ‘structural’ training, you chiropractors, osteopaths and physiotherapists are fortunate! It is wonderful to see how manipulative therapy and musculoskeletal medicine have developed during Karel Lewit’s lifetime – not least through his own research and that of his younger colleague Vladimir Janda, and then Vojta and Kolárˇ. I remember John Mennell in his later years insisting that it is the muscles that are important’ but not quite being able to explain why. Mitchell, Greenman and others had of course shown, with the muscleenergy technique, that the patient’s own muscles can achieve reversal of dysfunction. But one cannot underestimate the influence of Karel Lewit in stimulating the Czech school and many others to show the underlying neuromuscular causative mechanisms of dysfunction. And nowhere have the clinical manifestations and treatment implications of this newer understanding been better explained than in this book. Karel Lewit can sift the pearls of wisdom from the side-issues, misunderstandings and downright wrong very effectively, as we know (sometimes to our cost!) at meetings of the multidisciplinary International Academy of Manual and Musculoskeletal Medicine (formerly the FIMM Academy). So, he has done all the hard work for you: read on, and give the benefit to your patients. Richard Ellis
vii
Preface The first Czech edition of this book was published in 1967 out of the necessity of providing instructional material. There was a need to teach physicians and, later, physical therapists a new specialty – the diagnosis and treatment of dysfunction of the locomotor system. A way of teaching both theory and practical skills was required that did not involve spending too much time in lectures. There was no comprehensive textbook to teach fundamental theory, functional anatomy, clinical aspects of dysfunction of the locomotor system, relevant treatment indications and appropriate preventive measures based on the findings. Nor is there any such textbook to this day, apart from an increasing number of technical manuals representing various schools of manual medicine. This is probably the reason that translations of this book have appeared in numerous languages: German, Swedish, Dutch, Bulgarian, Polish, English, Italian, Spanish, Russian and Japanese. The first English edition was published by Butterworth in 1985. This was a shortened and therefore more concise version of the original Czech and the seven German editions. The second and third English editions were published by Butterworth-Heinemann. The last two Czech and the eighth German editions were restructured according to the English editions. This eighth (2006) German edition has been translated and updated for the present English version. The starting point was initially manual therapy, but it soon became evident that the true object of ‘manual medicine’ is dysfunction of the locomotor system; such dysfunctions account for 90% of the vast number of patients suffering from painful conditions of the locomotor system. Despite this, afflictions of this nature are termed ‘unspecific,’ hence without diagnosis and consequently inadequately treated. Nevertheless, these complaints are specific disturbances of function: they can be precisely diagnosed by clinical means, requiring in the first place specific physiological methods of treatment. Knowledge about this largely unexplored field grew rapidly, and Professor Janda and I decided to use the term ‘functional pathology of the motor system’. As our knowledge kept increasing, it became
necessary to revise each new edition, which was the main source of the truly dramatic development of what was originally called manual medicine – for which we are in no small degree responsible. The main interest at first was clearly in joints and therefore in manipulative techniques. However, the function and the physiology of the joints were unthinkable without the muscles, controlled by the nervous system. Since (passive) manipulation appeared from the outset to be untenable without (active) rehabilitation to obtain lasting results, our interest in the musculature became obvious. Through their ‘muscle energy technique,’ the osteopathic school of Fred Mitchell senior showed convincingly that the patient’s own musculature does have an effective role to play in manipulative therapy. This prompted us to develop techniques facilitating and inhibiting muscles, which had to be as simple as possible, so as to bring into play the patient’s own muscles, since using the patient’s own muscles is a more physiological approach than that of even the best practitioners. For this reason, selftreatment is of great importance. Soon it became obvious that joint movement restriction was regularly released when muscle relaxation was complete. This promoted the con clusion that a tense musculature and myofas cial trigger points play a predominant role in joint restriction. This point was made in 1975 by the great physiologist of osteopathy, Irwin Korr. We now devote out attention as much to the diagnosis and treatment of trigger points as to that of joint restriction. A further significant step was that it became obvious that trigger points and joint restriction do not occur in an isolated and haphazard manner, but appear according to certain fundamental rules. The practical importance of this principle is that if the most important link of the chain is treated, the entire clinical picture could be normalized. This does not only make treatment more economical, it makes it possible to plan further treatment and rehabilitation, and is the basis of a rational holistic approach. ix
Preface
The next question to be pursued was to find the most important causes of these chain reactions. These were closely related to the role of the musculature maintaining the human upright posture, which is very labile. A crucial role is played by the recently discovered deep stabilization system – of the feet, the trunk, the shoulder blades, and the craniocervical junction. This is closely linked, via the diaphragm, to respiration. Dysfunction of these mostly short muscles must be compensated by movement restriction due to trigger points in the long muscles which, by co-contractions of flexors and extensors, stabilize the upright posture with the spinal column in the sagittal plane. Activation is training the deep stabilization system and diaphragmatic respiration, thus normalizes chains of trigger points and joint restriction, without passive mobilization and even relaxation. Only well localized dysfunctions, frequently found
x
at the extremities, remain to be mobilized. This is also true of the soft tissues and the internal organs, which have to move in harmony with the motor system even during respiration. Manual diagnosis and therapy of these tissues often play a dominant role, particularly with scars. What then remains of manual medicine? It is clinical diagnosis with our palpating hands, without which no chains of trigger points, movement restriction or soft tissue change can be diagnosed. The object of treatment is, however, solving dysfunction of the motor system and all the methods of treatment have to serve this purpose. Analysis of the findings and problem-solving are thus our main tasks. This book has therefore gradually changed into a textbook not just of manipulation, but of ‘musculoskeletal’ or ‘neuromusculoskeletal’ medicine. Prof. Karel Lewit
Acknowledgments The first English edition would have been impossible without the devoted care and critical help of my English wife. To deal with such a vast, in many ways new, field made it necessary to work in a team, one in which we were simultaneously both teachers and students. It was Professor Henner’s Neurological Clinic that made this possible. Thus it was that my first students were my neuroradiology teacher, Professor Jirout, Professor Janda, to whom I gave instruction in neurology and who did pioneering work on dysfunction of the musculature, and the ˇihák, to whom I explained anatomist Professor C functional radiology and who was my constant advisor in questions of anatomy. It is to Dr Véle that I owe what little I understand of EMG and a more sophisticated way to examine reflexes. My thanks are due to Dr Zbojan for the use of gravity for the relaxation of many muscles, to Dr Rosina for the reliable diagnosis of sacroiliac restriction, to Dr Kubis for the diagnosis of restriction of the upper ribs, and to Dr Sachse for the accurate diagnosis of hypermobility. In the scientific field, I learned in particular from the histologist, Professor Wolf, from Professor Berger and Professor Ivanichev. I learned also a great deal from the physical therapists who were my students: from Mrs Hermach I learned about exteroceptive stimulation, and got much practical advice from Mrs Kafková and Klierovám Verchozinová; in recent years in particular from Professor Kolárˇ about developmental kinesionology and stabilization. Others from whom I learned were Professor Starý, Professor Macek, Dr Strˇeda, Dr Gutmann, Dr Biedermann, Dr Wolff, Dr Gaymans, Professor Greenman, Professor Ward, and finally,
indeed most of all, from Professor Simons. Many of those I named are no longer alive. I should like to express my thanks to the Central Railway Health Institute, where I was able to pursue the work in my field from 1973 to 1990, and to Dr Sereghy, who made it possible for me to return to the neurological clinic, which I was forced to leave in 1972. When Dr Sereghy ceased to head the clinic, it was thanks to Professor Kucˇera and Professor Bojar that I was able to move to the rehabilitation clinic in Prague – Motol. This clinic offers at present the most favorable conditions for the further development of musculoskeletal medicine, under the leadership of Professor Kolárˇ, and not only in the Czech Republic. It was a particular honor that the last Czech edition, which was translated for Elsevier into German and now into English, was published under the name of the Czech J E Purkynje Medical Associations, for which I express my special thanks to Professor J Blahoš. My thanks for the quality of the illustrations are due to Mrs Istlerová and Mrs Fabianová. My thanks are also due to Elsevier who pleasantly surprised me in 2004 by requesting a new edition of Manuelle Medizin, and in particular to the translators, Mr Beattie and Miss Richards, who put up with all my suggestions, corrections, even criticisms, to Ms S Davies, who took the responsibility for the editorial development, and to Ms S Wolfaard, who initiated it all. Prof. Karel Lewit Dobrˇichovice
xi
Abbreviations ASIS CT DC DO EMG HAZ MET
Anterior superior iliac spine Computerized tomography Doctor of Chiropractic Doctor of Osteopathy Electromyography Hyperalgesic (skin) zone Muscle-energy technique
MRI PIR PSIS RI TeP TrP
Magnetic resonance imaging Post-isometric relaxation Posterior superior iliac spine Reciprocal inhibition Tender point Trigger point
xiii
Chapter One
1
History and fundamental principles
Chapter contents 1.1 The history of manipulative therapy . . . . . 1 1.2 Fundamental principles of reflex therapy . . . . . . . . . . . . . . . . . 4
1.2.1 Nociceptive stimulation . . . . . . . . 4 1.3 Reflex therapy . . . . . . . . . . . . . . . . 6
1.3.1 Indications and methods . . . . . . . 1.3.2 Choice of method . . . . . . . . . . . 1.3.3 Structural and functional changes . . 1.3.4 The place of reflex therapy . . . . . .
6 6 7 7
1.1 The history of manipulative therapy To begin with a chapter giving a brief outline of the history of manipulative therapy is helpful for several reasons; not least because it is hard to appreciate its unique place in medicine without such an introduc tion. It is also important for the avoidance of mistakes and a correct appraisal of its further development. Manipulative therapy is probably as old as the history of humankind. Throughout that history there have been healers who knew how to reposi tion or ‘set’ joints, including the spine. Among some peoples it was the custom for children to run bare foot over the backs of their weary parents following heavy work. Importantly in this history, in the fifth century bc, Hippocrates, founder of European medicine, listed rachiotherapy as a further fundamental ele ment of medicine alongside surgery and medicinal
therapy. In his treatise on joints, he speaks of parathremata, a concept which corresponded to what chiropractors would recognize as slight disloca tion or subluxation. Waerland expresses it in these words: ‘the vertebrae are not displaced by very much; only to a very small extent.’ Hippocrates goes on to say that ‘it is necessary to have a good knowledge of the spine, because many disorders are associated with the spine, and a knowledge of it is therefore necessary for healing a number of dis orders.’ He also describes how to treat the spine: ‘This is an ancient art. I have the greatest respect for those who first discovered it, and also for their successors, whose discoveries will contribute to the further development of the art of healing in a natu ral way. Nothing should escape the eye and hands of the skillful physician, so that he can reposition the displaced vertebrae on the treatment table without harm to the patient. No damage can occur as long as the treatment is undertaken in the correct way.’ According to Hippocrates, the list of disorders caused by displacement of vertebrae includes phar yngitis, laryngitis, bronchial asthma, tuberculosis of the lungs, nephritis and cystitis, inadequate gonadal development, constipation, enuresis, etc. Manipulation therapy in ancient classical times can be seen on many reliefs. Patients would lie prone on a bed specially constructed for the pur pose, while longitudinal traction to the head and legs was carried out. The physician performed manipulation of a particular vertebra. This type of therapy was evidently practiced throughout antiquity; Galen knew that the peripheral nerves emerged from the spinal cord and that they were susceptible to damage at this point, as is clear from
Manipulative Therapy
his account of the treatment of the Greek Sophist Pausanias. Over the course of time – particularly in the last two centuries – development took place in the primi tive medicinal (herbal) therapy and the surgery of the Ancients, giving rise to modern pharmacotherapy and surgery; however, manipulation therapy continued in the same state as when the ancient classical civiliza tions had received it from the peoples of earlier antiq uity. Consequently the successes of modern medicine completely eclipsed primitive manipulation therapy, causing it to slip to a great extent into oblivion. The medical press, which enjoys generous support from the pharmaceutical industry, contributed to this pro cess. What we now see, therefore, is unequal develop ment in the field of medicine, leading to a situation in which one discipline, failing to keep pace with the progress in the other specialisms, became almost for gotten. All that persisted, as far as we can tell, was a group of lay persons – to some degree established – called ‘bone setters’ who practiced manipulation therapy. This remained the situation until into the second half of the nineteenth century. It was Andrew Taylor Still (born 1828), who practiced as a doctor in the American Civil War, who rediscovered the importance of manipulation of the spine. In 1874 he founded a school on a pro fessional basis in Kirksville, USA, with 17 students. From the outset he also provided training to lay persons. At first the courses lasted two years; later they were extended to four years. At the present day, the length of training for a doctor of osteopa thy (DO) in the United States is the same as that for medical students and permits them both to exercise their profession in general practice and to progress to specialization. Around the year 1895, DD Palmer founded the chiropractic school in Davenport. Until then he had worked as a grocer and in magnetic healing. According to his own account, he wit nessed manipulation being practiced by a phy sician by the name of Atkinson. Other sources say that he himself received treatment from Still. At first, the courses he provided lasted only around two weeks, and cost 500 dollars. By 1911 the courses lasted a year. At present, the training consists of four years of universitylevel study in the United States. Graduates obtain the title DC (doctor of chiropractic), which enables them to practice as primary care physicians. Differences between osteopathy and chiropractic persist to this day. The training given to osteopaths 2
in the United States endeavors to provide a com plete body of medical knowledge, whereas schools of chiropractic will not teach pharmacotherapy and sur gery. Among chiropractors, there is a substantial diff erence between those of the older and the younger generation. The older generation adheres dogmati cally to the outdated theoretical and technical tradi tion; the younger rejects the traditional dogmas – it strives for a rational, scientific method and strongly desires to cooperate at the professional level with medical practitioners. From the technical point of view, chiropractors confine their approach for the most part to highvelocity, low-amplitude (HVLA) treatment using short-lever techniques, taking very little interest in soft-tissue techniques. They are increasingly inter ested in rehabilitation and lifestyle (dietetics). Osteopaths, in contrast, place emphasis on soft mobilization and soft-tissue techniques as well as HVLA treatments; however, they show a pre ference for long-lever techniques, using indirect (unlatching) techniques to be able to work in a targeted way. Neuromuscular techniques – muscleenergy techniques (MET) – derive from the school of Fred Mitchell, sen, Greenman and Mitchell, jun. Although physicians in Europe initially knew little of manipulative therapy, even completely rejecting the concept, here too they gradually began to take an interest in spinal manipulation. The dis covery of a mechanical disorder, the herniated intervertebral disk, was partly responsible for this interest. Attempts were made to provide relief by means of traction, and even to perform manipula tion under anesthetic. While, on the one hand, osteopaths and chiro practors were regarded as charlatans, on the other, attempts at manipulation by physicians of tradi tional (allopathic) medicine were rough and ready. Nevertheless, physicians in Europe were beginning to concern themselves with maneuvers applied to the spinal column. As long ago as 1903, the Swiss physician O Naegeli published his book on neu rological complaints, Nervenleiden und Nervenschmerzen. Ihre Behandlung und Heilung durch Handgriffe. The most important proponent of manipulation therapy in Europe was the British professor of physiotherapy, JA Mennell. He made no secret of having received instruction from osteopaths. His many publications (including manuals) remain to this day exemplary models of their kind. How ever, he mainly trained physiotherapists (physical
History and fundamental principles
therapists). His successor, J Cyriax, was a passion ate proponent of manipulation therapy as well as an outstanding clinician and diagnostician. His Textbook of Orthopaedic Medicine remains to this day a classical textbook of the locomotor system. However, the techniques he describes and teaches do not measure up to comparison with those of Mennell. Another individual deserving of mention is A Stoddard. He was originally an osteopath, and later studied medicine. His Manual of Osteopathic Techniques can be regarded as a classical textbook of manipulative techniques for the spine. The London College of Osteopathic Medicine was the first institution to provide instruction in osteopathic techniques to physicians trained in traditional medicine, and these individuals played a role in the further development that took place in Europe. The French physician, R Maigne, is one example; he also studied under the neurologist and rheuma tologist, de Sèze, who was long the most influen tial proponent and teacher of manual medicine in France. He systematically held courses for phy sicians at the medical faculty in Paris and wrote textbooks. Despite the leading role played by Maigne, there are many splinter groups in France. In Britain, on the other hand, the British Institute of Musculoskeletal Medicine (BIMM, and its pred ecessor the BAMM) is organized in a unified way, holds courses and, under Dr Richard Ellis, pub lishes probably the most important medical journal in the field, International Musculoskeletal Medicine (formerly entitled the Journal of Orthopaedic Medicine). The development that has occurred in the German-speaking countries is also of particular interest. After the end of the war, a number of German physicians began, out of necessity, to take an interest in manipulation therapy. Soon they began to found specialist scientific associations concerned both with the critical study of the issue and with courses of instruction. In Germany there were two groups involved at this time, the Forschungsgemeinschaft für Arthrologie und Chirotherapie (FAC), initially based in Hamm but later in Boppard, whose leading figures were G Gutmann, F Biedermann, A Cramer, and HD Wolff, and the Gesellschaft für manuelle Wirbelsäulen-und Extremitätengelenkstherapie (MWE) under K Sell, which was based in Neutrauchburg. Physicians from the former German Democratic Republic of East Germany also took part in these
Chapter 1
courses up until the beginning of the 1960s. After 1961 this was no longer possible. Students of the FAC were therefore commissioned to organize courses in East Germany, which were to be on the same lines as the FAC, and at the Charité in Berlin, under Professor H Krauss and K Lewit from Prague. This task was more than could be done by just one person, so it was necessary to train instructors who would later take over the leadership of the Associa tion. The most important of these were E Kubis, J Sachse, K Schildt-Rutlow, and H Tlustek. After the reunification of Germany this group became established as the Ärzteseminar Berlin (ÄMM). Today the FAC, MWE and ÄMM together make up the Deutsche Gesellschaft für Manuelle Medizin (DGMM). The development in former Czechoslovakia is also of great interest, as a result of the profoundly different political situation and especially in view of the fundamental role it served as a model for other then-communist countries (including East Ger many). At the end of 1951 the Ministry of Health commissioned the university hospitals to undertake a review of the methods used by lay practitioners and practitioners of complementary medicine. To this end a chiropractor with a practice in Prague was reviewed at the neurological clinic (under Professor Henner). It was an ideal moment, when interest was focused on the intervertebral disk problem, and also on exploring the feasibility of reflex therapy. An additional factor there was the position of neurology in Czechoslovakia in Professor Henner’s time: there was an interest in problems of pain and the locomotor system, and neuro logy also had a leading role in the development of rehabilitation. This made it possible for the technique of manipulation therapy to be reviewed in a clinical domain. Later there came the provision of instruc tion too, emanating from a prominent university hospital and later also provided by the Institute of Postgraduate Medical Training (under Professor Z Macek). Instruction was given in the form of a series of three two-week courses. Later, physi otherapists began increasingly to be trained in neu romuscular mobilization techniques. This is done in association with their university training. This model was then taken up in East Germany, Poland, the former Soviet Union, and to some extent in Hungary and Bulgaria. Professional bodies for physicians working in manual medicine were founded in most of the 3
Manipulative Therapy
countries of Europe, beginning in Switzerland, as well as in Australia and New Zealand; a body was also set up in cooperation with osteopaths in the United States. The International Federation for Manual Medicine (FIMM) was founded in 1965 in London, with the Swiss physician JC Terrier as its first president. His son, B Terrier, has held this post since 2004. A world congress is held every five years. In this way manual therapy has become a medical discipline. A professional body whose name refers merely to a method is not entirely satisfactory to physicians, however, given that the object concerned is the locomotor system and especially its dysfunctions. A number of bodies therefore decided to reinterpret the initials FIMM to represent the name Fédération Internationale de Médecine Musculosquelettale (International Federation for Musculoskeletal Medicine). Despite considerable activity in scientific work, manipulation has continued to be regarded by a great number of traditional physicians as an outsid er’s method; dysfunctions are little understood and, in matters at the practical level, physicians find it difficult to keep pace with physiotherapists, osteo paths, and chiropractors.
1.2 Fundamental principles of reflex therapy Pain – both in general and in disorders of the loco motor system – is a curse that humanity has always suffered. The constant search for relief has led to a great range of treatments of all kinds. The tradi tional approach has regarded bed rest and – to an extent and with some reserve – pharmacotherapy as the only reliable answer. From another standpoint there are many other methods that belong mainly, although not exclusively, to the realm of physical therapy, and these all have their eager proponents. These include massage, various kinds of electro therapy, laser and magnet therapies, acupuncture, neural therapy, manipulation, local cold or hot applications, cupping, wheal therapy, remedial exer cise, and movement therapy. The common feature of all these methods is their reflex effect. We may ask why, when treating essentially the same disorders, preference is given sometimes to one method and sometimes to another. This some times gives the impression that the choice of method 4
depends on which treatment the practitioner is best able to perform, irrespective of actual suitability. The pathomechanism underlying most of these methods is the reflex effect; they act on sensory receptors to produce a reflex response in the region where the pain originates. They can therefore be termed methods of reflex therapy. We must next ask which receptors are activated and which struc tures they supply. The route by which the control by the nervous system operates is primarily that of reflex reac tion; it would be helpful to proceed from this to an understanding of where, how, and why we should apply one or the other method. The better we com prehend the various methods, the more effective the treatment we can deliver. Since these methods are most frequently applied in painful conditions, there follows a description of nociceptive (pain) stimulation.
1.2.1 Nociceptive stimulation Any localized pain stimulation begins by provok ing a reflex in the segment to which the stimulated structure belongs. In this segment we usually find a hyperalgesic zone (HAZ) in the skin, muscle hardening, trigger points (TrPs), painful periosteal points, movement restriction of the corresponding segment of the spinal column, and (perhaps) some dysfunction of a visceral organ (see Figure 1.1). This enables us to diagnose the changes present and use whichever method is appropriate to exert an effect on the skin, soft tissues, muscles, peri osteum, motion segment of the spinal column, or visceral organ involved. Working in this way and on a case by case basis, we can decide in each case which structure is the location of the most intense changes, and which is the probable source of the pain.
Figure 1.1 • Reflex relations within the segment.
History and fundamental principles
Figure 1.2 • Schematic overview of afferent and efferent connections between the periphery and central nervous system.
These reflex changes are not confined to a single motion segment. For example, visceral disturbances are accompanied by viscerovisceral reflexes: pain in the region of the gall bladder produces nausea; pain in the region of the heart produces a sense of oppression, etc. This kind of effect is still more strikingly seen in the locomotor system: an acute disturbance in one segment of the spinal column produces muscle spasm in substantial sections of the erector spinae; any local movement restriction produces effects in distant segments of the spinal column, after the manner of a chain reaction. Any serious lesion at the periphery also brings about a central response: the motor pattern, or stereotype, will change in order to spare the affected structure. In this way altered patterns of movement are formed, and can sometimes persist after the peripheral lesion has disappeared (see Figure 1.2).
Reflex relations between the periphery and the central nervous system Pain stimuli produce both somatic and autonomic responses at all levels. The somatic response to the stimulus consists mainly of muscle hardening or the opposite response of hypotension (inhibition of the muscle). The expression of pain is found in the form of trigger points both in hypertonic muscles and in (otherwise) hypotonic ones. The autonomic response takes the form of reac tions in HAZs and soft tissues, and of a vasomotor reaction (mainly vasoconstriction) within the seg ment. At the level of the central nervous system, these reactions may occur as stress affecting respi ration, the cardiovascular or the digestive system. At this level there can also be changes in motor pat terns, the stereotypes of muscle action.
Chapter 1
Once we know the source of nociceptive stimu lation, for example movement restriction of a spinal segment, and can assess its severity, then the inten sity of these reflex changes can provide information about the reaction of the patient and of the particu lar segment. We can use the subjective assessment of the pain to evaluate the nociceptive stimulus, the reflex reaction, and the central (psychological) susceptibility of the patient to pain. These somewhat schematic guidelines indicate some possible lines of action to take in painful dis orders, using essentially the same approach as a neurologist would employ in disturbances of mobil ity. This approach is essential if we are to act in a targeted way, that is if we are to know why, when, and where we should use one or other of the meth ods of reflex therapy. First, therefore, we need to distinguish the source of pain and the reflex effects in the segment, at the suprasegmental level and at the level of the central nervous system.
As a rule a nociceptive stimulus produces somatic and autonomic changes. It is necessary to understand these changes in order to arrive at a rational, targeted course of treatment.
The key to this difficult task lies in the functions, or the dysfunctions, of the locomotor system. Since this subject is the main theme of the present book, no more need be said at this stage than to point out that the locomotor system is by far the most frequent source of pain in the body. This is readily understandable, because not only does the locomotor system constitute about three-quarters of our body weight, but it is under the control of our will – consequently even at the mercy of our whims – and has no other way of protecting itself against misuse than by causing pain. First and fore most, then, pain warns us of harmful function or malfunction. Conversely dysfunction is the most common cause of pain originating in the locomotor system. Movement restriction in a segment and disturbed motor patterns or stereotypes at the central level are typical examples. It is no coincidence that pain from a wide variety of causes (e.g. visceral pain) is accompanied by muscular trigger points and is usu ally felt in the locomotor system; (for example the heart causes pain in the left arm, the shoulder, and 5
Manipulative Therapy
the chest wall; the gall bladder causes pain in the shoulder blade, etc.).
Dysfunctions of the locomotor system are the most frequent cause of pain, and pain is the most frequent symptom of dysfunction of the locomotor system.
A sound knowledge of the dysfunctions of the loco motor system is therefore essential for successful therapy.
1.3 Reflex therapy 1.3.1 Indications and methods Clearly the chosen therapy and method must depend on the structure upon which we wish to act. In our approach to the skin, for example, a great variety of methods are available, as the recep tors in the skin are easy to access (e.g. by mas sage, electrotherapy, wheal therapy, or simple skin stretching). Muscle hardness (myogelosis; TrP) can be treated by massage, and more effectively by post-isometric relaxation (PIR), reciprocal inhibition (RI), pressure and needling. Manipulation and mobilization are mainly used to treat functional, reversible movement restrictions of joints or segments of the spinal column. Painful periosteal points can be treated by mas sage, soft tissue techniques, needling, or, if they are the insertion points of muscles, by PIR and RI of the muscles concerned. The most appropriate treatment for disturbed motor patterns is remedial exercise.
1.3.2 Choice of method The next step is to decide which of the affected structures is most important and which less so; which change is probably primary and which sec ondary. The severity of the disturbance is also significant. Even at the segmental level, there is a kind of hierarchy: in general, visceral disorders and abnormal motor patterns tend to be primary. The 6
significance of disturbances in muscles, joints, and soft tissues can only be decided based on an analy sis of the pathogenesis. The particular importance of the fasciae and active scars should be emphasized in this connection. In the locomotor system and in the spinal column, there are regions of greater and of lesser importance. There are some sections in which primary lesions occur more frequently than in others. It is vital to recognize those faulty motor patterns which are regularly found to cause relapses if left untreated. In this connection psychological factors play a major part, because motor patterns are in part expressions of the state of mind: anxiety, depres sion, and an inability to relax exert a considerable influence on motor function; no less important is the subject’s psychological attitude to pain, since pain is the most frequent symptom in our patients. In addition to issues of pathogenesis, there are certain practical aspects of technique to be consid ered, since not all methods are equally effective or ‘economical.’ For example, needling or soft-tissue techniques are usually more economical for the treatment of periosteal pain points than periosteal massage, but wherever possible (i.e. if the perio steal point is a point of muscle insertion) we pre fer to use PIR with RI of the muscle, because these techniques are painless and usually suitable for selftreatment. The attractiveness of manipulation tech niques lies mainly in the fact that they are effective and quick to perform. We can see from this that there is a wide range of possible treatments from which to select the most suitable. The decision as to which to use is reached by making as accurate a diagnosis as possible of the individual changes, and from this make what is known as the ‘present relevance’ diagnosis – what Gutmann (1975) calls the pathogenetische Aktualitätsdiagnose. This aims to identify the change that is the most important link in the chain of pathology at a given moment. All too frequently methods are applied which, for example, stimulate the skin when no signs of a HAZ have been found, or relax a muscle when no tension has been diagnosed (no TrPs found); we even find manipulations being performed when no restriction was present. Clearly, too, it is a waste of time to prescribe remedial exercise when there is no diagnosis of faulty muscle control. Naturally, in order to produce an accurate ‘present relevance’ diagnosis of pathogenesis as explained above, we need to have identified the
History and fundamental principles
individual links in the chain of pathology and ana lyzed their significance. We must proceed in a sys tematic fashion, starting at the peripheral level and working up to the central, applying treatment according to our findings.
The ‘present relevance’ diagnosis according to Gutmann enables us to identify the most significant link in the chain of pathogenesis.
Nevertheless, at times the results of treatment fail to meet expectations. One of the reasons for this is the presence of a lesion which causes intense nociceptive stimulation and dominates the clinical picture without the patient being aware of it. This may be referred to as a field of disturbance. Most commonly the source of this is an ‘active scar,’ the expression of which is a HAZ, increased resistance to shifting, and, in the abdominal cavity, a resist ance that is tender on examination. If the usual methods of therapy are unsuccessful, it is essential to treat the scar. Another cause of repeated failure is masked depression. This should always be consid ered in patients presenting with chronic pain, and needs to be treated.
The dysfunctions of the locomotor system that are described here, together with the reflex changes they produce, may aptly be called the ‘functional pathology of the locomotor system.’
1.3.3 Structural and functional changes In this connection the unfortunate but frequent use of the term ‘functional’ as a euphemism for ‘psy chological’ is most regrettable – it implies a grave underestimation of the importance of function and its role in pathogenesis. In rehabilitation we are primarily concerned with function, and seek at the very least to improve it when dealing with conditions where there is underlying pathomor phological, structural change. This is readily under standable; dysfunction is the form in which any relevant structural lesion is clinically expressed. It
Chapter 1
is fundamentally important to distinguish structural disturbances from functional ones. Where the disturbance is functional, it would be a mistake to think of the dysfunction as being exclusively a matter of reflex changes and reflex control. What we are dealing with here is more than just ‘reflexes’; these are rather ‘programs,’ having memory and capable of being elicited. They affect the entire locomotor system and its disturbances. The most common disturbances, which are also the object of manipulation therapy, concern the spinal column. The term ‘vertebrogenic’ is often used for these, although it is not entirely applica ble, since vertebrogenic disorders often include diseases with a pathomorphological definition, such as ankylosing spondylitis, osteoporosis, neoplasms, etc. Those which interest us, on the other hand, are mainly dysfunctions. They are not confined to the spinal column but also affect the limbs, soft tissues and, most of all, the musculature, which is control led by the nervous system. In view of this it is more appropriate to speak of dysfunctions of the locomo tor system, rather than vertebrogenic disturbances.
1.3.4 The place of reflex therapy The question as to the place of reflex therapy is as difficult to answer as that of the importance of pharmacotherapy. Whereas pharmacotherapy has developed into a significant science, methods of reflex therapy for some time remained empirical, and the indications for their use are ill-defined. The indication for a given treatment is not gov erned by the particular disease (diagnosis), but rather is based on the findings that are significant in terms of the pathogenesis. If, for example, head ache is due to muscular tension, then muscle relax ation is most important. If this muscular tension is associated with joint restriction, then manipulation (mobilization) is indicated; if faulty posture is the cause, it is this that has to be corrected. The advantages of this type of therapy over pharmacotherapy are that the methods used are entirely physiological and (usually) incur no side effects; further – because of their reflex nature – their effectiveness can generally be checked at once. It is worth saying a few words here about the role of pharmacotherapy in dysfunctions of the locomotor system. It would be difficult to conceive 7
Manipulative Therapy
of a drug that could restore a specific motor func tion, although it is possible to alleviate muscle ten sion, ease pain, and damp down some of the reflex effects involved, all of which can facilitate the res toration of function. Additionally, they are a neces sary means of treating depression and anxiety. To sum up, neither the diagnosis nor individual clinical findings in themselves suffice as the basis for deciding the most appropriate therapy. An analysis of pathogenesis is the only means of iden tifying the disturbance that is the most important at a given moment.
8
After treatment the patient must be re-examined to assess the effect, and from this we can make further judgments about the appropriateness of the approach taken. If treatment has been effec tive, the follow-up examination will show a change in the patient’s condition (short term evidence). The task then begins again to decide which distur bance is now the most important. Therapy is therefore never a monotonous rou tine; at the same time the success of treatment is always verifiable, and this aids the practitioner in applying a reasoned, scientific approach.
Chapter Two
2
Etiology and pathogenesis
Chapter contents 2.1 The significance of morphological changes . . . . . . . . . . . . . . . . . . . 9 2.2 Theoretical aspects of manipulation therapy . . . . . . . . . . . . . . . . . . . 10 2.3 The significance of functional disturbances . . . . . . . . . . . . . . . . 12 2.4 Motion segment and joint dysfunctions . . 13
2.4.1 The barrier . . . . . . . . . . . . . . 13 2.4.2 Joint play and restriction . . . . . . 14 2.4.3 Reflex changes in joint restriction . 15 2.4.4 Is restriction an articular phenomenon? . . . . . . . . . . . . 16 2.4.5 The possible mechanism of restriction and manipulation . . . . 16 2.4.6 The effect of manipulation . . . . . 17 2.4.7 The pathogenesis of restriction . . . 17 2.5 The spinal column as a functional unit . . 19
2.5.1 The spinal column and balance . . 20 2.5.2 Key regions of the spinal column in dysfunctions . . . . . . . . . . . 20 2.5.3 The importance of nervous control . . . . . . . . . . . . . . . . 21 2.6 Dysfunctions of the spinal column in childhood . . . . . . . . . . . . . . . . . . 24 2.7 Restrictions and their sequelae . . . . . . 26 2.8 The significance of disturbed motor patterns (stereotypes) . . . . . . . . . . . 27 2.9 Sequelae of disturbed movement patterns . . . . . . . . . . . . . . . . . . . 29
2.9.1 Walking and standing . . . . . . . . 29
2.9.2 Straightening up from a forward-flexed position . . . . . . . 29 2.9.3 Raising the arms . . . . . . . . . . . 30 2.9.4 Weight carrying . . . . . . . . . . . 30 2.9.5 The effect of respiration on the locomotor system . . . . . . . . . . 30 2.10 The significance of constitutional hypermobility . . . . . . . . . . . . . . . 33 2.11 Reflex processes in vertebrogenic dysfunctions . . . . . . . . . . . . . . . 34 2.12 Radicular pain . . . . . . . . . . . . . . . 36 2.13 The term ‘vertebrogenic’ . . . . . . . . . 37 2.14 Conclusions . . . . . . . . . . . . . . . . 38
2.1 The significance of morphological changes Chapter 1 indicated the great range of application of manipulative therapy and most methods of reflex therapy, which can be used for many different cases of pain in the locomotor system; these often involve pain whose cause and therefore treatment remain controversial. For a long time they were generally considered to be of inflammatory origin, for the simple reason that this provided the easiest explanation for the pain. Indeed we still speak of rheumatic diseases, for example ‘soft tissue rheumatism,’ and many terms ending in ‘-itis’ bear witness to this attitude (spondylitis, arthritis, radiculitis, neuritis, fibrositis, myositis, and panniculitis, for example). Since, however, inflammation is a well-defined pathological condition which
Manipulative Therapy
can be demonstrated or disproved, the inflammation theory became untenable and had to be abandoned for lack of evidence. Pathological anatomy and the use of radiology to examine pathology in living patients (X-rays) played their part by demonstrating degenerative changes. In place of terms ending in ‘-itis’ we speak of spondylosis, arthroses, and ‘diskopathy.’ This approach offers the possibility of explaining the changes in tissues that are sometimes bradytrophic. Vascularization of the intervertebral disk becomes reduced at quite a young age and the nucleus pulposus dries out: the water content decreases from 90% in the first decade of life to 70% in the third decade. According to Schmorl, 60% of women and 80% of men at age 50 show evidence of degenerative changes of the spinal column, while by the age of 70 the figure is 95% for both sexes. The very abundance of degenerative changes makes it difficult to define their pathogenetic significance. Whereas the number of degenerative changes increases with age, back pain occurs most often between the fourth and sixth decade, to become less common in old age. Subjects with considerable degenerative changes may be completely without clinical symptoms; alternatively they may suffer an attack of acute pain which subsides after a time (while the degenerative changes remain the same) to leave them once more symptom free. There can even be severe pain in young patients with no degenerative changes at all. The main difficulty is the fact that the term ‘degenerative’ is so poorly defined. It is used on the one hand for destructive lesions typically only found in the hip and knee, and on the other hand for changes of little clinical significance, and which are better described as normal ‘wear and tear.’ Often the change is a compensatory process or adaptation – as in scolioses, in hypermobility, or even instability (for example in spondylolisthesis) which can thus be stabilized. It is often difficult to distinguish between changes resulting from trauma and degenerative ones. When we find degenerative changes, we should begin by asking about their clinical relevance. It is a mistake to draw clinical conclusions without good reason from the mere existence of non-destructive degenerative changes seen on X-ray; they do not in themselves justify speaking of ‘degenerative disease.’ There is certainly some correlation between degenerative changes and herniated disk; with a few exceptions, herniation occurs mainly in disks already showing some degenerative change. The 10
discovery that disk herniation can be a cause of pain was an important step historically, but the success of surgical treatment was often so striking that disk lesions came to be held responsible for most of the many instances of pain related to the spinal column. The principles that applied to radicular syndromes, mainly in the lumbosacral region, were uncritically applied to a whole range of complaints in all parts of the spinal column. ‘Diskopathy’ became the fashionable word for what we now refer to as vertebrogenic (or spondylogenic) disease. Everyday practice contradicts this view and serves to correct it. Although disk surgery is a routine procedure for radicular syndromes of the lower limbs, it is rarely performed for low-back pain or radicular syndromes of the upper limbs, and not at all for simple neck pain or vertebrogenic headache. Nor is disk herniation the only possible cause of pain in radicular syndromes of the lower limbs: in operation statistics no disk herniation is found in about 10% of the cases; many radicular syndromes resolve without operation, and this is true even of cases in which medical imaging had found a herniated disk. Disk herniation can sometimes persist after the symptoms have disappeared, although resorption is also possible. Not only that; computerized tomography (CT) or magnetic resonance imaging (MRI) examination frequently reveals a herniated disk in healthy individuals in whom it is of little relevance. It is only significant when it correlates with clinical findings. To conclude, in the overwhelming majority of cases of back pain and associated clinical symptoms the morphological changes discussed above do not provide an explanation. For this reason this type of pain is referred to as ‘nonspecific’ (Jayson 1970) or ‘idiopathic’ (without any morphological diagnosis).
The vast majority of cases of pain are not associated with demonstrable morphological changes in the locomotor system. In effect, therefore, these are patients with ‘no diagnosis.’
2.2 Theoretical aspects of manipulation therapy Successful manipulative treatment usually results in relief of pain. We may conclude from this that an
Etiology and pathogenesis
understanding of how this therapy works will give us a better insight into what causes pain in the locomotor system, especially in cases where no pathological changes are present. The explanation originally given for the effect of manipulative therapy was that it involved ‘repositioning’; the understanding was that what was being treated was an incomplete dislocation, for which ‘subluxation’ became the accepted term. This was what Hippocrates believed, and probably also Still and most practitioners providing manipulative treatment down the ages. Indeed, the sight of a patient with acute lumbago or wry neck, unable to straighten up, who receives successful manipulation treatment and becomes able to stand erect, makes it little wonder that they did see this as the likely explanation. The reason that physicians have had to abandon the subluxation theory lies in the radiographic findings, since X-rays show no change for the individual segments before and after manipulation. The only change is in the abnormal posture, whose cause is muscular. It has been shown by M Berger (personal communication) by means of cineradiography that when the head moves to an extreme position and back, it does not return to the same neutral position as before. We were able to confirm this by means of transoral radiography (see Figure 2.1). An analogous effect was demonstrated by Jirout (1979a) for synkineses of the cervical spine in the sagittal plane on side-bending; when images were taken in the neutral position before and after
Chapter 2
maximum side-bending, the position of the spinous processes was generally found to be changed. The conclusion that can be drawn from these observations is that in a structure consisting of such a number of mobile elements there can be no absolute, fixed neutral position. The same applies to any changes there may be following manipulation. It will be shown below that manipulation operates only on disturbed function, that is mobility in the affected motion segment. If, however, there is no absolute neutral position, it follows that manipulation enables the motion segments of the spinal column to adopt the position that is most favorable in the particular circumstances.
If the mobility of the motion segments of the spinal column is normal, the spinal column itself knows far better than the person giving treatment which position it should adopt for each particular posture or load.
According to the literature, some authors, such as Cyriax, Maigne, and Stoddard, believe that manipulation exerts some kind of effect on the disks. However, it is difficult to see how manipulation could achieve repositioning of a herniated disk when its exact position can never be known. Another point to consider is that manipulation is also effective in treating other locations, where
Figure 2.1 • (A) Almost symmetrical position of C2 in the neutral position. (B) On returning to the same neutral position immediately after maximum rotation of the head to the left there is marked rotation of C2 to the left.
11
Manipulative Therapy
there are no disks, such as the limb joints, the atlanto-occipital and atlantoaxial joints and the pelvis. Clinical experience supports this: manipulation is most effective in situations where there is no disk herniation, and often fails precisely in cases where there is. The precise examination techniques used by osteopaths have also provided a clearer idea of the effect of manipulation therapies; these are indicated when we find movement restriction in a joint or a vertebral motion segment, and if manipulation is successful, normal mobility is restored. In other words, manipulation does not achieve a change of structure, as Still thought, but normalization of mobility; that is of function. This is also true in cases of acute lumbago or acute wry neck: the position of the neck or the back in such cases is not in fact abnormal in itself; it is only the fact that the patient is unable to straighten from a position, such as flexion, or rotation plus inclination, that is pathological. Manipulation (mobilization) simply frees mobility and thus enables the patient to return to the neutral position. Acute lumbago and wry neck are in fact an exception in this regard; in the vast majority of cases the position observed is normal and the finding is simply one of movement restriction in the joint (or vertebral motion segment).
Manipulative techniques are used to diagnose and treat only functional movement restrictions in a joint or vertebral motion segment. The purpose of manipulation techniques is simply to normalize disturbed function.
2.3 The significance of functional disturbances As the above makes clear, it is above all clinical experience in the use of manipulation for diagnosis and treatment that constantly reaffirms, in countless patients, the principle that treatment, if technically successful, brings normalization of restricted mobility in the joint or motion segment. Normalization goes hand in hand with the restoration of function (bending or rotation to the left or right; in the case of the limbs, symmetrical findings in the left and right limb). Normalization of function also brings relief of pain. 12
A similar principle applies not only to the passive mobility of joints, but also to active muscle function. Janda in particular demonstrated the significance of muscular stereotypes and showed that faulty movement patterns (disturbances of these stereotypes) produce abnormal stress on passive structures, especially joints. Closely associated with movement patterns is the matter of body statics. In fact, static overload and its consequences have become an extremely important issue in our modern technologically developed society with its general lack of mobility. Here too we find that correction of faulty posture frequently relieves pain. The contribution made by Brügger is particularly helpful in this connection, since he has made a special study of the hunched sitting posture and its treatment. Manual functional diagnosis thus served as a model for many other dysfunctions of the locomotor system. The muscle trigger point (TrP) most clearly demonstrates the close connection with pain. In saying so we should stress that morphological lesions are also associated with disturbances of function. This is most clearly the case for herniated disks and may explain spontaneous recovery and recovery after conservative treatment (including manipulation). A similar situation applies to rehabilitation in traumatology, where our primary aim is to improve function despite the presence of irreversible structural changes, where the aim of rehabilitation is to achieve functional compensation. As will be shown in more detail later, function and its disturbances are rarely confined to one site or structure. Diagnosis must therefore take in the locomotor system as a whole, and consequently the terms ‘vertebrogenic’ or ‘spondylogenic’ will no longer suffice. Even in back pain, muscle function and its nervous control play an important role, as do the functions of the pelvis and lower limbs. Since ‘vertebrogenic’ diseases or lesions include such well-defined pathological conditions as ankylosing spondylitis and osteoporosis, the decisive criterion for the use of manipulation and other measures aimed at restoring function is whether the patient’s complaint is due (mainly or exclusively) to dysfunction, or to structural (pathomorphological) changes. The solution is not simple, and the problem lies in the fact that the method of examination has not yet been precisely defined. It is the great weakness of important methods of treatment – such as manipulative therapy, remedial exercise, and other methods concerned with improving the functioning
Etiology and pathogenesis
of the motor system – that they are often more concerned with the method than with its object or its potential for diagnosis. In many fields of medicine the significance of findings relating primarily to function is now well recognized. In the locomotor system, however, where function is paramount, this aspect finds least acceptance. Yet the functioning of the locomotor system is extremely complex, and diagnosis of disturbed function is correspondingly difficult. Nor is there a specific medical specialty responsible for this area; functional disturbances seem to be the realm of everyone and of no one. There is an additional disadvantage in that, for the most part, the only means of investigating dysfunctions of the locomotor system is by inspection and palpation. Today these are often regarded as ‘subjective’ and dismissed, while instrumental and laboratory methods are regarded as objective.
2.4 Motion segment and joint dysfunctions Dysfunctions of joints and vertebral motion segments (see Figure 2.2) fall into two categories: hypermobility and restricted mobility; manipulative therapy is concerned only with restricted mobility.
Chapter 2
Clinical criteria are the decisive factor in identifying such restriction, and are judged from the qualitative point of view as well as quantitatively. A reduced range of motion is easy to recognize and measure in a joint, but much more difficult in motion segments of the spinal column. Qualitative changes are therefore of considerable diagnostic value when dealing with the spinal column. This is the case when the finding is one of increased resistance, and especially a lack of ‘springing’ at the end of the range of motion, with abrupt resistance encountered in the end position of the joint or motion segment. In a normal joint the extreme position is never reached abruptly, and a slight increase of pressure can always increase the range of motion. In a joint with functionally restricted mobility, this springing or giving way has been lost and we abruptly encounter a hard barrier. This, termed joint ‘restriction’ (sometimes ‘blocking’ or ‘blockage’), is perhaps the most significant sign in diagnosis.
2.4.1 The barrier The concept of the ‘barrier’ is a familiar one in the osteopathic literature. Three kinds of barrier can be identified: 1. The anatomical barrier, created by the bony structures. 2. The physiological barrier, which is clinically significant and is found at that point in the examination where the first, minute degree of resistance is felt; the barrier yields slightly with a sense of ‘springing.’ 3. The pathological barrier, which restricts motion and is felt as a hard, abrupt stop, lacking the sense of spring. In addition there is often a change in the neutral position; for example in rotation of the head or trunk, so that this becomes asymmetrical (see Figure 2.3).
Figure 2.3 • The barrier phenomenon. A–A: the anatomical Figure 2.2 • The motion segment (after Junghanns).
barrier; Ph–Ph: the physiological barrier; Path: the pathological barrier; N0: neutral position; N1: shifted neutral position when a pathological barrier is present.
13
Manipulative Therapy
The barrier as a phenomenon was originally defined with reference to joints, but is also useful in relation to the elasticity and mobility of soft tissues, including muscles. The barrier is therefore relevant for all mobile structures; it has a protective function. The definition of the physiological barrier given above is not universally accepted. It is defined in an osteopathic publication (Kuchera 1997) as the limit of active motion. We consider this definition to be of no practical use on the grounds that passive examination of the barrier is used to investigate movement restrictions, both for motion segments and for joint play. The objection applies all the more to soft tissue diagnosis. In chiropractic, this barrier is defined as the limit of maximum passive motion, the important point being that passive motion has a greater range than active motion. If manipulation were to be performed on a barrier defined in such terms, it would elicit an intense stretch reflex. This would rule out any gentle techniques, let alone relaxation on the part of the patient. Perhaps there is an explanation here for the harshness of technique used by some chiropractors. The definition we have given above for the physiological barrier must therefore stand. It is useful both in diagnosis and as a principle that underlies our treatment, which produces release. We recognize fully that this does involve subjective evaluation. The first, minute resistance is found by means of palpation, which of course depends on the experience of the practitioner.
only be sensed by palpation, but can be demonstrated radiographically (see Figures 2.4 and 2.5). Joint play is by no means only a matter of theoretical interest: its practical clinical importance lies in the fact that joint play reveals restriction at a stage when functional mobility is still normal, and – as can be seen from Figures 2.5 and 2.6 – translational
2.4.2 Joint play and restriction There are two types of joint movement, both of which are affected by restriction: 1. Functional movement: movement that can also be performed actively. 2. Joint play (according to Mennell 1964): movement of the joint which can only be brought about passively. This comprises a translatory (sliding) movement of one joint surface against the other, sometimes also rotation, and also distraction of the joint facets. To give an example, actively we can flex, extend, or side-bend a finger, whereas passively it can be shifted against the metacarpal in any direction, rotated, or distracted by axial pull. These movements can not 14
Figure 2.4 • Lateral and medial gapping of the knee joint, visualized radiographically.
Etiology and pathogenesis
Chapter 2
Figure 2.7 • Direction of joint mobilization according to
Kaltenborn. With fixation of the concave partner of the joint, mobilization is performed in the opposite direction to that of functional movement. With fixation of the convex partner, mobilization is performed in the same direction.
Figure 2.5 • Distraction of the metacarpophalangeal joint, visualized radiographically.
Joint play can be likened to a drawer that has stuck: any attempt to open it forcefully could damage it, but if we shift it slightly to and fro in the sideways direction, we can then open it easily. The diagram according to Kaltenborn (1989) (see Figure 2.7) shows the direction in which joint play is freest.
2.4.3 Reflex changes in joint restriction Figure 2.6 • Joint play according to Mennell. (A) Normal
gliding motion during joint flexion. (B) Where there is a dysfunction of gliding motion, passive functional movement can injure the joint.
movements and distraction provide a much more gentle method of treatment than passive functional movement.
Normal joint play is necessary for normal joint movement.
Restriction in a joint and particularly in a vertebral motion segment produces reflex changes, mainly in the segment concerned, affecting the cutaneous and subcutaneous tissue and muscles. Korr (1975) speaks of ‘facilitation’ in the segment. The movement restriction itself is associated with muscular tension (TrP or spasm); this can similarly be said of the straight-leg raising test and of the antalgic posture in lumbago or acute wry neck. Korr, a physiologist who worked on the problem of manipulative therapy, said of the role of the muscles: ‘While usually thinking of muscles as the motors of the body, producing motion by their 15
Manipulative Therapy
contraction, it is important to remember that the same contractile forces are also used to oppose motion’ (Korr 1975). From this we can conclude that, in their role as a brake, muscles act as a considerable and highly variable impediment to mobility in a dysfunctional joint. Korr continues: ‘The high-gain hypothesis is consistent with, and offers an explanation for, the steeply rising resistance to motion (‘bind’) in one direction and the equally precipitous collapse of resistance (increasing ‘ease’) in the opposite direction … They [the muscles] would also be provoked into stronger and stronger contraction by the exaggerated spindle discharges as motions that tend to lengthen the affected muscles occur’ (Korr 1975). This would also explain the hard ‘feel’ in the end position. All the clinical findings encountered in restriction might therefore be explained as the result of muscle activity and not as a disturbance of the joint itself. That is why osteopaths prefer to speak of ‘somatic dysfunction’ (Greenman), a term that includes the dysfunction of the joint, the muscles, and the soft tissues. The role of shortened muscles in movement restriction is emphasized by Janda. Muscle relaxation techniques are used with much success in order to mobilize joints. It is therefore appropriate at this point to consider the actual role of the joint in restriction.
2.4.4 Is restriction an articular phenomenon? Clearly the view that passive movement is exclusively the expression of articular function is not one that can be maintained. In fact, as Korr has shown, most clinical findings in joint restriction can be explained by muscle activity controlled by the gamma system. If this is the case, what role is played by the joint itself? If we are dealing with a reflex response, what is the origin of the stimulus that evokes it? It must surely be more than mere coincidence that techniques which have been found in a purely empirical manner to be effective in manipulation correspond to joint anatomy. The importance of joint play is also consistent with this, as is the fact that the popping sound, or ‘click,’ that is heard on successful manipulation comes from the joint. The hypotonus regularly observed following such manipulation is however a muscular phenomenon. 16
There are some joints that are not under the direct control of a particular muscle; obvious examples are the sacroiliac, the acromioclavicular and the tibiofibular joints. Yet muscular fixation of these joints (other than the acromioclavicular joint) is regularly found. In the case of the sacroiliac joint, for example, this is caused by the pelvic floor, the ischiocrural muscles, or the piriformis; in the tibiofibular joint by the biceps femoris. In order to investigate further the role of the joint, we undertook the following experiments: in patients who were about to undergo operation under anesthetic with artificial respiration, the cervical spine was examined shortly before operation. Restrictions were found in ten patients, and the exact location and direction determined. The patients were re-examined under anesthesia, which used mainly thiopental, nitrous oxide and 100 g succinylcholine iodide, the patients being in a state of complete muscle relaxation. This involved brief interruption of the intubation. In all cases the movement restriction remained unchanged during narcosis.
2.4.5 The possible mechanism of restriction and manipulation The importance of the experiment just referred to lies first in demonstrating that the joint does also play a part in restriction; and second in showing that there is (also) a mechanical resistance. It was Emminger (1967) who first suggested that this might be attributed to a trapping of the meniscoids as previously described by Töndury and others. Kos & Wolf (1972) showed in addition that these meniscoids do also exist in the limb joints. The physiological role of the meniscoids is to fill the changing joint space as it alters during movement, since they are a highly mobile structure. Most joints have very incongruous facets; without the meniscoids to perform this role, gapping of the joint would occur during movement. The meniscoid is intimately connected with the joint capsule. Clearly such wellnigh chaotic-seeming motion must be prone to disturbance. However, Cihák (1981) points out that the deep layers of the multifidus muscles are linked with the joint capsule and so control this mechanism. This theory has been further elaborated by Kos & Wolf (1972). They describe the following hypothetical pathogenetic mechanism:
Etiology and pathogenesis
Chapter 2
Figure 2.8 • The entrapment of a meniscoid and its
emergence, according to Wolf & Kos (1972). The meniscoid normally lying in position a has moved between the joint facets, b; following treatment, the meniscoid overcomes the slight resistance offered by the constriction from c to d.
• The main body of the meniscoid is soft,
connected with the joint capsule. It has a hard free edge, which cannot easily be compressed and projects into the joint space. • Joint cartilage is hard and elastic only if the force that acts on it does so briefly. If, however, we subject the cartilage to constant pressure, it adapts to the material exerting that pressure as though it were fluid. If, therefore, the meniscoid is caught between the gliding surfaces of the joint facets, the cartilage adapts to the hard meniscoid, embedding it (viscoelasticity) (Figure 2.8). This diagram clearly illustrates the mechanism of manipulative techniques. High-velocity, low-amplitude (HVLA) techniques cause gapping of the joint capsule, as a result of which the meniscoid has only a short constricted area to overcome (Figure 2.9). In repetitive mobilization, the meniscoid is freed during the back-and-forth movement of the joint facets, and all that is apparently needed as we wait for release to occur is the relaxation of the muscles, which widens the joint space.
2.4.6 The effect of manipulation The effect of successful manipulation is two-fold: 1. It restores mobility, including joint play. 2. It produces an intense reflex reaction in all structures where changes had been present before manipulation. This occurs most strongly in the musculature, where a previous state of increased tension (TrPs; occasionally spasm) is replaced following manipulation by hypotonia. The skin, too, becomes easier to fold and stretch, and soft tissues easier to shift against each other. Tension is thus reduced in all tissues, especially in the corresponding segment. Depending on
Figure 2.9 • The effect of therapy. (A) High-velocity, low-
amplitude thrust. (B) Repetitive mobilization. (C) Widening of the joint space by release technique.
the significance of the vertebral motion segment or the joint concerned, the effect of the manipulation also extends to distant segments; this will be discussed later. The effects referred to here can not only be observed clinically, but can also be objectively demonstrated by physiological methods (see Figures 2.10–2.13).
2.4.7 The pathogenesis of restriction Overload and abnormal load In the case of the most minor restrictions, we know from our own experience how these come about: sitting or working for a long period in an unfavorable position, we sense a need to stretch 17
Manipulative Therapy
Figure 2.10 • Changes in skin temperature after root infiltration in root compression syndromes. (A) Temperature reaction. (B) (Slow) course of reaction: the ‘overall mean temperature change’ curve also includes decreases in temperature. The changes in temperature pursue a much slower course than occurs in traction therapy (see Figure 2.11).
Figure 2.11 • Changes in skin temperature following traction therapy of the spinal column in root compression syndrome of the upper and lower limbs. (A) Temperature reaction. (B) (Rapid) course of this reaction; ‘overall mean temperature change’ curve also includes decreases in temperature. The changes in temperature pursue a much more rapid course than occurs in root infiltration (See Figure 2.10).
Figure 2.12 • Summation electromyogram showing the
increase in muscle activity (force) in the triceps brachii during cervical traction.
18
Figure 2.13 • Summation electromyogram of the triceps brachii taken from three leads in a C8 root compression syndrome (A) before and (B) after cervical manipulation.
Etiology and pathogenesis
and move, that is to ease such minor inhibitions of movement. This is the stiffness that causes us to stretch ourselves on getting up in the morning. Minor restrictions can therefore arise even in physiological situations and in healthy individuals; and these resolve spontaneously. There is a fluid transition between such minor restrictions following physiological stress, and persistent restrictions following pathogenic, harmful stress. Both the stress itself and the neuromuscular system of the patient play a role here. One pathogenic factor is overload; another, more frequent cause is a disturbed movement pattern (motor stereotype) on the part of the patient, consisting of an imbalance of muscle function which impairs the joint (Janda). Modern civilization brings with it very one-sided, unvaried posture and movement, causing muscular imbalance. Lack of movement together with static or postural overload are a characteristic feature of modern life. Disturbed movement patterns and static overload are probably the most frequent causes of reversible restrictions and of their occurrence and recurrence.
Trauma Trauma is a further potential cause. It is important to point out that the borderline between patient groups suffering from overload and those suffering the effects of trauma can in fact be very fluid, because it is not always easy to say what should and should not be interpreted as trauma. It is usually defined as a force acting on the body and capable of damaging structure or function. However, even under normal conditions the forces acting on the spinal column are considerable. If these forces are suddenly increased because of sudden, unexpected movement, especially if this involves contraction of the powerful muscles of the back, it becomes extremely difficult to distinguish between overload and trauma. The somewhat vague term ‘microtrauma’ is then used.
Reflex processes A further complex of causes involves reflex processes within the segment. As has been stated already, the spinal column is routinely involved in disease processes in the body. Vertebral restrictions can therefore occur following – and also as a result of – disease elsewhere in the body. The primary
Chapter 2
condition creates a stimulus in the segment, which in turn produces a spasm (TrP) in the corresponding region of the erector spinae muscle, in particular in the deep layer. The effect is muscular fixation of the vertebral motion segment: a restriction. This is the same mechanism that, according to Hansen & Schliack (1962), leads to scoliosis in visceral disease. Today it is possible to distinguish a number of characteristic patterns related to visceral disease (see Chapter 7) which points to certain pathogenetic rules. Another characteristic feature of this type of restriction is its recurrence if the internal disease relapses or exacerbates. Admittedly, however, we know more about visceral influence upon the spinal column than about the influence of the spinal column on visceral organs.
2.5 The spinal column as a functional unit The most important functions performed by the spinal column are: • giving support and protection to neural structures • being the axis of motion for the body • helping to maintain the balance of the body. As we can see from the first two functions listed, these roles are contradictory; Gutmann (1965) expressed this succinctly when he said: ‘the spinal column should be as mobile as possible and as firm as necessary.’ The implications of this become clear when we consider the remarkable range of movement of the atlanto-occipital and atlantoaxial joints, and the fact that vital centers of the medulla oblongata are located at this level; these twin facts explain why disturbances of these two basic functions are linked. If a dysfunction produces a pain stimulus, a muscular defense reaction blocks the damaging movement. A spinal column with restricted mobility is no longer properly able to carry out its protective function. The effects extend to the structures of the nervous system, which in turn exerts an effect on the spinal column that is causing the damage to them. Sobotka (1956) demonstrated that damage to a nerve root causes trophic changes of the intervertebral disks. The function of the spinal column affects not only the structures inside the spinal canal, but also the entire locomotor system, including the limbs, and probably also internal organs. 19
Manipulative Therapy
The existence of all these functional interconnections means that the spinal column should always also be considered when the object of concern is the pelvis, limbs, or especially the muscles under central nervous system control.
2.5.1 The spinal column and balance The importance of the spinal column in the maintenance of balance is usually underestimated. This applies in particular to the craniocervical junction. It is often forgotten that the labyrinth is not absolutely essential for the maintenance of balance and posture, whereas proprioception is, especially in the spinal column. Clinical evidence confirms this (see Chapter 7). The experiments carried out by Norré and coworkers (1976), using Greiner and coworkers’ (1967) flexible-support chair, are particularly valuable in this respect. The method they used involves keeping the subject’s head fixed in position while turning the trunk from side to side with a pendular motion. They were able in this way to produce nystagmus, purely by stimulation of the cervical proprioceptors (Greiner et al 1967, Hülse 1983, Moser et al 1974, Norré et al 1976, Simon & Moser 1976). The effects are not limited to the cervical spine. Komendantov (1945, 1948) demonstrated in rabbits that tonic reflexes can originate not only from the neck but also from the lumbar spine. He distinguishes the lumbosacral-eyes and lumbosacral-head reflexes. On side-bending of the animal’s trunk in the lumbar region around a dorsoventral axis, with the upper body and head fixed, the eyes move in the opposite direction to the trunk. If the head is not held fixed, there is an additional slight turning of the head, also in the opposite direction. Leads from the muscles of the nictitating membrane and the rectus muscles (of the eye) showed this to be a tonic reflex. Komendantov’s experimental design enabled him to make neck and lumbosacral reflexes compete, with the neck reflexes usually proving stronger. However, the effect was dependent on the extent of side-bending; the greater the side-bending, the stronger the effect. Interestingly in the course over time, it was seen that immediately following the effect of a neck reflex, even a relatively weak lumbosacral reflex can also assert itself. This mechanism apparently enables the animal to keep the visual field constant during locomotion, despite the motion of the head 20
and trunk. The reflexes therefore have very short transmission times; changes were still being registered in the activity of the muscles investigated, even at a side-bending frequency of 200 side-bends per minute. These experiments demonstrate that the spinal column is a functional unit governed by reflex response; if certain changes in position or function occur at one end of the spinal column, these exert an instant reflex effect along the entire spine. It should be stressed that, in humans, both ends of the spinal column are held relatively constant: in the case of the pelvis this is achieved because of the length of the legs; in the case of the head, through reflex fixation of the plane of the eyes and labyrinth in space. This preservation of the head position is strongly maintained as a movement pattern (motor stereotype). Ushio and coworkers (1973) demonstrated the deleterious effect of low-back pain on vertigo and the beneficial effect of immobilizing the lumbar spine in lumbago.
2.5.2 Key regions of the spinal column in dysfunctions So far we have considered restriction and its origins without reference to its effects on the rest of the spinal column. This, however, would be to ignore one of the most frequent causes of restrictions: a restriction or trigger point in another section of the spinal column. These bring about a compensatory increase in mobility in the neighboring segment, which leads to overload and ultimately a further restriction. Chain reactions therefore come about, which explains why vertebrogenic disturbances tend over time to involve the entire locomotor system. Therefore we should always examine the entire spinal column, at least in terms of screening assessment. It is important to realize, not least in this respect, that not all vertebral segments have the same importance for the overall function. When performing a brief assessment we should therefore focus on ‘key regions.’ In most cases these are transition zones from one type of movement to another: • The craniocervical junction: the delicate vertebrae of the upper cervical spine bear the heavy weight of the human head and also enable extensive mobility in all directions. Dysfunctions here affect muscle tone in the postural musculature and lead to disturbances of balance. Restrictions of the atlanto-occipital and atlantoaxial joints impair the mobility of the
Etiology and pathogenesis
rest of the cervical spine. The most important type of motion between the atlas and the axis is rotation; the rest of the cervical spine is less well adapted for this, and so suffers if forced to compensate for a craniocervical rotation dysfunction. The vertebral artery runs through the atlanto-occipital and atlantoaxial joints, and can also be affected by dysfunctions in this region. • The cervicothoracic junction: this is the region in which the most mobile section of the spinal column meets the relatively rigid upper thoracic spine. It is also the place where the powerful muscles of the shoulder girdle have their attachment, providing the main connection with the upper limbs and explaining why this region is particularly susceptible to dysfunctions. • The middle thoracic spine is to some extent the ‘weak point’ of the muscles of the back, since the lumbar and cervical parts of the erector spinae muscles end here, and kyphosis is usually greatest at this point. • One of the reasons for the considerable load borne by the thoracolumbar junction is that here the mechanism of motion typical of the thoracic spine changes within a short distance (at vertebra T12) to the lumbar pattern. This can be seen from the difference in shape of the upper and lower articular processes. If during walking the pelvis tilts from one side to the other, the lumbar spine side-bends so that the vertex of the scoliotic curve lies at the level of L3, the thoracolumbar junction remaining vertically in line with the sacrum; the thoracic spine then forms a scoliotic curve in the opposite direction. Consequently the thoracolumbar junction does indeed represent a junction. • The lumbosacroiliac joint region forms the base of the spinal column and is therefore extremely important to spinal column statics. At the same time the sacroiliac joints transmit movement from the legs to the spinal column and act as shock absorbers. • In humans the feet are the body’s actual base; also the greatest density of proprioceptive, exteroceptive, and nociceptive receptors is found there. Dysfunctions in this region consequently have an effect on the whole of the locomotor system; they should not be overlooked.
Chapter 2
2.5.3 The importance of nervous control The spinal column could not act as a functional unit unless all its reactions were coordinated, under control of the nervous system. Certain kinds of posture and movement sequences play the major role in this respect; these, following the proposal of Janda, are termed ‘motor patterns.’ These motor stereotypes are so characteristic of an individual that we can recognize people by their gait. There is considerable variation in the quality of these patterns, and this goes hand in hand with the susceptibility to disturbance of the locomotor system in the individual case. Any disturbance of function in a single motion segment will have its repercussions throughout the spinal column and must be compensated. The decisive role in this is played by the nervous system, which is similarly important in the matter of pain, for it is the nervous system that determines how intensely the segment will react, and where the threshold of pain lies. In other words, it is the nervous system that determines whether the dysfunction will manifest itself clinically. If the reaction to the nociceptive stimulus is intense, dysfunction in one motion segment will produce an antalgic response and alter the normal movement pattern, causing the dysfunction to become fixed, so that the condition becomes chronic. It is, therefore, no coincidence that dysfunctions of the motor system are more likely to be found in subjects with labile nervous regulation, and this tends to be evidenced psychologically as well. The point was emphasized by Gutzeit (1951), who saw the psychological factor as being characteristic for patients presenting with vertebrogenic disturbances. Kunc and coworkers (1955) showed that the psychological condition of patients plays a major part in recovery after disk operation. They demonstrated by means of experiment that these patients very easily formed conditioned reflexes to other pain stimuli, and that these reflexes were more difficult to extinguish than in healthy controls. Šrácek & Škrabal (1975) observed two groups of psychiatric patients: 50 cases of neurosis with symptoms of anxiety and depression, and 25 schizophrenics with blunted affect. Restriction, most frequently in the cervical spine, was absent in only 5 neurotic patients and in 16 schizophrenic patients. This difference is statistically highly significant (p < 0.01). Buran & Novák (1984), studying a group of 105 21
Manipulative Therapy
chronic patients, distinguished constitutionally neurotic and psychopathic patients from those who were psychologically normal. They found a preponderance of the fatigue reaction in the electromyogram (EMG) in the neurotic patients, and more frequent occurrence of positive F-waves, indicating a correspondence between psychological lability and labile nervous regulation. Lisý (1983) found similar results in EMG studies of patients with cervical syndrome. The clinical findings made by Janda (1978) are also worthy of note: in 100 patients with poor motor patterns, he found: • minor neurological signs of ‘microspasticity,’ in which movements were not fully coordinated, appearing as clumsiness • slight sensory impairment, especially of proprioception • poor adaptation to stress situations and inadequate, ‘uncoordinated’ behavior. All these clinical signs correspond to ‘minimal brain damage’ (MBD). Found in 10–15% of the child population, this is quietly assumed to disappear without trace in adulthood. However, Janda’s findings suggest that this brain dysfunction is in fact manifested in adult patients in the form of vertebrogenic disorders, poor motor patterns, and a considerable degree of labile nervous and emotional regulation. Despite the role played by muscular imbalance and faulty neural control, these should not be equated with joint dysfunction or restriction of a vertebral motion segment. Dysfunctions of the joints or vertebral segments do occasionally appear even in subjects with good motor patterns, yet may be absent in patients with neurological disease. Tilscher and coworkers (1979) found that of 27 spastic subjects, only 18.5% complained of backache. In our experience, most patients with Parkinson’s disease complain of backache; this is clearly associated with the muscle rigidity, which also affects the spinal column.
Faulty neurological and psychological control are among the factors involved in the pathogenesis and clinical signs and symptoms of locomotor dysfunctions. However, they are not identical with them.
22
The importance of developmental kinesiology It is no coincidence that Janda associates disturbances of motor pattern in adults with disturbances of the central nervous system in infants. Developmental kinesiology can indeed help us better understand the pathogenesis of dysfunctions, especially the effects that a structure belonging to the locomotor system can exert on distant regions; in other words, on the entire system. In this context we shall attempt to present the essential thinking of Vojta & Peters (1992) and Kolárˇ (1996, 1999, 2006) on the present subject. Neurophysiology today has no explanation for the effects exerted on each other by parts of the locomotor system that are situated far apart, which are found as a matter of everyday experience in manipulative therapy; nor can it explain the chains of trigger points. The principles governing these can however be explained by developmental kinesiology. The first reflexes in the newborn (stepping reflex, crossed extension reflex) are spinal cord reflexes. They offer no stability and do not enable posture of any kind. The first postural reflexes arise when the infant begins to observe its surroundings, raising and holding up its head. This is the point when the flexion posture of the newborn (see Figure 2.14) is brought into balance with the developing extensors. This development is complete roughly at the end of the third month (see Figure 2.15). The difference observed in the limbs is that the flexion posture gives way to a balanced, neutral posture with slight abduction, external rotation, and extension. It should be stressed that this posture can be achieved shortly after birth, according to Vojta & Peters (1992), who states that this can be done by
Figure 2.14 • Posture of the newborn in the prone position.
Etiology and pathogenesis
Figure 2.15 • Posture of the infant in the prone position at the end of the third month of life. The infant is able to support itself on forearms, pubic symphysis, and knees.
stimulating points where there is an abundance of proprioceptors. These points are structures on which we support ourselves; as soon as we rest on one of these points (forearm, elbow, or knee) for support, our posture changes automatically, remaining balanced in each case. This enables us to achieve the most favorable position (centering) of our joints. The extensor system is therefore younger in developmental terms than the ‘tonic’ flexor system, and therefore more susceptible to disturbance. This explains why the tonic system always predominates in pathological states, pain, and even in mere fatigue. Both systems are involved in upright posture; it is therefore inappropriate to use the term ‘postural muscles’ for the tonic system alone. The decisive issue is which system is older or younger in developmental terms. This course of development gives rise to the coactivity of antagonists, which enables balanced, upright posture and can be seen at two levels. As an example, the erector spinae is the antagonist that corresponds to the pectoralis major muscle. The relationship is so specific that certain bundles of fibers of the pectoralis major correspond only to certain bundles of fibers of the erector spinae. The same kind of correspondence applies to adductors and abductors in the limbs, for instance. Clinically this is seen in the localization of trigger points. However, this antagonism applies not only to individual muscles, but to the entire system. This fact is extremely important: stimulation of a muscle that belongs to the extensor system inhibits the whole of the flexor system. The effect can most clearly be seen when stimulation is applied to one of the points where most receptors are located, such as the fingers and toes. To give an example, stimulation of the finger extensors can produce inhibition in the straight-leg raising test.
Chapter 2
The coactivity pattern relates to upright posture as a whole. Muscles that maintain the position of the head over the shoulders have their fixed point of attachment in the region of the shoulder girdle, the muscles of the thorax and scapula in the pelvic region, and the muscles of the pelvis in the region of the lower limb, down as far as the foot. As soon as the position of one of these superposed sections changes, the entire system has to react. Control of these reflex processes in the maintenance of human upright posture is located above the brainstem; it has been little researched experimentally. The long chains of antagonists which subserve upright posture act on the spinal column like ropes stabilizing a mast. However, unlike a stiff mast, the spinal column is formed by 24 vertebrae and the sacrum which, according to Panjabi (1992a, 1992b), are unstable and would buckle under the strain. This is prevented by what is called the ‘deep stabilization system.’ Another system that is developed only in humans is that of the ‘deep stabilizers,’ which serves to maintain the upright posture of the spinal column. It consists of the deep layers of the erector spinae and transversus abdominis muscles, the diaphragm, and the pelvic floor. The last three of these support the abdominal wall. The abdominal cavity and its internal pressure provide the anterior support of the lumbar spine. In humans, the diaphragm plays a significant role as a postural muscle; only in humans is there a close link between respiration and posture, with the diaphragm lying horizontally. A further function, which develops relatively late in infants (after the sixth month) and which is therefore also susceptible to disturbance, is (active) rotation of the trunk. This plays a particularly important role in humans, since the most forceful movements, such as throwing a discus or boxing, proceed from a rotation of the trunk. At every step the shoulder girdle rotates in the opposite direction to the pelvis. The significance of this movement can be seen in the rehabilitation of leg amputees and paraplegic patients, because it is this mechanism that enables them to learn to walk. According to Farfan et al (1996), however, the spinal column is less well adapted to rotation movements in terms of its constituent parts; this applies especially to the intervertebral disks. In practical terms, both for the facilitation of muscle activity and in mobilization, it makes sense to utilize the posture that most closely matches development. In the model of the three-monthold infant, the limbs are brought into the optimum 23
Manipulative Therapy
Figure 2.16 • Weight-lifter’s posture.
(centered) position and the muscles activated. This posture also corresponds to that of a weight-lifter (see Figure 2.16).
Vojta’s developmental kinesiology offers an explanation for the physiological principles governing the upright posture of humans.
2.6 Dysfunctions of the spinal column in childhood From what has been said it follows that dysfunctions are regarded as primary phenomena in the pathogenesis of vertebrogenic disorders. Hence studies try to investigate them in their pure form, that is in the absence of degenerative changes, which can be done by studying them in children and young people. Schön (1956), and later Gutmann & Wolff (1959), have shown the average age at which the first symptoms appear to be much earlier than the age when they become evident 24
radiographically. Dysfunctions, however, appear at the same time as clinical symptoms. The most typical clinical condition in children is cervical myalgia (acute wry neck). Although this usually remits spontaneously, traction and gentle mobilization techniques, if well applied, should give immediate relief. This is particularly true for neuromuscular techniques. In children with headache, the cervical spine plays an important role. This is true of various types of headache, including migraine. In a group of 30 children suffering from vasomotor headache, manipulation produced improvement in 28 cases. Janda (1959) reported similar success following traction of the cervical spine. In a group of 27 children suffering from migraine, only 3 failed to respond to manipulation treatment (Lewit 1959). Similar results were reported by Kabátníková & Kabátník (1966). A particularly important type of headache in children, known as ‘school headache’ and generally believed to be of psychological origin, was proved by Gutmann (1968) to be due to head anteflexion during school hours, when the children were reading and writing at horizontal desks. This was confirmed by Lewit & Kuncová (1971). One clinical manifestation of disturbed function in the lumbosacral and pelvic region frequently found in young girls is dysmenorrhea with negative gynecological findings; this can frequently start as early as the menarche. Patients complain not only of pain in the lower abdomen; they also experience low-back pain. Manipulative therapy is the treatment of choice in such cases. The point should be made here that dysmenorrhea at an early age is frequently the first sign of dysfunction of the spinal column in women. True lumbago is much less frequent in childhood, but there are rare cases of true disk herniation as early as puberty. With the exception of acute wry neck, dysfunctions in the spinal column tend to be manifested indirectly in the form of referred pain, as headache, and in girls as dysmenorrhea. We were interested to see how frequently dysfunctions could be found in healthy children of different age groups. The most striking finding in children and adolescents is pelvic distortion which is dealt with in detail in later chapters. In serial studies we found this in 11 of 80 children (aged 14–41 months) examined in crèches, in 81 out of 181 children (aged 3–6 years) in nursery school and in 199 out of 459 schoolchildren aged 9–15 years. Statistical evaluation showed no significant difference between the incidence in boys and girls.
Etiology and pathogenesis
Movement restriction in the cervical spine (mainly at the atlanto-occipital and atlantoaxial joints) was found in none of the infants in crèches, in only 8 out of 181 nursery school children examined, and in 73 of the 459 schoolchildren. These investigations were carried out over 40 years ago, when the technique of examination for the upper cervical spine was much less sophisticated than it is today. It has since been found that pelvic distortion in children is generally associated with craniocervical joint restriction, mainly in the C0/C1 segment; there is normalization of the pelvic findings after the C0/C1 joint has been treated. In 1982 we therefore examined a group of 75 nursery school children (aged 3–6 years). We found pelvic distortion in 24, of whom 23 had movement restriction of C0/C1. In 12 of these children manipulation of the craniocervical joints was carried out, following which there was normalization of the pelvic distortion in all cases. There is thus good reason to believe that most of the children in whom we found pelvic distortion in the examination we performed over 40 years ago also suffered from restriction at the craniocervical junction. We also found slight scolioses in 175 of the 459 schoolchildren examined at that time, and in 15 out of the 181 nursery school children. Among the children in crèches, this finding was made in only 1 out of 80 children. The overwhelming importance of the craniocervical (atlanto-occipital and atlantoaxial) joints
Chapter 2
in infants was pointed out by Seifert (1975). In children in whom function is normal, they found that, on turning the head to one side, the pelvis turns to the opposite side. This reaction was absent in 298 of the 1093 infants examined. Over a period of 4–9 months restriction of the atlantooccipital and atlantoaxial joints was found in 58% of this group. Biedermann (1993) described what he termed ‘KISS syndrome,’ characterized by a forced attitude of the head in the side-bending position, often found in association with considerable somatic and autonomic disturbances. These he treated by manipulation. In a study group of 76 children suffering from chronic tonsillitis, Lewit & Abrahamovicˇ (1976), found restriction of the atlanto-occipital and atlantoaxial joints in 70 (92%) of the subjects, mainly in the C0/C1 segment. In evaluating these results we needed to discover whether they were chance findings or represented continuing, constant dysfunctions. In collaboration with Janda we therefore followed up a group of 72 children who started school attendance in 1960, carrying out regular examinations over a period of eight years. Half the number with dysfunctions of the spinal column were treated, and the other half left untreated as controls. In addition to the spinal column, the rest of the locomotor system and particularly the musculature were tested. The results are summarized in Figure 2.17.
Figure 2.17 • Follow-up study of 72 schoolchildren of various class age groups over a period of eight years to find the incidence of pelvic distortion, scoliosis, difference in leg length, and cervical restriction.
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Manipulative Therapy
The most important finding for our conclusions was that dysfunctions in the regions of the pelvis and cervical spine remained constant and seldom showed spontaneous improvement. The tendency to remain constant was greater for these than for scolioses or differences in leg length. There were only a few relapses after treatment.
Dysfunctions of the spinal column can be found even at a very young age, and even in subjects who are clinically healthy. However, they can be clinically manifested, usually as acute wry neck, headache and, in girls, as dysmenorrhea. These symptoms can occur in the absence of any degenerative changes.
2.7 Restrictions and their sequelae If a restriction occurs in the intact terrain of the spinal column of a child or an adolescent, for example, the consequences may seem at first sight to be minor: there may be some transitory pain, which usually disappears quickly as tends to be the case with acute wry neck. The dysfunction is compensated. Of course, a restriction occurring in the rest of the locomotor system, particularly the limbs, becomes clinically evident immediately. In the spinal column, consisting as it does of complex parts (54 intervertebral joints, including the atlantooccipital and atlantoaxial joints and the sacroiliac joints), the lack of mobility of a single joint or motion segment can go unnoticed. There is, however, a price to be paid for this capacity of compensation: increased demands or abnormal stress on the compensating structures. This becomes especially evident when the restriction occurs in a key region (see Section 2.5.2), because neighboring regions cannot easily compensate. As mentioned previously, restriction of rotation between the atlas and the axis means that their role in the rotation of the head has to be taken on by the rest of the cervical spine, which is far less suited to the task. This may help explain why osteochondrosis of the lower cervical spine is so commonly found. As a general principle, then, movement restriction in one segment produces hypermobility in its 26
neighbor, and this is most marked in the case of restrictions in key regions. The most frequent consequence of chronic overload is the formation of osteophytes to stabilize the motion segment. The lack of motion in the restricted segment often leads to disturbances of trophicity, which particularly affects bradytrophic tissues such as ligaments and disks. This is confirmed by radiographic evidence, which shows osteophyte formation in temporarily hypermobile segments (above block vertebrae). The usual findings in restricted segments are that two adjacent vertebrae form a block with the narrowed disk showing degenerative changes. Müller (1960) have shown how the hypermobile segment, initially created to compensate for a hypomobile one, stiffens in its turn as a result of osteophyte formation, so that the osteochondrosis spreads from one vertebral segment to the next. The stabilizing role of the osteophytes, which are plate-like in shape, can best be seen in chronic spondylolisthesis. Degenerative changes in themselves need not produce clinical symptoms. They do, however, make the spinal column more susceptible to disturbance, and the same applies to dysfunctions. Even patients with degenerative changes experience no symptoms as long as function remains compensated, but there is a risk of decompensation. This explains why the sequelae of trauma are usually more severe when degenerative changes are already present. Frequently, what are called degenerative changes are better described as adaptive ones, or an attempt to compensate dysfunction. One important sequela of degenerative changes can be a herniated disk. Here too there is a close relationship between structural change and dysfunction. With modern imaging techniques we find that disk herniation revealed by CT or MRI need not be accompanied by any symptoms; also that, in cases where the herniated disk does produce pain, the clinical symptoms may disappear despite the fact that the herniation continues to be evident on CT or MRI examination. The relationship between function and structural pathology is clearly very complicated here. Nevertheless, in cases of disk herniation, dysfunction can be treated at joints and trigger points, in soft tissue and in the stabilization system, to produce clinical compensation. The close association of structural and functional changes is clearly seen in carpal tunnel syndrome, which involves compression of the median nerve. On close examination we regularly find increased
Etiology and pathogenesis
resistance to the translatory displacement of neighboring carpal bones. When mobility is restored in the early stages, the symptoms of paresthesia disappear. In other words, it is only when there is free mobility between the bones forming the tunnel that the walls can adapt themselves to the contents of the tunnel in all the movements of the wrist. We should remember that one wall of the carpal tunnel is formed by the flexor retinaculum.
The dynamic role – usually also the primary role – in the interrelation between dysfunction and morphological change is that of function.
2.8 The significance of disturbed motor patterns (stereotypes) Disturbed motor stereotypes are perhaps the most important factor in the etiology of functional, reversible restrictions. This would make remedial exercise the treatment of choice and especially the best means of prevention. It is less clear what the actual content of such therapy should be when treating – usually painful – dysfunctions of the locomotor system, since remedial exercise expects to deal with a well-defined lesion (for example paresis), and that is not what we are dealing with here. It was Janda who first addressed this problem. The main object of remedial exercise in dysfunctions of the locomotor system is the correction of faulty motor patterning (disturbed movement patterns or stereotypes), that is faulty coordination of muscle function due to disturbed central nervous control. The problem here lies in defining what is the norm, since these movement patterns are very different and highly individual, consisting of programs built up by each subject in the course of life on the basis of chains of unconditioned and acquired (conditioned) reflexes. The way each individual moves is so characteristic that we can recognize people by their gait, their gestures, or their handwriting. Ideally, motor patterns should allow movement to be as economical as possible, that is to consume the smallest possible quantity of energy. As in many other situations, it makes sense for our purposes to take the dysfunction as the
Chapter 2
starting point. Even a layman will recognize awkwardness of movement, and, more often than not, such movement is uneconomical in energy expenditure; therefore the layman is also able to correct the most obvious aspects – just as sports trainers, for instance, correct the movements of sportsmen and women. In patients with vertebrogenic pain, Janda systematically applied the classic muscle test to the individual muscles involved in particular movements. His results revealed that the simple movements used to examine muscle function in fact study a (fairly simple) movement pattern, involving a number of muscles, rather than a particular individual muscle. Examining hip extension by polyelectromyography, Janda showed that it is not only the gluteus maximus muscle which contracts in hip extension, as had been thought, but that the ischiocrural muscles are the first to contract, followed shortly afterwards by the erector spinae. The typical disturbance of movement pattern found in hip extension is the belated and inadequate activity of the gluteus maximus (see Figure 2.18).
Figure 2.18 • EMG study during extension of the right hip:
contraction of the right gluteus maximus is slight and occurs at a late stage. There is increased activity of the ischiocrural muscles and erector spinae bilaterally. (By kind permission of Janda.)
27
Manipulative Therapy
We learned over time to recognize in clinical examination which muscles actually take part in simple test movements, by means of palpation. This enables us to assess not only muscle force, but also quality of performance. This quality may be considerably altered while force remains normal. The strength of hip extension may remain normal, even if it is carried out only by contraction of the ischiocrural muscles and the erector spinae. In this case there is considerable disturbance of the movement pattern, with important consequences for locomotor function, as will be explained later. Regular testing of simple movements using the muscle test revealed a surprisingly constant pattern: certain muscle groups repeatedly showed a tendency to lesser activity (weakness) and hypotonia, whereas others equally regularly tended to hyperactivity and tension. This resulted in characteristic patterns of imbalance which are so constant and typical that we can identify them as syndromes with a clinical significance. They are each characteristic of a particular clinical picture: in some cases there is a preponderance of weakness, flabbiness going hand in hand with hypermobility, whereas in others there is increased muscle tension and stiffness. Table 2.1 sets out those muscles with a tendency to hyperactivity and those that tend to hypoactivity. This difference in the behavior of these two muscle groups can be seen under various clinical conditions and is regularly found in painful states: in a painful hip it is always the flexors and adductors that are tense and the glutei weak; in shoulder pain the pectoralis and subscapularis muscles and the superior part of the trapezius are taut whereas the supraspinatus, infraspinatus, and deltoid muscles are weak; in chronic painful conditions of the knee the vasti are atrophic while the rectus femoris is like a tight band. The findings are similar for fatigue: again the same muscles will be inhibited and their activity frequently taken over by those with a tendency to hyperactivity. This behavior continues to be found in central paresis, when again we find that muscles with a tendency to hyperactivity become spastic, and those with a tendency to hypoactivity become flabby. Neurologically, this kind of muscle imbalance can be termed ‘microspasticity.’ Janda referred to those muscles with a tendency to hypoactivity as predominantly ‘phasic,’ and muscles with a tendency to hyperactivity as predominantly ‘postural.’ In terms of develop28
Table 2.1 Muscle groups exhibiting a tendency to hyperactivity or hypoactivity
Hyperactivity
Hypoactivity
On the dorsal aspect of the body Triceps surae
Gluteal muscles
Ischiocrural muscles
Inferior part of trapezius
Lumbar section of the erector spinae
Serratus anterior
Quadratus lumborum
Supraspinatus
Superior part of trapezius
Infraspinatus
Cervical extensors
Deltoid
On the ventral aspect of the body Thigh adductors
Tibialis anterior
Rectus femoris
Extensors of the toes
Tensor fasciae latae
Peronei
Iliopsoas
Vasti
Obliquus externus
Rectus abdominis
Pectoralis major and minor
Deep neck flexors
Subscapularis
Digastric
Scalenes Sternocleidomastoid Masticatory
Upper limbs Flexors
Extensors
mental kinesiology (see Section 2.5.3), those of the first group belong to the younger system and the second group to the older one. It should be stressed that there is no substantial difference between the types of muscle fiber or the biochemistry of these two groups; the physiological reason for the difference between them rests on the developmental kinesiology. Both systems evidently have a postural function. Examination of simple movements by applying the muscle test is no more than the first step in investigating muscle function; our habitual movements are individually acquired patterns or stereotypes.
Etiology and pathogenesis
The concept of patterning is clearly illustrated by looking at antagonists. For example, the ischiocrural muscles and the quadriceps femoris can be considered as antagonists if we are thinking of the movement of knee flexion and extension. However, during walking both these muscle groups are acting primarily to stabilize the leg. A similar principle applies to the abdominal and back muscles, and to the flexors and extensors of the cervical spine. In fact, in well-coordinated straightening up from a stooping position it is mainly the deep abdominal muscles that provide stability, a point to be remembered in remedial exercise. It should be stressed here that when treating muscle imbalance involving a predominance of the muscles that regularly tend to hyperactivity, the effect of strengthening the weakened (hypoactive) muscle is not only experienced in the particular segment but also influences the overall balance between ‘phasic’ and ‘postural’ muscles. This is particularly important where there is a greater density of afferent nerve receptors, so that afferent stimuli are more strongly felt; it is the case at the fingers and toes, as Brügger has shown. He found that, following stimulation of the extensors of the fingers and toes, the patient finds it easier to resume upright posture; one of the other consequences is improvement in the straight-leg raising test. The training of different movement patterns involves the interplay of a number of muscles reacting in sequence, whose reaction can be triggered if specific stimuli are employed. For movements of the limbs, stimulation of the periphery is most effective, since receptors are numerous here. To facilitate walking, lifting the big toe is helpful: the patient will then find it easier to dorsiflex the foot; that in turn helps the flexion of the knee and hip. Similarly, flexion of the fingers helps anteversion of the elbow and shoulder. What the fingers and toes are for the function of the limbs, the eyes are for the trunk: looking up facilitates straightening of the body, looking down facilitates bending forward, while looking to the side facilitates rotation. Furthermore, as straightening of the body is connected with inhalation, and bending forward with exhalation, it is enough for the patient to look up to facilitate inhalation (as when sighing). Similarly, directing the gaze downward assists exhalation. Returning to the question of imbalance between those muscle groups which are older and those which are younger in developmental terms, the problem here is a form of defective coordination.
Chapter 2
This is particularly so in the interrelationship of antagonists, where the hyperactive muscle generally has an inhibitory effect on its weak antagonist. For example, hyperactive lumbar erector spinae muscles inhibit the abdominal muscles, and hyperactive adductors the glutei. This disturbs the centering of the joints involved, imposing excessive stress on them.
2.9 Sequelae of disturbed movement patterns Having looked in detail at the nature of disturbed movement patterns, we now turn to the mechanisms by which they impair the locomotor system.
2.9.1 Walking and standing The most frequent findings here are an imbalance between weak gluteal muscles and hyperactive hip flexors, between hyperactive lumbar erectores spinae and weak abdominal muscles, and between hyperactive adductors and weak abductors of the hip. In standing we see increased pelvic tilt, a protruding abdomen, and lumbar hyperlordosis. The actual pathogenic mechanism in standing is overload of the lumbar spine as a result of increased tension of the erector spinae muscles; in walking, overload results mainly from the fact that pelvic tilt places the hip joints in extension, and also from the weak gluteus maximus. As a result, the extension of the patient’s legs in walking is mainly achieved by extending the lumbar spine still more. This produces hypermobility of the lumbar spine in the sagittal plane. Hyperactivity of the adductor muscles and above all the weak gluteus medius causes instability in the frontal plane, especially when the patient is standing on one leg. The result is increased swaying of the pelvis from side to side while walking; causing, in other words, hypermobility and overload of the lumbar spine in the frontal plane.
2.9.2 Straightening up from a forward-flexed position If the trunk is imagined as a straight lever with the L5–S1 disk as the fulcrum, calculation of the 29
Manipulative Therapy
stress involved during weight-lifting has produced values of 1000 kg and above (Matthiasch 1956, Morris 1973). Such a force is more than the disk could bear. Measuring intradiskal pressure, Nachemson (1959) found that the pressure during weight-lifting from a sitting position was 275% of that when standing upright. The reason, according to Gracovetsky (1988), lies in the role of the lumbodorsal fascia, into which the erector spinae, the glutei, and the ischiocrural muscles fan out. The tension from the ischiocrural muscles enables the spinal column to ‘hook in’ to this fascia, as it were, so that the lever effect is eliminated. This mechanism is further supported by the abdominal muscles, which also fan out into this fascia and in addition draw the thorax toward the pelvis and maintain intraabdominal pressure. The effect is that the correct movement pattern assists this ‘unreeling’ mechanism and avoids the lever effect.
2.9.3 Raising the arms Here the decisive factor is correct fixation of the shoulder girdle; this is the function of the superior part of the trapezius and the levator scapulae from above, and of the inferior part of the trapezius and the serratus anterior, the first two muscles being attached to the cervical spine and the last two to the thoracic spine. The faulty movement pattern typically found here is tension in the muscles providing fixation superiorly and weakness of those providing stabilization inferiorly. The effect is to lift the shoulder blades and place excessive load on the cervical spine.
2.9.4 Weight carrying The key factor here from the point of view of the biomechanics is the position of the shoulder joint: if the shoulder of the weight-bearing arm is behind the line of gravity of the body, the shoulder girdle is fixed at the thorax by the serratus anterior, the inferior part of the trapezius, the rhomboid major and rhomboid minor. If the shoulder is in a raised and forward position, then the muscles providing fixation are the superior part of the trapezius and the levator scapulae, placing undue load on the cervical spine and at the same time to destabilize the lumbar spine. It is the upright positioning of the head that ensures the correct position of the shoulder. 30
The muscular imbalance involved here is a hyperactive pectoralis major, in particular the clavicular head of the muscle, hypoactivity of the weak rhomboid and serratus muscles and the inferior part of the trapezius, and increased activity of the superior part of the trapezius and the levator scapulae. The hyperactivity of the pectoralis major causes kyphosis in the lower part and hyperlordosis in the upper part of the cervical spine. These examples illustrate the pathogenic effects of faulty movement patterns on the locomotor system and spinal column. The motor stereotype which leads to the most marked consequences, however, is faulty breathing.
2.9.5 The effect of respiration on the locomotor system When we think of respiration, we tend to focus almost entirely on the organs of the respiratory system. In doing so, however, we forget that the thorax and diaphragm are essential to the function of the lungs. The locomotor system has to coordinate the specific function of respiratory movement with the function of locomotor activity. This task is so complex that it would be a miracle if disturbances did not occur. The most important issue here is the close link between respiration and the postural function. Skládal et al (1970) observed on radiographic images that the diaphragm became flatter and contracted when the patient stood on tiptoe during the exposure. They interpreted this as being a postural reaction, and drew the further conclusion that: ‘The diaphragm is a respiratory muscle with a postural function, and the abdominal muscles are postural muscles with a respiratory function.’ The way this is understood today is as follows: the diaphragm attaches dorsally to the spinal column and laterally to the inferior costal arch, while ventrally the fixed point is provided by the abdominal wall. Here, the co-contraction of the deep layer of the abdominal muscles has a key role. Kolárˇ (2006) showed radiographically that the diaphragm was angled downward in the ventral to dorsal direction if the abdominal muscles were weak. If the abdominal muscles are functioning normally, contraction of the diaphragm during inhalation is accompanied by eccentric contraction of the deep abdominal muscles. This can be clearly palpated laterally above the iliac crest. The effect is not only to
Etiology and pathogenesis
enable the diaphragm to function in the most efficient way and, as shown by Kapandji (1974), to expand the thorax, but also to fix the thorax to the pelvis and so stabilize the lumbar spine. The activation of the abdominal muscles during inhalation was also described by Campbell (1978) and Basmajian (1978). Holding the breath (the Valsalva maneuver) reinforces this postural function. Morris et al (1961) showed that the spinal column is supported on the diaphragm when bending forward (see Figure 2.19). Experience does indeed show that when we are about to lift a heavy weight using maximum force, or to perform a heavy blow or vigorous throw, we hold our breath. This is such an important mechanism that athletes hold their breath during demanding activity such as sprinting over short distances, sacrificing the respiratory to the postural function. The most important faulty respiratory stereotype, seen from the point of view of the locomotor system, is that in which the thorax is lifted during inhalation (Parow 1954). In this pattern the thorax is lifted in the cranial direction by the scalene and sternocleidomastoid muscles and the superior fixator muscles of the shoulder girdle, but without expansion of the chest. Termed ‘clavicular breathing,’ it involves a reversal of the normal
Chapter 2
respiratory mechanism, since the scalene muscles, which normally only fix the thorax, raise the lung; resistance is offered by the diaphragm. This is inefficient, not only from the respiratory point of view, in that the volume of the chest increases very little, but also for the locomotor system, because of the chronic overload that this causes to the cervical spine. A further effect is that fixation of the thorax to the pelvis no longer occurs, causing instability of the lumbar spine. The pattern of lifting the thorax during inhalation, or clavicular breathing, can be asymmetric, if one shoulder is raised more than the other. The stress on the cervical spine is then greater on this side. Clavicular breathing is the disturbance that typically occurs when sitting but not maintaining a straight posture, because this makes expansion of the thorax difficult. An extreme form of this breathing pattern is paradoxical breathing, in which the patient draws in the abdomen during inspiration. ‘Passive’ exhalation is brought about mainly through the elasticity of the lung. Active exhalation, including that against resistance, is brought about mainly by the abdominal muscles as well as the erector spinae, which contract strongly when exhaling deeply in a lordotic posture (Lewit, Janda, Veverkova 1998). Here too the facilitation of
Figure 2.19 • The stress on the lumbosacral junction (A) without and (B) with simultaneous contraction of the abdominal wall (Diagram after Kapandji).
31
Manipulative Therapy
postural activity is important. The shouts uttered by attacking soldiers and weight-lifters serve a practical purpose. The effect of respiration is significant above all for the spinal column, which means that it can be employed to outstanding effect in neuromuscular techniques. As a general rule, muscle activity is facilitated during inhalation, and exhalation produces relaxation. The actual situation is a little more complicated: the abdominal muscles are facilitated during active exhalation, especially against resistance, and, as mentioned previously, raising the gaze of the eyes is associated with inhalation and lowering the gaze with exhalation. It is appropriate at this point to explain the concept of ‘respiratory synkinesis,’ in which movement in one direction is linked with inhalation and in the other with exhalation. Where this is the case, it is difficult to do the reverse. Typical respiratory synkinesis can be observed during forward flexion of the trunk, and when straightening up from forward flexion. The fact that straightening up is usually associated with looking up, and forward flexion with looking down, makes clear why the initial act of looking up facilitates inhalation, and looking down, exhalation. Inhalation facilitates straightening up, not only from forward flexion, but also from side-bending. Side-bending itself is facilitated by looking down while exhaling. Another very important example of respiratory synkinesis is the opening of the mouth during inhalation, and the closing of the mouth during exhalation. This facilitates first the masticatory muscles, and then in particular the digastric muscle. Inhalation facilitates kyphosis of the thoracic spine, and active exhalation lordosis of the thoracolumbar spine, especially in lordotic posture (Lewit, Janda, Veverkova 2000). Resistance to traction of the cervical spine increases during inhalation; also during distraction of the hip. The resistance decreases during exhalation. Conversely, resistance increases in the lumbar spine on traction in the prone position, and decreases during inhalation. Clearly, then, these respiratory synkineses are extremely effective in mobilization and relaxation techniques for the spinal column. One especially remarkable example of synkinesis is that described by Gaymans (1980) in the cervical and thoracic spine. He found that, during side-bending, resistance increases in the even segments (in C0, C2, C4, and C6 and in T2, T4, T6, T8, and T10) during inhalation; it disappears 32
during exhalation. Conversely, resistance increases in the odd segments (C1, C3, and C5 and T3, T5, T7, and T9) during exhalation, and disappears during inhalation. At the cervicothoracic junction, and only here, in the region between C6 and T2, resistance always increases during inhalation and decreases during exhalation. This synkinesis is so effective that during side-bending all that is needed is to take up the slack to the point of initial tension, then (in the case of an even-numbered segment) to ask the patient to inhale, and then to wait during the period of exhalation for mobilization to take place automatically. An exception to this rule is found in the atlanto-occipital segment; here this synkinesis operates not only in sidebending but in all directions. The phenomenon described here is so reliable that it can be used to correct the diagnosis as to the level of the vertebral segment. It is most marked at the cranial end of the spinal column and decreases somewhat in a caudal direction; in particular, the relaxation that accompanies exhalation diminishes in the lower thoracic spine. The reason for this may be connected with the fact that the thorax is stabilized during inhalation, and the diaphragm and quadratus lumborum as well as the deep layer of the abdominal muscles contract. We can therefore refer to inhalation–exhalation segments and exhalation–inhalation segments. Marked respiratory synkinesis can also be found in trunk rotation; in the upright position, rotation of the trunk (including active rotation) increases during inhalation, while considerable resistance appears on exhalation. In a kyphotic sitting position, in contrast, resistance increases on inhalation and mobilization is therefore performed on exhalation. Too little attention is paid to the effect of respiration on the locomotor system and vice versa. There is little awareness of the respiratory synkineses, and too little use is made of them by manual therapists, despite the fact that they are physiological methods. Empirically, many of these effects are employed in yoga; these include not only the effects on motor functions but also those on autonomic ones. This is understandable when we remember that respiration is the only ‘autonomic’ function on which we are able to exert any degree of direct influence voluntarily, that is using the voluntary muscles. In this section we have attempted to show the importance of faulty movement patterns for the
Etiology and pathogenesis
pathogenesis of dysfunctions and to explain the processes involved. It seems all the more important to do so since modern civilization is guilty not only of chemically polluting the environment, but also of causing extensive changes to the human locomotor system. We move around too little, but suffer static overload, creating conditions that produce muscular imbalance, among them that of faulty breathing while sitting in a hunched posture. Rehabilitation focuses on faulty movement patterns, and their diagnosis and therapy will be explored in more detail in the relevant sections of this book. As we come to understand them, it becomes clear that the methods used in manual medicine, which are predominantly passive ones, are usually only lastingly effective if accompanied by the active participation of the patient.
Faulty muscle control originating from the central nervous system plays a significant part in the pathogenesis of dysfunctions of the locomotor system. Often, however, they are also a consequence of disturbances involving chronic pain. They, in turn, can then perpetuate and intensify the basic disturbance.
2.10 The significance of constitutional hypermobility Movement restrictions, dealt with in the foregoing sections, are the true focus of manipulation therapy; however, the experienced clinician is well aware that hypermobility is frequently an even more difficult problem. The contributions made by Sachse (1984, Sachse et al 2004) have been fundamental in this area. The following categories can be distinguished: • Localized pathological hypermobility. This may be primary or secondary (it is usually compensatory, occurring in the neighboring segment to a restricted joint). As such it is most frequently found in the spinal column. • Generalized pathological hypermobility. This is most often found in certain congenital neurological conditions.
Chapter 2
• Constitutional hypermobility. This type is
of the greatest interest to us. In essence it is a variant of the norm, but under certain conditions it can be significant for pathogenesis. As a general rule, mobility is greater in childhood than in adulthood, is greater in women than in men and, in the limbs, tends to be greater on the non-dominant side (Sachse et al 2004). There are conditions in which hypermobility may be an advantage, for instance in certain sports and in employment where mobility is a requirement. However, it involves the risk of decreased stability, and given the predominance of static load and overload in most occupations today, hypermobility is inappropriate. Individuals with constitutional hypermobility are at a particular disadvantage when working at a computer, as a driver, or in the majority of sedentary occupations, especially if the hypermobility is accompanied by laxity of the ligaments and weakness of the muscles. The situation is still more unfavorable if the hypermobility is accompanied by poor coordination and qualitatively poor movement patterns (Sachse 1984). The problem may even cross the boundary into minimal brain damage (MBD) as described by Janda (1978). In a study of 100 cases in which rehabilitation proved difficult, he distinguishes three types: 1. The first is ‘microspasticity,’ showing mild signs of first motor neuron lesion which is often asymmetrical. 2. The second is characterized by hypotonicity, with asymmetrical tendon and periosteal reflexes, signs of instability and restlessness, and – consistently with the account given by Sachse – severe hypermobility. 3. The third type shows disturbances of proprioception, which become more evident with eyes closed. This is expressed as a certain marked ‘clumsiness’ and accompanied by poor psychological adaptability, which makes rehabilitation more difficult. Hypermobility in itself is no more than a constitutional characteristic; however, there is a tendency toward instability that is pathological. The most important role here is that played by the deep stabilization system. 33
Manipulative Therapy
Figure 2.20 • Causes and sequelae of restrictions and dysfunctions of the spinal column.
So far we have dealt mainly with the locomotor system and dysfunctions of that system, in particular mechanical disturbances (Figure 2.20).
The dynamic role – usually also the primary role – in the interplay between dysfunction and morphological change is that of function.
2.11 Reflex processes in vertebrogenic dysfunctions Despite the importance of the mechanical factor for pathogenesis, it is not identical with clinical disease. Patients do not generally tend to complain of disturbances of mobility, but rather of pain, whether in the back, limbs, head, or viscera. They may even be suffering from considerable movement restrictions, yet they do not notice these. Examination may sometimes even reveal signs of nociceptive irritation (latent trigger points or hyperalgesic zones on the skin), yet the patient does not feel pain. The explanation lies in the capacity of the nervous system to react. We now need to know how it is that dysfunction produces pain. 34
Before presenting an explanation I should stress that it is not the purpose of this book to deal with the purely theoretical aspects of the pathogenesis of pain; we do however need to deal with the theoretical inferences that can be drawn from clinical diagnosis and therapy. Examination before and after therapy enables us to arrive at certain theoretical conclusions, as we might from an experiment, and the findings that are made after therapy not only show a normalization of mobility, but also a reduction of tension in the affected muscles, and that of the soft tissues. The effect is observed after manipulation, local anesthesia, needling, relaxation of trigger points, and massage. In each case, pain too is relieved. If the pain arises as a result of having to maintain an uncomfortable forced position, correction of the position is often enough to bring relief. The same is true of strenuous work; when we work beyond our strength we hardly notice it at first, but eventually pain forces it to our attention and we suspend the activity. After a short while the pain subsides. The common denominator in all this is the close connection between tension and pain in the locomotor system. Daily evidence of this is seen in the post-isometric relaxation of tense muscles; as the tension reduces, so the pain subsides, not only in the muscle itself but also in its attachments (see Chapter 6). This experience is in fact a general principle: any disturbance of function is bound to produce
Etiology and pathogenesis
increased tension: when there is a restriction, there will be increased tension when the patient tries to move in the restricted direction; hypermobility will produce tension in the end position as a result of excessive range of movement; static overload, strenuous movements, or any faulty motor pattern must also lead eventually to increased tension. The muscular TrPs provide direct evidence of this, since these involve a close association between tension and pain. This is in keeping with the biological role of pain as a warning sign: increased tension constitutes a threat, and it is pain that delivers the warning. The nociceptive stimulus – in the form of overload – warns us at the stage when the disturbance is still functional and reversible. As soon as we correct the posture or cease the activity causing the pain, and as soon as we treat the restriction or muscular TrP, the tension is eased and the pain subsides. If pain made its appearance only when morphological (pathological) changes had occurred, it would fail to fulfill its biological function. Since the locomotor system is controlled by our will – and whim – it has no way of protecting itself other than by causing pain. In this way the voluntary activity of the locomotor system is kept within due bounds by pain. The locomotor system is therefore by far the most frequent source of pain in the human body; it is more than mere coincidence that referred pain from other organs or systems is perceived in the locomotor system, and that pain receptors are located in those places where tension in the locomotor system is expressed: in muscles, joint capsules, the attachments of tendons and ligaments, root sheaths, and the anulus fibrosus of intervertebral disks.
Pain is the most common symptom of dysfunction, and functional disturbances of the locomotor system are the most common cause of pain.
The close connection between physical and psychological factors in the production of pain is easy to understand: pain itself is both a physical and a psychological phenomenon. The same is true of tension and also, especially, of relaxation: it would be difficult to imagine psychological relaxation without relaxed muscles, or to imagine relaxing the muscles without being mentally relaxed. This close interrelationship is true for the locomotor system in
Chapter 2
general, since movement is the effect of voluntary motion that originates in the psyche.
Since movement is an outward effect of psychological activity, it is also true that psychological activity is a factor in motor function.
The nociceptive stimulus produces a reaction in the segment, and the intensity of the reaction can vary enormously. This is clinically significant, because it allows us to estimate the capacity for reaction in the individual case. This applies not only to autonomic reactions, but also to those of the muscles, whose response may take the form of TrPs or spasm. Korr’s concept of ‘segment facilitation’ is therefore appropriate here. There may be considerable differences between patients, and reactions may also vary considerably in the same individual under different circumstances. If, for instance, acute pain has been provoked by a draught, it should not simply be ascribed to the cold air alone, for in such patients we find restrictions in at least one segment, with severe muscle spasm. The restrictions are clinically latent, but produce a skin hyperalgesic zone (HAZ) in the segment. The cold draught striking this HAZ is an additional stimulus which intensifies the patient’s reaction and causes muscle spasm which makes the clinically latent lesions manifest. It is a mistake to explain the pain as due to mechanical irritation of nerve fibers, as is frequently suggested. It would be a peculiar concept of the nervous system (a system whose purpose is to process information) that would have it reacting, not to stimulation of its receptors, but to mechanical damage to its own structures. Referred pain from the viscera is the typical model, or experimentally-induced referred pain from the infiltration of hypertonic saline solution into ligamentous structures of the spinal column, as performed by Kellgren (1939) and later by Feinstein et al (1954) and by Hockaday & Whitty (1967), and in the zygapophysial cervical joints by Pi’tha & Drobný (1972). Just as in these model experiments, pain arising from deep structures (joints, muscles, ligaments, and internal organs) is referred, especially within the affected segment, and also gives rise to corresponding HAZs, sometimes even paresthesia, imitating radicular pain and so leading Brügger (1962) to refer to it as ‘pseudoradicular.’ Other terms often used, 35
Manipulative Therapy
where there is a combination of pain in the muscles, tendons, and insertions, are ‘myotendinosis’ (Brügger 1962) or ‘myofascial pain’ (Travell & Simons 1999). The soft-tissue changes, such as HAZs in the skin and subcutaneous tissue, have mainly been described as reflex changes or as secondary phenomena. This is usually true in acute cases where there is no long history, and these changes are generally found to subside when the joints and spinal column are treated. However, in the later, chronic stage, these changes – especially in fasciae and muscles – can become chronic; resistance is found in the fasciae, muscles become shortened, and chronic TrPs form. Some authors call this the ‘dystrophic stage’ (Popelyanski 1983, Popelyanski 1984). Pathological barriers are also present in such cases, however, and it is possible to achieve release. When dealing with chronic TrPs, this can be done by means of needling. In such cases, even these changes may turn out to be functional and reversible. Nevertheless it is important to note that where there are ‘sticky’ fasciae (which do not shift), shortened muscles, or chronic TrPs, these do not subside following manipulative treatment of joint restrictions. On the contrary, if they do not receive specific treatment, they can cause chronic recurrent restrictions. The model described here has been that of characteristic painful disturbances within the segment. However, it should not be forgotten that the pain threshold, which is under central nervous control, is only crossed when the nociceptive stimulus has reached a particular intensity. Only then is it actually experienced as pain. So it is that, on careful examination, very frequently we find clinical changes when patients have no sense of pain at all. It can therefore be seen that dysfunctions of the locomotor system produce nociceptive stimulation whose effects are felt both suprasegmentally and also at the level of the central nervous system. The entire complex of function-related disturbance can be called the ‘functional pathology of the locomotor system.’
kind of excuse for ignorance of the true causes or the true pathology in most cases of pain affecting the locomotor system and spinal column. Yet what other explanation is there for the fact that, following manipulation, not only does the pain cease, but mobility is restored to clinical normality and muscle TrPs and HAZs instantly disappear? These are not mere coincidence; careful clinical examination can predict the rapid appearance of the effect. If these were pathomorphological changes they would need to heal, and this requires time. The situation can best be explained by comparing it to the working of a car: it may break down because of a burst cylinder or a damaged ball bearing (a pathomorphological change), but another reason for it to fail may be that the ignition is out of order, or the carburetor needs adjusting; the structure is intact, and the disorder is a functional, reversible one. Following a simple adjustment, the problem is instantly resolved. One of the reasons for the failure to recognize that dysfunction is the most frequent cause of pain in the locomotor system is that the evidence is simply based on clinical findings, often relying on palpation, and this is rejected as ‘subjective.’ Connected to this we see a systematical underestimation of clinical diagnosis as a scientific discipline, and neglect accorded to it in practice. Much the same applies to the solving of the ‘puzzle of pain’ in dysfunctions of the locomotor system: pain is closely linked to tension and the release of tension to relief of pain, and the key to understanding this lies in palpation. In differential diagnosis of conditions affecting the locomotor system, the fundamental distinction to be made is therefore between conditions due primarily to pathomorphological changes and those caused by dysfunction. Yet even where a morphological lesion is present, dysfunctions may still play a significant role and should be treated accordingly; rehabilitation is included here.
2.12 Radicular pain The complex of predominantly mechanical dysfunctions and reflex changes can be termed ‘functional pathology of the locomotor system.’
Unfortunately, so widespread is the lack of knowledge, often combined with skepticism, that the concept of ‘functional pathology’ is viewed as a 36
The point having clearly been made that pain in the locomotor system is due to nociceptive stimulation of pain receptors, we must proceed to look at how and why pain arises in cases of root compression. The mechanical compression of a nerve does not itself cause pain but anesthesia, paresthesia, and paresis. However, we should bear in mind that the herniated disk causing the compression
Etiology and pathogenesis
cannot impinge on the nerve fibers until after it has affected the dura and the dural sheaths, which are richly supplied with pain receptors (Wyke 1980), and that with every movement of the legs and trunk the dura is being rubbed against the disk. Nor should it be forgotten that Lasègue’s sign indicates meningeal involvement, even in root compression syndromes. This is in keeping with the clinical course: first of all there is usually severe pain, and the signs of neurological deficit appear later. Other clinical observations support this. Cerný (1948), using autodermography to study patients with radicular pain, found that this method was more reliable in localizing the disk herniation to the particular segment than the typical signs of neurological deficit. This can be understood anatomically in that spinal nerves do not contain fibers from one segment only; they also carry many transitory fibers from neighboring segments. As a result, the failure of a single spinal nerve does not usually lead to signs of deficit. There is an overlap of the areas of nerve roots. Hanraets (1959), however, demonstrated that this is not always the case. He frequently found, during neurological surgery, that spinal nerves vary considerably in thickness: if one is very thick, its neighbor is likely to be much thinner, because of the number of transitory fibers in individual spinal nerves. If a thin spinal nerve is compressed or even severed, deficit will not be observed, because the transitory fibers in the neighboring nerve roots are able to compensate sufficiently, but if a thick root is severed, the consequences are quite different. Most thin neighboring roots have very few transitory fibers that can provide compensation. When Hanraets (1959) stimulated such a spinal nerve during operation (at that time his operations were still being performed under local anesthetic), his patients also felt paresthesia in the neighboring segments. Our own findings (1958), working together with Starý, are also consistent with this. We examined patients following intervertebral disk operations. At that time, in cases where no disk herniation was found, the neurosurgeon cut the sensory spinal nerve. Most of these patients experienced little effect, but some complained of permanent numbness and especially disturbances of proprioception following the procedure. In these cases a thick nerve root had evidently been cut, as described by Hanraets (1959). The pain resulting from irritation of dural receptors is referred pain, which corresponds precisely to the segment affected. It is this projection pain that is shown by Cerný’s autodermography. We
Chapter 2
can conclude that radicular pain is a combination of referred pain originating from dural receptors, and signs of neurological deficit. This explains why autodermography, in which patients themselves draw their projection pain, produces the most accurate clinical localization of a herniated disk. There is yet another observation that points to a functional factor in root compression: this is the frequent immediate improvement of muscle strength in weak muscles and sometimes even of tendon reflexes, immediately after manipulation and even after traction. This has been demonstrated by electromyography (see Figures 2.12 and 2.13), and also shown by the work of Drechsler (1970) and Hanák et al (1970). They showed that, even in true radicular syndromes with muscle weakness, the speed of nerve conduction may be normal. In the light of this they interpreted the weakness as reflex inhibition. Drechsler also concluded that decreased conduction speed indicates a poor clinical prognosis.
Radicular compression syndrome is a mixture of root compression and reflex phenomena. The decisive factor for localizing the cause of pain is referred pain produced by stimulation of receptors.
2.13 The term ‘vertebrogenic’ Once the terms ‘degenerative disease’ and ‘diskopathy’ had been abandoned as inappropriate, ‘vertebrogenic’ became widely adopted as a concept. It too is not quite appropriate: it includes pathological conditions such as ankylosing spondylitis, and does not cover dysfunctions that lie outside the spinal column. The term is therefore acceptable only if it is used as a pars pro toto. So long as it is used for back pain and very closely related disorders, there can be little objection to it; the term becomes controversial if the attempt is made to apply it to pain deriving from the internal organs, as might particularly tend to happen if treatment of the pain is successful. A correct understanding of referred pain, or pseudoradicular pain (to use a less accurate term), leaves little room for controversy. We see from the publications of Melzack & Wall (1965), Bonica & Albefessard (1976) and Milne et al (1981) that impulses from nociceptive stimuli arriving from all structures in a segment converge to spinal cord cells in the lamina V 37
Manipulative Therapy
of the dorsal horn. This also applies to stimuli from receptors in the joint capsules of zygapophysial joints, from the anulus fibrosus, or from internal organs. So it is easy to see how the locomotor system (the spinal column) can readily simulate visceral pain, or how pain from an internal organ might simulate that from the locomotor system. Therefore we must constantly take this problem into account in differential diagnosis. The therapeutic consequences are clear. We should not forget, however, that many instances of pain described as ‘functional’ in fact have their origin in the locomotor system. As will be seen in further chapters, vertebrovisceral relations are very complex; the term ‘vertebrogenic’ should therefore be applied with caution. In many cases pathogenesis is due to more than one factor, and it is then better to speak of disease with a vertebrogenic factor. Migraine is a good example, since the true cause is unknown, although it is usually accompanied by findings in the locomotor system that do cause significant pain. We should reserve the term vertebrogenic for those conditions in which the spinal column (the locomotor system) is the decisive factor, for example when we describe a case of vertigo as vertebrogenic. As Junghanns (1957) has pointed out, the role of the vertebrogenic factor may change over the course of time. It may trigger the disease process, but once this has started it may develop independently. Gutzeit (1953) very aptly characterized the spinal column as being sometimes the ‘initiator,’ sometimes the ‘provoker,’ and in yet a third way as being the ‘multiplier’ of a disease state.
We should speak of vertebrogenic disturbance only when we wish to say that the spinal column is the primary and decisive factor in pathogenesis in a given case of disease.
2.14 Conclusions • Morphological changes cannot explain
pathogenesis in the great majority of painful conditions of the locomotor system. These changes often have the role of a locus minoris resistentiae. • The most frequent cause of pain in the locomotor system is dysfunction, in a joint, 38
muscle, soft tissue, body statics, or dynamics (the movement patterns or motor stereotypes). • The most important cause of dysfunction is overload caused by overexertion, faulty movement patterns or body statics, trauma, or visceral disease. This includes joint restrictions, muscle TrPs, and soft tissue lesions, especially of fasciae and active scars. All these cause an increase in tension. • When dysfunctions in the segment persist for a long time they eventually lead to degenerative (adaptive) changes, and do not remain confined to the segment concerned but affect the entire system. • The locomotor system and the spinal column together make up a functional unit which has to compensate for any dysfunction, so that equilibrium is always maintained. In other words, the ‘motor program’ is reprogrammed. This gives rise to compensatory movement patterns, often designed to reduce pain. These can persist even when the primary cause is no longer present. • Mechanical disturbance of function alone is insufficient to cause pain. However, it does represent a nociceptive stimulus which produces reflex changes, especially within the segment. If these are of sufficient intensity to pass the pain threshold, they are experienced as pain. The specific nociceptive stimulus in the case of dysfunctions is understood to be increased tension. • Pain in the locomotor system is primarily a warning signal of harmful functioning, which should cause us to correct this before it causes permanent morphological damage. It is the type of pain that occurs most frequently in the human body. • If the patient is able to describe and localize the pain, and if on clinical examination we find corresponding changes, above all reflex signs, then the diagnosis (once we have excluded gross pathology) must be the relevant dysfunction. Undiagnosed dysfunctions are the most frequent cause of pain in the locomotor system, and treatment which is directed only at the symptom of pain, without a thorough understanding and analysis of the dysfunction causing that pain, will be frustrating and ineffective. • The complex of changes in function of the locomotor system and the reflex effects caused by these changes constitute what may be called the ‘functional pathology of the locomotor system.’
Chapter Three
3
Functional anatomy and radiology of the spinal column
Chapter contents 3.1 General principles . . . . . . . . . . . . . 39
3.1.1 Structural diagnosis . . . . . . . . . 39 3.1.2 Functional diagnosis of spinal column mobility (kinematics) . . . . 40 3.1.3 Functional diagnosis of body statics . . . . . . . . . . . . . 40 3.2 Technique in functional diagnosis . . . . . 40 3.3 The lumbar spine and pelvis . . . . . . . . 41
3.3.1 X-ray of the lumbar spine and the pelvis . . . . . . . . . . . . . . . 41 3.3.2 X-ray evaluation of lumbar spinal statics . . . . . . . . . . . . . 43 3.3.3 The pelvis . . . . . . . . . . . . . . 49 3.3.4 The lumbar spine . . . . . . . . . . 54 3.4 The thoracic spine . . . . . . . . . . . . . 58
3.4.1 Functional anatomy . . . . . . . . . 58 3.4.2 X-ray anatomy of the thoracic spine . . . . . . . . . . . . 59 3.4.3 Evaluating functional aspects . . . 60 3.5 The cervical spine . . . . . . . . . . . . . 62
3.5.1 X-ray technique . . . . . . . . . . . 62 3.5.2 Assessment of X-ray films . . . . . 63 3.5.3 Functional anatomy of the cervical spine . . . . . . . . . . . . 65 3.5.4 X-ray anatomy of the cervical spine . . . . . . . . . . . . 71 3.5.5 Evaluation with respect to functional implications . . . . . . . 74 3.5.6 Movement studies . . . . . . . . . . 77 3.5.7 Morphological changes . . . . . . . 82
Manual techniques call for an accurate understanding of anatomy, especially when treating the spinal column. Textbooks of radiology are interested mainly in morphology, while our concern is mainly with function, the consistent focus of the present book. The use of radiology for functional studies can greatly improve our understanding in manual diagnosis. However, if we are to be able to interpret radiographic images from the functional point of view, we need a good knowledge of X-ray anatomy, such as we present here, as well as certain requirements as regards technique.
3.1 General principles For our purposes, X-ray diagnosis fulfills three basic tasks: 1. Structural diagnosis. 2. Functional diagnosis of spinal column mobility (kinematics). 3. Functional diagnosis of body statics (interpretation of curvatures of the spinal column).
3.1.1 Structural diagnosis Structural diagnosis provides information about the morphology of the bony structures. This is the essential focus of classic X-ray diagnosis, which is mainly concerned with form and structure and constitutes the basis of our knowledge. This type of diagnosis is very important for manual therapy in
Manipulative Therapy
that it alerts us to potential serious errors of diagnosis, providing a warning against manual therapy where inflammation, tumors, fractures, or other contraindications are present. It also reveals abnormalities and changes in structure, such as asymmetries, which can be significant for function. Diagnosis of structure can be found in the classic textbooks of radiology, so we shall deal here only with those morphological changes that are important for an understanding of dysfunctions.
3.1.2 Functional diagnosis of spinal column mobility (kinematics) Functional diagnosis in the narrower sense involves movement studies of the spinal column in which X-rays are taken in end of range positions, in anteand retroflexion (extension), side-bending and, less frequently, rotation. Examination of this kind is the only approach that can provide direct information about dysfunctions in the motion segment. It can also be used before and after treatment. It is of value for documentation and assessment, but is too time-consuming and uneconomical and the radiation exposure is too great for use as a routine procedure. Since manual therapy examination gives good information on mobility and disturbances of mobility, it is generally possible to dispense with movement studies. They do have an important role to play in research, however, and provide an understanding of the biomechanics of movement processes.
3.1.3 Functional diagnosis of body statics Although movement studies come first to mind when we think of functional diagnosis, it is no less important to diagnose disturbances of body statics. The images used to assess this must be taken standing (or, for the cervical spine, sitting), under static loading and under standard conditions. The curvatures of the spine, as explained below, should mainly be assessed from the point of view of static function. This applies not only to the sagittal but also the frontal plane, in which every obliquity (e.g. of the pelvis during walking) produces a corresponding scoliotic curvature and rotation. Curvature may be regular or irregular, so that a marked 40
deviation may be observed in one particular segment. This may be scoliotic, increased lordosis or kyphosis, rotation, or lateral shift (‘offset’). The significance of these signs of irregularities in the position of neighboring vertebrae (relational diagnosis) is highly controversial, and closely connected with the discredited subluxation theory. It is also closely linked to the problem of asymmetry, bearing in mind the fact that a degree of asymmetry is the rule rather than the exception. Jirout (1978) has shown that asymmetry of the position of the atlas in relation to the axis is present in the majority of adults. In a study to compare children of various ages, he found that its incidence increases with age. This can be shown particularly easily by observing the position of the spinous processes. He concluded that these asymmetries were the result of asymmetrical pull of the muscles due to the dominance of one cerebral hemisphere. From this we can conclude that asymmetry and other kinds of irregularity are not in themselves pathological, although they can be the expression of functional asymmetries. We know, for example, that if the axis is asymmetrically rotated in neutral position, the entire cervical spine will rotate asymmetrically during side-bending. In general it is advisable to be cautious when drawing conclusions about examples of asymmetry observed on an X-ray film, and always to take the clinical findings into account when interpreting the radiographic findings. One advantage of static functional diagnosis is that the examination is economical: only two X-rays are required, two projections, which must correspond to each other vertically. Standard conditions must be observed as regards static loading. As individual posture is highly characteristic, it also remains fairly constant. Gutmann & Véle (1978) said of static function: ‘The dominating principle of the spinal column is body statics. All other functions are subordinate to the requirements of upright posture on two legs. The human body is more ready to accept loss of mobility or painful impingement of nerve roots than to sacrifice erect posture.’
3.2 Technique in functional diagnosis Functional diagnosis of the spinal column makes considerable demands as to technique. The following criteria must be observed: the X-rays should be
Functional anatomy and radiology of the spinal column
taken in a position that corresponds as closely as possible to the patient’s natural posture, normally either standing or sitting (with the exception of the anteroposterior (AP) view of the cervical spine, which is taken with the patient supine). In general, then, any slight inclination or rotation in the patient’s posture ought not to be corrected. However, it may become necessary to do so in order to achieve: • assessability of the X-ray films • reproducibility and comparability. Reliable criteria for comparability are therefore necessary. Assessability is, of course, absolutely essential in order to be able to evaluate the films, so it is important to avoid distortion through errors of projection. To achieve this, it will sometimes be necessary to correct side-bending (in the lateral projection) or rotation (in both projections). As to the format, it is essential to visualize a sufficiently large area to provide landmarks as means of comparison. In the lateral projection of the cervical spine in the sitting position, the hard palate must be visible to enable you to assess the posture of the head, and the mandible needs to be visible so as to indicate any side-bending or distortion. The lumbar AP projection must include the coccyx and the pubic symphysis, to enable you to assess correct positioning. As long as these requirements are observed, it will be possible to evaluate and compare the films successfully, even if there are very minor errors of centering. Since the spinal column is a functional unit, the most appropriate format for the X-ray examination is to show the entire spinal column on a single film. An AP and a lateral view with the patient standing are required, with the feet placed in a standardized position. If this cannot be done, the sections of the spinal column that have been imaged need to be assessed in the light of the clinical findings. These can then make good whatever is missing in the X-ray.
3.3 The lumbar spine and pelvis 3.3.1 X-ray of the lumbar spine and the pelvis The imaging projections needed for routine examination of the static function and morphological changes of the spinal column are simply one AP and one lateral view with the patient standing.
Chapter 3
This is done using a device described by Gutmann (1970), in which a plumb line indicates the vertical line from the head. The procedure is illustrated in Figure 3.1A–D and is as follows: A line which corresponds to the center of the cassette is drawn on the floor in front of the middle of the stand. For the AP view the patient places one foot symmetrically on each side of the line, and is requested to distribute the weight of standing equally between both feet, with legs straight, so as to rest on a base that is in line with the center of the cassette. A plumb line extended downward from the center of the cassette will therefore meet the floor at the mid point between the patient’s heels, setting the base line. A movable plumb line of metal wire (so as to create contrast) is attached to the screen. The cassette is first raised to the level of the patient’s occiput and this metal wire plumb line moved to a point precisely below the middle of the occipital squama, where the external occipital protuberance can be palpated. This sets the plumb line that marks the head position. The cassette is then adjusted (taking care not to displace it to the side) to the height required to take a view of the lumbar region and the pelvis (with the central ray of the X-ray beam and the center of the cassette roughly at the height of the navel). By setting up the AP view in this way, the shadow of the metal wire marks the plumb line representing the head position, and the center of the film represents that of the base line. The same procedure is used for the lateral view of the lumbar spine, except that this time the patient stands with feet across the line on the floor that represents the center of the cassette, with ankles one finger’s breadth behind the line. The plumb line for the head is positioned at a point in line with the external acoustic meatus. Here – as in the procedure described for the cervical spine – it is helpful to align the central ray below rather than on the center of the cassette, directing the beam off-center to focus approximately on the lumbosacral junction, midway between the iliac crest and the greater trochanter. This technique has two great advantages: 1. There is considerably greater absorption of radiation at the lumbosacral junction (on which the pelvis is superimposed) than in the lumbar spine. If the central ray is aligned as usual on the middle of the lumbar spine, the result is either under-exposure of the lumbosacral junction, while the rest of the lumbar spine is correctly exposed, or 41
Manipulative Therapy
Figure 3.1 • X-ray technique for the lumbar spine after Gutmann (1970). (A) Positioning of the plumb line for the head and (B) patient position during radiography, as prepared for the AP view. (C) Positioning of the plumb line for the head and (D) patient position during radiography, as prepared for the lateral view.
42
Functional anatomy and radiology of the spinal column
Chapter 3
arms folded in front of the chest (see Figure 3.1D). The final step, once the apparatus and the patient’s position have been set up, is to tape the wire to the cassette so that it cannot be displaced, and then instruct the patient to lean against the screen so as to remain steady during the long film exposure.
3.3.2 X-ray evaluation of lumbar spinal statics
Figure 3.2 • Lateral view of the lumbar spine with perfect demonstration of the entire pelvis, including the iliac crests and femoral heads.
over-exposure of the lumbar spine while exposure of the lumbosacral junction is good. Aligning the beam on the lumbosacral junction evens out the exposure, and has the additional advantage of providing good imaging of the hip joints (see Figure 3.2). 2. If the beam is aligned to the center of the cassette (middle of the lumbar spine), the effect is to project the iliac crests away from each other, lying well apart as they do, although they are very important for body statics. The projection error produced at the much slimmer lumbar spine, on the other hand, is only slight. For both projections the focus-film distance should be as great as possible, depending on the power of the apparatus and the corpulence of the patient, the ideal distance being at least 2 m (78 inches). For technical reasons, the patient needs to stand with
The purpose of the films taken in the standing position is mainly to study body statics. The only structures in the frontal plane that can be assessed by clinical examination are the occipital protuberance, spinous processes, iliac crests, intergluteal cleft, and the midpoint between the heels. In the sagittal plane, clinical examination can show the posture of the head, position of the shoulders, the trochanters and the heels in relation to the plumb line, which takes the line from a fixed point at the external auditory meatus. Clinical examination cannot provide information about the position and inclination of the sacrum and the most caudal vertebrae (which mark the true base of the spinal column), information which is essential for a full understanding and evaluation of spinal statics. This may explain why clinicians interested in body statics have devoted their attention mainly to the question of body equilibrium as a whole, studying deviation of the head and deviation from the line of gravity by means of statovectography. However, Rash & Burke (1971) pointed out that with static load each body segment should be vertically above the center of the segment on which it rests. The principle is violated if tension of the ligaments or excessive muscular contraction are required to maintain balance. X-ray examination under static conditions provides information on precisely this type of static disturbance. The mechanism of body statics differs considerably in the frontal and the sagittal planes. One way to appreciate this is to observe the effect of a heel insert, a pad or block placed under one foot. A healthy subject experiences a height difference of as little as 1 cm as uncomfortable, whereas if a heel insert of 1 cm is placed under both feet it is hardly noticed. This is because in the frontal plane the center of gravity lies over both feet, such that body equilibrium is (relatively) stable. As a result, any mechanical change (the insert under the foot) has an immediate effect. In the sagittal plane, in contrast, body equilibrium is labile, over the two 43
Manipulative Therapy
Figure 3.3 • Normal body statics: (A) with the subject standing with his weight equally on both feet; (B) with support to raise the right foot; (C) with weight shifted onto the right leg.
44
Functional anatomy and radiology of the spinal column
Chapter 3
perfectly round surfaces of the hip joints. A slight mechanical change has little effect, because it is dynamic muscle function that is maintaining balance in this plane. The muscular force required should, however, be minimal.
Lumbar spinal statics in the frontal plane In the ‘ideal’ case the pelvis and spinal column lie symmetrically in a straight line in the AP view. The external occipital protuberance, spinous processes, pubic symphysis, and coccyx lie in the midline. Such a spinal column is the exception in real life; people simply do not place their weight symmetrically on both feet, but stand in a relaxed posture in which the weight is taken mainly on one leg. During walking, the pelvis constantly swings from one side to the other. The result is the constant creation of oblique planes. The main concern in assessing these is to discover how the spinal column reacts to obliquity in the frontal plane. The physiological reaction to obliquity can be seen by performing a test in healthy subjects: the subject must first relax, stand with legs straight, and rest the weight of the body on both feet; a block of wood is then placed under one foot. The subject’s pelvis then shifts to the higher side (see Figure 3.3). The radiographic image shows not only the shift to the side, but also scoliosis and rotation to the lower side. The summit of the scoliotic curve is usually at the mid-lumbar region, with the thoracolumbar junction vertically above the sacrum. The degree of rotation depends on the degree of lordosis of the lumbar spine. If there is no lordosis – as is often the case in acute lumbago – there is also no rotation. If there is kyphosis, there may even be rotation to the same side as the concavity. Reaction by the spinal column to an oblique plane is normal if: • scoliosis to the lower side results • there is rotation to the same side (when there is lordosis) • the thoracolumbar junction is vertically above the sacrum • the pelvis shifts to the higher side (see Figure 3.4). Slight thoracic scoliosis occurs in the opposite direction.
Figure 3.4 • Normal reaction of the lumbar spine and pelvis to standing on an unlevel plane.
These features reflect normal spinal statics and are closely associated with the problem of difference in leg length. From the point of view of body statics, a difference in leg length becomes significant only when accompanied by obliquity of the base of the spinal column (see Figure 3.5). In the light of this fact, the age-old dispute over how to measure a difference in leg length is beside the point. While it is possible clinically to establish the presence of pelvic tilt, we cannot determine the position of the sacrum relative to the sacral promontory and the lumbar vertebrae that constitute the base of the spinal column proper, as the pelvis may be straight while the sacrum is tilted, or vice versa. The determining factor in spinal column and body statics is the base of the spinal column. The only way to establish the position of these, and find how the spinal column reacts to an oblique base, is by X-ray examination with the patient standing (see Figure 3.6). 45
Manipulative Therapy
Figure 3.5 • (A) Pelvic obliquity with level promontory and straight spinal column. (B) Following placement of a support to raise the foot, straightening of the pelvis but oblique promontory and deviation of the lumbar spine from the plumb line.
Figure 3.6 • (A) Pelvic obliquity with oblique sacrum, which is lower on the left. Left scoliosis with deviation of the head and
neck to the left. (B) Straightening of the lumbar spine and head position following placement of a support to raise the right foot.
46
Functional anatomy and radiology of the spinal column
The most important findings where there is a disturbance of body statics are: • obliquity of the base of the spine without scoliosis or with inadequate scoliosis, so that the thoracolumbar junction is not vertically above the lumbosacral • no lateral pelvic shift to the higher side • no rotation when there is scoliosis together with lordotic posture of the lumbar spine or even rotation in the direction of the concavity. The practical decision to be made is whether to order a corrective heel insert. This is primarily a clinical decision, although the X-ray can provide useful clues. The following radiological criteria show when a heel insert can be helpful in the case of obliquity of the base of the spine: • If scoliosis is not sufficient to bring the thoracolumbar junction into a position vertically above the lumbosacral, or if scoliosis is absent. Use of a heel insert to raise one heel should bring the thoracolumbar junction to the vertical, or at least nearly so.
Chapter 3
• If the pelvis is shifted, usually toward the higher side, it should then return to the midline.
• If the scoliosis was statically balanced, it should decrease.
These criteria should all be checked again by X-ray. The spinal column may react positively or negatively to the heel insert, either ‘accepting’ or ‘rejecting’ the correction. If the response is negative it would be wrong to force correction upon the patient, because this would only worsen the situation at the base (see Figure 3.7). The typical reaction to obliquity as seen radiographically has been studied by Illi (1954) and Edinger & Biedermann (1957), with the subject walking on the spot. At each step, oblique planes appeared together with corresponding scoliosis to the side concerned; the summit of the scoliotic curve appeared at L3. The thoracolumbar junction remained vertically above the sacrum. Above T12 there was a scoliosis of the thoracic spine to the opposite side, but it was shallow. According to Edinger & Biedermann (1957), the thoracolumbar junction forms a kind of point of interchange, and
Figure 3.7 • (A) Pelvic obliquity with oblique sacrum, which is lower on the left, and uncompensated left scoliosis.
(B) Following placement of a support to raise the left foot, the pelvis and sacrum are more horizontal, but not L5. No change can be seen in the rest of the spinal column. The displacement of the pelvis and plumb line to the left indicates that the patient is placing more weight on the left leg. Positioning from L5 to S1 is exacerbated.
47
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should not swing more than 4 cm from one side to the other. The relation of the scoliosis to rotation and its dependence on the presence of curvature in the sagittal plane was studied by Lovett (1907), who found that rotation of the lumbar spine (in the sense of scoliosis) occurs if lordosis is present, but not in kyphosis. The explanation for this lies in the fact that, whereas the vertebral bodies have good mobility during side-bending, the joints of the vertebral arches are forced together in lordosis and so resist movement. In contrast, in kyphosis there is less close contact between the joints of the vertebral arches; but the vertebral bodies are pressed more firmly against each other, so that these are less free to side-bend. As a result, either there is no rotation at all or rotation occurs in the opposite direction. This is sometimes the case in patients with acute lumbago or in radicular compression syndrome (see Figure 3.8). The situation can also be found clinically in healthy subjects. On passive side-bending of a subject in lordosis, the spinous processes remain in the midline, and the vertebrae rotate in the sense of scoliosis. If the same is done in kyphosis, the spinous processes form a scoliotic curve: in other words, they move in parallel with the vertebral bodies.
Lumbar spinal statics in the sagittal plane In the sagittal plane, we often speak of ‘normal’ curvatures; these are generally held to be the convex cervical curve (lordosis), concave thoracic curve (kyphosis), convex lumbar curve (lordosis), and concave sacral curve (kyphosis). Sollmann & Breitenbach (1961) demonstrated on the basis of 1000 X-ray films in the sagittal plane that there is no such thing as a general norm; at best we can speak of an ‘individual norm.’ They do not, however, lay down any criteria for this kind of norm. Cramer (1958) showed, on the basis of 150 measurements of the lumbar spine with the subject standing, that there is a constant correlation between the tilt of L5 and that of T12, and more important still, that the T12 vertebra lies an average of 4 cm dorsally to L5. The results of our own study (Lewit 1973) gave complete confirmation of Cramer’s findings and also showed that the plumb line for the head follows a line down from the external acoustic meatus exactly to the navicular bone. We found that the sacral promontory lay an average of 4 mm 48
Figure 3.8 • Typical relief position in lumbago or radicular
compression syndrome (‘paradoxical scoliosis’). Level pelvis, uncompensated right scoliosis with left rotation and deviation of the thorax and head to the left; lumbar lordosis absent.
Functional anatomy and radiology of the spinal column
Figure 3.9 • Lateral view of the lumbar spine with forwardthrust position of the thoracolumbar junction.
anterior to this plumb line, and the transverse axis of the hip joints 12 mm anterior to the plumb line. Deviations from this norm indicate a disturbance of body statics as a result of lack of muscle coordination. This is most evident in muscle spasm due to acute lumbago or radicular pain, when there is forward-thrust posture (see Figure 3.9), in which the thoracolumbar junction lies exactly over or ventral to the lumbosacral junction. The reverse is found in ‘flabby’ posture, in which the sacral promontory lies well forward of the plumb line for the head, and T12 lies dorsal to L5 by some distance (see Figure 3.10). ‘Flabby’ posture is the expression of imbalance of the muscles of the pelvic girdle; it may be the result of weakened abdominal and gluteal muscles, but equally well of hyperactive hip flexors. The curvature of the lumbar spine is of course also dependent on pelvic tilt which, in turn, varies according to the ‘type’ of pelvis, as is shown in the following section. One further point to note is that a slight curvature (a ‘flat’ spine) goes hand in hand with hypermobility and lack of stability, while greater curvature (in both the sagittal and the coronal plane) corresponds to stability and less mobility.
Chapter 3
Figure 3.10 • Lateral view of the lumbar spine with anteposition due to ‘flabby’ posture.
The curvatures of the spine are an expression of static function, and should therefore be interpreted in terms of whether they fulfill this function. In the frontal plane, balance is relatively stable; in the sagittal plane, muscle activity is the determining factor. Curvature of the lumbar spine in the sagittal plane is normal if the thoracolumbar junction is dorsal to the lumbosacral, if there is no forward shifting of the sacral promontory (no more than 8 cm in front of the center of the cassette, which is double the average). The position of the thoracolumbar junction vertically above the lumbosacral is also the most important criterion in the frontal plane. If there is obliquity at the base, the normal reaction is scoliosis and rotation of the spinal column (if lordosis is present) and a shift of the pelvis to the higher side.
3.3.3 The pelvis The pelvis and the spinal column together constitute a functional unity, in which the pelvis serves 49
Manipulative Therapy
both as the base of the column and at the same time as the connection with the lower limbs. The pelvis transmits motion from the lower limbs, at the same time acting as a shock-absorber. The spinal column rests on the pelvis much as the mast of a boat rests securely on the firm base of the mast step (Benninghoff, 1944). The sacroiliac joints and the pubic symphysis allow for a degree of mobility with enough spring to act as a buffer while also providing adequate stability.
Pelvic types The function of the pelvis and its influence on body statics depend largely on its type; we owe the recognition of this relationship to Erdmann & Gutmann (1965). The variability observed here is evidence of the phylogenetic instability of this region; evidence of this variability can be seen in our description of the last lumbar vertebra as a ‘transitional’ vertebra; it is difficult here to speak of any such thing as a ‘norm.’ If the variations are asymmetrical as between the two sides, this results in obliquity at the base of the spinal column, and the effects on spinal statics are considerable. If the variations are symmetrical, this affects the length of the sacrum, which is closely associated with its position and inclination. Erdmann & Gutmann (1965) distinguish the following pelvic types with respect to the associated mechanism of pathology (see Figure 3.11 and Table 3.1). The authors call these Hohes Assimiliationsbecken (high promontory assimilation pelvis), Normalbecken (normal pelvis) and Überlastungsbecken (overload pelvis): • High promontory: the ‘assimilation’ type presents a long sacrum and high sacral promontory, with a tendency to hypermobility (see Figure 3.17) • Normal type: this is of average length, with a tendency to restrictions. • Low promontory: the ‘overload’ type has a low promontory and marked inclination of the sacrum. All the points summarized in Table 3.1 should be borne in mind when evaluating X-ray films; it will be seen that the type of pelvis affects the spinal curvatures, the height of the last intervertebral disk, and the shape of the vertebral bodies, and therefore also the mobility of the most caudal motion segments. The assessment to be made when 50
hyperlordosis is found will therefore be different in the case of a high promontory (assimilation) type and in that of a low promontory (overload) type. Similarly, a low L5/S1 intervertebral disk will be differently assessed.
Identification of pelvic type (see Figure 3.11 and Table 3.1) is extremely important for the assessment of dysfunctions, especially in the lumbar and pelvic region.
The sacroiliac joints There is some mobility of the otherwise firm pelvic girdle, due to the role of the sacroiliac joints and the pubic symphysis. The major role is that of the sacroiliac joints. The sacrum is wedge shaped in two directions; first the whole structure tapers in the caudal direction. A double contour is usually seen in the AP view, since there is another wedge in the ventrodorsal direction; the sacrum is somewhat broader ventrally, at least in its craniad part, although in this respect too there are considerable variations. It is helpful to note that the greater the distance between the two contours of the joint, the narrower the joint space appears. If on the other hand we see only one contour, the joint space appears to be wide and clearly defined. This is often the case with the high promontory type, and is a further sign of hypermobility. It is important to point out that, despite its unusual shape and limited mobility and the fact that there are no muscles to move the sacrum against the ilium, the sacroiliac joint is a true synovial joint (Colachis et al 1963; Duckworth 1970; Mennell 1952; Weisl 1954). According to Duckworth, the sacrum rotates relative to the ilia around an axis corresponding to the shortest sacroiliac ligaments, at the level of S2. This movement is one of nutation; with each step taken during walking, the weight of the spinal column produces a forward nodding motion of the sacrum, together with the sacral promontory, acting as a shockabsorber. This mobility of the sacrum within the pelvic girdle is easily palpated and is familiar to gynecologists in the management of labor. Perpendicular to this ‘functional’ motion, the joint play consists in a springing, wing-like motion about a
Functional anatomy and radiology of the spinal column
Chapter 3
Figure 3.11 • The pelvic types. Angle a = angle of inclination of sacral promontory; angle d = angle of inclination of sacrum. 1, Head and base plumb line; 2, plumb line of promontory. (A) High promontory. (B) Normal type. (C) Low promontory.
craniocaudal axis, the effect of which is a distraction of the joint.
The degree of mobility in the sacroiliac joint should be as little as possible, yet never to the point of restriction, just as a shock-absorber is firm but never immobile.
It is appropriate at this point to deal with a condition described as pelvic distortion, which requires explanation from the functional anatomical point of view. The finding on palpation is that the posterior superior iliac spine (PSIS) is lower on one side than the other. The finding is the same if the finding is made at the posterior border of the iliac crests at the point where they can be palpated in the vertebral region. Ventrally the opposite is found: on the side where the PSIS is lower, the anterior superior iliac spine (ASIS) is 51
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Table 3.1 Pelvic types
High promontory (assimilation)
Normal
Low promontory (overload)
Inclination of sacrum
50˚–70˚
35˚–50˚
15˚–30˚
Inclination of end-plate of S1
15˚–30˚
30˚–50˚
50˚–70˚
Position of L4 disk
Above the line of the iliac crests
At the height of the iliac crests
Below the line of the iliac crests
Position of the promontory in the pelvic girdle
Eccentric (dorsal)
At the center
At the center or ventral
Shape of L5 vertebra
Rectangular
Trapeze shaped
Trapeze shaped
Shape of L5 disk
Rectangular and higher than L4
Wedge shaped and thinner than L4
Wedge shaped and thinner than L4
Segment with maximum mobility
L5/S1
L4/L5
L4/L5
Effect of iliolumbar ligament
Slight fixation of L5
Good fixation of L5
Good fixation of L4 and L5
Weight-bearing structure
End-plate of S1
End-plate of S1
L5/S1 joints and sacroiliac joint
Spinal curvature
Flat
Average
Considerable
X-ray statics
Promontory and hip joints lie in front of plumb line for head
Promontory and hip joints almost on line of plumb line for head
Promontory and hip joints lie behind plumb line for head
Clinical signs
Hypermobility, pathological changes of L5 disk; ligament pain
Restrictions, pathological changes of L4 disk
Arthroses of L5/S1, sacroiliac joint and hip
found to be higher than on the contralateral side, and vice versa. The ventral parts of the iliac crests behave in the same way as the anterior iliac spines. The middle portion of the iliac crests may be symmetrical, although this need not be so. On first impression it seems as if one ilium is twisted relative to the other about a frontal transverse axis, although this is in fact impossible if the pubic symphysis is intact. The functional anatomy involved can best be illustrated anatomically by Cramer’s diagram (1965) (Figure 3.12). This shows a one-sided nutation of the sacrum brought about by its rotation between the ilia around its longitudinal axis. This in turn results in rotation of one ilium about a horizontal axis and of the other about a vertical one. All attempts to visualize these changes radiographically have remained without success as far as we know. However, we have been successful in 52
Figure 3.12 • The mechanism of pelvic distortion (after Cramer 1965).
Functional anatomy and radiology of the spinal column
showing X-ray evidence of a disturbance of body statics in the presence of pelvic distortion (see Figure 3.13). The pelvis was found to be shifted toward the higher side, and there was deviation
Chapter 3
of the angle between the sacrum and the lumbar spine. This disappeared following treatment of the atlanto-occipital and atlantoaxial joints. Lewit & Rosina (1999) were able to induce pelvic distortion
Figure 3.13 • Disturbed statics in pelvic distortion. (A) With deviation between the lumbar spine and the sacrum. (B) No
improvement after insertion of support to raise the left foot. (C) Normal findings following treatment of atlanto-occipital and atlantoaxial joints.
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by rotating the head to one side and then the other, but radiographic examination showed this effect to have been a palpatory illusion.
3.3.4 The lumbar spine Although only a little shorter than the thoracic spine, the lumbar spine consists of only five vertebrae. However, in ante- and retroflexion as well as in side-bending, the corresponding motion segments play a significant part in ensuring the mobility of the trunk. Meanwhile the inferior part of the lumbar spine also carries the weight of the trunk, so the vertebral bodies and articular processes of the lumbar spine are the most robust. The joints of the vertebral arches form massive gliding surfaces that can enable considerable excursion and also provide stability. The greater part of the articular facets runs vertically, almost in the sagittal plane. Ventrally, the smaller part is turned almost at a right angle to point medially, in the frontal plane. Frequently, however, the articular facets simply form an arc, whose concave aspect faces dorsally. If the two parts do stand at right angles to each other, the joint spaces can be easily visualized by X-ray; if they form an arc, this cannot be done. Given that the joints of the vertebral arches only develop their final shape after birth, during the first years of life there is considerable variation in this respect.
The shape of the joints determines the function of the lumbar spine; it mainly allows for anteand retroflexion and tends to inhibit side-bending, which occurs in combination with rotation. The joints inhibit rotation about a sagittal axis. Just as side-bending happens in combination with rotation, so rotation of the trunk produces the effect of lateral flexion. If the joints of the vertebral arches determine the quality of the movements of the lumbar spine, its great mobility depends on the thickness of the lumbar intervertebral disks. Their thickness usually increases from L1 down to L4; consequently maximum mobility is usually found at the L4/5 segment. Only in the ‘high promontory’ pelvic type is maximum thickness and mobility found at L5/S1. Retroflexion, however, is usually most extensive in the L5/S1 segment.
X-ray anatomy of the lumbar spine The oval shadow of the pedicles of the vertebral arches are the most striking feature in the AP views of the lumbar spine (see Figures 3.14 and 3.15). The last pedicles (only) are projected onto the lateral edge of the fifth lumbar vertebra; they are also less distinct. This is partly owing to the triangular shape of the spinal canal in the inferior lumbar spine. Taking the pedicle as a starting point, it is
Figure 3.14 • Anatomical structures of the lumbar spine. (A) Dorsal aspect of the lumbar spine and sacrum. (B) X-ray: AP
projection. (C) Ventral aspect of the lumbar spine and sacrum. 1, Spinous process; 2, superior articular process; 3, lamina of the vertebral arch; 4, pars interarticularis; 5, joint space; 6, inferior articular process; 7, glimpse into the spinal canal; 8, posterior superior iliac spine; 9, dorsal part of the sacroiliac joint; 10, intervertebral disk; 11, transverse process; 12, vertebral body; 13, pedicle; 14, ventral part of the sacroiliac joint.
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Figure 3.15 • Schematic drawing of the AP X-ray view of a lumbar vertebra (after de Sèze et al 1969).
Chapter 3
possible to identify the lamina of the vertebral arch and trace it along to the spinous process. Lateral to and above the pedicle we find the superior articular processes; from the vertebral arch downwards and below the pedicle, the inferior articular processes can be traced in a caudal and lateral direction toward the superior articular processes of the next vertebra below. The two inferior articular processes form an arch; this, together with the spinous process of the caudal neighboring vertebra, forms a frame around a lucency which offers a glimpse into the spinal canal. At this point the canal is not covered by bone, and this is the location where lumbar puncture can be performed. Where both articular processes meet is the joint space. It is possible to see into the joint space if part of it is aligned in the sagittal plane. The lateral view (see Figure 3.16) also shows the thick pedicles, situated immediately behind
Figure 3.16 • Anatomical structures of the lumbar spine. (A) Lateral view. (B) Lateral view (X-ray). 1, Pedicle; 2, pars interarticularis; 3, inferior articular process; 4, superior articular process; 5, joint space; 6, intervertebral foramen; 7, transverse process.
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the bodies of the vertebrae. The superior and inferior articular processes arise from the pedicles. It is often also possible to see the joint space if the medial part of the joint lies in the frontal plane. Between the superior and inferior articular processes is the pars interarticularis (pars isthmica), which tends to be the site of spondylolysis in true spondylolisthesis. Between the pedicles of adjacent vertebrae can be seen the intervertebral foramen, dorsal to the vertebral bodies and intervertebral disk and bordered dorsally by the articular processes. It lies almost exactly in the frontal plane, and its width is almost that of the spinal canal. The lamina is covered by the articular processes, and dorsal to these can be seen the massive spinous processes. The transverse processes are projected onto the articular processes, appearing as a thick shadow. The fifth (last) lumbar vertebra occupies a special position in that it serves a transitional function between the mobile lumbar spine and the rigid pelvis. In terms of its shape, it is therefore adapted to the base (craniad end) of the sacrum. In the lateral view, the vertebral body of L5 is trapezoid. An important point to note is that the powerfully developed transverse processes of L5 – often resembling the pars lateralis of the sacrum – provide attachment to the iliolumbar ligaments, which stabilize the last lumbar vertebra in the pelvis. L5 therefore plays a part in the shock-absorbing function of the pelvis. The intervertebral foramen of L5 is usually narrower than the others of the lumbar spine, despite the generally powerfully developed pedicle of L5. This vertebra is usually considerably inclined, so the L5/S1 joints usually lie in the frontal plane, to prevent forward gliding. The most important anomalies of the lumbosacral junction have already been dealt with under ‘pelvic types’ (see Section 3.3.3). When there is a transitional vertebra, it can be difficult to decide whether this is a sacralized L5 or a lumbarized S1. It is especially difficult if the image shows six vertebrae with lumbar characteristics and the task is to decide whether the last is indeed a lumbar vertebra or a lumbarized sacral vertebra. In cases where a neurosurgical intervention is to be carried out, this decision can be very important. The most reliable criterion to use is an imaginary line drawn between the two iliac crests: this line usually corresponds to the fourth intervertebral disk (see Figure 3.17). If, however, this line projects across the middle of a vertebral body, the 56
Figure 3.17 • High promontory pelvic type with obliquity at
L4, left scoliosis, and rotation. Here the line between the two iliac crests runs level with the L5/S1 disk.
identification becomes well-nigh impossible, unless an X-ray of the thoracic spine is also available. Sometimes, instead of the massive transverse process of L5, a transitional lumbosacral vertebra may have a pars lateralis which forms a pseudarthrosis with the pars lateralis of S1, and may even cause clinical symptoms. The most serious anomaly, clinically, is probably spinal canal stenosis. In the lateral view the usual finding shows massive vertebral bodies with short, stubby pedicles and markedly narrow intervertebral foramina. The line of the inferior articular processes is noticeably steep. In the AP view the massive appearance of the articular processes is striking, it is possible to see clearly into the joint space, and the lucency between the inferior articular processes below the spinous process is particularly narrow. The effect is to give the spinal canal a trefoil shape. CT offers the best insight into the anatomical relations in the spinal canal; it can also visualize the narrow lateral recesses and the narrowed, trefoilshaped spinal canal. A narrow spinal canal adversely affects root compression and is often accompanied by radicular claudication. It is of course important to be able to assess the thickness of the intervertebral disks correctly. Straightforward disk hypoplasia is a quite common anomaly, and should not be confused with disk
Functional anatomy and radiology of the spinal column
Figure 3.18 • The anterior inferior border of the vertebral
body of L5 is lower (arrow) in relation to the sacrum on the left side than on the right. The L5/S1 disk is therefore narrower on the left. There is compensatory lumbar scoliosis with marked rotation.
degeneration. This is especially true in the case of an L5 transitional disk. If this vertebra shows no signs of degenerative changes and no shift that might indicate laxity, the practitioner should not be too hasty in diagnosing a narrow disk as degeneration. A useful sign of disk hypoplasia is a finding that shows abbreviated end-plates either side of a narrow disk. Although we usually rely on lateral views for the assessment of disks, marked asymmetry in the AP view can be a useful sign, particularly for the L5/S1 disk, where anomalies are frequently found (asymmetrical L5/S1 disk, see Figure 3.18).
Evaluation of function from X-rays In order to evaluate radiographic films from the point of view of function, they must be taken under standard conditions. The film must be taken with the patient standing erect, and if possible using the technique described in Section 3.3.1. A functional evaluation of the lumbar spine can only be done if the pelvis, hip joints and pubic symphysis are included on the film. A 30 × 40 format is therefore recommended for both projections, so that the entire sacrum and hip joints can also be seen
Chapter 3
in the lateral projection. A focus-film distance of at least 1.5 meters is needed to keep distortion to a minimum. Careful assessment of rotation can be important, because rotation is to some extent related to scoliosis and the degree of lordosis; if the relationship is disproportionate, this can be a sign of dysfunction. Rotation of a vertebra is recognized by a deviation of the spinous process and the pedicles in the direction opposite to that of rotation. On the side of rotation the pedicle appears wider and it is easier to see into the joint space; the transverse process is slightly shorter (because it is nearer the cassette). Deviation of the spinous process alone should never be taken to be a sign of rotation; absence of the other criteria, especially the corresponding asymmetry of the pedicles and the row of transverse processes, etc., indicates that the deviation observed is simply asymmetry and not rotation. Scoliosis should always be assessed according to the principles of body statics. The lateral view is used to assess lordosis, kyphosis and ventral or dorsal shift. If an apparently blocked position is found, this can also be significant. Slight shifting (ventrally or dorsally) is a sign of instability. This may become more marked during ante- or retroflexion. However, very slight, proportional shifts in ante- or retroflexion, especially in young patients, may be normal. There are two potential pitfalls to beware of: 1. Incongruence of the end-plates of two adjacent vertebrae, most frequently observed between L5 and S1 in the lateral view. In such cases the superior end-plate of S1 is usually slightly longer than the inferior endplate of L5, and the shift that is observed can be seen either only at the dorsal or ventral edge of the adjacent vertebra. 2. Slight rotation in patient positioning: here the shadows of the anterior and posterior borders form a double contour which can be mistaken for a shift. Slight shifts due to hypermobility or slight instability need to be distinguished from true spondylolisthesis (with spondylolysis) and from degenerative ‘pseudospondylolisthesis or spondylotic listhesis’ as described by Junghanns (1930), in which the superior articular process of the adjacent vertebra below (most frequently L5) is bent in the ventral direction, so that the vertebra above it (usually L4) glides ventrally over it. 57
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Radiographic movement studies Films taken in erect posture may not always provide any clues to disturbed function, which only becomes evident in movement studies. These are usually performed to study ante- and retroflexion and side-bending. In the normal case, movement is fluid and all segments of the lumbar spine participate. Where there is disturbed function, it is possible to distinguish segments of reduced or increased mobility. We find a sign of reduced mobility at a block vertebra position, and the segment concerned does not participate in the movement. Where there is increased mobility, local ventral or dorsal shifts may be observed in ante- and retroflexion. In young and hypermobile subjects, slight step-like shifting of vertebrae and shifting that occurs to an equal degree in all segments may be considered normal (Jirout 1956). Even the formation of an exaggerated sharp bend is a sign of local hypermobility. However, if this sharp bend is accompanied by a ventral narrowing of the disk in anteflexion, without a corresponding dorsal widening, this is indicative of a disk lesion. The same can be said if it is accompanied by dorsal narrowing of the disk without a corresponding widening ventrally (Jirout 1965). In the lumbosacral segment a ‘paradoxical’ shift sometimes occurs; instead of the ventral shift in anteflexion and dorsal shift in retroflexion that is observed in the other segments, there is a ventral shift during retroflexion and dorsal shift during anteflexion (Jirout 1957). This presumably occurs as a kind of leverage mechanism. Movement studies are mainly indicated where there is a clinical reason for doing so; usually where particular movements give rise to symptoms. These studies are particularly important in order to find out whether or not spondylolisthesis is already fixed. In side-bending, the main object is to look for asymmetry and to assess the relationship between flexion and rotation.
3.4 The thoracic spine 3.4.1 Functional anatomy The thoracic spine is the longest section of the spinal column, but also the one with the least mobi lity. The main reason for this is its firm, though 58
jointed, connection to the relatively rigid thoracic cage. The narrowness of the intervertebral disks is the morphological expression of this minimal mobility. In the frontal plane the joint spaces are almost vertical, but laterally they fall away anteriorly, as if on the periphery of a circle (cylinder) whose center is ventral to the vertebral body. This arrangement would allow for considerable rotation in the thoracic region were it not for the ribs and the intervertebral disks. Side-bending, and to some degree also anteflexion, are similarly limited by the thoracic cage. Anteflexion is also held in check by the tension of the inter- and supraspinal ligaments. Retroflexion is limited mainly by the articular and the spinous processes, which overlie each other in the manner of tiles on a roof. At a certain point in retroflexion this arrangement therefore obstructs bending in this direction.
Transitional regions One important reason for the significance of the thoracolumbar junction is that there is a sudden change in joint structure occurring in the region of a single vertebra (T12): whereas the articular processes above this point are those of the thoracic spine, those below it have the form and mechanical features of the lumbar spine. During walking on the spot, the thoracolumbar junction acts as a fixed point, where scoliosis of the lumbar spine to one side changes to scoliosis of the thoracic spine to the opposite side. The anatomists’ view that trunk rotation takes place mainly in the thoracolumbar junction was refuted by Singer & Giles (1990). They demonstrated directly by means of CT during trunk rotation that the rotation occurring in this segment was hardly any greater than that in the neighboring thoracic and lumbar motion segments. We confirmed these findings using AP films of trunk rotation taken in the sitting position with fixed pelvis. We demonstrated that scoliosis with rotation occurs in the entire lumbar spine (see Figure 3.19).
Just as side-bending (scoliosis) of the trunk is combined with rotation, so rotation of the trunk is accompanied by side-bending. In principle, movement of the spine occurs by coupled movements in all three planes.
Functional anatomy and radiology of the spinal column
Chapter 3
The ribs
Figure 3.19 • Right rotation with right lumbar scoliosis
during right rotation of the trunk in the sitting position, with fixed pelvis.
Another transition region which is commonly the site of dysfunctions is the cervicothoracic junction down to T3/T4; this is where movements of the head and neck end, as is most clearly seen in ante- and retroflexion. The same is true for sidebending and rotation, though it is evident only in erect posture. One possible reason for the frequency of dysfunctions in this region may be that it is the point of transition between the most mobile section of the spine and the least mobile section. Another is that this is the site where the powerful muscles and tendons of the upper limbs have their origin. The middle thoracic spine is an important transitional region, because this is where the cervical erector spinae muscle ends and the lumbar portion of the muscle begins. Around T5, therefore, the apex of the thoracic curvature of the spine, is the weakest point of the muscles of the back. All transitional regions are rich in anomalies. There may be rudimentary ribs at T12 or lumbar ribs at L1; cervical ribs at C7 or enlarged transverse processes at C7 are quite common. It is rare, on the other hand, for the first rib at T1 to be absent. The uncinate process at C7 may sometimes be absent on one or both sides.
The ribs articulate with the vertebrae at the costovertebral and costotransverse joints. The head of the rib articulates with the superior border of the body of the corresponding vertebra and with the inferior border of the next vertebral body above. The tip of the head of the rib (crista capituli) is attached to the intervertebral disk by ligaments. The third rib therefore articulates with the bodies of T2 and T3, and is attached to the T2 intervertebral disk. Exceptions to this rule are the first rib, which articulates exclusively with the body of the first thoracic vertebra, and the last two floating ribs, which are attached simply by a syndesmosis to the rudimentary transverse processes of the corresponding last thoracic vertebrae. Rib movement occurs about an axis running from the head of the rib through the neck of the rib to the costotransverse joint. In the upper thoracic spine, this axis is horizontal in the frontal plane. The movement about this axis causes the thorax to rise and fall and the sternum to undergo a pumping motion. In the inferior thoracic spine, the axis runs in an oblique, laterodorsocaudal direction, and produces a wing-like movement. At the last floating ribs there is no joint, so there will be no motion restriction here. If pain occurs here it is due to muscle attachments, especially that of the quadratus lumborum. The articulation between the ribs and sternum is often painful; this too is usually due to muscle attachments with TrPs in the pectoralis and scalene muscles.
3.4.2 X-ray anatomy of the thoracic spine X-ray imaging of the thoracic spine demonstrates the structural details less clearly than imaging of the lumbar spine. In the AP view (see Figure 3.20) the vertebral bodies, pedicles, and spinous processes can be clearly seen. The joint spaces are not visible because they lie in the frontal plane; the laminae of the vertebral arches and the superior and inferior articular processes can also not be seen. The spinous processes are angled downward. As a result, from about T4 to T10 the tip of the spinous process is projected onto the body of the next vertebra below. The characteristic feature of the thoracic spine is the costovertebral joint. The head of the rib can 59
Manipulative Therapy
Figure 3.20 • Anatomical structures of the thoracic spine. (A) AP radiograph. (B) Dorsal aspect of the thoracic spine. 1, Spinous process; 2, pedicle; 3, rib; 4, transverse process; 5, costotransverse joint.
be seen in close contact with the intervertebral disk and, laterally to it, the neck and tubercle of the rib are superimposed on the transverse process. The costotransverse joint space usually runs at a steep angle from dorsocranial to ventrocaudal, so is difficult to visualize much or at all. Sometimes, especially in the lower thoracic region, the joint space runs more dorsoventrally and horizontally, and is then easily seen. In this case the superimposed rib lies approximately on the transverse process. The first rib articulates only with the first thoracic vertebra. The two last ribs only contact the rudimentary transverse processes of the last thoracic vertebrae. The sternum and sternocostal joints are not generally visualized when the usual technique is used. In the lateral view (see Figure 3.21) the ribs and structures of the lungs are superimposed on the vertebral bodies and disks. At the vertebral arches this superimposition is still more troublesome. Nevertheless, if the film is technically successful enough to give good visualization, the pedicles and intervertebral foramen are easily seen. The foramen opens ventrally at an angle of approximately 15° to the frontal plane, but there need be little distortion 60
if the lateral projection is set up accurately. The joint space and articular processes are clearly visualized. The ribs are superimposed on the laminae and the greater part of the spinous processes, although the tips of the spinous processes can be seen if the image is good. The superior portion of the thoracic spine (approximately above T3) is completely hidden in the lateral projection and can only be demonstrated using oblique views or by tomography. It can sometimes be difficult to identify which thoracic vertebra is which in the lateral view, as T1 cannot be seen and it is hard to be sure of identifying T12, because the last rib can sometimes be rudimentary. It is therefore useful to look for the inferior angle of the scapula (which is usually at the level of T7), the bifurcation of the trachea (approximately at T5), the arch of the aorta (level with T4), and the dome of the diaphragm (usually level with T10).
3.4.3 Evaluating functional aspects The curvatures of the spine are important here as they are in all sections of the spinal column.
Functional anatomy and radiology of the spinal column
Chapter 3
Figure 3.21 • Anatomical structures of the thoracic spine. (A) Lateral aspect of the thoracic spine. (B) Radiograph, lateral
view. 1, Inferior articular process; 2, joint space; 3, superior articular process; 4, intervertebral foramen; 5, pedicle; 6, rib; 7, transverse process.
Scoliosis and increased kyphosis are the most frequent findings. It is always useful to know whether the curvatures are in static equilibrium. For this, the films must be taken under static conditions. It is important to note that the greater the curvature, the less the mobility and the greater the stability. Conversely, if the curve is flat, this indicates hypermobility and a tendency to instability. Dysfunctions may be associated with rotation, in which a sudden deviation is found in the line of the spinous processes (see Figure 3.20). The asymmetrical position of the spinous process is insufficient on its own to enable a diagnosis of rotation to be made; for this, there must also be a shift in the position of the pedicles in the same direction (see Figure 3.22). In the lateral view of the thoracic spine it is rare to see shifts between two adjacent vertebrae, or a lordotic or kyphotic deviation between neighboring vertebrae in cases of simple dysfunction. Kyphotic deformity, on the other hand, whose cause is morphological, does frequently occur here in the
Figure 3.22 • Schematic drawing to illustrate rotation of a vertebra.
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context of juvenile osteochondrosis (Scheuermann’s disease), following a traumatic compression fracture, or as a consequence of osteoporosis. Dysfunctions of the ribs can be recognized by changes in the spaces between them.
3.5 The cervical spine The cervical spine is the most mobile section of the whole spinal column; it is also the most vulnerable. This region is the richest in afferent proprioceptive nerves, which exercise an effect on the entire locomotor system. Dysfunctions here are therefore particularly important, and their treatment is correspondingly rewarding.
3.5.1 X-ray technique A suitable and effective technique is essential in order to obtain pictures that can be evaluated for function. The usual technique, which usually produces very poor visualization of the upper portion of the cervical spine in the lateral view and does not visualize it at all in the AP one, is not even adequate for morphological diagnosis and is completely useless for the evaluation of function. The Sandberg–Gutmann technique (Sandberg 1955) (see Figure 3.23A) best meets the requirements for a successful image in the AP projection. For this,
the patient is supine. Positioning is done using the following technique, so as to represent the patient’s posture accurately: the patient begins by sitting on the X-ray table, intergluteal cleft exactly on the midline of the table and legs extended, symmetrically side by side. Only then is the patient requested to lie down. Ask your patient to do so without use of the arms, looking straight ahead and in a completely natural manner. To check that the finding is representative rather than chance, this procedure may be repeated. If the head regularly deviates to one side, this must not be corrected; instead you should adjust the cassette and the X-ray tube accordingly. If you correct the head position you might either correct or artificially produce cervical scoliosis and at the same time induce axis rotation and lateral deviation of the atlas. The film format used is either 18 × 24 cm or 15 × 40 cm; it can be helpful to include the upper thoracic spine as well. Position the cassette so as to be able to assess the upper margin of the foramen magnum, the front incisors and, caudally, at least T1. This is usually achieved when the upper edge of the cassette is aligned slightly craniad to the patient’s external ear. Ask the patient to open her mouth as wide as possible and place a cork between her front teeth. The patient should then draw in her chin until the forehead (glabella) and upper lip (filtrum) are on the same horizontal plane. For this, a pillow beneath the head is often necessary, except when the patient is a child.
Figure 3.23 • X-ray technique for the cervical spine according to Sandberg–Gutmann. (A) Alignment of the central ray for the AP projection with the aid of a string. (B) Alignment for the lateral view of the cervical spine.
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Now the X-ray tube can be centered. The central ray must be aligned through a point one finger’s breadth below the upper premolars to a point one finger’s breadth above the palpable inferior border of the occiput (posterior margin of the foramen magnum) in the midline. Either a light field indicator or a piece of string running from the center of the focal spot to the appropriate position on the patient’s face can be used for this alignment. The X-ray tube is then aligned so that the line of the central ray is an extension of that of the string (or light) (see Figure 3.23A). For edentulous patients, the central ray is aligned through a point one finger’s breadth below the maxilla to the border of the occipital squama, and in infants who do not yet have teeth, from the inferior border of the maxilla to the border of the occipital squama. Finally, correct any rotation of the patient’s head since this would make the film hard to evaluate. This projection can also be taken with the patient seated, aligning the beam in an analogous manner. This approach is slightly more difficult but has the advantage of being performed under static conditions. Nevertheless, there can be an advantage in having taken the AP projection with the patient supine and the lateral one with the patient seated, if the findings reveal discrepancies. It is always possible then to perform an additional AP view taken in the sitting position. One objection to the open-mouth technique is that the mandible is superimposed on the mid-cervical spine. This problem can be avoided if the patient rapidly opens and shuts her mouth while the film is being taken; in this way the shadow of the mandible is blurred. The risk in this case is that there will be slight associated movement of the head, which might cause blurring of the image at the craniocervical junction. For the lateral view the patient is seated relaxed in front of a vertical stand (see Figure 3.23B). The film may be 18 × 24 cm or 24 × 30 cm, and must be placed so that the image demonstrates the cranial base as far as the sella turcica, and the cervical spine down to the cervicothoracic junction. In subjects with very tapering shoulders it will also be possible to include the first thoracic vertebra. The patient’s gaze should be fixed on a distant object at eye level, maintaining the hard palate horizontal. Take care that there is no inclination or rotation of the patient’s head, so that the two mandibles are exactly superimposed. This is necessary for accurate assessment of the film. Do not align the central ray on the mid-cervical region as is usually done, but on the tip of the mastoid process. The light field indicator can be used for this. It is best to use a film-focus distance of
Chapter 3
1.5 meters or more. This produces an undistorted image of the cranial base and the entire cervical spine and also evens the exposure; the density of the cranial base means that it demands more irradiation than the cervical spine.
X-ray films of the cervical spine that do not provide good visualization of the atlanto-occipital and atlantoaxial joints and cranial base and of the cervicothoracic junction are inadequate for the evaluation of function.
3.5.2 Assessment of X-ray films The technique described here provides sufficient criteria to evaluate all the images and to repeat them for comparison, even if all structures are asymmetrical. In the AP projection (see Figure 3.24) the first task is to make sure that both
Figure 3.24 • Anatomical structures of the craniocervical
junction, anteroposterior view. 1, Inferior border of the clivus; 2, foramen magnum; 3, occipital condyle; 4, inferior border of the anterior arch of the atlas; 5, lateral triangle; 6, foramen transversarium of the axis; 7, inferior contour of the occipital squama; 8, medial lucency of the atlas; 9, transverse process of the atlas; 10, inferior border of the posterior arch of the atlas; 11, pedicle of the arch of the axis; 12, lamina of the axis (superior border).
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occipital condyles, the atlas, and the axis are well visualized, and whether it is possible to look into both foramina transversaria (which give passage to the vertebral artery). At the caudal end, ensure that at least the first thoracic vertebra is included in the image. Next the centering should be checked, to make sure that the image is straight. If the positioning is correct, the middle point between the incisors should be vertically in line with the middle of the dens of the axis and of the occipital squama. The tip of the chin will be projected onto the middle of the cervical spine, which must run symmetrically between the two rami of the mandible. The position of the mastoid processes should also be symmetrical. In order to evaluate the inferior part of the cervical spine, it is necessary to ensure that the superior thoracic spine is not rotated. In the lateral projection (see Figure 3.25), first ensure that the cranial base, including the sella turcica and hard palate, can all be seen. If possible the cervical spine should be shown as far down as C7, although this is often not possible in heavily built patients or those with high shoulders. Check that the alignment is perfect before beginning to evaluate the findings on the film. It is particularly
important that the line of the hard palate should be horizontal. Fineman et al (1963) showed that a difference of only 10° in inclination of the head is sufficient to change lordotic to linear posture, or even to change it to the extent that lordosis becomes kyphosis. It is important that the two halves of the mandible should overlie each other exactly. If the vertical borders of the rami appear projected side by side, the head is rotated to one side. Projection of the horizontal line of the mandible one above the other indicates that the head is inclined to one side. Another sign of rotation is if the shoulders are projected apart. The oblique projection (for which the patient adopts a position turned at an angle of 45°) gives the clearest imaging of the intervertebral foramina. This projection is indicated especially for radicular syndromes and vertebral artery syndrome. As recommended by Gutmann (1956), this projection should be taken with the patient’s head in retroflexion, because this more clearly displays any narrowing of the intervertebral foramen. It is also recommended to take it not with the patient’s back to the cassette, but with the patient facing toward it (see Figure 3.26).
Figure 3.25 • Lateral view of the cervical spine, indicating
the plane of the foramen magnum, of the atlas and of the axis. Dotted lines indicate the clivus and basion (white), and the posterior border of the spinal canal (black).
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Figure 3.26 • Oblique view of the cervical spine showing a narrowed intervertebral foramen of C5/6.
Functional anatomy and radiology of the spinal column
3.5.3 Functional anatomy of the cervical spine The cervical spine has two distinct sections: the atlanto-occipital and atlantoaxial joints, and the rest of the cervical spine from C3 to C7; nevertheless it is a functional unity, since all the movements it performs originate at the atlanto-occipital and atlantoaxial joints, these movements being anticipated by eye movements. The anatomical description will accordingly be treated in separate sections. The function of the cervical spine will then be dealt with as a whole.
Functional anatomy of C3–C7 As in other parts of the spinal column, the degree of mobility in the cervical spine corresponds to the thickness of the intervertebral disk, which is greatest in the segments C3/C4 and C4/C5. The characteristic feature of the cervical spine is the raised lateral margins of the vertebral bodies, the uncinate processes. The disk therefore thins laterally, with the consequence that thinning of the disk brings about contact in this lateral region. This is where early degenerative changes occur, tending to form unco vertebral joints (neoarthroses). The position of these is very close to the intervertebral foramen. The significance for cervical function is that the shape of the vertebrae with their lateral margins limits sidebending and favors ante- and retroflexion. The intervertebral joints are almost parallel, inclined at an angle of about 45° from ventrocranial to dorsocaudal. The angle is greatest at C2/C3. In this segment the joints are frequently not parallel but arranged as if on the circumference of a cylinder with its center behind the vertebra; it is therefore not pathological if the joint space at C2/C3 is less clearly delineated than in the other segments of the cervical spine in the lateral projection. As a general principle, laterally the joints in the lordotic section of the cervical spine are inclined slightly posteriorly and in the kyphotic section slightly anteriorly. According to Janda (2002) the transition from the one to the other occurs roughly at C3/ C4. The inclination of the intervertebral joints in the sagittal plane means that side-bending produces rotation, the two kinds of movement being coupled. Similarly, rotation brings about side-bending, always to the same side (see Figure 3.30A and B). During anteflexion, a slight ventral shift of the cranial partner vertebra relative to its caudal neighbor is
Chapter 3
often observed. In retroflexion there is a slight caudad shift. This too is associated with the inclination of the joints. Penning (1968) describes this motion as a rotation of the upper vertebra relative to the lower one, around a frontal axis in the dorsal part of the vertebral body. Experience shows this motion to be physiological, as long as it occurs evenly in the motion segments of the cervical spine. It is regularly seen in young subjects with good mobility. If it is not observed in less mobile, older patients, this absence is not pathological. The shift is greatest between C2/C3 (see Figure 3.32 B and D) where the range of motion is least in adulthood. It is also important to note that the cervical spinal canal lengthens considerably during anteflexion, shortening during retroflexion. This produces a significant movement of the meninges and dural sheaths of the nerve roots relative to the spinal cord, which becomes longer and thinner in anteflexion and shorter and thicker in retroflexion. The course of the vertebral artery also has an important role. This enters its bony canal at C6, passing upward through the intervertebral foramina in close contact with the intervertebral joints and uncinate processes almost at right angles to the course of the nerve roots. Therefore, as the intervertebral foramen (canal) narrows in retroflexion, this may affect both the nerve root and the vertebral artery.
Functional anatomy of the craniocervical junction In order to understand function it is important to look first at the anatomy of the individual articular structures and ligaments. The superior articular surfaces of the atlas run obliquely from dorsolateral to ventromedial. The facets are oval in shape, converging anteriorly like a section of the surface of a sphere with its center located above both articular surfaces. The most important movement of the atlanto-occipital joint is ante- and retroflexion of about 16° (see Figure 3.27). Gliding of the
Figure 3.27 • Diagram to illustrate ante- and retroflexion between the occipital condyles and the atlas.
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Figure 3.28 • AP X-rays of an isolated axis: (A) in neutral position and (B–H) in various positions of rotation. These images provide a suitable reference for evaluating X-ray films.
occipital condyles occurs in the dorsal direction during anteflexion and in the ventral direction during retroflexion. Very slight rotation is also possible, which Jirout (1981) was able to demonstrate as a synkinetic movement during side-bending of the head. Slight side-bending is also possible, coupled with rotation in the opposite direction. The atlantoaxial joint is made up of the articulation between the anterior arch of the atlas and the dens of the axis, between the dens and the transverse ligament of the atlas with its articular cartilage, and between the lateral mass of the atlas and the body of the axis. Its main function is that of rotation, and it also performs ante- and retroflexion. All these articulations participate in rotation. On one side the lateral mass of the atlas glides ventrally on the body of the axis, rising as it does so, while on the other side the lateral mass of the atlas glides dorsally and downward. The rotation is limited by the joint capsules and the strong alar ligaments, which have their attachment to the margins of the foramen magnum. The average range of motion of this rotation (our own results) is 25° in each direction, although we have found a range of motion up to as much as 40° (see Figure 3.28). Dvorák, using CT, even obtained average measurements of 41.1° to the right and 44° to the left. Huguenin, on the other hand, in measurements made using CT, obtained figures corresponding to our own. 66
Figure 3.29 • X-ray film of rotation between atlas and axis. With the subject erect and head fixed, the subject’s body was turned in maximum rotation counter to the sagittal beam (here at 40° axis rotation).
Ante- and retroflexion between atlas and axis is considerable, amounting on average to 15°. The anterior arch of the atlas slides up and down on the dens of the axis, while the atlas itself performs a tipping motion (see Figure 3.29).
Kinematics of the cervical spine Rotation Rotation begins between the atlas and the axis and the movement takes place mainly there until
Functional anatomy and radiology of the spinal column
the range of motion in this segment is exhausted, that is to about 25° to each side. Up to this point the head rotates about a vertical axis in the horizontal plane. From this point onwards the other segments participate in succession in the rotation movement, from C2/C3 to C6/C7, as long as the cervical spine is in a position of slight kyphosis. If the neck is completely upright the cervicothoracic junction also rotates, down to and including T3. In passive rotation there is still some slight additional rotation between the atlas and the occiput. The moment rotation below C2 begins, the inclined course of the intervertebral joints brings about simultaneous lateroflexion to the same side unless the subject deliberately resists this synkinesis.
Side-bending Side-bending can be studied only by X-ray, hence the decision to deal with it under functional radio graphic studies (see Figure 3.30). Like rotation, it begins at the atlanto-occipital and atlantoaxial joints. This can be demonstrated by looking at the craniocervical region in passive side-bending (‘side-nodding’). This shows that side-bending starts with rotation of the axis relative to the atlas. At the same time we find a synkinesis in which the atlas shifts relative to the occipital condyles and C2 in the direction of the side-bending (see Figure 3.30C). During this side-bending the cervical spine rotates, maximum rotation occurring at C2. Jirout (1968) demonstrated that this rotation is absent in the lower cervical spine during side-bending to the right, but during side-bending to the left it continues down into the upper thoracic spine. He explains this as being due to the stronger pull of the muscles of the shoulder girdle on the right side, whose attachment to the spinous processes exerts a pull to the right and so brings about left rotation. This combination of side-bending and rotation is consistent with the positioning of the intervertebral joints, although this cannot be the true cause, as is usually thought, because the side-bending originates at the axis. This rotates even with the slightest side-bending, followed by the other segments. If rotation of the axis does not take place, there is no rotation of the rest of the cervical spine (see Figure 3.47B) According to Jirout (1968), the forces that bring about axis rotation are the product of side-bending
Chapter 3
of the head (see Figure 3.31). Side-bending of the head involves rotation of the head about a sagittal axis at the level of the root of the nose. This creates a pull on the spinous process of the axis, which causes rotation of the axis with simultaneous tipping in the sagittal direction. This tipping motion in the sagittal plane, which takes place both in side-bending and in rotation, is, according to Jirout (1968), the joint play of the cervical spine. The sideways shift of the spinous process can easily be palpated, and occurs as soon as the subject’s head inclines to the side even to a slight degree. Interestingly, Gaymans (1973) demonstrated that a shifting of the spinous process of the axis (rotation of the axis) occurs even on mere leaning against slight resistance in the neutral position and with minimum pressure, thus simply through the pull of the muscles. He obtained radiological evidence of this.
Rotation of the axis on side-bending of the cervical spine is not simply the combined result of rotation movements of the individual vertebrae, due to the inclination of the zygapophysial joints of C7, C6, etc.; on the contrary it results from the inclination of the head itself, in which the head rotates about a sagittal axis and exerts a pull on C2. If there is no rotation of the axis, there is also no rotation of the other vertebrae of the cervical spine during side-bending. At the same time there is a tipping motion in the sagittal plane, so that the movement occurs in a coupled way in all three planes.
Anteflexion and retroflexion Two distinct kinds of anteflexion should be distinguished. The first is a nodding movement limited to the atlanto-occipital and atlantoaxial joints. The other is a forward flexion involving the entire cervical spine. This distinction does not exist for retroflexion. The two kinds of anteflexion of the head are to some extent mutually exclusive. If we draw the chin in toward the chest (forward nodding), this usually inhibits full anteflexion. If we drop the head far forward in anteflexion, this renders nodding more difficult except in hypermobile subjects. The explanation lies in the tipping mechanism of the atlas. 67
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Figure 3.30 • AP X-ray of the cervical spine of a healthy subject, to compare the (asymmetrical) neutral position, active
side-bending, and passive ‘side-nodding.’ (A) In neutral position the atlas is to the right in relation to the condyles and axis; the plane of the condyles and that of the axis therefore converge on the right, with the axis rotated about 5° to the left. (B) In active side-bending to the left the atlas is still slightly to the right, and the plane of the condyles and that of the axis still converge to some extent to the right, while the axis is now more markedly rotated (about 10°) to the left. (C) In passive ‘side-nodding’ to the left, the atlas is now clearly to the left of the condyles and the plane of the condyles and that of the axis are parallel. The axis is rotated about 10° to the left. Transmission of the axis rotation to the next vertebra below can clearly be seen. (D) Diagram to illustrate the rotation of C2.
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Chapter 3
spine according to Jirout (1968). During side-bending the head inclines about a sagittal axis (x) passing through the anterior cranial fossa. The diagram shows how the cranial base, together with the occipital condyles, shifts relative to the atlas in the opposite direction to the side-bending, and how the axis, together with the lower cervical vertebrae, is brought into rotation in the direction of the side-bending, while the axis is tilted ventrally by a cranial pull on the spinous process.
atlanto-occipital and atlantoaxial joints are in maximum anteflexion. • In maximum anteflexion (see Figure 3.32C), the cervical spine is almost horizontal; there is a proportional slight ventral shift of the individual cervical vertebrae up to C2. Anteflexion between C1 and C2 is at its maximum. In contrast to the situation in the erect posture and in forward nodding there is now retroflexion of the head relative to the atlas, which can be greater than in retroflexion with the subject seated. Anteflexion of the atlanto-occipital and atlantoaxial joints is thus reduced as compared to forward nodding, closer to the degree of anteflexion in the erect posture. Consequently the angle between the clivus and dens is usually the same with the head erect as during maximum anteflexion. There is also a forward shift of the clivus (basion), together with the atlas, relative to the tip of the dens. • In maximum retroflexion with the subject seated (see Figure 3.32D), there is maximum retroflexion of the atlas (relative to the axis). Retroflexion of the cranium, on the other hand, is seldom at its maximum (it is usually very little greater than during anteflexion of the head). Here, too, we see a proportional dorsal shift of the individual cervical vertebrae from C7 to C2 and of the clivus and atlas relative to the tip of the dens. • In passive retroflexion with the subject sidelying and so without the effect of gravity (see Figure 3.32E), there is now maximum retroflexion of the head relative to the atlas, while retroflexion of the atlas relative to C2 is even less than in the erect posture. There is no dorsal shift of the basion with the atlas.
The following changes can be observed in X-ray studies of anteflexion and retroflexion (see Figure 3.32): • In the erect posture (see Figure 3.32A), the atlas is already in a position of slight retroflexion with an average angle of about 5°. • During forward nodding (see Figure 3.32B), anteflexion of the atlas increases only slightly. This movement causes an anteflexion of the head (the plane of the foramen magnum); in the erect posture the head had been in a position of anteflexion relative to the atlas. In this position the
The mechanism underlying these processes, which appear paradoxical at first sight, has been termed the tipping of the atlas. It is based on the following (see Figure 3.33): in anteflexion with the subject sitting, as soon as the center of gravity of the head shifts ventrally, the occipital condyles exert pressure on the anterior, rising part of the concave articular surface of the atlas. This causes the atlas to tip forward and downward. There is an analogous process in retroflexion with the subject sitting: the atlas tips backward. This does not happen, however, with the subject lying on one side, which explains why in this case retroflexion of the occiput relative to the atlas attains its maximum.
Figure 3.31 • Mechanism of side-bending of the cervical
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Figure 3.32 • Ante- and retroflexion of the cervical spine. (A) Erect posture. (B) Forward nodding. (C) Maximum anteflexion. (D) Maximum retroflexion. (E) Passive retroflexion.
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Chapter 3
Figure 3.33 • Diagram to illustrate tipping of the atlas: 1, in erect posture; 2, in ‘forward nodding’; 3, in maximum anteflexion; 4, in maximum retroflexion; 5, in passive retroflexion.
3.5.4 X-ray anatomy of the cervical spine Anteroposterior view The AP view (see Figures 3.34 and 3.35) shows the arc of the anterior margin of the foramen magnum,
at the cranial end of the cervical spine. Its superior border is formed by the clivus and its lateral part by the occipital condyles. Beneath the condyles lie the two articulations of the atlanto-occipital joint, meeting at an angle of about 125–130°. Below the condyles, to either side of the dens of the axis, can be seen the lateral masses of the atlas. These are wedge shaped, tapering towards their medial
Figure 3.34 • The cervical spine (ventral aspect) to enable comparison of the anatomical structures. (A) Skeleton. (B) AP X-ray. 1, Anterior margin of the foramen magnum; 2, inferior border of the anterior arch of the atlas; 3, foramen transversarium; 4, intervertebral foramen; 5, course of the vertebral artery; 6, uncinate process; 7, pedicle of the vertebral arch.
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Figure 3.35 • The cervical spine (dorsal aspect) to enable comparison of the anatomical structures. (A) Skeleton. (B) AP
X-ray. 1, Foramen transversarium; 2, inferior border of the posterior arch of the atlas; 3, lateral mass of the atlas with lateral triangle, 4; 5, joint space; 6, spinous process.
border. Close to this border we often see a medial lucency which should be interpreted as a normal finding. Laterally to the lateral mass, the transverse processes can be seen. It is sometimes possible to see into the foramen transversarium, which gives passage to the vertebral artery. The spindle-like posterior arch (broadest in its medial portion) can be traced from one transverse process to the other. It separates the ‘lateral triangle’ from the lateral mass. Sometimes the anterior arch can also be seen, projected across the tip of the dens. The inferior contour of the lateral mass forms the superior articular surface of the joint between C1 and C2. At the medial border of the joint facet of the axis there is a tiny notch marking the border of the dens. The tip of the dens usually lies well below the superior border of the foramen magnum. Just below the lateral end of the superior joint facets of the axis is the foramen transversarium. Medial to this foramen, the point-like projection of the pedicles of the axis can be seen. From here can be traced the shadow of the arch of the axis on both sides, through to the spinous process. If there is hyperlordosis it is sometimes possible to see into the spinal canal above the arch of the axis. Below the axis can be seen the typical cervical vertebrae with their characteristic uncinate process either side. This causes the intervertebral disk to be 72
much higher medially than laterally. Beneath the unciform processes lies the shadow of the pointlike pedicles. The spinous processes can be seen in the midline and the lateral contour is formed by the transverse processes. The intervertebral foramen is visible, but less clearly. Rarely, the intervertebral joint space can be seen.
Lateral view The lateral view (see Figure 3.36) offers an undistorted image of the cranial base and the atlantooccipital and atlantoaxial joints. The clivus can be followed in its entirety down from the sella turcica to the anterior margin of the foramen magnum (basion) which is situated directly above the tip of the dens. The posterior margin of the foramen magnum (opisthion) cannot always be clearly distinguished from the squama of the occipital bone; it helps to follow the posterior margin of the cervical spinal canal from caudad to craniad. Where the arc-shaped prolongation of this margin meets the occiput is the opisthion. The mastoid process frequently overlaps the condyle and atlanto-occipital joint; therefore this joint is not always visualized in the lateral view, although it is often clearly seen (see Figure 3.37).
Functional anatomy and radiology of the spinal column
Chapter 3
Figure 3.36 • The cervical spine (lateral aspect) to enable comparison of the anatomical structures. (A) Skeleton.
(B) Lateral X-ray. 1, Transverse process; 2, width of the spinal canal; 3, joint space; 4, inferior articular process; 5, intervertebral foramen; 6, superior articular process.
The plane of the foramen magnum can be established by drawing a line from the basion to the opisthion on the posterior margin of the foramen magnum. The plane of the atlas corresponds to a straight line through the middle of the anterior and posterior arches of the atlas.
The plane of the axis lies on a straight line linking the inferior border of the transverse processes and the inferior border of the spinous process. These lines are used to determine the ante- or retroflexion of the occiput, atlas, and axis (see Figures 3.25 and 3.38).
Figure 3.37 • Atlanto-occipital joint, lateral view.
Figure 3.38 • Anteflexion of the atlas (relative to the axis).
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The dens of the axis is projected just behind the anterior arch of the atlas. The tip of the dens is usually at the same level as the superior border of the anterior arch of the atlas. It should not be much above the palato-occipital line; this is the case in basilar impression. In this section of the spinal column, unlike the others, the pedicles and transverse processes are projected onto the vertebral bodies in the lateral view but not in the AP view, because here the spinal canal is wider than the vertebral bodies. The superior border of the transverse processes lies slightly above the superior end-plate of the vertebral bodies, which can cause them to appear somewhat blurred. In the lower cervical spine the shadow of the transverse processes lies more in the dorsal direction and in the superior cervical spine more ventrally; at C2 the position of this shadow of the transverse process is such that its anterior border overlies the anterior border of the vertebral body. The shadows of the articular processes and joint spaces are projected behind the vertebral bodies. If the projection is well executed, all that can be seen is a lucency, showing that the joints are essentially parallel. This need not be so at C2/C3, where it can be quite normal to see some fuzziness of outline. The posterior margin of the spinal canal corresponds to a line linking the bases of the spinous processes (posterior border of the vertebral arch) – a rule that thus also applies to the atlas, which does not have a spinous process. If, however, this shadow is absent at the atlas, this is a sign of spina bifida atlantis, a frequently-found anomaly.
3.5.5 Evaluation with respect to functional implications The most characteristic disturbance of statics in the cervical region is the forward-drawn posture (see Figure 3.39). Even when statics are normal, the centre of gravity of the head is slightly in front of its support, so that electromyographic studies reveal a slight degree of muscular activity in the nuchal muscles even with the subject in normal erect posture. As soon as there is any forward inclination (not flexion!), whether of the entire body or of the neck alone, tension can immediately be palpated in the muscles of the back of the neck. The forwarddrawn position therefore creates overload of the cervical spine and compensatory hyperlordosis at 74
Figure 3.39 • Typical forward-drawn position of the head.
the atlanto-occipital and atlantoaxial joints, and tension in the short extensor muscles of the neck. In order to demonstrate the patient’s natural posture radiographically, lateral projections should be taken with the subject seated in a relaxed manner, in a backless chair, as described by Gaizler (1973). It is important to ensure that the patient remains relaxed, with gaze fixed on an object at eye level, so that there is no anteflexion of the head despite the natural posture. We took projections of a group of 50 patients with the patients in erect posture (kneeling), and sitting both upright and relaxed. Whereas with the subject sitting upright the external auditory meatus was projected almost exactly above the anterior border of C7, in the erect posture it was 7 mm in front of C7, and sitting relaxed it was projected forward by 16 mm; in individual cases even by 5 cm. This was particularly the case where a patient’s relaxed sitting position involved lumbar kyphosis. In addition to disturbances of statics, localized irregularities can be observed. Examples of these are slight relative shifts in neighboring vertebrae or local lordotic or kyphotic deviations. In the
Functional anatomy and radiology of the spinal column
craniocervical region the atlas may be in a position of ante- or retroflexion in relation to the axis. The older expressions ‘atlas superior’ or ‘atlas inferior,’ which were adopted by chiropractors, are less appropriate because they refer to the position of the atlas relative to the occiput rather than the axis, whereas the criterion being assessed in the rest of the spine is always the position of the upper of two vertebrae relative to the one below it. The tipping of the atlas means that the atlas is usually in a slightly retroflexed position if there is cervical lordosis, with the occiput in anteflexion; if the posture is kyphotic the atlas would be in anteflexion and the occiput in retroflexion (see Figures 3.33, 3.39 and 3.40). Other frequent findings are the rotation of several vertebrae (see Figure 3.46) and, in the region
Chapter 3
of the atlanto-occipital and atlantoaxial joints, lateral shifting, an asymmetrical position of the condyles relative to the atlas, and of the atlas in relation to the axis. This is often described as a shift of the atlas to one side relative to the condyles and to the axis, which is not quite appropriate: the description should always be given in terms of the upper element relative to the lower. The description in this case would not be of the atlas to the right relative to the condyles and axis, but of the atlas to the right relative to the axis, and the condyles to the left relative to the atlas (see Figures 3.41–3.43). Isolated rotation of the atlas in relation to both the occiput and the axis is fairly uncommon. The joint space between atlas and axis is narrower on the side of rotation, the lateral triangle of the lateral mass becomes larger, the center of the posterior arch is shifted in the opposite direction to the rotation, and the lateral mass becomes larger on the side opposite to rotation. Much more frequent than rotation of the atlas is axis rotation in neutral posture (see Figure 3.44). A 5° or occasionally even 10° rotation of the axis is not unusual. Interestingly, the rotation of the axis is caudally transmitted, down to the rest of the cervical vertebrae and even down as far as the cervicothoracic junction, particularly when rotation is to the left. This can happen even in the simple case of lateral deviation of the spinous process. The mechanism clearly seems to be the same as that discussed in connection with side-bending, which brings about left rotation of the lower cervical spine and cervicothoracic junction.
Figure 3.40 • Kyphotic posture of the mid-cervical spine
with balanced body statics: the external auditory meatus and the dens of the axis are not projected in front of the anterior border of C7. The position of C7 is consistent with a flat thoracic spine.
Figure 3.41 • Diagram to illustrate the asymmetrical position of the atlas relative to the occipital condyles and the axis.
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Figure 3.42 • (A) Asymmetrical position of the atlas relative to the occipital condyles and axis. (B) After manual therapy the position is symmetrical.
Figure 3.44 • Dextrorotation of the axis. (A) X-ray. (B) Diagram.
Figure 3.43 • Dextrorotation of the atlas. (A) X-ray. (B) Diagram.
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Figure 3.46 • Rotation of the cervical spine: X-ray, lateral view. The joint spaces, articular processes and transverse processes are projected apart.
Figure 3.45 • Schematic drawing to illustrate the rotation of a cervical vertebra in the AP view.
The characteristic features of axis rotation in the AP view are the deviation and position of the pedicles and the spinous process to that of rotation. The foramen transversarium widens on the side of rotation and the joint space narrows on the opposite side. Rotation of the other cervical vertebrae is characterized not only by the deviation of the spinous process and rotation of the pedicles to the opposite side, but also by distortion of the unciform processes (see Figure 3.45). In the lateral view, the structures that usually overlap are projected apart. This applies particularly to the joint spaces,
together with the articular processes and transverse processes. At C2 one transverse process is projected in front of the vertebral body (see Figure 3.46). An important sign of static disturbance is discrepancy between the AP view taken with the patient supine and the lateral view with the patient sitting, in particular if there is rotation in the view taken sitting and none at all in the AP view with the patient supine. The cause may be an oblique plane below the cervical spine.
3.5.6 Movement studies Radiographic movement studies are used to investigate restrictions and hypermobility. X-rays are taken in ante- and retroflexion and side-bending. Rotation is less studied by this method because interpretation is difficult. 77
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The physiological reaction of the cervical spine during side-bending has been described in Section 3.5.3. The study of side-bending is useful in the diagnosis of movement restrictions. We
find that if there is no rotation of the axis, there will be none in the rest of the cervical spine (see Figure 3.47). Even if, on side-bending, an asymmetrical spinous process of the axis fails to
Figure 3.47 • (A) Neutral position. (B) Side-bending with absence of axis rotation. Rotation of the other motion segments is also absent. (C) After treatment, rotation of the axis is restored and the other motion segments now also rotate. The extent of side-bending has also increased.
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Functional anatomy and radiology of the spinal column
Chapter 3
It is not usually difficult to demonstrate a restriction of side-bending between the atlas and axis. When this is done, rotation is (also) seen to be blocked (see Figures 3.47 and 3.49). The radiological evidence of restriction in the other motion segments of the cervical spine is much more difficult to achieve. According to Jirout (1971) side-bending is accompanied by slight synkineses in the sagittal plane, consisting of ante- and retroflexion movements that can be recognized by a change in the position of the spinous processes relative to the vertebral bodies. Comparison of the films taken before and after manipulation found a more marked reaction of these synkineses in restrictions than actual side-bending as seen radiographically. To summarize: Figure 3.48 • Schematic drawing to illustrate the effect
of asymmetry of the spinous process of C2 on the caudad vertebrae during side-bending. (A) Neutral posture with spinous process of the axis to the right of the midline. (B) On inclination to the right the axis rotates to the right in the normal way, but the asymmetrical spinous process travels no further than the midline. The vertebrae below therefore remain in the central position and do not rotate.
reach any further than the midline, the rest of the cervical spine will not rotate. This demonstrates that the rotation is transmitted through the spinous processes in a caudal direction. Lack of rotation in the lower cervical spine does not in any way impair rotation above the restriction (Jirout 1972) (Figure 3.48). Although lateral shifting of the atlas occurs in side-bending, this shifting can sometimes be absent without implying any movement restriction, especially if there is marked asymmetry. More importantly, the shifting may still be seen in the radiographic image even in cases where there is restriction. If there is restriction blocking axis rotation, no side-bending occurs at the atlanto-occipital and atlantoaxial joints (see Figure 3.49). This is in keeping with the fact that in cases of atlas assimilation, side-bending at the craniocervical junction occurs in the normal way. This raises the question as to whether restriction between occiput and atlas on side-bending can be demonstrated radiographically at all. We have shown this to be possible (Lewit & Krausová 1967) with the head rotated to the side, locking the atlas/ axis motion segment. This is necessary to obtain an accurate diagnosis.
• Lateroflexion of the head against the cervical
spine (side-bending; ‘side-nodding’) is mainly performed by means of rotation of the axis relative to the atlas. Normalization of sidebending at the atlanto-occipital and atlantoaxial joints also normalizes this rotation. • Lateroflexion between occiput and atlas can be established radiographically and clinically only if the more mobile segment (C1/C2) is locked, that is if the head and atlas are rotated by at least 45°. The movement restriction between occiput and atlas does not affect sidebending in the frontal plane or the synkinesis between occiput and atlas during side-bending in the sense of a lateral shift accompanied by simultaneous rotation of the axis. • Ante- and retroflexion is the movement most frequently examined by X-ray. The disadvantage of this examination from the point of view of manipulation therapy is that this is the movement most frequently and preferentially performed and so the least susceptible to dysfunction. Hypermobility, on the other hand, is more readily revealed here. This can reveal increased shift between neighboring vertebrae, increased lordosis or kyphosis between neighboring vertebrae, and the following signs of hypermobility at the craniocervical junction: - Laxity of the transverse ligament of the atlas and a widening of the joint space between the anterior arch of the atlas and the dens of the axis, especially the superior part (see Figure 3.50). As a consequence the basion also shifts anteriorly. During anteflexion the distance between the anterior arch of the atlas 79
Manipulative Therapy
Figure 3.49 • Restriction of side-bending between atlas and axis. (A) In the neutral posture the position of the atlas is
slightly asymmetrical, to the left relative to the condyles. (B) On attempted left lateroflexion there is almost no side-bending at the craniocervical junction, although the atlas has moved markedly to the left. (C) After manipulation, normal lateroflexion is restored, with (slight) rotation of the axis. (D) Spontaneous side-bending to the left; position analogous to (C) with acute cervical myalgia.
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Functional anatomy and radiology of the spinal column
Chapter 3
Figure 3.50 • Increased distance between the anterior
arch of the atlas and the dens of the axis, especially in the superior part, with anterior shift of the basion.
and the dens and the angle between the clivus and the dens decreases. This happens not only on forward-nodding, but also anteflexion (see Figure 3.51). - Hypermobility between the occipital condyles and the atlas without laxity of the transverse ligament of the atlas can be recognized by a shift of the basion and opisthion in relation to the dens of the axis (see Figure 3.52).
Figure 3.52 • Hypermobility between the occiput and
atlas during ante- and retroflexion of the head. (A) During anteflexion, the basion lies above the anterior arch of the atlas and the opisthion above the posterior arch. (B) On retroflexion the occiput is shifted posteriorly by about 2 cm.
Figure 3.51 • Hypermobility of the atlas on anteflexion of the head with slackening of the transverse ligament of the atlas.
(A) Neutral posture. The articular facet of the anterior arch of the atlas lies parallel to the dens of the axis. (B) On maximum anteflexion the anterior arch of the atlas and dens of the axis create a gap that is open cranially, the basion shifts anteriorly, and the angle between the clivus and dens (obtuse) becomes noticeably smaller than in the neutral posture.
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3.5.7 Morphological changes It is not the task of this book to deal in detail with morphological and structural changes; nor is it necessary to do so, since this field forms the subject of textbooks of radiology and orthopedics. Therefore only certain aspects, the limited number of those that are particularly important from the point of view of manual medicine, are touched on here.
Anomalies Block vertebrae Block vertebrae lead to a compensatory hypermobility in the neighboring segments. The coalescence may be complete or partial, or sometimes simply consist of a hypoplastic intervertebral disk, in which case the vertebral bodies adjacent to the hypoplastic disk are narrower (see Figure 3.53). This occurs because the adjacent end-plates – between which the hypoplastic disk lies – are also the zone of
growth. This anomaly could easily be confused with the consequences of childhood rheumatoid arthritis (Still’s disease). The difference lies in the obliteration of the joints, while the vertebral arches and spinous processes are normally developed.
Cervicothoracic transitional vertebra A transitional C7 cervicothoracic vertebra with a very large transverse process or with a cervical rib is another frequent anomaly. There may also be an absence of the unciform process on one or both sides. A transitional T1 vertebra is however rare.
Spinal canal stenosis A narrow spinal canal is particularly important clinically, because it is the most important cause of cervical myelopathy. From the practical point of view in diagnosis it is more helpful to look at the change in the proportions of the individual anatomical structures than to measure the sagittal diameter of the spinal canal; the proportions of the structures can be seen at first glance. Normally, in the cervical spine, the spinal canal is wider than the vertebral bodies. In spinal canal stenosis this is not so; also (if there is no rotation in the radiograph) the articular processes overlie the entire width of the spinal canal (see Figure 3.54).
Figure 3.53 • Incomplete block vertebra (congenital
coalesence) of C5/C6 with a hypoplastic intervertebral disk and narrowing of the vertebral bodies in the region of the narrowed disk. The articular processes and vertebral arches are normally developed.
82
Figure 3.54 • Spinal canal stenosis. The spinal canal
is markedly narrower than the vertebral bodies, and the articular processes cover its entire width.
Functional anatomy and radiology of the spinal column
Basilar impression As a region of transition, the craniocervical junction, the region of the atlanto-occipital and atlantoaxial joints, is the site of many anomalies. Probably the most important of these is basilar impression (see Figure 3.55), which is the result of hypoplasia of the basiocciput. In this condition the occipital part of the clivus is shortened and therefore the dens axis appears as if shifted into the foramen magnum, so as to lie above the palato-occipital line in the lateral view (see Figure 3.55A). In the AP view the dens can be above the occipital condyles, placing it
Chapter 3
well above the line between the mastoid processes and digastric muscles (see Figure 3.55B). At the same time the foramen magnum may be narrower than usual, unless there is also an Arnold–Chiari malformation, in which case displacement of the tonsils of the cerebellum below the foramen magnum has the effect of widening it. These changes can cause syndromes associated with compression of the medulla oblongata, similar to those of spinal canal stenosis in the cervical region. Frequently basilar impression is accompanied by hypoplasia or assimilation of the atlas to the occipital bone and its condyles. Less frequently there can
Figure 3.55 • Basilar impression. (A) The lateral view shows hypoplasia of the clivus, and the dens high in the foramen
magnum. (B) In the AP view the dens of the axis is again seen in a high position. (C) Diagram: a, sphenoid part of the clivus; b, occipital part of the clivus; c, palato-occipital line; d, distance (according to Klaus 1974) of the dens of the axis from a line joining the tuberculum sellae and the internal occipital protuberance; e, plane of the foramen magnum.
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be a block vertebra involving coalescence of the axis with a lateral mass of the atlas. All the anomalies listed here are frequently asymmetrical, so that lateral displacement of the atlas and also rotated positions of the axis can be found simultaneously. In addition there can also be hyperlordosis. It is therefore little wonder that these anomalies often also lead to dysfunctions which in turn cause pain.
Hypoplasia of the dens of the axis Hypoplasia of the dens or especially the os odontoideum leads to pathological instability (see Figure 3.56). Another anomaly deserving of mention is reclination of the dens (Gutmann 1981), which results in retroflexion of the atlas and therefore places increased strain on the transverse ligament of the atlas during head anteflexion.
Figure 3.56 • Os odontoideum, lateral view in neutral position (B). Pathological shift of the atlas relative to the axis (A) during retroflexion and (C) during anteflexion.
Figure 3.57 • Spondylarthrosis in a case with a horizontal course of the articular facets. (A) Joint spaces well visualized
in the AP projection as a result of the horizontal direction of the beam; also the condensation. (B) The lateral view provides clear evidence of the horizontal course; the condensation and extension of the articular processes can clearly be seen.
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Chapter 3
Degenerative changes Degenerative changes can be of clinical significance, especially if they affect the intervertebral foramen, if they are closely associated with the nerve root and the vertebral artery, or if they cause additional narrowing of an already narrow spinal canal. These changes mainly develop in the region of the uncinate processes when there is thinning of the disk, bringing the uncinate processes into close contact with the body of the vertebra above. This can lead to the formation of uncovertebral joints (neoarthroses) and osteophytes. Degeneration of the articular processes also has an effect on the intervertebral foramina. Arthroses of the zygapophysial joints often occur as a consequence of their horizontal position, whether this has come about as an anomaly or in the case of hyperlordosis. In such cases the joint facets, rather than the end-plates of the vertebral bodies, become the weight-bearing structures. This causes a broadening and condensation of these joints, and they can therefore be clearly seen in the AP view (see Figure 3.57) as well as the lateral view. Finally, the significance of a divergent course of the paired joints in the cervical spine needs to be highlighted. This change can clearly be seen in a well-centered lateral view. It causes rotation of the
Figure 3.58 • Difference in the inclination of the articular facets in the C3/C4 segment.
upper of two neighboring vertebrae, relative to the caudally adjacent one, during retroflexion, and consequent narrowing of the intervertebral foramen on the side of the rotation (see Figure 3.58).
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Chapter Four
4
Diagnosis of dysfunctions of the locomotor system
Chapter contents 4.1 Patient history . . . . . . . . . . . . . . . 88
4.1.1 Course of the disease . . . . . . . . 88 4.1.2 Localization . . . . . . . . . . . . . 89 4.1.3 Trauma . . . . . . . . . . . . . . . . 89 4.1.4 Load, posture, and position . . . . 89 4.1.5 Non-mechanical factors . . . . . . 90 4.1.6 Psychological factors . . . . . . . . 90 4.1.7 Paroxysmal character . . . . . . . . 90 4.1.8 The significance of patient age . . . 90 4.2 The inspection: posture . . . . . . . . . . 90
4.2.1 The dorsal aspect . . . . . . . . . . 91 4.2.2 The lateral aspect . . . . . . . . . . 91 4.2.3 The ventral aspect . . . . . . . . . . 92 4.2.4 Inspection of the seated patient . . 93 4.3 Palpation (soft-tissue examination) . . . . 93
4.3.1 Hyperalgesic zones . . . . . . . . . 93 4.3.2 Subcutaneous tissue and fasciae . 94 4.3.3 Trigger points . . . . . . . . . . . . 94 4.3.4 Periosteal pain points . . . . . . . . 96 4.3.5 Radicular syndromes . . . . . . . . 96 4.3.6 Conclusion . . . . . . . . . . . . . 100 4.4 Mobility testing . . . . . . . . . . . . . . 100
4.4.1 Active mobility . . . . . . . . . . . 100 4.4.2 Movement against resistance . . . 100 4.4.3 Passive mobility . . . . . . . . . . 100 4.5 Examination of the pelvis . . . . . . . . . 101
4.5.1 Screening examination . . . . . . 101 4.5.2 Pelvic obliquity . . . . . . . . . . . 102
4.5.3 Pelvic distortion . . . . . . . . . . 4.5.4 Pelvic tilt . . . . . . . . . . . . . . 4.5.5 Restriction of the sacroiliac joint . 4.5.6 Shear dysfunction (Greenman) (upslip and downslip) . . . . . . . 4.5.7 Outflare and inflare . . . . . . . . . 4.5.8 The pelvic floor and coccygeus muscle . . . . . . . . . . . . . . . 4.5.9 The painful coccyx . . . . . . . . . 4.5.10 Ligament pain . . . . . . . . . . .
102 103 103 106 106 106 107 107
4.6 Examination of the lumbar spine . . . . . 108
4.6.1 Screening examination of active movement . . . . . . . . . . . . . 108 4.6.2 Examination of individual motion segments . . . . . . . . . . . . . . 109 4.7 Examination of the thoracic spine . . . . 112
4.7.1 Screening examination of active movement . . . . . . . . . . . . . 4.7.2 Palpation of mobility . . . . . . . . 4.7.3 Anteflexion . . . . . . . . . . . . . 4.7.4 Side-bending . . . . . . . . . . . . 4.7.5 Rotation . . . . . . . . . . . . . . .
112 113 113 114 114
4.8 Examination of the ribs . . . . . . . . . . 115
4.8.1 Screening examination . . . . . . 115 4.8.2 Examination of the first rib . . . . 116 4.9 Examination of the cervical spine . . . . 116
4.9.1 Screening examination . . . . . . 116 4.9.2 Examination of passive mobility . . . . . . . . . . . . . . . 117 4.9.3 Examination of the motion segments . . . . . . . . . . . . . . 118
Manipulative Therapy
4.9.4 Testing of mobility between occiput and atlas . . . . . . . . . . 122 4.10 Examination of the limb joints . . . . . 124
4.10.1 The shoulder . . . . . . . . . . . 4.10.2 The elbow . . . . . . . . . . . . 4.10.3 The wrist . . . . . . . . . . . . . 4.10.4 The hip . . . . . . . . . . . . . . 4.10.5 The knee . . . . . . . . . . . . . 4.10.6 The foot . . . . . . . . . . . . .
124 126 127 127 128 129
4.11 Examination of the temporomandibular joint . . . . . . . . 130 4.12 Examination of disturbances of balance . . . . . . . . . . . . . . . . . 130 4.13 Examination of muscle function . . . . 132
4.13.1 General principles . . . . . . . . 132 4.13.2 Examination of muscles with a tendency to weakness . . . . . 133 4.13.3 Examination of muscles with a tendency to shortening . . . . . 136 4.14 Examination of hypermobility . . . . . . 140
4.14.1 The spinal column . . . . . . . . 140 4.14.2 The joints of the upper limb . . 143 4.14.3 The joints of the lower limb . . . 144 4.15 Examination of coordinated movements (motor stereotypes) . . . . . . . . . . . 145
4.15.1 Examination with the patient sitting . . . . . . . . . . . . . . . 145 4.15.2 Examination with the patient standing erect . . . . . . . . . . 149 4.15.3 Movement patterns of respiration . . . . . . . . . . . . 150 4.16 Syndromes . . . . . . . . . . . . . . . . 151
4.16.1 The lower crossed syndrome . . 151 4.16.2 The upper crossed syndrome . 152 4.16.3 Stratification syndrome (according to Janda) . . . . . . 152 4.17 Retesting . . . . . . . . . . . . . . . . . 153 4.18 Dysfunctions and the course of examination . . . . . . . . . . . . . . . 153 4.19 Adjusting our thinking to the functional approach . . . . . . . . . . . 154 4.20 Chain reactions of dysfunctions and motor programs . . . . . . . . . . . . . 155
4.20.1 Function and chain reactions . . 155 4.20.2 Chain reactions in the light of developmental kinesiology . . . 157 88
4.20.3 The pathomechanisms of chain reactions . . . . . . . . . 4.20.4 Causes of chain reactions . . . 4.20.5 The role of the diaphragm . . . 4.20.6 Rotation of the trunk . . . . . . 4.20.7 Unilateral chains of dysfunction 4.20.8 Analysis of chain reactions . . .
159 160 160 161 161 161
4.21 Differential diagnosis . . . . . . . . . . 162
4.21.1 Problems . . . . . . . . . . . . . 4.21.2 Case studies . . . . . . . . . . . 4.21.3 Common differential diagnoses 4.21.4 Conclusions . . . . . . . . . . .
162 163 164 165
As in every other field of medicine, examination starts with taking the patient history. The model we shall take here is the diagnosis of vertebrogenic disturbances, which are among the most frequent type of dysfunction. Dysfunctions should not simply be diagnosed by a process of elimination; if we approach the task by ruling out all other possible causes of the lesions (especially pathomorphology) we cannot expect to arrive at helpful findings. Instead, diagnosis should be based on characteristic symptoms. Precise criteria for the patient history have been laid down by Gutzeit (1951). Following the patient history, the next step is the physical examination. There is no clinical field in the whole of our experience in which the purely clinical examination plays such a decisive role; nor does any other make such high demands as the examination of motor function. The examination begins the moment the patient enters – the very first steps into the room, the way the patient sits down, even the way the patient undresses. It is important that patients should undress for the first examination (to their underwear, since most patients feel more at ease if they can keep their undergarments on, and so move more naturally). Present-day knowledge of functional inter-relationships shows it to be essential to study the entire locomotor system at the initial examination.
4.1 Patient history 4.1.1 Course of the disease Unless we are dealing with a young patient, symptoms will usually have been present for some time;
Diagnosis of dysfunctions of the locomotor system
in most cases for years or decades, though sometimes in mild form, interspersed with periods of complete absence of pain. The frequency, duration, and intensity of the individual episodes are all relevant, but such details can often only be discovered by careful, specific questioning. For example, female patients will tend not to recall or mention low-back pain during menstruation unless specifically asked, because they consider this irrelevant. In contrast to this pattern, a short, progressive course should give rise to concern, especially if the patient is advanced in age.
4.1.2 Localization Over the course of years, pain may occur in various different parts of the spine and locomotor system; it is exceptional for dysfunctions to remain confined to a single region. Again, specific questioning is usually needed to elicit this information. Patients presenting with headache will have little idea that there might be a connection between this and their low-back pain, any more than patients with lumbago will associate this with vertigo originating from the spinal column. Patients may suffer from a number of complaints that might, if taken individually, be seen as having a variety of different causes, yet all have a common denominator in the spinal column or locomotor system. The greater the number of complaints a patient has – all of which, however different, could have a vertebral origin – the greater the likelihood that these are indeed vertebrogenic dysfunctions. This serves to confirm Gutzeit’s (1951) view that the spinal column is the link that runs like a bright red thread through a thoroughly varied list of different complaints. Vertebrogenic pain is typically asymmetrical as between sides and often unilateral. This applies both to radicular pain and to reflex, referred pain such as headache or pseudovisceral pain. The asymmetry usually increases as a patient’s condition deteriorates, and decreases as it improves. If (in the case of dysfunctions) a unilateral pain spreads to become bilateral, this does not usually indicate deterioration.
4.1.3 Trauma As has already been emphasized (in the discussion of pathogenesis), trauma is a significant factor in the etiology of vertebrogenic disturbances. If an accident features in the previous history it becomes all the more likely that the presenting complaint has a vertebral origin. Almost any kind of trauma, even if
Chapter 4
it ‘only’ affects the limbs, affects the spinal column. This is particularly so in the case of head injury. Nevertheless, it is well known that many patients tend to forget ‘minor’ injuries, serious as the consequences often turn out to be. Children who wrench their neck in an awkwardly performed somersault in a gymnastics lesson at school, or fall and sit down heavily, seldom suffer any painful consequences at the time; if they do, they compensate quickly. However there can be consequences, but they often appear very much later. It is therefore advisable not to accept straight away an answer that your patient cannot remember ever having had any accident. Instead, it should become a routine question to ask patients what sports they practice. To give a typical example: a patient who answered a direct question about injury by saying that he ‘never suffered any trauma’ replied to one about sport by saying that he had been a boxer!
4.1.4 Load, posture, and position Function and its disturbances in the locomotor system are influenced by movement, load, posture, and position, especially if the position maintained is stressful. Therefore one of the most important points in recording the case history is to discover under what conditions the pain occurs. This is not only useful in arriving at a diagnosis, but also important from the point of view of prevention. Details in the history such as these are essential, but often very difficult to discover from the patient. It does little good to ask what happened just before the onset of symptoms, because patients will give an answer based on all sorts of theories they have heard or formed for themselves. What we need to know are the circumstances in which pain was initially felt and which cause it to recur on a regular basis. Patients often find this very difficult to recall, thinking that it would not help to say, for example: ‘when I got up from my chair …’; ‘I was shaving, and when I tried to look more closely in the mirror …’; ‘… getting out of bed in the morning …’; ‘I was going to pick up a piece of paper from the floor …’; yet these are significant details. It is also important to ask which position or movement gives relief. It is important to know whether pain is provoked by sudden movements, by an extended period of sustained, strenuous effort, or by an enforced position. Even apparently irrelevant details can be important. The point that has 89
Manipulative Therapy
to be identified is whether a particular pain symptom occurs on bending slightly forward, as when working at a desk, or on maximum flexion, as when stooping to wipe a floor, or while straightening up from a stooping position. The mechanism behind the problem is very different in each case. In this context too it is necessary to find out about patients’ work and sporting activities.
4.1.5 Non-mechanical factors Dysfunctions of the locomotor system are not simply a mechanical problem, but involve every aspect that affects the reactive capacity of the body. The nervous system in particular plays a role, as can be seen in susceptibility to changes in the weather, to chills, and infectious diseases. This is especially so if these cause raised body temperature. Hormonal disturbances, the clearest effects of which are those experienced by women during menstruation, can also be important; allergy can likewise have an effect.
4.1.6 Psychological factors Since, as we know, the locomotor system is subject to human will, and pain is the most frequent symptom of dysfunction, it is hardly surprising that psychological factors play an important part. Psychological involvement in no way excludes, but rather corroborates, the diagnosis of vertebrogenic dysfunction. It must be stressed that appropriate treatment of the dysfunction is the best means of easing the pain. It also provides the practitioner with the best means of dealing with the psychological problems. It is ultimately the course of the illness that indicates how significant the psychological factor is in the particular case. The psychological problems may ease when the patient’s pain is relieved, or may persist; they may even cause relapse as a result of increased muscle tension, and an inability to relax. This is particularly the case in masked depression. One general principle needs to be stressed: we should guard against categorizing pain as psychological if patients are able to localize it accurately and if they give the same account of the symptoms each time they describe them. The conclusion we should draw in this case, assuming that no pathomorphological lesion is found, is that there is a dysfunction 90
of the locomotor system. Signs that a problem is caused by purely psychological factors are these: if the patients are unable to localize the pain, if they constantly change their account, or if they cannot describe the pain. They are often confusing their psychological suffering with the pain.
4.1.7 Paroxysmal character Gutzeit (1951) is entirely right when he describes the paroxysmal character of vertebrogenic complaints, especially if the symptoms involved are autonomic and vasomotor in nature: examples are headache, vertigo, pseudocardiac or other pseudovisceral problems. If the pain has the same, sustained intensity, for example headache, this tends to suggest another cause rather than a vertebral one. At the same time it should be pointed out that patients often speak of pain as being ‘constant’ when they are never completely free of it, although its intensity rises and falls paroxysmally with a certain frequency.
4.1.8 The significance of patient age For differential diagnosis it is important to bear in mind that the age of the patient plays an important role. In adolescents we might expect to find ‘ordinary’ restrictions or juvenile osteochondrosis, and in slightly older patients, ankylosing spondylitis. In the middle-age group, the most common serious conditions are herniated disc and ‘ordinary’ dysfunctions. In older age groups, osteoporosis is the most important, especially in women; also osteoarthritis, especially of the hip and knee joints. In this older age group, malignant disease must also be considered, especially if the patient is over 50 years of age and the disease has followed a progressive course. True vertebrogenic disease tends to decrease after the age of 60, accompanied by a rise in the incidence of osteoarthritis of the limb joints.
4.2 The inspection: posture The inspection usually begins with the dorsal aspect. The plumb line is positioned so as to fall between the heels. This is followed by the lateral and finally the frontal aspects. If possible the
Diagnosis of dysfunctions of the locomotor system
patient should also be assessed in the sitting position, again from all sides.
The inspection is the quickest way of gaining an overall impression so that the manual stage can be carried out in as targeted and economical a way as possible.
4.2.1 The dorsal aspect The inspection begins with an assessment of overall posture, looking for any deviation from the plumb line and any asymmetries. The next stage is the systematic inspection. Working upward from the feet, the specific points to examine are: • the shape (roundness) and position of the heels • the shape of the foot • the shape and thickness of the Achilles tendons and the calves, observing their medial and lateral contours • the position of the knees • the shape of the thighs • the height of the gluteal folds • the tone of the gluteal muscles • the course of the intergluteal cleft • the shape of the hips: whether symmetrical or projecting to one side • the waist • the distance of the pendant arms from the trunk on either side. Further details to examine are: • the rhomboid of Michaelis between the dimples situated at the posterior superior iliac spines (PSIS), and further craniad, the prominence of the erector spinae muscles. Between these lie the spinous processes, set within a groove between these muscles. This may follow a vertical course, or may be found to deviate from the vertical • the apex of the lordosis and the transition to kyphosis • the position of the shoulder blades: how high, and, if prominent, how symmetrical • the relative height and shape of the shoulders • the quadratus lumborum and latissimus dorsi muscles; these form the lateral contour of the
Chapter 4
trunk up to the axilla. The superior border of the shoulders is formed by the deltoid and superior portion of the trapezius, and medially to these by the levator scapulae. The inspection should note whether the superior contour takes a concave or convex (hypertonic) course and observe whether there is symmetry • the neck: note whether the neck deviates to one side or the other, and observe whether it is long, slim, or stocky • the hair line: note whether this is well above the shoulders or low down as in basilar impression • the head: look for any deviation. Does it deviate to the same side as the neck, or to the opposite side?
4.2.2 The lateral aspect Inspection of the lateral aspect also begins with an assessment of posture as a whole. The center of gravity of the head should normally be above the shoulder girdle; more precisely the external auditory meatus should be vertically above the pelvic girdle and this in turn above the feet, so that a plumb line from the external auditory meatus falls approximately 2 cm in front of the ankles and touches the scaphoid of the foot (navicular bone). During this inspection the patient’s gaze should be directed at an object at eye level. It is extremely important to register a forwarddrawn position, in which the head is in front of the shoulder girdle, and this in front of the pelvic girdle, with the pelvis above the anterior part of the foot. It is important for diagnosis to note any tension of the muscles of the back, and especially of the back of the neck, which disappears on sitting. When carrying out the systematic inspection, the examiner again works upward from the feet. Points to assess are: • the shape of the lower leg and especially the knee: genu recurvatum is a sign of laxity • the shape of the buttocks • the lumbar curvature: note whether the apex of the lordosis is located at or above the lumbosacral junction. In cases of increased lordosis with flabby posture, the abdomen is seen to protrude; this is not always a sign of adiposity. This protrusion may be at its maximum at the navel; however, if there is a drooping belly the level may be much lower 91
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• the level of the transition from lumbar lordosis
to thoracic kyphosis: note whether the patient has a flat or round back; if the thoracic spine is flat there is frequently increased kyphosis at the cervicothoracic junction • the shape of the spinal column • the position of the shoulders: whether drawn forward or protruding. Cervical lordosis largely depends on the shape of the thoracic spine. If the thoracic spine is flat, cervical lordosis may be completely absent. This is particularly seen in individuals of the athletic type with broad shoulders and a flat thoracic cage; similarly in ballet dancers. If the back is round, on the other hand, the thoracic kyphosis often continues into the lower cervical spine, with only the upper part of the cervical spine showing lordosis. In flabby posture, exaggerated cervical lordosis is sometimes seen; the thyroid cartilage (and trachea) may protrude, giving the impression of an enlarged thyroid gland. This, however, disappears in the supine position. In a forward-drawn posture there is frequently hyperlordosis in the craniocervical region.
4.2.3 The ventral aspect At inspection of the ventral aspect the most striking features are asymmetries between one side and the other, especially those that fall into the category of hemihypertrophy. Working from caudal to cranial, the points to observe are: • the position of the feet and their transverse and longitudinal arching • the knees: varus or valgus alignment • the thighs • the lower abdomen. Note a protruding abdomen and also the navel; the position of the navel is important. Specific points to note are whether it is central, and whether it lies on the surface or at some depth. If the patient has a large abdominal circumference and the navel is deep-lying, this indicates corpulence, but if the abdomen is enlarged and the navel ‘floats’ in a superficial position, it is indicative of muscle weakness. The lateral contours of the abdominal wall are normally concave, but if the abdominal muscles are weak, the contour is convex bulging • the epigastric angle: this may be obtuse or acute 92
• the sternum and pectoral muscles. It is mainly in male patients that these are easily seen
• the clavicles, noting how they move during
inhalation and exhalation and the extent to which they participate in the movements of respiration (markedly or little). The depth of the supraclavicular fossae is important; these are deeper when the thoracic cage remains in an inspiratory position, as happens in emphysema, for example, or where there is a functional problem of faulty breathing. In this case there is also hypertonus of all the other upper fixators of the shoulder girdle, which is manifested as a ‘Gothic shoulders’ posture • the position of the shoulders: asymmetry is almost the general rule • the jugular fossa in the neck region between the medial ends of the clavicles, and the sternoclavicular joint: one joint is often found to be more prominent than the other, although this need not be clinically significant. The sternocleidomastoids can be seen either side of the jugular fossa; the lateral attachment of this muscle on the clavicle is usually less distinct. Between the sternocleidomastoids and the trapezius, some bundles of the scaleni may be visible in slim patients • the thyroid cartilage: this can be seen more distinctly in males. Any lateral shift in its position is clinically very significant, since this indicates tension in one of the digastric muscles, drawing the hyoid to one side along with the thyroid cartilage. This observation is accompanied by distortion and asymmetry of the floor of the mouth, which is shallower on one side and deeper on the other • hyperactivity of the masticatory muscles: this can often also be seen at rest. Another manifestation is that the patient’s mouth hardly opens during speech. • the face: facial asymmetry is very frequent, and can be combined with asymmetry of bite and even ‘facial scoliosis.’ This in turn can be associated with scoliosis of the spinal column and hemiatrophy.
To summarize: inspection of the dorsal and ventral aspects enables the practitioner to detect asymmetries, either in the sense of relative
Diagnosis of dysfunctions of the locomotor system
weakness of one side (hemihypogenesis), or simply of the marked dominance of one side. Dominance is clearly recognized by the arm that is more powerful. In the lower limbs, the stance leg is more powerful and solid, though it is the swing leg that is dominant.
4.2.4 Inspection of the seated patient Examination of the patient in the relaxed, sitting position can produce very different results from those obtained with the patient standing. This is particularly so with hypermobile subjects, in whom lumbar hyperlordosis standing changes to a kyphotic posture when seated and relaxed. This is accompanied by a forwarddrawn neck and hyperlordosis at the atlanto-occipital and atlantoaxial joints. This is particularly important in subjects whose profession is mainly sedentary. Inspection from above would reveal rotation of the shoulder girdle in relation to the pelvic girdle and the feet.
4.3 Palpation (soft-tissue examination) Palpation is extremely important in the diagnosis of painful structures of the locomotor system and essential for all manipulative techniques. This examination therefore follows next, immediately after the inspection. The first step in palpation is to place a hand (finger) onto the surface of the patient’s body, and then to focus one’s attention on the aspect to be tested: warmth, moisture, consistency (whether the surface is rough or smooth), mechanical properties (resistance, mobility, stretch capacity), and whether the examination causes the patient to feel pain. Given that palpation is associated with touch, and this in turn with pressure, we might think that an objective way to perform it would be to use a pressure gauge. Sadly this idea is misleading; palpation is never a matter of mere (static) pressure, but a process that involves movement of the hands (fingers). Whether attempting to penetrate down from the surface to underlying layers, or to examine some aspect of the tissue by feel, we are constantly moving tissue aside or drawing it apart. Palpation therefore involves a combination of alternating pressure
Chapter 4
and movement. It is registered using not only our pressure receptors but also, simultaneously, our proprioceptors. Further, touch constantly evokes a reaction from the patient, and this reaction must also be registered. Feedback operates between the examiner and the patient, and is extremely important in diagnosis; a non-reproducible process of feedback is taking place between two systems. Palpation is a method that reveals a great deal to the experienced examiner; a host of information that a technological instrument is incapable of providing. The fact that it is not reproducible frequently leads to its rejection as too subjective: however this is not only absurd on practical grounds but also theoretically untenable; computers that process information are in essence no more than imperfect copies of the nervous system. The information that we obtain from them is uncritically accepted as ‘objective’ while the original, the human brain and the hands that provide the sensory input of information, are rejected as unreliable. Yet there is already radiological evidence to demonstrate ‘palpatory illusions’ (see Figure 4.11).
The palpating hand has receptors to sense heat and cold, to distinguish pressure, motion, position, and tissue quality. No technological instrument is able to detect and integrate all these factors simultaneously. There is also a feedback process between practitioner and patient, both during diagnosis and during treatment.
4.3.1 Hyperalgesic zones The quickest, most elegant method of finding a hyperalgesic zone (HAZ) is to run one’s fingers very lightly over the surface of the skin: heightened friction is felt at an HAZ on account of increased sweat production. The lighter the touch of the fingers, the more readily this is detected. The ‘barrier’ phenomenon is used when examining all the tissues of the locomotor system other than bones (see Figure 2.3). The points to note are: • the point at which the first resistance is felt on moving away from the neutral position: on stretching or folding the skin, stretching a subcutaneous fold, or displacing muscles relative to the bone 93
Manipulative Therapy
• in the movement of a joint, the point at which
the barrier is reached • whether the barrier is normal or pathological. A small area of skin can be examined by stretching it between the fingertips (the interdigital folds are an example) – a larger area is examined between the thumbs and the palms of the hands – always taking up the slack until the point where the barrier is engaged, and always comparing one side with the other (see Figure 6.56).
4.3.2 Subcutaneous tissue and fasciae To examine – and also treat – subcutaneous connective tissue, including that in scar tissue and shortened muscles, the practitioner should create a fold (see Figure 6.57) and stretch (not squeeze) it until the barrier is reached. If it is not possible to create a fold, slight pressure alone is enough to arrive at this barrier. In examining fasciae, the most useful characteristic to look for is their mobility against the underlying layer, that is mobility of the subcutaneous layer against the muscle and especially of the muscle against the bone. This mobility is examined as follows: • The muscles of the back in the cranial or caudal direction, with the patient prone. • The gluteal muscles in the cranial direction. • The muscles around the thorax in the dorsoventral direction. • The muscles of the neck around the longitudinal axis of the neck. • The muscles of the limbs around their longitudinal axis (pp. 232–234). The scalp also behaves in the same way as a fascia relative to the skull. Resistance (pathological barrier) is often discovered at periosteal pain points when trying to shift the subperiosteal tissue in various directions, and an easing of the pain is achieved when mobility is restored. This applies particularly at the attachments of tendons and ligaments. Bones that are linked not by joints but by connective tissue also move relative to one another. Examples are the metacarpal and metatarsal bones, and the fibula relative to the tibia. Testing of their mobility relative to each other often reveals pathological barriers, which are treated in analogous 94
ways. Everything that has been said about softtissue lesions applies to active scars.
The soft tissues surround the muscular and articular structures everywhere, and need to move in harmony with them. The same principle also applies to the internal organs. For this reason, dysfunctions that are closely associated with the function of joints and muscles can be diagnosed in the soft tissue. It is the mobility and elasticity of the soft tissues that enable them to move, and there is a harmonious interplay between these and movement. This mobility has been little studied, but if it is disturbed, the neuromusculoskeletal system cannot function normally.
4.3.3 Trigger points Palpation is the means of diagnosing the most characteristic change, the myofascial trigger point (TrP). Various terms for this exist in the literature; it is known, for example, under the names myogelosis, fibrositis, or local hypertonus. Here we shall apply the definition and terminology given by Travell &
Figure 4.1 • Flat palpation of TrPs. (A) Taut muscle bundle (detected by palpation). (B) Local twitch response.
Diagnosis of dysfunctions of the locomotor system
Simons (1999), who describe the TrP as a hyperirritative spot in skeletal muscle, which is associated with a hypersensitive palpable nodule in a taut band. A twitch reaction can be elicited by snapping palpation which can be registered by electromyography. At the same time the patient feels characteristic pain, which is accompanied by signs from the autonomic nervous system (see Figures 4.1 and 4.2). A muscle bundle in which there are TrPs contains some muscle fibers that are in a state of contraction, alongside others that are uncontracted (relaxed). If we succeed in relaxing the contracted fibers, using post-isometric relaxation, reciprocal
Chapter 4
inhibition, ‘spray and stretch’ or simple pressure, the problem usually disappears instantly, showing it to be a functional, reversible disturbance. Recent studies show that the hardening derives from the part of the muscle fiber that is stretched, and that the nodule of contracted muscle is the actual myogelosis. These changes have also been demonstrated histologically (Windisch et al 2001), findings which indicate that there are also TrPs that are chronic and irreversible. These respond little to the reflex methods mentioned above, requiring instead aggressive therapy such as needling (see Chapter 6, p. 248).
Figure 4.2 • Examination of myofascial TrPs. (A) Flat snapping palpation. (B) Palpation using pincer grip.
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Myofascial TrPs can also be studied objectively by means of electromyography (EMG) using monopolar needle electrodes. This method has successfully been used (Hong & Yu 1998; Hubbard & Berkoff 1993; Simons 2003) to show that what they were observing were end-plate potentials originating in TrPs. Two kinds of TrP can be distinguished: active and latent. Active TrPs are those that give rise to pain, especially referred pain. Latent TrPs do not give rise to spontaneous pain, but are painful on palpation and participate, often decisively, in chain-reaction patterns. Myofascial TrPs are not the only pain points that can be palpated; points of tenderness can also be found at the periosteum, in joint capsules, at attachment points of tendons and ligaments, and within muscles in the absence of any area of hardness. Since the hardened area forms part of the definition of a ‘TrP’ the term cannot strictly be applied in this case and instead it is best to use the term ‘tender point’ (TeP). These can also be the point of origin of referred pain. If the TeP is the attachment of a tendon, this is usually closely associated with the TrP of the corresponding muscle, the actual cause of the pain at the tendon attachment. Characteristic muscular pain points are also present in system-wide disease, as for instance in fibromyalgia syndrome, but a particular feature of these is that there are no areas of hardness. There is also no twitch response, and these pain points do not respond to reflex relaxation. Table 4.1 lists some muscle TrPs that are important for their diagnostic implications.
4.3.4 Periosteal pain points Numerous pain points on the periosteum are also found in most cases of dysfunctions of the locomotor system. The appearance and resolution of these pain points – as well as their treatment – play an important role in the course of the dysfunction. Many periosteal pain points are sites of attachment of tendons or ligaments closely associated with TrPs in the muscles, and have the effect of producing increased tension there. This is called enthesopathy. On examination, mobility testing of the subperiosteal tissue against the underlying bone reveals characteristic resistance in one or more directions on the affected side as compared with the healthy side. 96
Pain points can also be found in the region of the vertebral and limb joints wherever these are accessible to palpation. At the spinal column this is particularly so in the cervical region. They are also found at the sternocostal joints and at the temporomandibular joint. Table 4.2 lists the most important periosteal points and their clinical significance.
4.3.5 Radicular syndromes As already stressed, radiating pain alone (even mere paresthesia) are not sufficient for the diagnosis of a radicular syndrome. Conclusive evidence of radicular syndrome is provided by neurological deficit, the main signs being: • hypesthesia • localized hypotonia and/or atrophy • muscle weakness • decreased tendon and periosteal reflexes • increased idiomuscular excitability. Unless these signs are present we may suspect root lesion, but this requires further proof. There are certain signs, however, which strongly suggest radicular syndrome, without being positive proof. These are if the pain and paresthesia radiate down to the fingers (or toes), especially if objective examination also finds increased resistance to stretching at the interdigital fold, and difficulty in the mobility relative to each other of the metacarpals (metatarsals) in the corresponding segment. If the straight-leg raising test produces a finding below 45°, this also raises suspicion. Another sign is when the patient reports that control of the limb feels different from usual. The individual radicular syndromes are dealt with in Section 7.8.2. There is disagreement as to the dermatomes, and some individual variation has to be expected. The scheme we observe, particularly for the trunk, is that of Hansen & Schliack (1962) (see Figure 4.3A–C and E); for the lower limbs, that of Keegan (1944) (see Figure 4.3D). In radicular syndromes and herpes zoster, the authors work on the basis of Head zones (referred pain) findings. There is very credible evidence to support the existence of the cervicothoracic and the lumbosacral hiatus; this term describes the fact that segments C5–T1 are only found on the upper limbs and segments L2–S2 only on the lower limbs. This means that on the trunk, segment C4 is followed immediately by T2,
Diagnosis of dysfunctions of the locomotor system
Chapter 4
Table 4.1 Muscular trigger points
Muscle
Clinical significance
Soleus
Pain at the Achilles tendon
Quadriceps femoris
Lesion in L4 segment; pain at the upper edge of the patella; ‘pseudo hip and/or knee pain’
Tensor fasciae latae
Pain at the hip and at the superior border of the patella
Thigh adductors
Lesion in the hip joint; TrP in pelvic region
Iliacus
Lesion in S1 segment; coccyx; pseudovisceral pain
Piriformis
Lesion in L5 segment; ‘hip pain’
Ischiocrural muscles
Lesion in segments L5, S1 (straight-leg raising test positive); pain at the ischial tuberosity and head of the fibula
Levator ani
Pain at the coccyx
Coccygeus
Low back pain; many chain reactions due to pelvic floor dysfunction
Erector spinae
Back pain in the corresponding segment
Psoas major
Pseudovisceral pain; restricted rotation of trunk
Quadratus lumborum
Acute lumbago; restricted rotation of trunk
Rectus abdominis
Tenderness at xiphoid process and pubic symphysis; pseudovisceral pain
Pectoralis major
Pain at chest wall; pseudocardiac pain
Pectoralis minor
Tender coracoid process, sternocostal joints, and superior thoracic aperture
Diaphragm
Chest pain; cervical syndrome
Transverse (middle) part of trapezius
Cervicobrachial and radicular syndromes
Subscapularis
Pain in the shoulder; in the arm; at the lesser tubercle; pseudocardiac pain
Supraspinatus, infraspinatus
Pain in the shoulder; in the arm; at the greater tubercle
Supinator, biceps brachii, forearm extensors
Radial (lateral) epicondylopathy
Triceps brachii
Pain in the axilla; epicondylopathy
Finger flexors
Ulnar (medial) epicondylopathy
Descending (superior) part of trapezius
Neck pain; headache and shoulder pain
Levator scapulae
Shoulder pain; headache; neck pain
Scalene muscles
Pain at Erb’s (supraclavicular) point; at the superior thoracic aperture
Craniocervical extensors
Upper cervical syndrome
Sternocleidomastoid
All cervical syndromes
Masticatory muscles
Earache; upper cervical syndrome
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Table 4.2 Clinically important periosteal points
Periosteal point
Clinical significance
Head of metatarsals
Metatarsalgia in the case of splay foot; also in the case of tarso-metatarsal restriction
Calcaneal spur
TrP of deep plantar flexors
Head of fibula
TrP in biceps femoris, tibialis posterior; restriction of fibular head; forward-drawn posture
Pes anserinus (tendinous expansions of muscles at medial border of tuberosity of tibia)
TrP in the hip adductors; osteoarthritis of hip joint
Insertion of collateral ligament
Lesion of a meniscus in the knee
Superior border of patella
TrP in quadriceps femoris and tensor fasciae latae
Ischial tuberosity
TrP in the ischiocrural muscles
Posterior superior iliac spine (PSIS)
Frequent but not specific
Lateral border of the pubic symphysis
TrP in the hip adductors; hip
Superior border of the pubic symphysis
TrP in the rectus abdominis; forward-drawn posture
Coccyx
TrP in the levator ani, tension in the gluteus maximus
Iliac crest
TrP in the gluteus medius and quadratus lumborum
Pain at spinous process
Hypermobility with TrP in the erector spinae muscles
Spinous process T4—T6
Weakest region of erector spinae with TrP
Spinous process of C2
Lesion in segments C2—C4; TrP in levator scapulae
Xiphoid process
TrP in rectus abdominis
Ribs in the medioclavicular line
TrP in pectoralis minor
Ribs in the axillary line
TrP in the serratus anterior
Sternoclavicular joint
TrP in the scalene muscles and superior parts of the pectoralis muscles
Sternum just below 1st rib
Sternocostal joint of 1st rib
Angle of ribs
TrP in subscapularis; restriction of ribs
Sternal end of clavicle
TrP in sternocleidomastoid
Pain at Erb’s point
TrP in scalene muscles; radicular syndromes
Transverse processes of atlas
TrP in sternocleidomastoid
Posterior margin of foramen magnum
Restriction of retroflexion at C0/C1; headache; migraine
Nuchal line
Referred pain from the short craniocervical extensors, insertion of splenii capitis muscles
Condylar process of mandible
TrP in masticatory muscles
Hyoid
TrP in digastric and mylohyoid muscles
Styloid process of radius
Lesion of the radioulnar joint
Radial (lateral) epicondyle
TrP in biceps, supinator, extensor muscles of the fingers
Ulnar (medial) epicondyle
TrP in flexor muscles of the fingers
Attachment of deltoid
TrP in deltoid; frozen shoulder
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Chapter 4
Figure 4.3 • The dermatomes. (A) Ventral aspect. (B) Dorsal aspect. (C) Lateral aspect of the trunk (after Hansen &
Schliack 1962). (D) Lateral aspect of the lower limb (after Keegan 1944). (E) The perineum (after Hansen & Schliack 1962).
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patient. The muscle contraction is then described as concentric, isometric, or eccentric. If testing is not performed isometrically, the movement against resistance can be performed isotonically (i.e. maintaining the same force) or isokinetically (i.e. at constant speed). The object of testing is to examine not only the force produced by the muscle but also the provocation of pain, and coordination. Figure 4.3 • (Continued).
and L2 by S2. These dermatome charts regularly show a ‘step’ on the trunk, approximately on the axillary line, which marks the boundary of the area supplied by the dorsal ramus and ventral ramus of the spinal nerve, and which is usually clearly observable in herpes zoster (see Figure 4.3).
4.3.6 Conclusion There are many functional and reflex changes that correspond to nociceptive stimulation of the skin, subcutaneous tissues, and muscles, at the periosteum and the points of attachment of tendons and ligaments. These changes can be diagnosed clinically and can also be registered instrumentally, by means of thermography, measurement of electrical resistance, and EMG. These present a means of precise diagnosis by straightforward methods, so enabling targeted treatment.
4.4 Mobility testing This section will deal with general principles only. The regular procedure should be to examine active and passive mobility and movement against resistance.
4.4.3 Passive mobility First and most obviously, the testing of passive movement examines joint function. Very considerable changes in joint function may be found, however, as a result of muscle tension. Findings fall into three categories: normal mobility, movement restriction, and hypermobility; this relates both to functional movement and to joint play (see Chapter 2). The following changes should be looked for during examination: • Restriction of the movement of a joint as compared with the contralateral joint or the neighboring spinal segment. • Increased resistance during movement, particularly during the examination of joint play. • Resistance to springing in the end-of-range position (i.e. at the barrier). Note whether this resistance is physiological or pathological, or whether it is found during functional movement or on testing of joint play. Figar & Krausová (1975) were able to measure the resistance to springing using a resistance transducer. This was done in a restricted cervical segment before treatment, during manipulation, and after treatment (see Figure 4.4).
4.4.1 Active mobility Active movement includes muscle activity and joint mobility in the absence of any influence on the part of the examiner. This corresponds to voluntary movement.
4.4.2 Movement against resistance The force applied by the examiner may be less than, equal to, or greater than that used by the 100
Figure 4.4 • Measurement of force during the examination
of side-bending of the cervical spine: increased resistance in the restricted segment (left); resistance during manipulation of the restricted segment (center); equal resistance after manipulation (right). The peak preceding each curve is the gauge of 400 g (after Figar & Krausová 1975).
Diagnosis of dysfunctions of the locomotor system
The spinal column It is important when examining the spinal column to discover which of two neighboring segments is restricted. The question as to which of the paired joints is restricted is less important because the determining factor is the direction in which the treatment is applied.
The lumbar spine It helps to picture the joints as positioned with the articular facets fully covering each other in retroflexion, but as being in their end position in anteflexion. If anteflexion of a spinal joint is restricted, the spine deviates to the restricted side in anteflexion. If retroflexion is restricted, then also the spine deviates to the restricted side during retroflexion (see Figure 4.5). However, the deviation to one side that is observed is frequently the result of antalgic posture in order to relieve reflex pain, for example in radicular syndromes.
The cervical and thoracic spine In the cervical and thoracic spine, it is (in theory) possible to discover on which side the restricted joint is by examining side-bending first in retroflexion and then in anteflexion. If side-bending is more restricted in retroflexion, then the joint on the side to which the patient is bending is affected; if side-bending is more restricted on the opposite side, then it is the joint on the opposite side that is restricted.
Figure 4.5 • Schematic drawing of side-bending of two lumbar vertebrae.
Chapter 4
4.5 Examination of the pelvis Examination of the pelvis is usually preceded by screening assessment of the lower limbs, in particular since problems there can be the cause of pelvic obliquity.
4.5.1 Screening examination Inspection Points to observe are: • deviation to one side • unilateral prominence • height of the buttocks • irregularities of the rhomboid of Michaelis, which is formed by the dimples above the PSISs, the spinous process of L5, and the uppermost point of the intergluteal cleft. Deviation of the upper end of the intergluteal cleft to one side is the result of asymmetrical positioning of the inferior end of the sacrum and coccyx.
Palpation Palpation begins at the iliac crest, which the examiner can find by sliding the edge of his forefinger downward from the patient’s ribs. The reason this is important is that the iliac crest is often considerably higher than might be expected from the localization of the contours of the buttocks (often it is even just below the costal arch). A spirit level can be used to confirm the horizontal position of the pelvis (see Figure 4.6).
Figure 4.6 • Comparison of the level of the iliac crests using a spirit level.
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If the pelvis deviates to one side, this creates the impression that it is higher on the side toward which it deviates. This is because the examiner can easily contact the top of the iliac crest on the side to which the pelvis deviates, whereas on the other side the superior border of the iliac crest is hidden under the costal arch and has to be searched for. Working in a medioparavertebral direction, the examiner can then locate the PSISs. The most reliable way to perform the palpation of the PSIS is from laterally and below, since this corresponds to the shape of the spines. The same approach is suited to the palpation of the anterior iliac spines. If both the anterior and posterior iliac spines are at the same level on both sides, the pelvis is horizontal in the neutral position. A point worth mentioning here is that the rise in obesity has made palpation more difficult in many cases, and this is especially true when palpating the posterior iliac spines. Deviation of the pelvis to one side can be the result of a difference in leg length; in this case the pelvis deviates to the higher side. More frequently it is the result of (usually minor) scolioses, the pelvis being horizontal. In the case of true pelvic obliquity the iliac crest and anterior and posterior iliac spines are lower on one side.
4.5.2 Pelvic obliquity Measurement of leg length is more difficult than might be thought, because the head and neck of the femur are not externally evident. Pelvic obliquity is therefore the most reliable clinical sign of difference in leg length, unless there is a measurable difference in the length of the lower leg. However, this may be compensated by the length of the thigh. Where there is a difference in leg length the pelvis is generally seen to deviate to the higher side if the patient stands with weight equally distributed on both legs. The shoulder is typically seen to be lower on the side where the pelvis is higher. The findings can be tested clinically by placing a block or heel insert under the shorter leg. When this is done the pelvis becomes horizontal and no longer deviates to one side, and the shoulders level out. However, this effect only takes place if any significant movement restrictions have already been resolved. 102
A check can be made at the same time by placing each of the patient’s feet separately onto a balance scale, and placing a heel insert under the shorter leg to equalize the length. This produces one of three possible results: 1. The difference remains the same. 2. The difference is equalized. 3. The difference increases. The patient should be asked each time whether it is more comfortable with the heel insert, or whether it feels awkward. If the patient finds at the very least that the (unaccustomed!) heel insert does not feel awkward, the effect is seen to be favorable. Equalization of length can then be recommended, unless of course the patient has one flat foot. An X-ray check (with patient standing) is recommended to confirm the difference in leg length.
4.5.3 Pelvic distortion This is a curious phenomenon which must be distinguished from pelvic obliquity. The dorsal inspection usually shows the pelvis to deviate to the right, with the appearance of being slightly rotated to the left. Palpation of the iliac crests may show their height to be symmetrical laterally, but as the examiner’s palpating fingers (the edge of the forefingers) advance medially and approach the PSISs, they do not meet: one of the iliac spines (usually the right) lies higher than the other. This can be confirmed by direct palpation of the PSIS (from below). The finding for the anterior iliac spines is the converse: here the right anterior superior iliac spine (ASIS) is usually lower than the left. The two ilia seem to be twisted relative to each other. There is always a discrepancy when the position of the ASIS, PSIS, and the iliac crests are compared. However, the difference at the anterior or posterior iliac spines, and at the iliac crests, can vary, so that it is not always easy to distinguish pelvic distortion from pelvic obliquity, especially if both changes are simultaneously present. In such cases it is advisable to begin by treating the pelvic distortion and then to repeat the process of measurement. Another feature of pelvic distortion is the overtake phenomenon. On anteflexion the PSIS that is lower (usually the left) momentarily ‘overtakes’ the right. After 10–20 seconds the finding reverts to what it was before. Cramer’s (1965) analysis of the
Diagnosis of dysfunctions of the locomotor system
Chapter 4
mechanism involved (see Figure 3.12) appears best to match our understanding of what is happening. This also leads us to expect findings such as external rotation of the leg on the side of the ilium that is tilted so as to be lower posteriorly. The aspect that now seems to us to be more significant is that of muscular dysfunctions which are associated with pelvic distortion and accompanied by asymmetrical muscle function. Pelvic distortion is always secondary, and the cause is usually located in the atlanto-occipital and atlantoaxial joints (see Chapter 2); the findings at the muscles are inconsistent.
Testing for ‘overtake’
4.5.4 Pelvic tilt
The spine sign test
A third condition can be distinguished in addition to pelvic obliquity and pelvic distortion; this is pelvic tilt. To examine for this it is necessary to palpate the anterior and posterior superior iliac spines. The line between them is normally horizontal. In patients with a drooping belly the pelvis is usually tilted forward, and in patients with tension of the gluteal and ischiocrural muscles it is tilted backward.
The ‘spine sign’ is a more successful test to use with non-adipose patients, following the method devised by Dejung (2003) (see Figure 4.7). The examiner sits behind the standing patient, placing one thumb on the posterior inferior iliac spine and the other on the spinous process of L5. The patient is then told to bend the knee and lower the hip on the side being
Testing for the overtake phenomenon, as described above in connection with pelvic distortion, is more difficult to assess in patients with a degree of adiposity. The changes observed in overtake, unlike those in pelvic distortion, are not transitory, but remain during anteflexion. Bear in mind that it is not possible to retain hold of the posterior iliac spine, since it disappears under the skin during anteflexion; it does not present the same surface in anteflexion, and of course, if the restriction is bilateral the test fails completely to reveal it.
4.5.5 Restriction of the sacroiliac joint There is still a frequent tendency to overestimate the importance of restriction of the sacroiliac joint. One reason for this is the fact that there are no muscles between the sacrum and ilium, yet despite this, restrictions here were a relatively frequent finding, and this led to the assumption that this was a ‘pure’ joint restriction, with no involvement of muscle spasm or TrPs. However, this view has proved untenable, because it is often possible to release ‘indirect’ restrictions in the case of TrPs in the biceps femoris (head of the fibula), pelvic floor, piriformis muscle, and elsewhere, after which it is usually found that restrictions of the sacroiliac joint are also resolved. Such chain reactions indicate that most restrictions of the sacroiliac joint are secondary. There is also a practical problem: diagnosis usually relies on palpation of the mobility of bony structures, which often lie under a considerable layer of fat and connective tissue. This reduces the reliability of comparative examination.
Figure 4.7 • The ‘spine sign.’
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Figure 4.9 • Springing test of the ilium against the sacrum Figure 4.8 • Springing test of the ilium against the sacrum
with the patient in the side-lying position.
with the patient supine, one leg flexed.
examined. The normal finding is that the distance between the examiner’s two thumbs increases: the thumb on the iliac spine moves caudad and laterally while the thumb on the spinous process of L5 remains still. If there is restriction, the distance does not increase and the examiner can feel the laterally directed pressure of the spinous process of L5.
Springing test with patient supine The remaining examination methods are all ‘springing’ tests. The springing test with the patient supine (see Figure 4.8) is much used. The examiner stands by the table and grasps the patient’s contralateral leg (which is bent, while the other remains extended) and adducts her leg until the pelvis begins to follow. This engages the barrier and sets up the position from which the test is performed. With the hand that is guiding the patient’s knee, the examiner exerts pressure in the longitudinal axis of the thigh in the direction of the PSIS, to take up the slack. The examiner then exerts springing pressure. The springing is palpated with the hand under the posterior iliac spine. Adduction (to the barrier) is usually measurably restricted on the affected side. This is a useful test to use as a screening examination and is simple to perform.
Springing test with patient in the side-lying position This test produces a springing response of gapping (distraction) of the joint, so that the technique is also suitable for use in therapy (see Figure 4.9). 104
The patient is side-lying with the uppermost leg bent, knee resting on the treatment table. The examiner’s caudad arm should be placed so that his forearm lies gently on the region of the ASIS and iliac crest, and is angled to point ventrally, medially, and cranially. Gliding pressure with a springing movement is then exerted on the ala of the ilium in the same direction. This has the effect of producing a dorsal gapping (distraction) of the sacroiliac joint. The thumb of the examiner’s other hand senses the springing motion between the PSIS and sacrum.
Springing test with patient prone The superior portion of the sacroiliac joint is examined with the patient lying prone. The practitioner takes hold of the patient’s ASIS from the ventral side by curling the fingers of one hand around it, then lifts it slightly on taking up the slack, and shakes it upward with a springing movement. The thumb of his other hand is meanwhile used to palpate the sacrum, to sense whether it moves together with the ASIS. It will only do so if the joint is restricted (see Figure 4.10). The inferior portion of the sacroiliac joint is examined by applying pressure with a springing movement to the inferior apex of the sacrum with the patient prone. Mobilization techniques, which are described in Chapter 6, can also be used for examination.
Test technique according to Rosina The ‘traditional’ tests described so far all involve some degree of unreliability in view of the great number of obese patients. Lewit & Rosina (1999)
Diagnosis of dysfunctions of the locomotor system
Figure 4.10 • Springing test with the patient prone, to examine the superior part of the sacroiliac joint.
has developed a technique that is also reliable when examining such patients. Lewit & Rosina (1999) observed that, when the subject’s head is turned, the ASIS is displaced caudally on the side toward which the head turns. Following this observation we found that the opposite happens at the posterior iliac spines; in other words, that pelvic distortion occurs. On the side to which the head turns, the posterior border of the iliac crest also rises at the same time as the posterior iliac spine. For this test the patient is standing. The examiner places the edges of the forefingers of both hands on the iliac crests, approaching them from the lateral aspect of the iliac crests in a medial direction just above the PSIS. The patient is then asked to rotate her head to the side. After a few seconds’ latency, in a normal subject the examiner finds that the forefinger rises on the
Chapter 4
side to which the head is turned. Only very slight pressure from above is required in this test. The layer of fat on the iliac crest does not influence the result (Lewit & Rosina 1999). The effect is absent if there is restriction of the sacroiliac joint. The mechanism involved in this test is unknown. Although the difference in height of the two iliac crests is very noticeable, no difference in their position can be demonstrated radiologically. The effect must therefore be due to a shifting of soft tissues, producing a palpatory illusion (see Figure 4.11). On anteflexion with head turned, it is even possible to observe a transitory overtake phenomenon on the side that lies lower. There is no movement if the sacroiliac joint is restricted. (No explanation for this has been found.)
Pain points There may be pain points at the upper margin of the sacroiliac joint, at the lower end of the joint, and also, more rarely, in the iliacus muscle, at the attachment point of the adductors at the symphysis (slightly positive Patrick’s sign) and above the posterior iliac spine, although these findings need not be present.
The position of the pelvis is usually normal in cases of restriction of the sacroiliac joint. The relevant factor is simply the movement restriction, the sign of which is the poor springing of the joint.
Figure 4.11 • Palpatory illusion. (A) The ischia and ischial tuberosities are seen to be symmetrical, but to palpation
they seem extremely asymmetrical. (B) The bones of the pelvis are unchanged; what has changed is the position of the examiner’s thumbs.
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4.5.6 Shear dysfunction (Greenman) (upslip and downslip) When there is tenderness at the superior border of the pubic symphysis and tenderness to pressure at the ischial tuberosities, the usual finding on palpation is that the medial end of the pubic bone is higher on the side that is painful, and that the ischial tuberosity is lower on the side where the gluteus maximus is tense. Clinically we have found these to be signs of a syndrome associated with tension (TrPs) of the rectus abdominis muscles, forwarddrawn posture, tension of the erector spinae and neck extensors, gluteal muscles, and biceps femoris. The sacroiliac joints do not themselves play any significant role in our experience. Curiously, the position of the symphysis and ischial tuberosities appears to be symmetrical when the patient is standing. Still more remarkably, after treatment the palpatory finding had normalized but the X-ray showed no evidence of change even though palpation had found changes of up to 2 cm at the ischial tuberosities. To try to find an explanation for this, X-rays were taken showing the examiner’s thumbs as they palpated before and after treatment. The result was clear: what had changed was not the position of the bones, but that of the examiner’s palpating thumbs (see Figure 4.11). In this way we were able to obtain evidence to document a ‘palpatory illusion.’ It must be remembered that bones are often overlain by a layer of soft tissues, including muscles, and this may sometimes be considerable. If painful disorders produce a change in tension in these tissues, that must exert an effect on the position of the fingers palpating the site. In the particular case described here, this would be taking place at the attachment of the rectus abdominis on the pubic symphysis and that of the biceps femoris at the ischial tuberosity. The general principle to be drawn is that if there is asymmetry of tension in the soft tissues, a deviation in the position of the underlying bone (e.g. spinous processes) can generally be palpated; these are then found to be ‘repositioned’ once tension has been balanced. The same effect can be observed if cotton wool or foam rubber of varying thickness is wrapped around the corners of a matchbox and the object is then palpated with eyes closed: the shape of the matchbox is felt to be distorted. 106
4.5.7 Outflare and inflare Greenman and Tait (1986) described an apparently isolated change in the position of the ASISs, which caused a distortion of the triangle formed by these iliac spines and the navel (see Figure 7.3). Our experience shows this change to be clinically important, and it is discussed in more detail in Chapter 7 (see Section 7.1.8). One iliac spine (usually the right) is usually found to be flatter and its distance from the navel to be greater (‘outflare’) than the other (usually the left), which is more prominent and closer to the navel (‘inflare’). At the same time, palpation shows tonus in the lower part of the abdomen on the flattened side to be (relatively) decreased, as compared with the other side. In this case the finding is certainly not a palpatory illusion, because the tissue layer over the anterior iliac spine is very thin, and the asymmetrical positioning is clearly visible in slim patients. In adipose patients it is necessary to palpate it, since otherwise a clinically important lesion would be missed; one that is easy to treat. The clinical significance (i.e. the effect of treatment) was for a long time a mystery, but we have recently been able to establish (Lewit & Olšanská, 2005) that this change is always associated with an asymmetrical internal rotation of the hip joint. This rotation is restricted on the side of the inflare and instantly becomes normal following treatment.
4.5.8 The pelvic floor and coccygeus muscle Examination of the pelvis also includes palpation of the pelvic floor, the coccygeus muscle. In 1989, Silverstolpe described a syndrome which he called ‘pelvic dysfunction.’ He performed the examination by exerting pressure next to the coccyx, in the direction of the sacrotuberous ligament, and this had the effect of provoking intense pain. The types of pain reported by the patients usually varied considerably and included visceral pain. In these patients he found extremely painful TrPs in the region of the thoracolumbar erector spinae muscles, and snapping palpation of the prone patient produced dorsiflexion of the lumbar spine and pelvis. By maintaining the (painful) pressure in the direction of the sacrotuberous ligament he was able to resolve most of the symptoms these patients were experiencing (see Figure 4.12).
Diagnosis of dysfunctions of the locomotor system
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misleading; only pain experienced at the tip of the coccyx is diagnostically useful. Patients often report pain at the coccyx when what they are experiencing is in fact referred pain from other pelvic structures, in which case pain points will also be found laterally (pelvic floor, lower sacroiliac joint, etc.). In addition, a HAZ is often found in the sacral region, resembling a cushion of fat. There are often concomitant findings in the straight-leg raising test and Patrick’s test and a TrP in the iliacus muscle. In the history, the patient may report pain on sitting.
4.5.10 Ligament pain Figure 4.12 • Palpation of the coccygeus muscle from a
paracoccygeal position in the direction of the sacrotuberous ligament.
If this palpation provokes pain, the examiner will sense distinct resistance; if the pressure is maintained, the resistance resolves. What this palpation has found is a TrP in the coccygeus muscle, the pelvic floor. The great significance of this finding is that the pelvic floor forms part of the deep stabilization system which gives rise to effects in the form of chain reactions in the entire locomotor system. This explains the importance of finding this TrP.
A condition known as ‘ligament pain’ (Barbor 1964, Hackett 1956) tends to be found where there is sustained static load; this may be associated with sacroiliac restriction, especially if there is hypermobility. It particularly involves the iliolumbar and the sacroiliac ligaments. The key to diagnosis is the ability to provoke pain, and the following technique is used. The patient lies supine on the table with one leg bent at the hip and knee. The examiner should stand beside the table. He grasps the patient’s bent leg at the knee and adducts the thigh, at the same time exerting pressure along the axis of the thigh to take up the slack (see Figure 4.13).
4.5.9 The painful coccyx A coccyx that is tender to pressure should never be ignored, because it is a considerably more frequent contributory cause of low-back pain than coccygodynia. Palpation of the coccyx should therefore be carried out when diagnosing low-back pain. Palpation of a painful coccyx can be more difficult than might be expected. The problem here is one of myotendinosis (insertion tendopathy) resulting from tension of the gluteus maximus and a TrP in the levator ani, which can be palpated quite easily via the rectum. A tender coccyx is always ventrally curved. The pain point is typically on the ventral surface of the tip of the coccyx, so it is necessary to feel around for the ventrally curved coccyx, which produces resistance from the tense gluteus maximus. Mere touch is enough to provoke pain. Any strong pressure here is always painful and therefore
Figure 4.13 • Testing of ligament pain.
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At about 90° of hip flexion, the maintenance of adduction tests primarily the iliolumbar ligament, and the patient will feel pain in the groin. At a hip flexion of 60–70° it is mainly the sacroiliac ligaments that are tested. This time, as the examiner maintains the adduction, the pain radiates down the leg in the S1 segment. It is important to ensure before testing the ligaments that there is no sacroiliac joint or lumbosacral restriction. The localization of the provoked pain is the main criterion for diagnosis. Closer examination will show that in these patients adduction is restricted on the painful side. It is easy to measure this by looking at the distance between the adducted knee and the table. This degree of increased resistance cannot be due to ligaments alone. The fact that it is often resolved using post-isometric relaxation (PIR) suggests a muscular cause. The authors quoted above treat ligament pain with injections of hypertonic solutions at the attachments of the ligaments, and we have also treated this type of pain by means of straightforward needling. This we follow with PIR and reciprocal inhibition (RI), both of which are suitable methods for use in self-treatment.
If movement restriction is found on testing of the iliolumbar or sacroiliac ligaments, this is due to muscle tension, which can be treated by PIR and RI.
4.6 Examination of the lumbar spine 4.6.1 Screening examination of active movement Retroflexion Examination of the lumbar spine can properly be said to have begun with that of the pelvis. The examination starts with the patient standing, ideally in retroflexion, and the examiner should not only assess the overall range of motion but also observe whether the movement extends into the lumbosacral segment. In normal cases this is easily seen, because dorsiflexion is greatest in the lumbosacral segment, while the excursion in other directions of movement is greatest in the L4/L5 segment. The examiner can 108
not only identify movement restriction, but also local hypermobility, which is seen as a sharp lordotic bend on retroflexion, often in the inferior-most part of the lumbar spine or at the thoracolumbar junction. If retroflexion is painful and inhibited without actual restriction, this may be a sign of TrPs in the rectus abdominis muscle with tenderness to pressure at the pubic symphysis, or pain at the spinous processes.
Side-bending When examining side-bending, the examiner needs to ensure that the patient’s movement does not deviate in the forward or backward direction. He should then compare on both sides how far down the leg the patient’s arm extends when side-bending with arms and fingers extended. (Do the fingertips reach as far as a point above, or – more frequently – beyond the knee?) As the patient bends, the examiner notes whether the spinal column arches over in an even curve, or with a sharp bend at some point, or whether it remains stiff. A further aspect to look for is rotation synkinesis, in which the pelvis rotates in the opposite direction to the side-bending as soon as the side-bending movement reaches the thoracolumbar junction. This movement is evidently determined by the rotation of the lumbar spine during side-bending.
Anteflexion When examining anteflexion with the knees held straight, the examiner should test how close to the floor the patient’s fingertips reach with knees fully extended, and at the same time note the arch of the lumbar spine and the position of the pelvis; it is important to distinguish whether anteflexion happens mainly at the pelvis with minimal lumbar kyphosis, or whether the main action is flexion of the lumbar spine with shortened ischiocrural muscles. Certain kinds of flattening of the bend during anteflexion are common and can be normal variations. These occur at the thoracolumbar junction and at the lumbosacral junction. The examiner compares the prominence of the transverse processes as well as that of the erector spinae muscles that are stretched over them. This provides a sign of rotation as found in scoliosis, or possible deviation to one side such as happens in radicular syndromes. When measuring the distance between the reach of the fingertips and the floor it is important to note
Diagnosis of dysfunctions of the locomotor system
not only an increased fingertip–floor distance but also a negative measurement. If the patient is able to place the flat of her hand on the floor, this is a sign of hypermobility. The patient’s body proportions should be noted, looking at the length of the trunk, legs, and arms. Anteflexion can be painful, even when there is no restriction. One reason is the ‘painful arc’ described by Cyriax (1978): during anteflexion, often shortly after beginning to bend forward, the patient feels considerable pain. An evasive movement of the spinal column can often be seen, as if the patient is working around some obstacle, after which the action continues quite normally. On straightening again the pain reappears and there is an evasive reaction at the same point. This sign indicates disk herniation. It is also possible for the patient to carry out the anteflexion movement normally but experience the pain on straightening. This indicates joint restriction in retroflexion. If the fingertip–floor distance is increased, movement restriction of the lumbar spine is not the only possible cause, since this finding may also be linked to a positive straight-leg raising test. Therefore, if an increased fingertip–floor distance is found, the examiner should also test anteflexion in the sitting position with knees bent. If anteflexion is also restricted in sitting, and mobility of the hip joints is normal, this localizes the disturbance to the lumbar spine. Before testing the mobility of the individual motion segments of the lumbar spine it is advisable to examine muscles with TrPs that are characteristic for disturbances in particular motion segments (see Table 4.1).
Chapter 4
disks), so that it is important to avoid testing the spinous processes at the same time. The thenar and hypothenar eminences of one hand are placed on the transverse processes, ‘bridging’ over the spinous process. The examiner exerts very slight pressure with the extended arm to take up the slack, followed by ‘springing’ pressure (see Figure 4.14). Another method is to place the tips of the second and third fingers of one hand on the transverse processes from the caudal direction, then using the ulnar (medial) edge of the other hand to take up the contact, then taking up the slack and applying the springing pressure (see Figure 4.15). The springing test is not totally specific to a particular segment. If there is joint restriction, increased resistance (an absence of springing) is felt after the slack has been taken up, and the patient may also experience pain. However, if the patient feels pain when springing of the segment is normal, this is a sign of disk pain.
If the springing test produces pain in the lumbar spine and joint restriction is either absent or has been resolved, this indicates a disk lesion.
4.6.2 Examination of individual motion segments Palpation The examination can begin with palpation. The fingertips are used to provoke pain at the spinous processes. Although the spinous process lies in the midline, careful palpation will show that it is only truly tender to pressure on one side.
Springing test Following palpation, the springing test is applied. This examines resistance and also provokes pain in the deeper-lying structures (mainly the joints and
Figure 4.14 • Springing test, using the thenar and hypothenar eminences and with the arm extended.
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Figure 4.15 • Springing test, using the tips of the second and third fingers. (A) Position of the fingertips. (B) Position of the
fingertips, illustrated using a skeleton (schematic drawing). (C) The arm applying the springing pressure exerts this using the medial (ulnar) edge of the hand placed on top of the fingertips.
Palpation of mobility Carefully directed palpation of mobility serves to localize a hypomobile or hypermobile motion segment more precisely.
In a normal case this is sensed as a slight dorsal shifting of the lower of the two vertebrae against the upper one that is fixed. This movement is not felt if there is restriction, as long as the
Retroflexion Restricted retroflexion can be localized as follows to the segment affected: the patient is in the sidelying position on the treatment table, with hips and knees flexed at an angle of about 100°. The examiner stands facing the patient, and begins by fixing the upper vertebra of the segment to be examined. This is done by placing one finger of each hand, one on top of the other, on the spinous process. Using his thighs he should then exert pressure against the patient’s bent knees in the dorsal direction, toward the fingers that are holding the vertebra fixed (see Figure 4.16). Having taken up the slack, he applies springing pressure to the knees, taking up the impulse at his fingers. 110
Figure 4.16 • Examining retroflexion of individual lumbar segments by means of springing pressure.
Diagnosis of dysfunctions of the locomotor system
Chapter 4
Figure 4.18 • Examining anteflexion of individual lumbar segments by means of palpation.
Figure 4.17 • Examining retroflexion of individual lumbar segments by means of palpation.
examination is not being done forcefully. It has been shown radiologically that this is in fact a slight, localized dorsiflexion, not a shift. It is extremely important when carrying out this technique that the application of very slight pressure to the patient’s knees to take up the slack by the fingers should be done in absolute synchrony. The examiner can achieve this by straightening his trunk, which forces his thighs forward to deliver the push to the patient’s knees at the same time as bringing his arms backward. This technique is one of the very few that can localize the restriction to one single segment. In 35 patients examined at random independently by two examiners familiar with that technique there was full agreement in 30 cases and only 5 disagreements (see Figure 4.16). Retroflexion can also be examined with the patient in the side-lying position. The examiner should grasp the patient’s lower legs above the ankles and push them away from the neutral position in a dorsal direction, so flexing the lumbar spine dorsally. The fingers of the other hand palpate between the spinous processes as these approach one another. Resistance is felt if there is restriction (see Figure 4.17). It is important for the success of this technique to keep the patient’s ankles on the treatment table, and not to lift them, when exerting the push in the dorsal direction.
Anteflexion Anteflexion of the lumbar spine is examined with the patient in the side-lying position, with knees
flexed to the abdomen and positioned so to lie close to the edge of the treatment table. The examiner stands facing the patient and fixes her thoracic region by placing one elbow on it from above. With his thighs, he exerts a push against the patient’s knees so as to produce kyphosis of the lumbar spine and take up the slack. With the other hand, which is resting on the patient’s buttocks, he now applies a springing pressure designed to create further kyphosis. At the same time, the fingers of the hand fixing the upper thoracic spine palpate the mobility, sensing the separation of the spinous processes of two neighboring vertebrae, or sensing the resistance if there is restriction (see Figure 4.18). It is important for the practical success of this technique to ensure that the hand fixing the spinal column from above is used to take up the pressure delivered by the examiner’s other hand and thighs. If the patient is very tall and the examiner small, this will make it impossible to reach the spinous processes of the lower lumbar spine with the same hand while it continues to fix the patient’s shoulder region. In that case it will be necessary to use the fingers of the hand on the patient’s buttocks both to palpate and to deliver the pressure.
Side-bending The patient adopts the side-lying position for this examination. Her underneath leg should be bent at right angles both at the hip and at the knee, so that her lower legs lie parallel to the line of her trunk, knees protruding slightly over the edge of the table. The examiner stands facing the patient, and grasps the underneath leg just above the ankle. 111
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underneath leg, like a lever operating from a point of support resting against his thigh, using this to side-bend the lumbar spine (see Figure 4.19). The thumb of the other hand, which is on the spinous process of the upper vertebra in the segment being examined, is used to palpate movement (or resistance).
4.7 Examination of the thoracic spine 4.7.1 Screening examination of active movement
Figure 4.19 • Examining side-bending of the lumbar spine by means of palpation.
As he does so, her other leg becomes more flexed, so that her foot is now behind the thigh of the underneath leg. With the thumb of the other hand, the examiner fixes the upper vertebra of the segment being examined, from above. The examiner should now raise the lower part of the patient’s
Examination begins with active movement. The patient should sit astride the end of the treatment table and bend backwards and then forwards, easing out the body as she does so; she should then bend to each side, and rotate to each side with a slightly kyphotic posture. This enables the examiner to note the angle between her shoulder girdle and the table, and to see clearly any irregularities in the line of the spinous processes. A springing test is performed using the same technique as that described for the lumbar spine, with the patient lying prone (see Figures 4.14 and 4.15). The spinous processes are palpated; this is best done with the patient seated in a kyphotic position (see Figure 4.20).
Figure 4.20 • (A) Palpation of the spinous processes, patient sitting in a kyphotic posture. (B) Schematic drawing using a skeleton.
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Chapter 4
Mobility of the individual segments can be observed from the side with the patient prone, by means of deep inhalation and exhalation as described by Tesarová (1969). It is helpful if the patient is asked to inhale first into the abdomen and then into the chest. This enables the examiner to observe the rise and fall of the back and also the fan-like movement of the spinous processes as they expand and separate during inhalation and draw together during exhalation. If this movement is absent anywhere, this indicates joint restriction. This test cannot be applied in a case of pronounced clavicular breathing (in which the thorax is lifted during inhalation), because the chest wall is not being expanded.
4.7.2 Palpation of mobility For the specific palpation of mobility the examiner should stand to one side behind the patient. The patient sits on the table with arms clasped behind the back of her neck.
Figure 4.21 • Examining retroflexion of individual segments of the thoracic spine by means of palpation.
Retroflexion The patient’s elbows should be angled forward, and the examiner grasps them from below with one hand. With his other hand he should palpate with one finger between two spinous processes (see Figure 4.21). Then he should bring the patient’s thorax into retroflexion until the barrier is engaged, following this with a springing pressure. In those locations where the spinous processes do not move toward each other, the examiner will simultaneously sense resistance if there is joint restriction. It is important in this technique to guide the patient’s trunk in such a way that the apex of the retroflexion occurs at the position of his palpating hand. This can be done if the patient is made to lean against the examiner’s body and the two move in concert.
4.7.3 Anteflexion Figure 4.22 • Examining anteflexion of individual segments
To examine anteflexion, practitioner and patient adopt the same position as for retroflexion; this time, however, the practitioner grasps the patient’s elbows from above. He should anteflex the patient’s trunk in kyphosis to take up the slack, and apply a springing pressure (see Figure 4.22), palpating
of the thoracic spine by means of palpation.
between the spinous processes with the fingers of the other hand to sense the increase in tension during the springing pressure. No springing is felt if joint restriction is present. The hand which 113
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anteflexes the patient’s trunk also feels increased resistance, which makes the diagnosis easier. Again, in this examination it is important to move the patient’s trunk in such a way that the point of maximum kyphosis is the site of palpation by the examiner’s other hand.
4.7.4 Side-bending To examine side-bending the practitioner stands behind the patient, who is sitting. The practitioner should place one hand dorsally around the patient’s ribs at the level of the segment being examined, the thumb palpating between the spinous processes of the segment from laterally. He places his other hand at approximately shoulder height (according to the level of the segment being examined) on the other side, side-bending the patient’s upper body to engage the barrier (see Figure 4.23). With his palpating hand the practitioner stabilizes the patient’s thorax while the thumb palpates the resistance to the springing pressure delivered by his other hand. Resistance is greater if there is joint restriction. For this technique it is important for the fingers on the ribs to create a fulcrum as they support the patient’s trunk. At this point it seems as if the thumb will not be able to reach the spinous processes, but during the side-bending the thoracic spine rotates, which brings the spinous processes into contact with the palpating thumb.
Figure 4.24 • Palpation of the thoracic spine in sidebending with the patient sitting, in broad-shouldered patients.
If the patient has a very broad back (and the examiner has a very small hand), the following technique is more appropriate: the examiner should stand at the patient’s side, grasp her farther elbow, which is raised, and draw that elbow toward him. He uses the thumb of the other hand, from a lateral direction, to fix the spinous process of the lower vertebra in the segment being examined (see Figure 4.24).
4.7.5 Rotation
Figure 4.23 • Examining side-bending of individual
segments of the thoracic spine by means of palpation.
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For this examination the patient should sit astride the end of the treatment table, with her back toward the examiner, and actively turn her trunk from one side to the other. The examiner compares the extent of rotation and notes any asymmetry. On palpation (sometimes even on inspection) with the patient in slight kyphosis it is often found that the spinous processes in the region of the thoracolumbar junction do not move evenly to each side. In the past this was interpreted as a sign of restriction; however, this was disproved by Singer &
Diagnosis of dysfunctions of the locomotor system
Giles (1990) in a computerized tomography (CT) study during rotation. Further, clinically it was then found that the rotation restriction to one side is muscular in origin; it is produced by TrPs in the thoracolumbar erector spinae, psoas major, and quadratus lumborum muscles, especially those on the contralateral side to the rotation restriction. The treatment we give to our patients, therefore, consists almost entirely in relaxation of these contralateral muscles. Because of the way that these muscles are linked, to relax just one of them is enough to normalize rotation (see Chapter 6).
4.8 Examination of the ribs 4.8.1 Screening examination The examination continues with the thorax, including the ribs. Just as the spinous processes are palpated for tenderness when examining the thoracic spine, so it is the angle of the rib that is palpated when examining the ribs for pain points (Tilscher & Oblak 1974). The angle of the ribs is the most prominent part dorsally, situated laterally to the erector spinae muscles. It is accessed by abducting the scapula, which can be done by pressing the patient’s elbow against the thoracic cage on the same side. Pain points at the angle of the rib must be differentiated from a frequently-found TrP in the middle part of the trapezius, which tenses like a tendon medially to its attachment to the scapula when this is fully adducted, and is also tender to pressure. There is a pain point at the sternocostal joint that generally corresponds to pain points at the angle of the rib. (This is the point of attachment of the pectoralis minor muscle.) The respiratory excursion of the ribs is examined by comparing rib movement on both sides during inhalation and exhalation, with the patient lying down. This movement should be assessed visually and by palpation of the area between the ribs. The patient should be asked to inhale and exhale deeply. When the excursion of the ribs is at its maximum it is easiest to assess whether the inhalation (or exhalation) stops sooner on the affected side than on the healthy side. When the patient is supine, an overtake phenomenon is often observed in the region of the upper ribs. One rib is found to be slightly lower than its opposite number; during inhalation, the
Chapter 4
rib that had been lower ‘overtakes’ the other. This indicates joint restriction on the side that was ‘overtaken.’ The most useful method of examining the upper and middle ribs is the palpation of resistance during retroflexion as described by Kubis (1970). The patient is sitting. For this examination she should adopt the same position as was used to examine retroflexion of the thoracic spine, except that this time she should raise only the elbow on the side of the rib to be examined. This she raises to the maximum, placing her hand on the back of her head. The examiner stands on the other side, grasps the elbow from in front, and uses it to bend the patient’s trunk backwards. The pads of the fingers of his other hand take up contact with the angle of the rib under examination and offer resistance (see Figure 4.25). The examiner applies pressure in a dorsal direction to the raised elbow, toward the fingertips of the other hand, to take up the slack, followed by
Figure 4.25 • Palpation of resistance at the upper ribs during retroflexion, by the method according to Kubis (1970).
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springing pressure to test whether the springing of the joint at the end of range is normal. It is important to support the patient’s body, and to guide the elbow in such a way that movement occurs only in the sagittal plane and that there is no rotation of the patient’s trunk. When examining in the region of ribs 2–5 it is necessary to palpate through the shoulder blade, but this does not affect the quality of the palpation. Putting pressure on the lower arch of the thorax (mainly the 10th rib) between two fingers from inside and outside is diagnostic for a ‘slipping rib’.
Palpation of mobility is carried out by the following method. The patient is sitting. The examiner begins by drawing the patient toward him and placing the lateral edge of one forefinger on her clavicle, laterally to the neck, to create a fulcrum. The patient’s neck is rotated contralaterally and then inclined forward until resistance is felt (see Figure 4.26). If there is restriction of the first rib, this diagonal anteflexion will be markedly restricted as compared with the normal side. There is a close link between restrictions of the first rib and dysfunctions of the cervicothoracic junction.
4.8.2 Examination of the first rib
4.9 Examination of the cervical spine
The first rib occupies a special position, and dysfunction causes pain at the upper border of the shoulder and just below the clavicle, toward the sternal manubrium, where the first rib articulates with the sternum. Restriction of the first rib is common. The simplest method of testing for this is to apply springing pressure from above, which is done as follows: the examiner should stand behind the patient, place the radial (lateral) edge of one forefinger on the first rib from above and apply slight pressure to take up the slack. This is followed by springing pressure, and the examiner can then sense whether there is any springing at the first rib.
Figure 4.26 • Examination of restriction of the first rib.
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4.9.1 Screening examination This begins with inspection, concentrating in particular on head posture and symmetry, followed by palpation of the soft tissues and TrPs. The assessment of active movement looks at anteflexion, retroflexion, side-bending (inclining the ear toward the shoulder), and rotation to both sides. Examination against (isometric) resistance is also important in order to diagnose any muscular lesion, especially following an accident. Palpation is done with the patient supine, her head beyond the end of the treatment table, slightly raised and supported against the examiner’s thighs (see Figure 4.27). In this position all the muscles are relaxed and the examiner can palpate not only
Figure 4.27 • Palpation of the structures of the cervical spine, patient supine with the head raised.
Diagnosis of dysfunctions of the locomotor system
the spinous processes but also the transverse and articular processes. The supine position with head raised is necessary in order to palpate the short craniocervical extensors, posterior arch of the atlas, and posterior border of the foramen magnum, where important pain points are found. The pain points at the nuchal line are secondary. In order to palpate the site of important pain points on the lateral aspect of the spinous process of C2, the examiner should incline the patient’s head to the opposite side. As he does so, it rotates toward his fingers, which he uses to palpate from a lateral position. The patient can be either sitting or lying down. Palpation of the transverse process of the atlas is better carried out with the patient sitting, palpating from laterally and below, between the mastoid processes and the ascending ramus of the mandible. This transverse process is more prominent laterally than those of the other cervical vertebrae. Following this, the examiner should palpate TrPs in the two sternocleidomastoid muscles, between his thumb and forefinger. Accurate localization of the spinous process of C7 can sometimes be important for precise orientation, since the examiner has to ensure that the process found is that of C7 which is not always the vertebra prominens. This is best done during retroflexion, placing a finger on each of two neighboring spinous processes at the cervicothoracic junction. During retroflexion the spinous process of C6 moves deeper, while that of C7 remains in the same place.
4.9.2 Examination of passive mobility The assessment of passive mobility begins with a screening examination of the whole of the cervical spine. The patient is sitting and the examiner must fix (immobilize) the cervicothoracic junction so that any resistance, or indeed tenderness, can be detected.
Retroflexion and anteflexion Retroflexion is examined as follows: the examiner should stand beside the patient and ease her head backward, testing springing of the cervicothoracic junction. To test passive anteflexion the examiner should guide the patient’s chin toward the chest while
Chapter 4
holding the upper thoracic spine fixed from behind, and noting the tension. The most common cause of restriction here is shortened neck muscles. If pain is felt at the start of anteflexion, this may indicate restriction of the atlanto-occipital and atlantoaxial joints; meningeal or radicular pain is typically felt during the course of anteflexion, and pain felt at the barrier, after a period of latency, is most probably ligament pain (see Section 7.6.1, Anteflexion headache, p. 332).
Side-bending In order to test side-bending, the examiner should fix the shoulder from the side toward which the side-bending is performed and ease the patient’s ear down toward her shoulder, comparing mobility in both directions.
Rotation This test is the most important for diagnosis.
Examination with patient sitting The patient should be sitting erect. The examiner fixes her shoulder from in front, on the side away from that to which the patient’s head is to be turned, using his elbow to do so. As he turns her head, the examiner should note how close it is possible to bring the chin to the shoulder on either side (see Figure 4.28A). Care must be taken to rotate the head accurately about a vertical axis. An alternative method is to perform this test with hands crossed. To turn the patient’s head to the left, the examiner applies lateral pressure with the right hand to her chin, while his left hand guides the occiput to the right. The examiner should fix the patient’s right shoulder, using his forearm from behind (see Figure 4.28B).
With the head in maximum anteflexion To test rotation in maximum anteflexion the examiner stands behind the patient, who is sitting. With one hand on the occiput he should ease her head into maximum anteflexion, while using the fingers of the other hand to fix her chin. 117
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Figure 4.28 • Examination of rotation of the entire cervical spine. (A) Shoulder fixed by the examiner’s elbow, from in front. (B) Shoulder fixed using the forearm from behind, hands crossed.
In this position, rotation takes place almost entirely between the atlas and axis. It is particularly important in this case to ensure that the rotation takes place about the longitudinal axis of the cervical spine; the cervical spine will now be almost horizontal. This can only be achieved by ensuring that the main movement is that of the occiput from one side to the other, while the chin is held fixed as described (only the minutest amount of movement should be permitted). Because the examiner sees only the patient’s occiput, he only sees the movement there, and so tends to move the chin. A warning must be given: when carrying out rotation in maximum anteflexion it is a serious mistake to exceed an angle of 45° in either direction.
With maximum forward nutation of the head To test rotation with the patient’s chin drawn to its maximum extent towards the neck (forward nutation), the examiner stands behind the patient and eases her chin toward her neck, rotating her head as far as it will go to one side and then the other and at the same time applying slight traction. According to Jirout (1979b), rotation takes place almost exclusively in the C2/C3 motion segment. Again it is important to ensure that rotation takes place about the correct axis, and this is done by moving mainly the occiput, and permitting the minimum of movement at the chin. 118
In retroflexion In retroflexion the atlanto-occipital and atlantoaxial joints are locked and the examination looks at the region below C2/C3. The farther backward the cervical spine is inclined, the more the rotation takes place in the lower and cervicothoracic sections. Here, too, care has to be taken to ensure that rotation occurs about the longitudinal axis of the cervical spine. The crossed-hand hold shown in Figure 4.28B is helpful here. One hand simultaneously moves the chin to one side and raises it. Again, the chin should move only minimally, and it is mainly the occiput that is moved. Care should be taken not to permit any lateroflexion. Having completed these investigations, which are designed essentially as a screening examination, we proceed to the examination of the individual motion segments.
4.9.3 Examination of the motion segments Side-bending This can be performed with the patient sitting or lying down. For each segment, the examiner inclines the patient’s head to the side with one hand while the other creates a fulcrum at the lower vertebra of
Diagnosis of dysfunctions of the locomotor system
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Figure 4.29 • Examination of side-bending of individual motion segments of the cervical spine with the patient supine (A) between the atlas and axis; (B) between the vertebrae from C3 to C7.
the segment under examination; the examiner uses the edge of his forefinger to do this and the cervical spine is inclined over this fulcrum. With the hand that moves the patient’s head, the examiner then applies very slight pressure to take up the slack. Springing pressure is given to test springing at the end of range (resistance) as well as range of movement. The findings are compared with the other side and with neighboring segments.
With patient supine For the examination in the supine position the patient’s head extends beyond the end of the table and is cradled in the examiner’s hand, slightly raised and rotated gently toward the contralateral side. When examining C1/C2, the cervical spine up to C2 should remain as far as possible in the neutral position, with only the head nutated to one side: to be precise, the head is rotated about an axis at the level of the root of the nose (see Figure 4.29A). For the lower segments the index which forms the fulcrum is lowered to the examined segment and the head side bent accordingly to take up the slack and to sense resistance against springing in end position (see Figure 4.29B).
With patient sitting For side-bending at the cervicothoracic junction, the patient must be sitting as erect as possible. Using the ulnar (medial) fingers of one hand in the region of the zygomatic bone, the examiner should bend the patient’s head backward and to the side, at the same time rotating it in the opposite direction to that of the side-bending. While performing this rotation, the examiner uses the thenar eminence of the other hand to contact and fix the spinous process of the upper vertebra of the pair in the segment being examined. With the thumb of the other hand, he applies springing pressure from the side to the spinous process of the lower vertebra of that segment and senses the resistance (see Figure 4.30).
With patient in the side-lying position The examination is somewhat easier to perform with the patient in the side-lying position. The examiner should stand facing the patient, with his forearm under her head, his elbow supported on the table, and his hand cradling the patient’s occiput. The examiner should now push the supporting elbow forward on the table, so that his hand automatically produces a side-bending movement 119
Manipulative Therapy
Figure 4.30 • Examination of side-bending of the cervicothoracic junction with the patient seated: (A) as seen from the rear; (B) as seen from in front.
of the patient’s head combined with rotation to the opposite side. This is done until the barrier is engaged, when he applies springing pressure in the same direction. The thumb of his other hand meanwhile fixes the spinous process of the lower vertebra of the pair (see Figure 4.31).
Figure 4.31 • Examination of side-bending of the
cervicothoracic junction with the patient side-lying.
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The examiner will find it easier to perform this test with his knee supported on the treatment table.
Rotation The patient is sitting, and the examiner stands behind her. He fixes the vertebral arch of the lower vertebra of the segment, from one articular process to the other, between the thumb and forefinger of one hand. With his other hand, he should rotate the patient’s head to the side (usually guiding it by the chin) until he senses resistance at the thumb or forefinger of the hand fixing the vertebral arch. He can then deliver slight springing pressure (see Figure 4.32). The examination begins by fixing the axis and establishing the range of movement between atlas and axis; it then proceeds with C2/C3, and on down to C5/C6. The range of movement increases stepwise. If there is a restriction in a segment, this step increase is absent on one or both sides. This method can be used to register the movement found, which was successfully done by Berger (1990) by means of cervicomotography (see Figure 4.33). The following points are important in order to perform this technique accurately:
Diagnosis of dysfunctions of the locomotor system
Chapter 4
Figure 4.32 • Examination of rotation of individual motion segments of the cervical spine.
Figure 4.34 • Examination of rotation of the cervicothoracic junction.
Figure 4.33 • Step diagram produced using
cervicomotography according to Berger (1990). 1, Movement restriction between C1/C2 and C2/C3 (arrows), and hypermobility between C3/C4. 2, After mobilization, restriction between C2/C3 and hypermobility between C3/ C4. 3, Normal finding after further treatment.
forehead rests in the crook of his elbow. With the little finger of the same hand, he should then span the arch of the upper vertebra of the segment being examined. The thumb of his other hand fixes the spinous process of the lower vertebra from the contralateral side (see Figure 4.34). Next the examiner should turn the patient’s head to take up the slack, and exert gentle springing pressure.
Shifting techniques • The vertebra that is fixed during the investigation
must be held exactly in the neutral position. • Only the minimum of force should be used to fix the vertebra, because as soon as the finger that is fixing (palpating) the vertebra reaches the articular process, a reflex response by the patient causes it to stop, which has the effect of determining the range of motion. Another useful place to examine rotation is at the cervicothoracic junction. The examiner stands behind the patient, who is sitting erect on a low chair. The examiner takes hold of the patient’s head between his forearm and upper arm, so that her
These techniques are used to examine joint play in the cervical spine in the ventrodorsal and laterolateral directions. The patient should be sitting erect. The examiner stands at the side and takes hold of the patient’s head between his forearm and upper arm. The little finger of the same hand spans the vertebral arch of the upper vertebra of the segment to be tested. From this point, two methods are possible: 1. The examiner shifts the patient’s head backwards until the barrier is engaged, and then applies springing pressure. In this case he 121
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Figure 4.35 • Examination of dorsal shifting (springing) in the motion segments of the cervical spine with the exception of C1/C2 but including the occiput–atlas.
should fix the lower vertebra of the segment at the vertebral arch by holding it between thumb and forefinger. 2. The examiner side-shifts the patient’s head and that part of the cervical spine down as far as the upper vertebra of the segment, holding the lower vertebra of the pair fixed using either his thumb, working toward him, or his forefinger, away from him. Each time, on engaging the barrier he applies gentle springing pressure (see Figure 4.35). This technique can be used to examine the segments from C2/C3 down to C5/C6 backward and to the side. It can also be used successfully, in the backward direction only, to test the occiput–atlas segment. In this case slight anteflexion of the head is advisable. The fixing hand grasps around the arch of the axis, but shifting is only possible between the atlas and the occipital condyles, not between the atlas and axis. From C6 to T3, the shifting technique can be used successfully in the backward direction for diagnosis. The patient is sitting erect on a low chair. The examiner takes hold of the patient’s head between his forearm and upper arm, so that her forehead rests in the crook of his elbow. With the ipsilateral hand, he applies pressure in the dorsal direction to 122
Figure 4.36 • Examination of dorsal shifting (springing) at the cervicothoracic junction.
the patient’s trapezius muscle. The lower vertebra of the segment is fixed with the finger or the thumb of the other hand (see Figure 4.36). The backward pressure applied to the shoulder muscles has the effect of delivering a dorsal push to the spinal column while fixation of the lower vertebra of the segment localizes it.
4.9.4 Testing of mobility between occiput and atlas Anteflexion The patient is supine. The examiner should place his hand, palm uppermost and completely relaxed, on the treatment table, allowing the patient’s occiput to rest in the palm. He should rest his thumb and forefinger on the superior, posterior border of the transverse process of the atlas to fix the vertebra from the cranial direction. The other hand is placed on the patient’s forehead and she is asked to look down toward the chin to engage the barrier (see Figure 4.37). In this position, springing pressure is applied. This is done using the fingers on the transverse
Diagnosis of dysfunctions of the locomotor system
Chapter 4
Figure 4.37 • Examination of anteflexion between the occiput and atlas.
processes of the atlas, as the fingers release their hold, so that the examiner can verify how effective fixation of the atlas is. At that moment, anteflexion should increase.
Side-bending The patient lies supine, head beyond the edge of the table. The examiner should take hold of the patient’s head and rotate it so as to lock the atlas/ axis segment, then very gently carry out sidebending between the occiput and atlas sufficiently to engage the barrier, and apply springing pressure (see Figure 4.38). With older patients, head rotation need not exceed 50–60°.
Figure 4.38 • Examination of passive side-bending between the occiput and atlas.
This test is carried out once with the patient’s head rotated to the right, and once to the left.
Rotation The patient is sitting erect. The examiner should stand behind the patient, place one hand on the patient’s cheek and, with this hand, rotate the
Retroflexion The patient lies supine, head well beyond the edge of the table. The examiner should take hold of the patient’s head by the chin and at the occiput, well up toward the top of the skull, then raise the head a little and rotate it so as to lock the rest of the cervical spine. In this position, the examiner should incline the head backward sufficiently to engage the barrier, and apply springing pressure (see Figure 4.39). The hand on the occiput needs to be placed high enough up the skull so that it does not obstruct retroflexion (this also applies during the mobilization).
Figure 4.39 • Examination of passive retroflexion between the occiput and atlas.
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patient’s head to one side. It is stabilized against the body of the examiner. Care should be taken to ensure that the head rotates about a vertical axis. Using the very minimum of force, the examiner should take up the slack and gently apply springing pressure, again with the absolute minimum of force. Springing is sensed with a fingertip of the other hand, placed on the transverse process of the atlas. If there is joint restriction, no springing is felt, either at the chin or at the transverse process of the atlas.
4.10 Examination of the limb joints Dysfunctions of the locomotor system affect the limbs as much as they do the spinal column, and both are so closely linked that it is always hard to decide the location of the primary or more serious disturbance. As a result, the diagnosis and treatment of these disturbances are an important part of everyday practice. Examination always begins with inspection, followed by active movement, then passive movement and movement against resistance, so as to differentiate between a disturbance of the joint and one of the muscle. Weakness in a muscle need not be the result of paresis; it may be caused by pain. When examining passive movement, a distinction has to be made between functional movement and joint play. In disturbances of functional movement, we distinguish between a situation in which movement is affected within the joint itself, and one in which it is affected by an external obstruction (such as a disturbance of the subdeltoid bursa at the shoulder joint). In this case, mobility of the joint is restricted only in the direction in which the obstruction operates; for example abduction of the shoulder if there is a disturbance in the region of the subdeltoid bursa. In the other case, all the movements of the joint are affected; not to the same degree in every direction, but nevertheless a clear proportional relationship can be observed. This has been termed a ‘capsular pattern’ by Cyriax (1977). Every joint has its own characteristic capsular pattern, and it is this pattern that determines the diagnostic significance. Movement restriction of the joint itself usually also involves restriction of joint play. Therefore this should always be examined; joint play and the 124
re-establishment of joint play are fundamental to therapy. The technique used to examine joint play is identical to that used for joint mobilization performed for the purpose of therapy; it is therefore described in Chapter 6, in connection with therapy.
4.10.1 The shoulder Active movement Active movement can be further classified into the categories of abduction, adduction, internal rotation, anteflexion, and retroflexion. The most commonly found disturbance, and also the most painful, is that of abduction. Pain is felt on movement within a circumscribed range, which can be overcome (the ‘painful arc’): the patient feels pain during abduction at a particular angle of less than 90°, but if it is possible to pass this point, abduction continues quite normally to the full extent. The cause of this lies in the fact that the head of the humerus and rotator cuff slip under the acromioclavicular ligament during abduction. This is enabled by the subdeltoid bursa. If there is a disturbance of the subdeltoid bursa or in the rotator cuff, this initially results in a transitory constraint; however, if the change is more advanced it leads to a painful, absolute, isolated barrier to abduction. This is the interpretation given by Cyriax (1977) and is the basis of ‘impingement syndrome,’ and is widely accepted. Examination of patients with this clinical picture, that is impaired abduction but normal rotation with the arms in abduction, regularly presents lack of joint play as shown in Figure 4.42. After mobilization – restoring joint play – abduction is regularly restored (see Figure 6.13). The explanation lies in the biomechanics of the glenohumeral joint as given by Latarjet (Testut 1928). On page 592 we read: ‘If the distal part of the humerus is lifted, its proximal part or its head slips down in the fossa glenoidalis; on the other hand, if the same extremity moves upward in the glenoid cavity then the humerus which was previously raised returns to its position of rest in adduction’ (see Figure 4.42). ‘Whatever the role of tears in the rotator cuff and/or changes in the bursa subdeltoacromialis, once joint play is restored, that is the normal biomechanics of the glenohumeral joint, the patient can abduct (lift his arm) normally and without pain.’
Diagnosis of dysfunctions of the locomotor system
Chapter 4
Figure 4.40 • Provoked pain, tested by means of isometric tension, of the muscle attachments: (A) against isometric abduction, of the supraspinatus; (B) against isometric external rotation, of the infraspinatus; and (C) against isometric anteversion, of the long biceps tendon.
The most commonly found painful changes of muscle attachments in the region of the rotator cuff can be investigated by isometric contraction against resistance in the starting position. Pain produced by the tension of abduction with the arm fully adducted (see Figure 4.40A) indicates a lesion of the supraspinatus. Pain produced by the tension of external rotation (see Figure 4.40B) indicates a disturbance of the infraspinatus. The long biceps tendon can be palpated directly, but if the patient reports pain when this is done, it originates from the attachments at the crest of the greater or the lesser tubercle. A more reliable method is to provoke the pain by anteversion of the supinated arm, bent at the elbow, against resistance (see Figure 4.40C). The subscapularis, the most important internal rotator muscle, has to be palpated deep inside the axilla.
Figure 4.68) or from the side at the inferior angle of the scapula.
External rotation It is important when examining external rotation to ensure that the patient’s upper arm remains adducted and the elbow flexed at 90°. External rotation is usually examined on both sides at once (see Figure 4.41).
Passive movement If passive mobility is impaired at the shoulder joint itself (the scapulohumeral or glenohumeral joint), the characteristic capsular pattern observed is, according to Sachse (1995), the following: first and most commonly, abduction is restricted, followed by external rotation and then internal rotation. The starting position is with the arm adducted and elbow ventrally directed. The shoulder blade must be fixed, either from above (see
Figure 4.41 • Examination of external rotation with the arms in adduction and elbows flexed at right angles.
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Internal rotation
The acromioclavicular joint
Internal rotation is usually also examined on both sides at once, by drawing the patient’s thumbs upward behind her back and comparing the two sides. When this examination is performed, adduction produces a degree of retroflexion.
Two more joints frequently cause shoulder pain: the acromioclavicular and the sternoclavicular. Disturbance of the former is very frequent, although its involvement is seldom recognized; however diagnosis is not difficult: adduction of the arm in front of the thorax causes the patient to feel pain and is restricted in comparison with the normal side. This is done by passively moving the elbow of the affected side toward the opposite shoulder. Direct palpation of the joint itself is also painful.
Abduction In this case there is a characteristic disturbance of joint play: with the upper arm abducted at a right angle, the examiner applies slight pressure to the head of the humerus from above to engage the barrier, followed by springing pressure (see Figure 4.42). If there is a true capsular pattern and the patient is still able to abduct her arm to approximately 90°, joint play is normal, indicating that the frozen shoulder is not due to dysfunctional joint restriction but to reactive capsulitis. If abduction alone is restricted, there is generally also a disturbance of joint play. In this case the head of the humerus cannot glide down from the narrow, upper part of the glenoid cavity as it needs to in abduction. It is important when performing this test to ensure that the pressure is applied at the correct point: on the head of the humerus, which is lateral to the apex of the deltoid (see Figure 4.42).
The sternoclavicular joint Dysfunction of the sternoclavicular joint is a much less common condition. The patient experiences pain when moving the shoulder blades and on movements involving greater excursion of the shoulders; on palpation the joint is tender to pressure. The following points should be noted, however: tenderness of the medial end of the clavicle is also found in cases of myotendinosis of the sternocleidomastoid. Also, laterally below the clavicle is the joint between the first rib and the manubrium of the sternum, and this is tender to pressure in cases of restriction of the first rib.
The expression ‘periarthritis humeroscapularis’ or ‘shoulder periarthritis’ is still much used, but is meaningless and unhelpful as a description of frozen shoulder. Specific diagnosis of the disturbance is required.
4.10.2 The elbow
Figure 4.42 • Examination of joint play in the shoulder joint
by springing pressure applied from above to the head of the humerus, with the arm abducted at 90°.
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Disturbances of the elbow joint produce restriction in flexion and extension, with flexion being more markedly affected in accordance with the capsular pattern. The joint play here is a sideways (radial or ulnar) springing of the forearm, especially of the ulna relative to the upper arm. The elbow is also the location of the radioulnar joint, and it is here that pronation and supination take place. The most frequently found clinical condition is pain at the epicondyles. There is tenderness on palpation involving application of pressure. If the
Diagnosis of dysfunctions of the locomotor system
radial epicondyle is affected, pain is produced by shaking hands or lifting a chair with the arm pronated. Lifting with the arm supinated is painful if it is the ulnar (medial) epicondyle.
4.10.3 The wrist The wrist joint is complex, consisting of the radius and ulna, the carpal bones, and their articulations with the metacarpals. In order to localize findings anatomically it is useful to know that the skin fold on the dorsal aspect of the wrist in dorsiflexion corresponds to the radiocarpal joint, and that the fold on the palmar aspect in palmarflexion corresponds to the carpometacarpal joints. The general appearance of the wrist joint (articulatio radiocarpalis) is at first sight rather like an egg that is free to move around in every plane in the shallow joint socket of the radius. Its functional movements, in combination with the midcarpal joint (articulatio mediocarpalis), are in fact limited to dorsal extension and palmar flexion and radial and ulnar abduction. Rotation is entirely possible in terms of joint play, but as regards functional movement the muscles to perform active rotation are lacking. The wrist joint and midcarpal joint each have a distinct role to play in dorsal extension and palmar flexion. Palmar flexion takes place mainly in the wrist joint, the proximal row of the carpal bones gliding in a dorsal direction relative to the radius. Dorsal extension takes place mainly in the midcarpal joint, the distal row of the carpal bones gliding in a palmar direction relative to the proximal row. In ulnar abduction, the proximal row glides radially (laterally) relative to the radius. In ulnar abduction, the proximal row glides radially (laterally) relative to the radius. Radial abduction involves the most complicated mechanism. The proximal end of the first metacarpal draws closer to the radius, and as it does so the lateral end of the scaphoid tips in the palmar direction. The trapezium and trapezoid glide in the palmar direction, rather as they do in dorsal extension. This explains why it is possible to perform radial abduction at the same time as dorsal extension, but not simultaneously with palmar flexion. In dorsal extension, ulnar abduction is prevented. A further factor affecting ulnar abduction and, still more, radial abduction, is the mobility of the
Chapter 4
ulna relative to the radius. Radial abduction is accompanied by a synkinetic pronation of the forearm when the hand is kept in the same plane. Similarly, on ulnar abduction there is a corresponding slight supination. The radius also moves proximally relative to the ulna during radial abduction, and distally during ulnar abduction. Lateral movements in the wrist are therefore dependent on the mobility of the radius relative to the ulna. This is the main cause of certain frequently occurring painful conditions, such as pain at the radial styloid process or, less frequently, at the ulnar styloid process, tenosynovitis and persistent pain following fracture of the radius.
The cause of restricted abduction of the wrist in a radial (lateral) or ulnar (medial) direction is most frequently found in the radioulnar joints, most importantly at the elbow.
The metacarpophalangeal joints are in fact ball and socket joints, which permit movement in every plane, but the absence of rotator muscles means that only flexion, extension, and laterolateral movements are actively possible. The only exception is the saddle joint between the trapezium and first metacarpal. This joint permits movement in all three planes, whereas the first metacarpophalangeal joint only permits flexion and extension. The interphalangeal joints are hinge joints, which permit only flexion and extension. Joint play in the finger joints is dealt with in Section 6.2.1.
4.10.4 The hip Although the hip is a limb joint, clinically it is part of the pelvis, borne out by the fact that frequently the first symptom in lesions of the hip joint is lowback pain. In disorders of the hip joint, the hip – and therefore also the knee – is in flexion; it is also in external rotation, which often has the effect of increasing the lumbar lordosis. This makes it possible to distinguish hip pain from acute lumbago at first glance. The distinction is still clearer in retroflexion. 127
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Figure 4.43 • Patrick’s sign (‘frog-leg’ position). Figure 4.44 • Examination of internal rotation of the hip joint with the patient supine, hip and knee flexed at 90°.
The most constant sign to be looked for is Patrick’s sign (see Figure 4.43), and it is with this that the examination proper begins. The leg to be tested is flexed at hip and knee (‘frog-leg’ position). The test is positive if abduction of that leg is restricted. The capsular pattern in dysfunction is first and most markedly restriction of internal rotation. This is tested with the patient supine, with the knee and hip flexed (see Figure 4.44) or with the patient lying prone with the hip straight (examining both sides at the same time). This is followed by an examination of extension (with the patient prone), of maximum flexion (patient supine), and finally external rotation. In addition, active abduction of the leg with the patient in the side-lying position is painful. The range of motion may be normal at first, but springing in the end position is painful. The most important pain points are at the femoral head in the groin, the greater trochanter, and the attachment of the adductors on the pes anserinus of the tibia, which the patient experiences as pain in the knee. The articular head and socket being largely congruous, the only joint play is distraction. 128
4.10.5 The knee The inspection of the knee should note: • valgus or varus alignment • genu recurvatum (back-knee) • deterioration of fine structural features as in osteoarthritis • the height of the hollows of the knees. Again, asymmetry here can cause pelvic obliquity. The knee, like the elbow, consists of two joints: it is made up of the true knee joint, between the femur and the tibia, and the joint between the tibia and fibula (the tibiofibular joint). The movements that take place at the knee joint are flexion, extension, and, when the knee is flexed, rotation. There is considerable joint play, partly because the joint surfaces are incongruous, and partly on account of the articulation with the patella. The joint play consists of gliding in the ventrodorsal direction with the knee flexed, distraction, laterolateral shifting, and springing with the knee extended; also of craniocaudal and laterolateral shifting of the patella.
Diagnosis of dysfunctions of the locomotor system
The joint pattern of the knee means that the first and most common restriction is that of flexion. This must therefore be examined first, by bringing the heel toward the buttock as far as it will go. It will be necessary to guide the patient’s heel so as to deviate slightly medially or laterally, to avoid obstruction of the approach caused by the substantial belly of the calf and ischiocrural muscles. Rotation between the upper and lower leg can also be examined when the patient’s knees are flexed. The most important pain points are at the medial collateral ligament, in the hollow of the knee, at the superior border of the patella, and at the attachment of the patellar ligament (housemaid’s knee). The tibiofibular joint participates in the rotation of the lower leg on the thigh. Passive movement can most accurately be examined by comparing the internal and external rotation of the feet with the patient prone and the knees flexed. The joint play consists of dorsomedial and ventrolateral rotation of the fibular head, and is best examined with the patient supine and with knees flexed. Restriction of the head of the fibula is clinically very significant. The fibular head is the point of insertion of the biceps femoris, and restriction of the fibular head is regularly associated with a TrP in this muscle. This disturbs the fixation of the pelvis, affecting the abdominal and gluteal muscles and so overall posture (forward-drawn posture).
4.10.6 The foot Some aspects have already been dealt with when discussing the inspection. Assessment of flat foot can be carried out most accurately and with equivalence on both sides by inserting the tip of the finger under the longitudinal arch from medially, pushing the fingertip inward, and comparing findings. The finger meets resistance sooner on the side that is flattened. If asymmetry is found, this is often the cause of pelvic obliquity. The patient should be asked to stand supported on the lateral edges of the foot; both iliac crests then become horizontally level. Besides establishing the shape of the foot, a functional diagnosis is needed. For this, the examiner must observe the arch of the foot from medially, during walking. The point that needs to be checked is whether the arch of the foot is maintained or yields during the action of walking, irrespective of the degree of arching or flatness of the foot. In
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normal locomotion the heel strikes the ground first; the foot then uncurls, mainly along its lateral border, into pronation and pushes off with the aid of the toes. If the patient concentrates on the lateral border and tries to sense this during walking, this is often enough to restore the function of the foot. The function of the toes in pushing off often suffers restriction. This insufficiency of the toe flexors is closely associated with splay foot. Véle’s test (personal communication) examines this. If the patient, standing barefoot, transfers her weight forward without going on tiptoe, this automatically (as a reflex response) produces flexion of the toes, evidently as a defensive action to prevent falling. This reflex is frequently absent, especially when there is weakness of the short flexors of the foot in the case of splay foot or S1 radicular syndrome. Therefore, in the case of splay foot, this synkinesis needs to be practiced. The patient is asked to rock rhythmically to and fro. Hallux valgus is commonly found, representing a deviation of the great toe toward the lateral side of the foot as a result of wearing constricting shoes, and involving a weakness of the abductor hallucis. This muscle also supports the longitudinal arch of the foot, so that the patient has to learn (laboriously!) how to exercise the muscle. Shoes are a factor not only in hallux valgus, but also in causing the deficient function of the toes and so also for splay foot. The best method of screening all the joints of the foot is to test rotation about its longitudinal axis. The patient is supine, the examined leg flexed with the heel resting on the table. The examiner grasps the foot with one hand at the first metatarsal head and the other at the fifth, and rotates it around the longitudinal axis, which passes through the talar head. If there is dysfunction in any of the foot joints, this rotation is impaired: either the foot deviates from the axis before the end of the rotation, or increased resistance is found if the axis of rotation is maintained. The ankle joint (articulatio talocruralis) is a hinge joint which allows only the movements of dorsiflexion and plantarflexion. As a result of its joint pattern, the prime, most common restriction of this joint is dorsiflexion. This is generally examined with the patient’s knees flexed, because, with the knee extended, a short gastrocnemius muscle hinders dorsiflexion. Joint play consists of ventrodorsal shifting of the tibia and fibula against the talus, and distraction. It is important to realize 129
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that, when there is dysfunction of this joint, this is clearly shown by the joint play, while the range of functional movement often remains normal. The joints of the foot include the subtalar (talocalcaneal) and talocalcaneonavicular joints between the talus, the calcaneus and the navicular bone, the transverse tarsal (Chopart’s) joint, and the tarsometatarsal (Lisfranc’s) joints between the tarsals and metatarsals. They enable active pronation and supination combined with eversion and inversion. Joint play in particular should be examined, and this is used for mobilization (see Section 6.2.2). Examination of the toe joints is done in the same way as that of the finger joints. Although there is no articulation between the heads of the metatarsals, in the foot their free mobility one against the other is especially important. This mobility is often disturbed in painful splay foot and in radicular syndromes. The problem is due to a soft-tissue lesion between the metatarsals.
4.11 Examination of the temporomandibular joint The temporomandibular joint forms a functional unit together with the masticatory muscles and muscles of the floor of the mouth, and it is of great importance, as can be seen from the term ‘mandibulocranial syndrome.’ In fact, the mandibulocranial syndrome can cause symptoms that are difficult to distinguish from craniocervical syndrome, including headache and even vertigo. When the main symptom is pain in the face, differential diagnosis is important to exclude trigeminal neuralgia. Pain in the region of the ear, and dysphagia, sometimes also tinnitus, are also typical symptoms. An important diagnostic indication is tenderness to pressure of the capitulum in front of the tragus, on palpation from the direction of the external auditory meatus. This may intensify on opening and closing of the mouth. TrPs in the masticatory muscles are another important sign. The functional movements of this joint are the opening and closing of the mouth, shifting the mandible from anterior to posterior and also laterally. Dysfunction causes restriction of mouth opening. It is normally possible to insert the width of three finger knuckles between the upper and lower incisors. Joint play consists of distraction and side-toside movement. 130
TrPs can be found in the temporal region in the temporalis muscle, through the cheeks or from the mouth in the masseter muscle, behind the mandibular angle in the medial pterygoid muscle and, most frequently, in the lateral pterygoid in the mouth above the wisdom teeth; this TrP is most intensely painful. Tension in the floor of the mouth, caused by TrPs in the digastric and mylohyoid muscles, is also important. These are best diagnosed by palpation of resistance at the thyroid cartilage or at the hyoid, which is more difficult to perform. The tension on one side is often so considerable that lateral deviation of the thyroid cartilage is seen toward the side of the tension, as well as distortion of the floor of the mouth. The characteristic muscular imbalance is shortening of the masticatory muscles, with weakening of the muscles that govern the opening of the mouth. The main causes are a faulty bite, ill-fitting dentures, or trauma, or they may be functional and brought about by stress and grinding of the teeth (bruxism). Functional chain reactions are frequent, especially in the craniocervical region.
4.12 Examination of disturbances of balance As has already been made clear (see Section 2.5), the spinal column plays a significant part in maintaining or disturbing balance; and it is therefore important to have straightforward methods of clinical examination to assess dysfunctions of the spinal column in cases of disturbed balance. Hautant’s test seems the most suitable for this purpose. The patient is seated comfortably in a chair which supports her back, with eyes closed and both arms stretched forward. The examiner stands facing her, with his thumbs pointing at the patient’s fingertips (see Figure 4.45). This enables him to detect whether the patient’s arms deviate (not owing to rotation of the trunk) and then assess the role played by the cervical spine. The test is repeated with different positions of the head relative to the trunk and enables the examiner to recognize ‘pathogenic’ and also relief positions, by judging whether the deviation appears, increases, or disappears. Between each test, when the patient changes the position of her head, the examiner must hold her hands in neutral position to prevent deviation due to synkinesis of the arms. When testing each head position, the examiner should wait
Diagnosis of dysfunctions of the locomotor system
Chapter 4
Figure 4.45 • Hautant’s test to assess lateral deviation of the patient’s outstretched arms.
for about 5–10 seconds to see whether deviation sets in or is spontaneously corrected. This test has great advantages: being seated with the back supported, the patient feels safe even if dizziness occurs, and any deviation that is found is not caused by nervousness, as is often the case in Romberg’s test or Unterberger’s stepping test. The second advantage is that with the patient’s back leaning against a chair, the back is fixed and only side deviation of the arms is possible. There is no swaying to and fro as in disturbance of the labyrinth. If the patient is asked to turn her head when in the sitting position, this best enables the examiner to assess the role of the cervical spine. The reaction produced is so characteristic that it is possible to speak of a ‘cervical pattern’ (see Section 7.6.2). This examination is therefore indicated whenever the patient complains of disturbances of balance and also when the test standing on two scales produces a difference of more than 4 kg. Berger (1990) has constructed a simple technique to register this deviation: the patient is sitting with eyes closed; in one outstretched hand she holds a ballpoint pen and moves it from right to left and back for about 1 cm each time on paper that is moving forward at a constant speed. In this way
Figure 4.46 • Trace registering lateral deviation using
Berger’s recording apparatus: In the sections marked ‘g’ the patient’s head is in the neutral position, in section ‘r’ it is rotated to the right and in section ‘l’ it is rotated to the left. In that bottom section, the line on the left (marked ‘3’) can be seen to deviate toward the right. After treatment, the line on the right (marked ‘4’) shows no deviation.
deviation can be registered for various head positions (see Figure 4.46). The test can be performed before and after treatment for comparison. For the test using two scales, the patient is asked to stand with legs extended and to distribute her body weight equally on both, since otherwise it is natural to place more weight on the stance leg. What is tested is therefore the patient’s ability to estimate accurately the symmetrical distribution of body weight on the legs. It is of course essential to make a distinction between the position of the head relative to the trunk and the position in space of the head and trunk together, that is to diagnose positional vertigo. To do so we must change the position of the patient’s head and trunk simultaneously (e.g. sitting up and lying down are done with the patient’s head in a neutral or rotated position; turning to one side or the other supine is done by turning the head and 131
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the rest of the body simultaneously). The positional vertigo produced in this way is true labyrinthine rotatory vertigo. Although it lasts only a few seconds, it is usually very intense, as can be seen from the patient’s reaction. The patient tends to close her eyes, so that it is not usually possible to see the nystagmus, which lasts only very briefly. To determine the role of the vertebral artery in vertigo, the patient is examined in positions assumed to restrict blood flow in the artery on the contralateral side to the rotation. De Kleyn’s test is suitable for this. The patient is supine, with her head beyond the end of the treatment table. Rotation is examined in retroflexion. The examiner needs to wait to see whether the patient begins to experience vertigo; if her eyes are open, nystagmus will be seen. This test is particularly conclusive if there is no restriction in the position being tested, and all the symptoms can therefore be attributed to the disturbance of blood flow. If concomitant restriction is found, this should be treated and the test then repeated. If the result of the test is again positive, the cause must lie with the vertebral artery. In some instances de Kleyn’s test may provoke positional vertigo. If this is observed the examiner should recognize the fact and follow either of two options, the first being to repeat the test at short intervals. In positional vertigo, adaptation soon occurs so that no vertigo is provoked. No such adaptation takes place if there is insufficiency of the vertebral artery. The other option is to maintain the test position and wait. Positional vertigo never lasts more than a few seconds, whereas the patient’s condition gets worse if there is insufficiency of the vertebral artery; this situation involves some degree of risk.
Differential diagnosis of vertigo can be considerably refined by using manual techniques.
4.13 Examination of muscle function 4.13.1 General principles One fundamental difficulty of examination is undoubtedly the lack of established definitions as to what is to be considered normal. Diagnosis has to be 132
based almost exclusively on clinical examination, since the alternative, electromyography, is so cumbersome and time-consuming that it is seldom practicable.
Clinical kinesiological examination In addition to neurological screening, the examination should include: • muscle strength (muscle tests) • shortened muscles • hypermobility • overall tonus, mobility, and elasticity of the soft tissues including the fasciae • posture, standing and sitting • sensitivity, especially in the regions of the hands and feet • simple movements • gait, including tests of walking in unaccustomed posture such as on tiptoe or on the heels, or with arms raised or hanging down. In the neurological examination the signs of special interest are those characteristic of minimal brain damage, such as marked asymmetry, especially of the face and the limbs, restlessness, clumsiness, agitation, and also minor deficits such as slight paresis, hypesthesia, and paresthesia.
Evaluation of muscle function The muscle test was originally introduced to examine paresis of individual muscles or of muscle groups in such diseases as poliomyelitis. It essentially examines muscle strength during a simple coordinated movement. This enables the strength of one specific muscle or muscle group to be assessed. Standard conditions must be maintained, so that results are comparable. Results are graded as follows: • 0: No muscle activity. • 1: Muscle twitch without motor effect. • 2: Muscle contraction enabling movement without resistance, therefore in the horizontal plane. • 3: Movement against gravity. • 4: Movement against moderate resistance. • 5: Movement against maximum resistance. Our patients are for the most part seeking treatment for painful conditions, and none of them apart from those with radicular syndromes are suffering from true paresis; consequently the values
Diagnosis of dysfunctions of the locomotor system
we find range between grades 4 and 5, and only the abdominal muscles and deep neck flexors occasionally exhibit weakening to grade 3. As a result, the degree of distinction that can be made using grades 4 and 5 is not fine enough to be useful for the assessment of our patients. Without going into details, the examiner must bear in mind the following principles when performing the muscle test: • The position of the patient must be constant. • Resistance must remain constant throughout the movement. • The direction and speed of movement should remain as constant as possible. • The movement must above all be isotonic. • Isometric resistance can also assess the degree of force in the muscle but does not assess coordination. Some modification of the muscle function test therefore are helpful for our patients, who do not suffer from paresis. The most important techniques are described below. In the sections dealing with muscular stereotypes (see Sections 2.9 and 4.15),
Chapter 4
a distinction is made in line with the work of Janda between those muscles with a tendency to weakness and laxity and those with a tendency to hyperactivity and shortening.
4.13.2 Examination of muscles with a tendency to weakness The gluteus maximus Before performing the classic muscle test we begin by examining active retroflexion (hyperextension) of the hip, with the patient prone in order to identify the patient’s accustomed stereotype (movement pattern; see Figure 4.47). Electromyography has established that, far from simply being a function of the gluteus maximus alone, retroflexion of the hip is carried out by the coordinated action of the ischiocrural muscles (knee flexors), gluteus maximus, and erector spinae. The major role is performed by the ischiocrural muscles, rather
Figure 4.47 • Examination of the gluteus maximus by palpation of the gluteus maximus, the ischiocrural, and erector
spinae muscles (A) with the lower limb extended; (B) with the knee flexed; and (C) with the lower limb in external rotation.
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than the gluteus maximus. The action begins with contraction of the ischiocrural and gluteus maximus muscles, followed by the erector spinae on the contralateral and finally the ipsilateral side. It is therefore advisable to palpate the gluteus maximus and ischiocrural muscles with one hand, and the erectores spinae of both sides with the fingers of the other. In the frequent cases of an inhibited gluteus maximus, contraction is found to be retarded, so that it is passed over and the contraction of the ischiocrural muscles is immediately followed by an exaggerated contraction of the ipsilateral erector spinae. In the most severely disturbed movement patterns muscular contraction may start at the superior part of the trapezius. The muscle test proper is performed with the patient prone, face down and knee flexed. Resistance to the extension of the hip is applied above the knee (see Figure 4.47B). If we wish to facilitate the gluteus maximus, the best approach is to examine retroflexion of the hip with the leg in external rotation (see Figure 4.47C). If the patient’s leg, in extension, is allowed to hang down beyond the edge of the treatment table so that the extension of the hip begins from that position, the examiner will see that the gluteus maximus does not contract until the leg is horizontal, whereas the ischiocrural muscles are active from
the very beginning of the movement. The same applies in upright gait. On the other hand, when the person is getting up from a chair or climbing steps, the gluteus maximus contracts immediately.
The gluteus medius The gluteus medius is examined with the patient in the side-lying position, her underneath leg flexed slightly. She should be asked to raise the uppermost leg laterally (i.e. upward from the table), completely spontaneously. The examiner should make no intervention at this stage, but instead observe whether she makes a true abduction (see Figure 4.48A), or a combined movement, involving flexing of the hip and external rotation of the leg (see Figure 4.48B). Only the first is genuine abduction, employing the true abductor muscles (gluteus medius and minimus) at the same time as contracting the tensor fasciae latae. The second reveals incoordination, in which there is substitution by the tensor fasciae latae. It is therefore advisable to palpate both the gluteus medius and the tensor fasciae latae during the examination. In incoordination there is also premature contraction of the quadratus lumborum, producing side-bending of the trunk rather than hip abduction.
Figure 4.48 • Examination of hip abduction by contraction of the gluteus medius with the patient in the side-lying position.
(A) Pure abduction correctly carried out. (B) False abduction (incoordination) by substitution by the hip flexors, particularly by the tensor fasciae latae. (C) The ‘classic’ test for the abductors.
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The classic test is performed by applying resistance against the lower third of the thigh from laterally and above, at the same time fixing the pelvis in such a way as to prevent substitution by the quadratus lumborum (see Figure 4.48C). Meanwhile, with the thumb and forefinger of the other hand, the examiner should palpate the gluteus medius and tensor fasciae latae.
The rectus abdominis The classic test is performed with the patient supine, knees flexed, and arms clasped behind the back of her neck. The examiner fixes the patient’s lower limbs and pelvis. She is then asked to sit up, beginning by lifting her head, then her thorax, ‘curling up’ in the process. For our purposes it is better if the patient sits up unaided with arms stretched forward (see Figure 4.49). This can only be done if the abdominal muscles are sufficiently strong. Very strong patients will even be able to sit up with arms clasped behind the back of the neck. Although bending the knees inhibits the hip flexors to some degree, sitting up is always the result of coordinated action together with the hip flexors. To examine the abdominal muscles alone, excluding the hip flexors, the examiner should place his hands under and behind the patient’s heels, telling her to press down onto his hands with her heels. Then she is asked to lift her head and her thorax in succession. The moment the patient starts using the hip flexors, the pressure of her heels on the examiner’s hands ceases. The stronger the abdominal muscles, the higher the patient can lift her head and trunk without relaxing the pressure of her heels.
Chapter 4
The transversus abdominis The transversus abdominis cannot be tested by means of a particular movement; the examiner simply has to observe whether the patient’s flanks are drawn inward during sitting up or rotation of the trunk. If the patient’s flanks bulge outward, this is a reliable sign of insufficiency. Another indication of insufficiency is seen when the patient’s abdomen bulges on lifting an object from a position of anteflexion.
The inferior (ascending) part of the trapezius For this muscle test the patient should be prone, face down, and with the arm on the tested side stretched forward. With one hand, the examiner grasps the outstretched arm, and with the other he should grasp the inferior angle of the scapula, telling the patient to pull her arm and shoulder down in the caudal direction (see Figure 4.50). For our purposes, the best way to diagnose incoordination is simply inspection. The patient is face down, with her arm against her body. She is then asked to draw one shoulder down in the caudal direction (i.e. in line with the muscle fibers). If the trapezius is weak, the inferior scapular angle moves medially like a hook and protrudes under the skin, as it does in winged scapula (scapula alata). This movement, which is normally forceful, can in this case be prevented easily by the thumb and forefinger of the examiner’s hand. The patient should be able to move the scapula in a caudal (and slightly medial) direction against resistance.
Figure 4.49 • Examination of the rectus abdominis (see also Figure 6.139A).
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arms rather than putting the weight on her knees, and her shoulder blades should be abducted. She can flex her elbows slightly as she does this (see Figure 4.51). She must then maintain this position while the examiner waits and observes. If the muscle is weak, then after a period of latency the medial border of the scapula lifts, leading to the appearance of slight winged scapula.
The deep flexors of the neck
Figure 4.50 • Examination of the inferior part of the trapezius.
The serratus anterior This muscle is tested with the patient on all fours. She should distribute her weight forward onto her
The patient is supine and is told to lift her head in an arching movement, drawing her chin toward the jugular fossa. The examiner fixes the patient’s chest from above with one hand while the other, on her forehead, applies resistance (see Figure 4.52). If there is weakness of the deep neck flexors, a ventral shift of the head (incoordination) is seen, due to predominance of the sternocleidomastoid muscles. There is a useful ‘quantitative’ test that can be applied: the patient is asked to raise her head as if reading (without lifting the thorax). If strength is normal, this position can be maintained for half a minute or even longer, but if the muscles are weak, the patient’s head sinks back down onto the treatment table after a few seconds. To test the sternocleidomastoid muscles, the examiner should apply resistance to the ventral lifting of the head.
4.13.3 Examination of muscles with a tendency to shortening Figure 4.51 • Examination of the serratus anterior with the patient positioned on all fours.
Evaluation of those muscles that tend to hyperactivity and shortening – the ‘predominantly
Figure 4.52 • Examination of the deep neck flexors. (A) Head raised in an arc: good muscle function. (B) Head raised vertically: insufficiency; predominance of the sternocleidomastoid muscles.
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Chapter 4
Figure 4.53 • Test for shortening of the soleus. (A) Normal muscle stretch. (B) Raising of the heel from the floor on adopting a squatting position: this indicates shortening.
postural muscles’ identified by Janda (see Table 2.1, p. 28) – is essentially a matter of observing how far a muscle can be stretched without the use of force; as this is done in the same way as if taking up the slack in PIR, only those muscles for which the techniques differ are dealt with here.
The soleus If this muscle is shortened, dorsiflexion of the ankle joint is restricted. This can be tested by asking the patient to squat down without raising her heel from the floor. If she has to lift her heels from the floor, then it is primarily the soleus that is shortened (see Figure 4.53). If, as often happens, it is only the gastrocnemius that is shortened, dorsiflexion of the ankle joint is restricted with the knee extended but not with the
knee flexed, and this can be shown quite simply by comparing dorsiflexion with the knee extended and flexed (see Figure 4.54). For this reason the mobility of the ankle joint should never be tested with the knees extended. The foot must be guided precisely at the lateral border while applying traction at the heel.
The ischiocrural muscles The ischiocrural muscles are tested in the same way as in the straight-leg raising test. The patient is supine. The leg that is not being examined should be fixed on the table from above, and the other leg flexed at the hip, with the knee extended. The ischiocrural muscles are considered shortened if the extended leg cannot be flexed at the hip to an angle of 90°. All the patient feels in this case is tension in
Figure 4.54 • Examination of muscle stretch of the gastocnemius by dorsiflexing the foot (A) with the leg extended and (B) with the knee bent. A marked difference in dorsiflexion indicates that the gastrocnemius is shortened.
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the hollow of the knee and in the thigh, but (unlike in radicular syndrome) no real pain. Shortening of these muscles is the most frequent reason why a clinically healthy subject cannot touch the floor when bending forward with the arms and legs straight. This is most clearly evident when observed from the side: on anteflexion, considerable kyphosis of the lumbar spine is seen, but ventral inclination of the pelvis is inadequate.
The hip flexors These comprise the iliopsoas, the rectus femoris, and the tensor fasciae latae. They are examined in the position for Mennell’s test. The patient is supine with the buttocks at the end of the table, and draws one knee toward her chest, close enough to flatten lumbar lordosis (see Figure 4.55). The other leg (the one to be tested) is allowed to hang down over the edge of the table. In this position
some disturbances can be identified straight away by simple inspection: if the iliopsoas is shortened, the knee of the leg being tested will be raised. If the rectus femoris is shortened, the lower leg will not hang vertically; instead there will be an obtuse angle between the lower leg and thigh. If the tensor fasciae latae is shortened, the thigh will be slightly abducted and the patella will deviate slightly outward. To evaluate the individual muscles, the examiner should reinforce fixation of the flexed knee (the one not being examined) from above with one hand. With the other hand, the examiner then: • exerts pressure from above on the knee of the leg being tested in order to assess shortening of the iliopsoas • applies pressure to the lower leg to flex the knee: the knee of the leg being tested rises prematurely, even with knee flexion greater than 90°
Figure 4.55 • Examination of the hip flexors. (A) The examiner notes whether the thigh is raised above the horizontal,
and/or whether the lower leg is extended forward, or the thigh and patella deviate to the side. (B) By pressure from above, the examiner brings out the shortening of the iliopsoas; by pressure from the side, the examiner brings out the shortening of the tensor fasciae latae. (C) Flexion of the knee produces the avoidance reaction of hip flexion if the rectus femoris is short.
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Figure 4.56 • Examining for shortness of the lumbar erector spinae muscles. (A) Drawing the forehead to the knees.
(B) The patient fixes her pelvis with her hands. Restricted anteflexion in the lumbar spine due to short spinal erectors can now be easily diagnosed.
• applies lateral pressure to the slightly abducted
knee. Premature resistance is felt and the tension can be seen in the iliotibial tract, as if in a groove on the lateral aspect of the thigh.
The lumbar erector spinae Examination for a shortened lumbar erector spinae is carried out with the patient sitting, the knees flexed and the trunk in anteflexion. The patient’s hands should rest behind her body, palms uppermost and the back of her hands flat on the treatment table (see Figure 4.56A). She is asked to draw her forehead to her knees. This cannot be done if the erector spinae muscles are shortened. However, other factors are also capable of preventing this: for example it is impossible if the patient’s trunk is long and her thighs short. Conversely, however, if the patient has a short trunk and long thighs, it is possible to perform the movement even if the muscles of the back are shortened. A modified version of the test is therefore more reliable: the patient, seated, fixes her pelvis by placing her hands on the iliac crests, and humps her spine to create lumbar kyphosis. If the lumbar part of the erector spinae is shortened, lumbar lordosis remains unaltered (see Figure 4.56B).
The quadratus lumborum Shortening of the quadratus lumborum can be identified on side-bending, but scoliosis or a difference in leg length can give a false impression of shortening of this muscle. Examination with the patient
Figure 4.57 • Examination of the quadratus lumborum.
side-lying is more accurate; the patient should raise her upper body, supported on her elbow and forearm, so as to produce side-bending of the lumbar spine. The lower part of her trunk should remain on the table (see Figure 4.57); if necessary the examiner should fix the patient’s pelvis from above to prevent her from raising her trunk too far. If the quadratus lumborum is shortened, side-bending is reduced.
The muscles of the nuchal region The technique used to test for shortening of the superior (descending) part of the trapezius, pectorales, and levator scapulae muscles is identical to that used in PIR treatment to take up the slack, and is described in the section dealing with this (see Section 6.8). 139
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of hypermobility in pathogenesis has already been described (see Section 2.10); here we shall focus on diagnosis. The guidelines in this respect have been set out by Sachse (1969), and enable the examiner to make the distinction between normal mobility, hypomobility, and hypermobility, all within the range of the normal. It is nevertheless important to bear in mind the great variability between individuals, and also between age groups. What may be considered hypermobile in an adult male may be perfectly normal in a female or a child. With this proviso in mind, it will be helpful in what follows to present the results not in the form of a continuous scale of measurements, but of three levels of mobility, A, B and C: • A: hypomobile to normal • B: slightly hypermobile • C: marked hypermobility. I also compare Sachse’s criteria with the data given by Kapandji (1974) and describe the technique.
4.14.1 The spinal column Figure 4.58 • Overload of the upper fixators of the
shoulder girdle and superiorly convex ‘Gothic’ shoulders.
On inspection, shortening of the pectoralis is shown by increased thoracic kyphosis, shortening of the superior part of the muscle is shown by forward-drawn shoulders, and hypertonus of the superior part of the trapezius is revealed by the upwardly convex ‘Gothic’ shape of the shoulders (see Figure 4.58). For rapid screening assessment, the muscles of the nuchal region are examined as follows. The patient should draw her chin to her chest (with mouth closed). If the muscles are short, the patient will be unable to do this, and a gap remains, which the examiner can measure in terms of fingers’ breadth. Short nuchal muscles are the most frequent cause of inability to bring the chin down on to the chest.
4.14 Examination of hypermobility Not only weakness and tautness, but hypermobility, too, is mainly muscular in origin. The significance 140
The overall mobility of the spinal column on the basis of X-ray examination is 145° for anteflexion, 135° for retroflexion, 75° for side-bending, and 90–95° for rotation to each side, as found by Kapandji (1974). Clinically, each of these movements is measured separately. One sign of hypermobility of the lumbar spine which is of particular clinical importance is this: hyperlordosis is seen when the patient is standing, and changes to hyperkyphosis when the patient adopts a relaxed sitting position.
The lumbar spine Retroflexion The average range of retroflexion is 35° according to Kapandji (1974). Clinical examination may show the maximum angle of retroflexion to be either lumbosacral or thoracolumbar. According to Sachse (1969) the test is carried out with the patient prone so as to exclude synkineses of the pelvis. The patient’s hands should be placed underneath her as support, flat on the table, and positioned so that her fingertips are immediately under her shoulders (see Figure 4.59A). The examiner should fix her pelvis
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Figure 4.59 • (A) Testing the range of retroflexion of the trunk. (B) Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
from above. The patient is asked to direct her gaze at the floor and to lift her upper body by the pressure of her arms, raising it as far as her lumbar spine will allow without involving any movement of the pelvis. The degree of movement can be read indirectly by looking at the internal angle of the elbow. Range A is up to 60°, range B up to 90°, and range C in excess of 90° (see Figure 4.59B).
Anteflexion The average range of anteflexion is 60° according to Kapandji (1974). When this is tested by having the patient bend to touch the floor, hip flexion is also tested, and if done with legs extended, this also tests the muscle stretch of the ischiocrural muscles (see Figure 4.60). Range A covers a finger–floor distance through to 0 cm. Greater flexibility, through to the point where the patient is able to touch the floor with her knuckles, is classed as range B. Range C covers anything beyond this. The patient is sometimes even able to place the chest against the thighs. This examination has the disadvantage that it tests not only the kyphosis of the lumbar spine but also muscle stretch of the ischiocrural muscles. The following test can focus much more specifically on anteflexion of the trunk: for this the patient is in the sitting position and is asked to bend and try to touch her knees with her forehead. In this test, range A describes anteflexion that does not go beyond a forehead–knee distance of 10 cm, range B covers anteflexion to the point where the patient
Figure 4.60 • Testing the range of anteflexion of the
trunk. Evaluation: A, hypomobile; B, slight hypermobility; C, marked hypermobility.
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can touch the knees with her forehead, and in range C the patient can put her forehead between her knees.
Side-bending The lumbar spine allows side-bending of approximately 20° to each side; in the test devised by Sachse (1969) the patient stands with legs closely together and flexes to the side. The plumb line from the fold of the contralateral axilla reaches no further than the intergluteal cleft in range A. In B it reaches beyond this point as far as the middle of the buttock of the side toward which the patient is side-bending, while in C it reaches beyond the lateral aspect of the buttock (see Figure 4.61). When testing anteflexion and side-bending the examiner must take into account the mobility of the hips and, in particular, the body proportions of the patient: there may be ‘false’ hypermobility due to a long trunk and short legs. In anteflexion this impression can also be given if the patient has long arms.
Rotation The range of lumbar rotation is given by Kapandji (1974) as 5°, which is not capable of being clinically tested.
The thoracic spine Rotation The figure given by Kapandji (1974) for trunk rotation is 35° to each side. The patient sits astride the end of the treatment table and fixes her shoulder girdle with her hands, which are clasped behind the nape of her neck. She is asked to turn to the right and left in succession, while the examiner ensures that the pelvis remains fixed. Up to 50° to each side is defined as range A, from 50–70° as range B, and beyond 70° as range C (see Figure 4.62). We now know that rotation of the trunk produces simultaneous side-bending of the spinal column in a coupled movement, in which the lumbar spine also participates (see Section 3.4.1).
Anteflexion, retroflexion, and side-bending Testing of anteflexion, retroflexion, and side-bending of the trunk also involve the thoracic spine. The examination of these movements (with the patient in the standing position) has already been described above as tests for the assessment of the lumbar spine. Kapandji (1974) gives the range of movement for the thoracic spine as 45° in anteflexion, 25° in retroflexion, and 20° to each side in side-bending. If the examiner wishes to measure anteflexion and retroflexion of the thoracic spine clinically, this
Figure 4.61 • Testing the range of side-bending of the trunk. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
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Figure 4.62 • Testing the range of trunk rotation.
Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
Diagnosis of dysfunctions of the locomotor system
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Figure 4.63 • Testing the range of rotation of the head.
Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
should be done with the patient sitting, asking her to hump her back and straighten up.
The cervical spine Rotation In the cervical spine, rotation can be measured clinically. According to Kapandji (1974), this movement is 50° to each side. When tested with the patient’s head in perfectly erect posture (see Figure 4.63), the degree of movement is assessed as range A when it is up to 70° to each side, B from 70–90°, and C when it is over 90°. When examined in this way the rotation also involves the upper thoracic spine. If the head is held slightly bent forward, this synkinesis can be eliminated.
4.14.2 The joints of the upper limb The figures used in this section are those given by Sachse (1969).
The metacarpophalangeal joints In passive dorsal extension (in which the interphalangeal joints may be bent), an average range of movement of up to 45° is assessed as A, between 45° and 60° as B, and measurements beyond this as C (see Figure 4.64).
The elbow At the elbow joint, there is often a correlation between valgus alignment and hypermobility. The
Figure 4.64 • Testing the dorsal extension of the
metacarpophalangeal joints. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
following test is based on this fact. The patient is asked to bend her elbows and place her forearms and hands firmly together in front of her. She should then extend her arms as much as she can without separating her elbows (see Figure 4.65). If the internal angle at the elbows remains less than 110°, this is assessed as range A, an angle of 110– 135° is range B, and beyond this is range C.
The shoulder For this test the patient is asked to bring the horizontally raised upper arm towards the shoulder of the opposite side. Range A mobility enables the patient to bring the elbow to the midline at most, range B from there to a point half way between the midline and the contralateral shoulder, and range C beyond this. In extreme cases the elbow may even reach the contralateral shoulder (see Figure 4.66). Another test examines the patient’s ability to make both hands meet diagonally behind the back. The test is performed on both sides, and relates to the side of the hand approaching from below. The result is recorded as range A if the fingers do not touch or if the fingertips just come into contact, as range B if the patient’s fingers overlap, and as C if the fingers can be placed in the palm (see Figure 4.67). There must be no hyperlordosis of the spinal column. The best way to test the mobility of the glenohumeral joint specifically is by means of passive abduction. If the examiner fixes the shoulder blade 143
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Figure 4.65 • Testing elbow extension, forearms aligned and touching. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
precisely in position from above, abduction of 90° is assessed as range A, from 90° to 110° as range B, and beyond this as range C (see Figure 4.68).
4.14.3 The joints of the lower limb The knee
Figure 4.66 • Bringing the elbow towards the contralateral shoulder. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
The knee joint is best tested by means of hyperextension. This is assessed as range A when the limit of this extension movement is at 0°. Hyperextension of up to 10° is range B, and extension beyond this is assessed as range C (see Figure 4.69).
Figure 4.67 • Making both hands meet behind the shoulder. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
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variations on that test is followed by the study of more complex movements. We begin with assessment of posture (see Section 4.2).
Motor stereotypes are the result of conditioned and unconditioned reflexes and/or programs acquired in the course of ontogenesis.
Figure 4.68 • Testing the abduction of the glenohumeral
4.15.1 Examination with the patient sitting
The hip
The patient is examined sitting on a height-adjustable stool. The examiner notes the position of the feet and the level of the iliac crests, the posture of the lumbar spine, and the tonus of the abdominal, paravertebral, and gluteal muscles. In correct sitting posture, the feet are flat on the floor and the iliac crests level; the lumbar lordosis should be flattened, and muscles only slightly tensed with the tonus evenly distributed (see Figure 4.71).
joint, with shoulder blade fixed. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
To evaluate the hip joint, the most satisfactory method is to measure the combination of external and internal rotation with the hip flexed at 90°. Combined external and internal rotation of up to 90° is assessed as range A, between 90° and 120° as B, and more than 120° as C (see Figure 4.70).
4.15 Examination of Anteflexion: stooping and coordinated movements straightening (motor stereotypes) Examination of individual muscle groups by means of simple movements in the muscle test and the
For correct stooping, one leg moves forward in front of the other and the knee of that leg is bent. At the same time the trunk bends forward, the movement
Figure 4.69 • Testing hyperextension of the knee joint. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
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Figure 4.70 • Testing internal and external rotation of the hip joint. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
Figure 4.71 • Sitting on a stool. (A) Correct posture; (B) and (C) two types of faulty sitting posture.
starting with the head, the body then curling up from caudal to cranial as the abdominal and gluteal muscles contract slightly (see Figure 4.72A). The erector spinae contracts initially, but relaxes again at the point of maximum anteflexion. As the body straightens up again, the knees are extended and at the same time the trunk 146
uncurls, lifting first the lumbar spine, then the more cranial sections of the spine, and finally the head (see Figure 4.72A). This action is brought about by contraction of the abdominal and gluteal muscles. The whole of this movement is the result of coordinated activity by the muscles of the gluteal
Diagnosis of dysfunctions of the locomotor system
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Figure 4.72 • (A) Stooping and (B) lifting an object correctly.
Figure 4.73 • (A) Stooping and (B) lifting an object, performed incorrectly.
region, abdomen, and back. The knee of the forward leg is positioned under the thorax so that the center of gravity of the body constantly lies above this point of support. The trunk must never be
raised stiffly like a ramrod, because this acts as a long lever and places great stress on the lumbosacral junction (see Figure 4.73B). Nor must the abdomen be allowed to bulge. 147
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Trunk rotation, sitting This test mainly examines the thoracic spine and shoulder girdle. The patient is seated on a stool, holding a small book in her hands. Correct sitting posture is important. The shoulder girdle should be relaxed and posture erect, including the shoulders. The patient is now asked to place the book on a shelf behind her, at head height (see Figure 4.74). The examiner should observe the rotation of the trunk, which should be about a vertical axis, and check for coordinated activity of the back and abdominal muscles, fixation of the shoulder blades, and minimal tension in the superior part of the trapezius. If performed properly, the rotation is seen as a fluid movement in which the pelvis and legs do not participate. There is only moderate activity of the abdominal and back muscles, the inferior angles of the scapula do not diverge, and the superior part of the trapezius remains relaxed.
Figure 4.75 • Head rotation, sitting: (A) correct; (B) faulty
Rotation of the head and neck
Raising the arms
The examiner should begin by observing head posture with the patient standing and sitting. The normal posture is slightly lordotic, but this lordosis may be absent if the thoracic spine is flat. The angle between the mandible and neck should be about 90°. During head turning, the examiner observes neck rotation and also the cervical muscles and position
When raising the arms, the patient also raises her shoulders and shoulder blades. This activates the upper fixators of the shoulder girdle, in particular the superior part of the trapezius and the levator scapulae, especially if fixation of the shoulder blades from below by the inferior part of the trapezius is insufficient (see Figure 6.152).
posture.
of the shoulders (see Figure 4.75). If the movement is performed correctly, lordosis should not increase and there should be minimal side-bending. The sternocleidomastoid should not be overstrained, and neither shoulder should be drawn forward or lifted.
Figure 4.74 • Trunk rotation, with the patient sitting and holding an object in the hand: (A) correct; (B) faulty posture.
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causing tension in the upper fixators of the shoulder girdle and muscles of the upper limbs (see Figure 4.76). If a weight is to be carried correctly, the shoulders should be behind the center of gravity of the body and the head and neck remain erect. When this is so, the hand carrying the weight is also relaxed.
Standing on one leg
Figure 4.76 • Carrying weights: (A) correct; (B) faulty posture, with forward-drawn shoulders and neck.
4.15.2 Examination with the patient standing erect Weight carrying Here the typical fault is a forward-drawn position of the head and a drawing forward of the shoulders,
The examiner should observe all the joints of the stance leg, the line and center of gravity of the body, the pelvis and iliac crests, the spinal column and muscle tension, especially that of the hip stabilizers (the gluteus medius and minimus). In correct posture on one leg, all joints of the stance leg are in the line of gravity; the center of gravity moves forward as compared with stance on two legs, to the second and third metatarsal heads. The iliac crests remain horizontal, the physiological curvatures of the spine remain unchanged, and no scoliosis occurs. The hip stabilizers, in particular the abductors, contract on the side of the stance leg. The flexors and extensors of the lumbar spine (the abdominal and erector spinae muscles) and of the hip should contract evenly, as should the quadratus lumborum (see Figure 4.77A). If the abductors are weak, as is frequently found in patients with faulty posture, the patient raises the iliac crest on the side opposite to the stance leg (see Figure 4.77B). Trendelenburg’s sign, in
Figure 4.77 • Standing on one leg. Dorsal view: (A) correct; (B) faulty posture. Lateral view; (C) correct; (D) faulty posture.
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which the iliac crest is lowered, is mainly found in decompensated hip luxation and extreme muscle weakening.
Gait In normal gait the steps are even and the weight is placed equally on each leg in turn. Each foot strikes the ground heel first, the entire foot then uncurling along its lateral edge to end in pronation and propulsion by the toes. The examiner should note the extension of the knees and hips. The pelvis sways from side to side, remaining horizontal but rotating about a vertical axis; the excursion is more pronounced in women than in men. The spinal column curves from one side to the other in waves, the greatest excursion being at L3; there is some counter-excursion in the thoracic spine, the point of change occurring at the thoracolumbar junction, which remains vertically above the sacrum. The head should move very little and the arms should swing symmetrically (in right-handed individuals, slightly more on the left than the right). This movement comes from the shoulder, which rotates in the opposite direction to the pelvis. The shoulder blades are fixed against the back by the caudal fixator muscles. The body’s center of gravity shifts only slightly, from one side to the other and up and down; that is the person should neither waddle nor rock. Significant asymmetries of gait are also clearly audible, especially if the patient is walking quickly. Certain faults only become observable if the patient walks with eyes closed, on tiptoe, on the heels, or with upstretched arms. If it is possible to examine patients in their typical working position (lifting weights, at the computer, at a machine or instrument, etc.), this can provide important insights.
Respiration can be examined starting with the patient at rest, supine. In the supine position, abdominal respiration should predominate. In erect posture, standing or sitting, the abdominal muscles must also perform their postural function during respiration, and this occurs when the thoracic cage widens, beginning from the waist. To find whether this is happening, the examiner should place his hands on the patient’s lower ribs on each side, and sense whether his hands are moved apart as the patient breathes in, or whether they move upward with no widening of the thorax (lifting of the thorax during inhalation – clavicular breathing – see Figure 4.78). If this faulty breathing pattern is very pronounced, the thorax may remain permanently in the inhalation position and the lifting of the thorax during inhalation may be seen even at rest. In this case the sternocleidomastoid and scalene muscles and all the upper fixators of the shoulder girdle are found to be taut
4.15.3 Movement patterns of respiration Although the prime purpose of respiration is the exchange of gases, it is the function of the locomotor system that underlies it. The muscles involved in breathing are in their turn extremely important for the function of the locomotor system, so much so that breathing patterns are considered the most important of all motor stereotypes (see Section 2.9.5). 150
Figure 4.78 • Clavicular and paradoxical breathing: tension in the muscles that fix the shoulder girdle from above; deep supraclavicular fossae; the thorax in the inhalation position; the abdomen is drawn in at inhalation.
Diagnosis of dysfunctions of the locomotor system
and the supraclavicular fossae are deep. In the most severe cases the patient may draw the abdomen in during inhalation (paradoxical respiration, see Figure 4.78). In these cases clavicular breathing can be evident even when the patient is lying down. In less severe cases it is only observed when the patient inhales deeply. This lifting of the thorax can also be asymmetrical; the shoulders are each lifted to a different extent and there is often weakness of the inferior part of the trapezius on the side that rises more. Another consequence of the lifting of the thorax is that breathing is performed mainly by the contraction of the scalene muscles and the diaphragm is not sufficiently activated. The movement of the ventral wall of the thorax may even cause the diaphragm to be cranially angled; if this happens there will be no co-contraction of the diaphragm together with the abdominal muscles, and therefore no fixation of the thorax to the pelvis. As Figure 4.78 also shows, the effect is not only to overload the cervical spine, but to lift the thorax away from the pelvis, so that there is no fixation of the lumbar spine. The photograph also shows the hypotonus in the region of the waist and lateral abdominal wall (see Section 2.9.5). Therefore the tonus of the lateral abdominal wall should also be palpated and the patient asked to exert pressure against the examiner’s palpating fingers. The patient often finds this impossible to do. According to Kolárˇ (2006), the following tests can then be performed: • The patient lies supine with knees flexed. Resistance is applied to the knees and the patient asked to flex the knees further against the resistance; alternatively the patient, sitting erect, is asked to raise both knees against gravity. The examiner palpates the abdominal wall laterally at the waist. The lateral abdominal wall contracts (the patient can feel this by touch, and so can provide feedback), but the thorax should not rise as it does so. • The patient lies supine and slowly lifts the head and trunk while the examiner palpates the medioclavicular line. As the neck is flexed, the abdominal wall begins to contract, and when the thorax is lifted, the lateral part of the abdominal wall contracts. The equivalent method with the patient prone is used to examine the extension of the head and shoulders as the muscles at the waist contract. The close relationship between posture and respiration can be seen not least in the effect of a
Chapter 4
hunched sitting posture, which makes it difficult for the thoracic cage to expand and so leads to clavicular breathing. This kyphotic posture is associated with a forward-drawn position of the head, which is compensated by hyperlordosis of the cervical spine. This close relationship is also shown by holding the breath during muscular effort (Valsalva maneuver); the body achieves maximum stability at the expense of respiration, as is done, for example, when delivering a tennis serve. Holding the breath is even maintained for the period of a short sprint: the body temporarily reinforces postural function at the expense of respiratory function. Inhalation and exhalation have about the same duration; the patient should be able to extend that duration considerably, to at least 10 seconds. (Professional singers should be able to sustain a breath for much longer.) A quiet breathing sound is heard, the sound coming from the nose. The nostrils expand during deep inhalation and narrow during exhalation. In the prone position the progress of the respiratory wave can be observed traveling up from the lumbar spine to the upper part of the thoracic spine during deep breathing. This wave may be interrupted where there is a restriction. If there is a faulty breathing pattern the wave may be completely absent.
The close relationship between the locomotor system and breathing means that a faulty breathing pattern, especially clavicular breathing (in which the thorax is lifted during inhalation), is highly pathogenic. It should never be overlooked.
4.16 Syndromes 4.16.1 The lower crossed syndrome In this syndrome there is imbalance of the following muscle groups: • Weakness of the gluteus maximus; shortening of the hip flexors and tension of the ischiocrural muscles. • Weakness of the rectus abdominis and shortening of the lumbar and thoracolumbar part of the erector spinae. 151
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• Weakness of the gluteus medius, tension of the
tensor fasciae latae, adductors, and quadratus lumborum. There is also substitution for the weak gluteus maximus by the ischiocrural and erector spinae muscles, for the gluteus medius by the tensor fasciae latae and quadratus lumborum, and for the rectus abdominis by the hip flexors. Clearly this syndrome renders the curling of the spinal column on lying down from a sitting position impossible. The main visible result of imbalance between the rectus abdominis and the lumbar erector spinae is lumbar hyperlordosis; if there is imbalance between the gluteus maximus and hip flexors, the hyperlordosis occurs at the lumbosacral junction. The psoas major does not only flex the hip but also brings about lordosis of the lumbar spine (‘psoas paradox’). There is also increased pelvic tilt (see Figure 4.79).
4.16.2 The upper crossed syndrome There is imbalance in the following muscle groups: • Between the upper and lower fixators of the shoulder girdle. • Between the pectorales and the interscapular muscles. • Between the deep neck flexors (longus colli, longus capitis, omohyoid, and thyrohyoid) and the neck extensors. There may be shortening of the superior part of the ligamentum nuchae with fixed lordosis in the upper cervical region. The ascending part of the trapezius is extremely important for the fixation of the scapula. Activity of this muscle portion can produce reflex relaxation of the upper fixators. Tension of the pectoralis muscles leads to increased thoracic kyphosis and forward-drawn shoulders, as well as kyphosis of the lower part and hyperordosis of the upper part of the cervical spine. The correct movement of arched anteflexion from a supine position is only possible if there is coordinated activity of the scalenes and deep neck flexors. If these are weak and the sternocleidomastoids hyperactive, there is ventral shifting of the head (incoordination). The cause that leads to weakness of the deep neck flexors is often weakness of the deep stabilizers of the lumbar spine. This is because the longus colli has its point of attachment here.
4.16.3 Stratification syndrome (according to Janda)
Figure 4.79 • (A) Lumbosacral and (B) lumbar hyperlordosis.
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In this syndrome, alternating strata of hypertrophic and weak muscle groups are found: on the dorsal aspect, working in a caudocranial direction, we find fairly slim calves, but hypertrophic ischiocrural muscles; hypotrophic, lax gluteal muscles and underdeveloped lumbar erectores spinae, and above these the bulging hypertrophic, thoracolumbar erectores spinae; above these we find flabby interscapular muscles and hypertrophic, taut upper fixators of the shoulder girdle. On the ventral aspect the inferior part of the abdominal wall bulges, but lateral to the rectus abdominis muscles there is a hollow corresponding to the taut obliquus abdominis muscles; lateral to this the abdominal wall may bulge again in the region of the waist (‘pseudohernia’).
Diagnosis of dysfunctions of the locomotor system
The significance of the stratification syndrome lies in the alternation of sections marked by contraction and lax, hypermobile sections. Hypermobility in the region of the lumbosacral junction is especially pathogenic in its effect. Dysfunction of the feet appears to play an important part here. Minor variations in balance are normally absorbed by the toes; in fact by the muscles of the foot and especially the calf. The function of the toes is often inhibited by the shoes, and the muscles of the thighs then take over the task of managing static balance. There is a simple explanation for the fact that the interscapular muscles are often found to be weak, if we look at developmental kinesiology: in infants, the development of upright posture takes place in the form of two lordotic curvatures, and is brought about through the activity of the cervical and thoracolumbar erector spinae muscles. The weak point is at the place where the two meet, at T4 or T5.
4.17 Retesting Clinical examination routinely provides a wealth of data to give us the information we need about dysfunctions, and therefore also to compare findings before and after therapy. The effects of such treatment are often instantaneous, by reflex response. Immediate, post-treatment testing, or retesting, is therefore a means of feedback, and is indispensable for all practitioners who want to use solid criteria. This plays the role of short-term evidence. Yet – with a few exceptions – this kind of instant check is simply not possible for other modalities such as pharmacotherapy, for example. Given the great variation in the course of patients’ complaints, there is great value in this. Nevertheless, however good the immediate effect, this must not be confused with actual therapeutic success, because patients are rarely suffering from a single dysfunction; the therapeutic effect depends to a great extent on how relevant the lesion is that we have treated. If treatment of that lesion achieves only a partial effect, there is no reason why we should not continue by treating a further lesion and retesting once more. In principle, every abnormal finding at clinical examination can be compared by testing before and after treatment. Where the test involves actual measurement, such comparison can be especially useful; examples include the range of movement
Chapter 4
of joints or sections of the spinal column, and the straight-leg raising test. Side deviation in Hautant’s test can also be compared before and after. Even in radicular syndromes, an increase of strength in weakened muscles may be found on retesting (see Figures 2.12 and 2.13). Routine testing before and after treatment can also be carried out for reflex changes such as muscle TrPs, HAZs, and mobility of fasciae, for example following therapies such as mobilization, needling, PIR, RI, or local anesthesia. Instrumental methods such as thermography may also be used. Subjective statements by the patient are also valuable. Most patients seek treatment because they are suffering pain, so it matters that they should find relief after treatment. The practice of concluding treatment by letting patients palpate their pain points found during the examination is a helpful one; they can palpate them with their own hands and confirm for themselves that the symptoms have indeed improved or disappeared. Testing also gives a useful indication as to the most suitable further therapy. The practitioner can test the application of a particular treatment approach. For example, if we wish to find out whether traction or the treatment of an active scar is indicated, we can test whether the planned approach brings immediate relief. An immediate (reflex) result can be useful evidence-based medicine that indicates the effectiveness of a particular method, although this should not be equated with therapeutic success.
4.18 Dysfunctions and the course of examination The question to be answered is how to carry out a systematic examination of a patient suffering from dysfunctions. If we wish to draw up the medical report of a patient with functional disorders as described by Brügger (2001), what would this look like? Having described the various clinical examination techniques, the next issue is how to proceed in practice; how to obtain useful results and avoid errors as far as is humanly possible. The answer is not simple, as the object of examination – the locomotor system, including morphological changes and dysfunctions – is in fact the concern of many different fields of medicine. The locomotor system can in many ways be said to be 153
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a reflection of everything that is happening in the body. Some patients present with problems belonging to the field of internal medicine; others with neurological, orthopedic, or rheumatological complaints. Still others are in the fields of ear, nose, and throat, or gynecology. For some, the main problem lies in disturbed muscle function, for others, in disturbed joint mobility; yet others may be suffering from a great range of reflex changes. To examine each patient from all of these aspects would demand far more time than is practicable, especially given the outpatient nature of most consultations. The problem is essentially that our focus of interest lies in dysfunctions for which there is no specific, established medical field, since they relate to the locomotor system as a whole.
4.19 Adjusting our thinking to the functional approach The examination techniques described in detail so far deal with dysfunctions, as do the demanding techniques used in treatment. However, they can only be used effectively if we have a proper understanding of these disturbances of function. Practitioners need not only master the techniques but must adjust their thinking to understand in a functional way.
It is as important – and still more difficult – to adjust our thinking to the functional approach as to master the technical aspect of manual medicine.
The following points present in general terms the most important differences between the usual, pathomorphological understanding and the functional approach. • The first and fundamental task in classification and differential diagnosis is to decide whether the particular case is primarily pathomorphological or primarily one of dysfunction. • Function (physiology) is as real as is morphology (anatomy). • If a disorder is mainly pathomorpholological, the task is to localize it and decide what precisely is 154
affected. Function and dysfunction, on the other hand, are the result of the interplay of a whole chain of different structures which are variously located. • The clinical picture correlates far more with the functional disturbances than with the pathomorphological changes. Consequently, pathological processes often do not manifest themselves until they cause dysfunction. Dysfunctions, on the other hand, can cause very marked clinical symptoms, even in the absence of any morphological changes. • Thus: pathomorphological changes cause dysfunctions, which manifest themselves in clinical symptoms. • Consequently, even pronounced pathomorphological findings can often exist without causing any clinical symptoms, and may even be clinically irrelevant (e.g. disk herniation at CT, scoliosis, or spondylolisthesis). Concomitant dysfunction, on the other hand, can be of decisive importance clinically. • In such cases, if the pathomorphological changes are assumed to be the key to the disorder, therapy fails; on the other hand, even if the pathomorphological changes are clinically relevant, we still may improve the patient’s condition if we improve function – for example by rehabilitation. It is, however, necessary to be aware of the limits of what can be achieved. Compensation can occur, so should not be forgotten. • In pathomorphological diagnosis, the aim is to localize the lesion exactly and to identify its nature (principle of localization). • In diagnosing dysfunction, the aim is to identify the pathogenetic chain of reactions and to assess the interrelationships and relevance of the individual links (holistic principle). • In pathological processes, the cause of pain lies in the nature of the lesion; in dysfunction, the cause of pain is mainly pathological tension brought about by the dysfunction. • In pathomorphological conditions, if therapy is successful it is continued until healing is achieved. Alternatively a decision may be made to intervene surgically. • If therapy is successful in conditions due to dysfunction, the next step is usually to treat another link in the pathogenetic chain. If the
Diagnosis of dysfunctions of the locomotor system
same lesion needs to be treated again, we should consider whether there is another link in the chain that is more relevant and requires treatment. Change of approach in therapy is therefore the norm. • In pathomorphological conditions, success depends on drug treatment or surgery; success in dealing with dysfunctions depends on the relevance of the particular link in the pathogenetic chain we address at that moment. • When treating dysfunction, the practitioner is lost – or rather his patient is – if he treats it at the point where pain is felt. • Because dysfunctions are by definition reversible, the effect of treatment can be immediate, giving the impression of a miracle cure. This is by no means unusual; at times it is even what we would expect. • Modern technology achieves wonders in dealing with pathomorphological lesions, but often fails when it turns to the treatment of dysfunction, where it is at best cumbersome. Clinical skill is decisive in such cases, but is often undervalued as ‘subjective’ and too little put into practice. As a result, too much stress is often placed on morphological changes, which may in fact be of little relevance. • The psychological factor is important in all disease. In dysfunctions of the locomotor system, however, psychology is itself a link in the pathogenetic chain, because voluntary motor function is the effector of psychological activity. Here, too, pain is the main symptom, and tension and its relaxation play a very important role. Practitioners need to decide in each case how relevant the psychological factor is and how amenable it is to treatment. • In pathomorphological conditions, the relationship between cause and effect tends to be clear. In dysfunctions, what had been the cause can often turn into the consequence. Pain, whatever its origin, will produce changes in movement patterns or stereotypes; these in turn cause dysfunction which perpetuates pain. Chronic tension and joint restriction cause impaired mobility of the fasciae, and resistance in the fasciae in turn becomes the cause of recurring joint restrictions. • When dealing with pathomorphological conditions, it is easy to produce statistics,
Chapter 4
and such findings are indeed very important. The task is incomparably more difficult when dealing with dysfunctions. Even in diagnosis, the symptom can be the result of a long chain of various disturbances in various locations, and the relevance of each link can change. In therapy, if we have treated one link successfully, there would be no sense in repeating treatment there. If the symptoms continue, we treat another link in the chain, and so on. If at the end of the process the clinical symptoms have disappeared, there is no reason to conclude that the treatment of the first link contributed less to the success. • The functional approach is difficult. We may compare function to the ‘software’ and structure to the ‘hardware’ of the system.
4.20 Chain reactions of dysfunctions and motor programs 4.20.1 Function and chain reactions In view of the argument presented in the previous section, which emphasizes that dysfunctions normally affect the entire locomotor system, or at least the major part of it, we must turn to the question of how to approach the individual case. Experience has shown that if on examination we find ‘A’, we expect ‘B’, and must then test ‘C.’ What regularly occurring patterns or rules can we observe or expect? What can we take as our screening guidelines in the clinical situation? The first test is based on the premise that these regularly occurring patterns are associated with certain basic functions of the locomotor system. Basic functions or programs relate to the following: • Gait, and especially the lower limbs and pelvis. • Body statics, and especially the trunk, neck, and head. • Respiration, and especially the trunk and neck. • Prehension, and especially the upper limbs and shoulder girdle. • Eating and speaking, and especially the orofacial system, head, and neck. 155
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Table 4.3 Reaction chains of dysfunction
Lower limb — gait — swing phase – extension Tension
Flexors of toes and foot, soleus, ischiocrural muscles, glutei, piriformis, levator ani, erector spinae
Painful points of attachment
Calcaneal spur, Achilles tendon, fibular head, ischial tuberosity, coccyx, iliac crest, greater trochanter of femur, spinous processes of L4—S1
Joint dysfunction (restrictions)
Small joints of foot, ankle joint, fibular head, sacro-iliac joint, lower lumbar spine, (atlanto-occipital and atlanto-axial joints)
Lower limb — gait — stance phase — flexion Tension
Extensors of toes and foot, tibialis anterior, hip flexors, hip adductors, recti abdominis, thoracolumbar erector spinae
Painful points of attachment
Pes anserinus of tibia, patella, lesser trochanter of femur, superior border of pubic symphysis, xiphoid process
Joint dysfunction (restrictions)
Knee, hip, sacroiliac joint, superior lumbar spine, thoracolumbar junction (atlanto-occipital and atlanto-axial joints)
Trunk — body statics Tension in muscle pairs
Sternocleidomastoid and: short craniocervical extensors Scalenes + deep neck flexors + digastric and trapezius + levator scapulae + masticatory muscles Iliopsoas + recti abdominis and: erector spinae + quadratus lumborum
Painful points of attachment
Posterior arch of atlas, spinous process of C2, nuchal line, sternal end of clavicle, superior and medial border of scapula, xiphoid process, pubic symphysis, lower ribs, iliac crest
Joint dysfunction (restrictions)
Atlanto-occipital and atlanto-axial joints, cervicothoracic junction and upper ribs, thoracolumbar junction (trunk rotation), lumbosacral and sacroiliac junction, temporomandibular joint
Lifting the thorax during inhalation (clavicular breathing) Tension
Superior parts of abdominal muscles, pectoralis, scalene, diaphragm, sternocleidomastoid muscles, short craniocervical extensors, levator scapulae, superior part of trapezius
Painful points of attachment
Posterior arch and transverse processes of atlas, spinous process of C2, nuchal line, sternal end of clavicle, superior border of scapula, sternocostal joints and upper ribs
Joint dysfunction (restrictions)
Atlanto-occipital and atlanto-axial joints, cervicothoracic junction, upper ribs, thoracic spine
Upper limb — prehension — restricted flexion Tension
Extensors of fingers and wrist, thenar eminence, supinator, biceps brachii, triceps brachii, deltoid, supraspinatus, infraspinatus, upper fixators of scapula, interscapular muscles
Painful points of attachment
Radial styloid process, radial (lateral) epicondyle, attachment of supraspinatus and infraspinatus, attachment of levator scapulae, spinous process of C2
Joint dysfunction (restrictions)
Elbow, acromioclavicular joint, middle cervical spine, cervicothoracic junction, upper ribs
Upper limb — prehension — restricted extension Tension
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Flexors of fingers and wrist, pronators, subscapularis, pectoralis, sternocleidomastoid, scalene muscles
Diagnosis of dysfunctions of the locomotor system
Chapter 4
Table 4.3 (Continued). Painful points of attachment
Ulnar (medial) epicondyle, sternal end of clavicle, sternocostal joints, Erb’s point, transverse process of atlas
Joint dysfunction (restrictions)
Carpal bones, elbow, glenohumeral joint, cervicothoracic junction, atlanto–occipital and atlanto-axial joints
Head and neck — eating — speaking Tension
Masticatory, digastric, sternocleidomastoid muscles, craniocervical extensors, trapezius, levator scapulae, deep neck flexors, pectoralis muscles
Painful points of attachment
Hyoid, posterior arch and transverse processes of atlas, spinous process of C2, nuchal line, sternal end of clavicle, superior border of scapula, angle of upper ribs
Joint dysfunction (restrictions)
Temporomandibular joint, atlanto–occipital and atlanto-axial joints, cervicothoracic junction, upper ribs
The chain reactions of dysfunction envisaged here are given in Table 4.3. These do not claim to be complete; although these are the chains especially affected, the disturbance is not limited to the details listed. The intention is rather to provide some means of screening. Our understanding is further focused and extended by our insight into developmental kinesiology.
4.20.2 Chain reactions in the light of developmental kinesiology What is said here follows on from Section 2.5.3, which describes the development of the co-contraction pattern of flexors and extensors, adductors and abductors, and external and internal rotators. As a prerequisite for human upright posture, antagonists developed into synergists, a development that can most clearly be seen at joints such as the knee and individual segments of the spinal column. This pattern appears yet more fundamental in the craniocaudal direction, with the formation of muscle chains in the sagittal plane beginning at the feet, connected through their points of attachment and stabilizing the spinal column just as a mast is stayed. These muscles, as pointed out by Richardson et al. (2004), are long, most of them spanning two or more joints. This is the more important for the fact that the spinal column, unlike a mast, is jointed. Panjabi et al. (1992a) showed that the motion segments are unstable, and require the activity of the short, deep muscles of the back to stabilize them. If it were not for these muscles, the contraction of the long
muscles would cause individual motion segments to buckle. Therefore, in parallel with the co-contraction pattern, there developed the system of the deep stabilizers. This includes not only the multifidi, but also, ventrally, the abdominal cavity and its walls: the diaphragm, transversus abdominis, and pelvic floor, sustaining intra-abdominal pressure. The importance of this stabilization function is so great that, in the action of raising the arm, the diaphragm or transversus abdominis contract before the deltoid (see Figure 4.80). We even observed a patient who was unable to raise her arm if her pelvis was not fixed, on account of paralysis of the deep muscles of the back. If her pelvis was fixed, however (in the sitting position), she was able to carry out the action without difficulty (Lewit & Horácek 2003). The development discussed so far has been that of the postural program, which takes place automatically and is also associated with the optimal positioning (centering) of the limbs. This development is completed in overall terms in the fourth month of life, but only fully completed at four years of age. As indicated previously in Section 2.6, in a considerable proportion of children this development does not proceed straightforwardly. As soon as children learn movement, their own individual programming of movement patterns begins to take shape, in line with their particular interests and opportunities. The way this happens will become clearer if we use an example: playing tennis. On the basis of neurology we would expect the following: as soon as the player sees the ball, the image strikes the retina. From there, the stimulus travels to the diencephalon and is transmitted to the occipital lobe, from there to the parietal lobe, and finally to the motor cortex. From here, 157
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Figure 4.80 • EMG of the deltoid muscle and diaphragm on raising the arm: contraction of the diaphragm takes place in advance of contraction of the deltoid (modified after Richardson et al 2004). vdi, transdiaphragmatic pressure; Pga, intra-abdominal pressure; Poes, intrathoracic pressure.
the neurons of the central nervous system communicate with the spinal cord and peripheral neurons with the muscles. There is then feedback via the posterior horn and the cerebellum. Assuming a transmission speed of 100 m/s, the ball will be long since out of play. The only way to understand this problem is once more by looking at the developmental process: first, we place the ball firmly in the child’s hands. (The child has successfully passed through the stage of 158
postural development.) Then we carefully throw the ball to the child, who stands with hands ready to receive it. It takes some time before the child is actually able to catch the ball, first with both hands, then with just one. Only now do we give our child a tennis racquet for the next stage: learning to hit the ball. What has been happening during those years? The brain, that most accomplished computer of all, has constructed a program, and the moment the eye sees the ball, the program springs into action:
Diagnosis of dysfunctions of the locomotor system
the movements of eye, head, trunk, and limbs all take place automatically. This understanding is extremely important in determining our practical approach. It clearly shows that the program involves the entire system. If a disturbance appears somewhere along its course, we must reprogram it. It also follows that symptoms, in this case dysfunctions, can appear in many places, and it is our job to discover which is the most important dysfunction, the one that is the key link in the chain reaction. Understanding this development enables us to organize our approach in a rational way and draw up certain rules that describe how this system behaves as a whole. A good way to illustrate this ‘holistic’ approach is with reference to the programmed reaction of supporting oneself, for example with hand, elbow, or knee, in standing posture. As soon as we do this there is an instant change in our posture in every section of our locomotor system. This reaction must originate from the receptors of these points of support, which are also very important, according to Vojta & Peters (1992), as points of stimulation. The only way that a programmed function can be directed is by the nervous system, by means of the musculature. Therefore we must take the muscles as our starting point if we wish to understand and analyze the chains of reaction. The function of the muscles is closely linked with that of the joints: the earlier discussion of TrPs made clear that these are linked with movement restrictions; this is manifested in practical terms in the use of neuromuscular techniques of treatment. In this context it becomes evident that TrPs in fact have the function of establishing stability at the cost of mobility. They are found in antagonists in motion segments or limbs: adductors–abductors; extensors–flexors. In the case of fan-shaped muscles such as the pectoralis major, a section of the muscle corresponds to a particular section of the erector spinae. However, the antagonism is not limited to the particular segment: if, for example, an extensor is stimulated, this does not only inhibit its specific antagonist, but also the entire flexor system. As demonstrated by Brügger (2001), this effect is especially pronounced when the extensors of the fingers and toes are stimulated, since the density of receptors is particularly great in these locations. As an example, stimulation of the toe extensors can inhibit the activity of the ischiocrural muscles, with consequent weakening in the straight-leg raising test.
Chapter 4
The co-activation pattern applies not only within the segment; it also serves to maintain upright posture. From their anchor point at the feet, the muscles and their attachments work together to maintain upright posture just as a mast is stayed by the rigging. Dysfunctions often produce TrPs in the muscle chains that form these ‘mast stays.’
TrPs are markers that trace out chain reactions, and these chain reactions also involve joints and soft tissues.
4.20.3 The pathomechanisms of chain reactions A further principle can be drawn from developmental kinesiology: the developmentally older function is less susceptible to disturbance, and therefore predominates. In pain, exhaustion, aging, and the phenomena associated with paresis, the predominating model is that of the newborn. The same principle follows equally from the disturbances of movement pattern in the concept developed by Janda (see Table 2.1) and from Brügger’s (1971) ‘sterno-symphyseal syndrome.’ In both these cases it is possible to speak of a chain reaction in which the flexors predominate. In Janda’s terms these are the ‘primarily postural muscles’; in terms of current knowledge they are the developmentally older muscle groups. Brügger’s (1971) explanation of the round-shouldered sitting position, however, is not based on muscular imbalance, but on the position of the joints: in sitting with thighs adducted, the pelvis tips backward, and if the arms are folded in front of the chest, it becomes impossible to straighten the thorax. This situation also shows the close relationship between joint function and muscle activity. A further chain reaction in which the balance between flexors and extensors is disturbed is the forward-drawn posture when standing. On inclining forward, all the erector spinae muscles, including the nuchal muscles, become taut. Proof of this can be found by palpating one’s own neck muscles. If patients are found to have tense nuchal muscles in standing posture, and if restriction of the atlanto-occipital and atlantoaxial joints has been excluded, the following test is decisive: the patient 159
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whose nuchal (and back) muscles are tense when standing is asked to sit on a chair; the tension disappears on sitting excluding the role of the lower limbs. TrPs are generally found in the sternocleidomastoid and especially the rectus abdominis. There is often tenderness to pressure of the attachment points on the xiphoid process, inferior costal arch, and especially the superior border of the pubic symphysis, at least on one side. The chain usually continues on down to the ischiocrural muscles, especially the biceps femoris and its insertion at the fibular head, and there is generally restriction relative to the fibula. If the chain does not end here, there may be TrPs in the short toe flexors and short extensors with restrictions in Lisfranc’s (tarsometatarsal) joint. The most distal link in the chain is generally the decisive factor, and in many cases this is in the foot, which also belongs to the deep stabilization system. The pathogenesis of this chain lies in the important role played by the powerful ischiocrural muscles in the fixation of the pelvis. If there is a TrP here, the fixation of the pelvis is disturbed and has to be compensated by the rectus abdominis and the gluteus maximus. The consequence of this is tension of the rectus abdominis in particular, and this helps cause the forward-drawn posture. Often such patients complain of headache and pain in the nape of the neck; the cause, however, often lies in the region of the patient’s feet.
4.20.4 Causes of chain reactions The most frequent cause of chain reactions is dysfunction of the deep stabilizers. These form a chain in their own right, as was demonstrated by Richardson and coworkers (2004) in their electromyographic study of the contraction of the pelvic floor. The muscles involved are the diaphragm, the transversus abdominis, the pelvic floor, and the multifidi. TrPs can be palpated directly on the pelvic floor and diaphragm. In the case of disturbance here, the long muscles react with the emergence of TrPs in an attempt to compensate for the disturbed stability, a task to which they are little suited. In the trunk region, the longissimus, quadratus lumborum, and psoas major, and sometimes the rectus abdominis, are the muscles involved. The irritability of the erector spinae is sometimes so marked that snapping palpation of a TrP in the thoracic portion sometimes produces a twitch reaction in the lumbar portion as well. This causes strong 160
dorsiflexion of the pelvis, described by Silverstolpe (1989) hence called ‘S’ reflex. Working in the cranial direction, the next muscles are the pectoralis and subscapularis, the upper fixators of the shoulder girdle, scalenes, sternocleidomastoid, short craniocervical extensors, and the masticatory and digastric muscles. Working in the caudal direction, the next muscles are the hip adductors, the ischiocrural muscles, and quadriceps femoris; then in particular the soleus and painful Achilles tendon and the short muscles of the foot.
4.20.5 The role of the diaphragm The diaphragm clearly seems to play a special role because it combines a postural function with that of respiration. This means that disturbance of the deep stabilizers is associated with faulty breathing, or, conversely, that correct breathing and good stabilization of the lumbar spine depend on the coordinated contraction of the diaphragm and abdominal wall. According to Kolárˇ (2006), this can be examined by means of the following tests: the patient is supine or sitting, thorax caudalized in exhalation. The examiner should fix the thorax in the exhalation position, simultaneously palpating the lateral abdominal wall at the waist. The patient is asked to exert pressure against the examiner’s palpating fingers. To facilitate this, the patient’s knees should be bent and, if the patient is supine, resistance is applied to the flexed knees. If the patient is sitting, the only action necessary is for the patient to lift the bent knees slightly; the lateral abdominal wall tenses at that moment. This tension should be maintained during inhalation to prevent clavicular breathing (in which the thorax is lifted during inhalation) and oblique positioning of the diaphragm. Contraction of the diaphragm is then concentric, and this counters the eccentric contraction of the transversus abdominis in particular. The examiner should at the same time ensure that there is contraction of the muscles of the lower abdomen, and to a lesser degree the upper abdomen, so that the navel does not move in the cranial direction. If supine, the patient should slowly raise the head and to a slight degree also the trunk, and the examiner should palpate the lower ribs in the medioclavicular line. The raising of the patient’s head activates the abdominal muscles, so that the thorax remains caudalized. Further raising of the thorax
Diagnosis of dysfunctions of the locomotor system
causes activation of the lateral abdominal wall, even caudad to the navel. However, the abdomen should not bulge, either forward or laterally. If prone, the patient should be asked to lift the head and bend upward to create a slight lordosis of the back. This should cause the erector spinae muscles and lateral abdominal wall to contract. If there is insufficiency of the muscles, there will be no contraction of the lateral abdominal wall, and if there is excessive activity of the thoracolumbar erector spinae, the shoulder blades will move craniad.
4.20.6 Rotation of the trunk Trunk rotation is another function that is recent in developmental terms. As in the case of the deep stabilizers, a muscle chain is responsible for this movement. If trunk rotation is restricted, TrPs are found in the thoracolumbar erector spinae, quadratus lumborum, and psoas major, usually on the opposite side to the restricted rotation. Release of one of these three muscles is sufficient to remove the TrPs in the other two, whereupon trunk rotation becomes symmetrical again. This function is so important that, in cases where rotation of the cervical spine is also restricted, the treatment of trunk rotation frequently has the effect of normalizing findings at the cervical spine.
4.20.7 Unilateral chains of dysfunction In very painful conditions such as radicular syndrome, a unilateral chain pattern tends to be observed. This involves the sternocleidomastoid, short craniocervical extensors, trapezius, pectoralis muscles, subscapularis, and erector spinae, and sometimes the iliacus and quadratus lumborum, piriformis, glutei, hip adductors, rectus femoris, and soleus, down to the TrPs and restrictions of the foot, though it may not include the deep stabilizers. If this is the case, the disturbance derives from the ‘deep’ short stabilizers of the foot, which can similarly elude voluntary control; for example the abductor pollicis brevis. Another very important feature here is this: in such unilateral chains, sensitivity is noticeably asymmetrical, both overall and, in particular, on the soles of the feet. This is clearly evident from the involuntary reaction to exteroceptive stimulation of the sole of the foot. In
Chapter 4
such cases this test of exteroceptive stimulation is decisive, meaning that the afferent disturbance is the most relevant link in the chain. In addition there are shorter chains, which are of particular local significance. In the case of lateral (radial) epicondylopathies, these chains consist of TrPs of the extensors of the fingers and wrist, the supinator, the biceps brachii and tripceps brachii, all muscles with a point of attachment on the lateral epicondyle and with a role in prehension. Usually, however, these muscles are also linked with chains of dysfunction in the cervical spine. Even more important is insufficient fixation (stability) of the shoulder blade on the same side. The syndrome of the superior thoracic aperture represents a chain of muscular and joint dysfunctions in its own right. This chain consists of the cervical spine, the scalenes, the upper fixators of the shoulder girdle, the pectoralis minor and subscapularis muscles, and the uppermost ribs and cervicothoracic junction, as a rule associated with clavicular breathing and therefore also with the deep stabilizers. The soft tissues have for the most part been excluded from the discussion so far for the sake of clarity. However, fasciae that ‘stick,’ especially around the thorax, the back, and the scalp, can often play a decisive role in the chains. The most pathogenic soft tissue lesions are ‘active scars,’ which will be discussed in Chapter 5.
4.20.8 Analysis of chain reactions Chain reactions are not always complete, and sometimes there may be more than one chain. Diagnosis seeks to find the most relevant link in the chain, since treatment of this key link will often normalize the entire chain, enabling therapy to be given in the most efficient way. Equally importantly, the practitioner needs to know the direction in which to proceed when planning further treatment. What, then, are the criteria to be used in this analysis? • The patient history should give an indication as to which symptoms occurred early on and which later, and also which symptoms tend to recur and under what circumstances. • The intensity of a given finding can be important. • It is very important to identify whether the part affected is a key region, structure, or function. For example, the problem may affect the feet, 161
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the joints of the craniocervical region, structures of the deep stabilization system, faulty breathing, or an active scar; this is particularly important if the symptoms appeared shortly after trauma or an operation. • Having decided on the treatment, the practitioner should of course check the effectiveness of therapy by re-examining the patient immediately afterwards. • Therefore, diagnosis does not end until the first treatment procedure is given. If the expected effect is not achieved, the practitioner should turn to another link in the chain. The first treatment is often chosen with an eye to diagnosis, in order to establish the relevance of a particular link in the chain (i.e. that of a particular finding). In the case of active scars, this is the normal procedure. If these are found to be highly relevant, any other treatment would fail. • Even if the first therapeutic/diagnostic procedure proves successful, this does not necessarily mean that another might not also be successful. If the chain reaction runs in one direction, this does not necessarily mean that it might not run in the opposite direction; these chains are not ‘one-way streets’ (Hermach 2007).
An understanding of chains of dysfunction is fundamental to a holistic approach to their treatment.
4.21 Differential diagnosis 4.21.1 Problems As has already been mentioned, the locomotor system reacts to some degree to everything that happens in the body, and reflects it. As a result, clinical diagnosis is multifaceted and a highly responsible task. The problems essentially fall into two fundamentally different categories. The first concerns conditions which to varying degrees involve the spinal column and locomotor system: headache, vertigo, and a number of visceral symptoms in which vertebrogenic disturbances regularly play a part, such as chest pain, pain in the abdominal cavity, dysmenorrhea, etc. 162
In the case of these conditions the task is to decide the significance of the concomitant findings that usually exist in the locomotor system, and to determine whether they require treatment. This problem covers the whole field of medicine, and so can often only be solved with the collaboration of specialists in the relevant branches of medicine. The second problem is the differential diagnosis of disturbances of the locomotor system and the spinal column itself. Here the task is to decide whether the lesion is a pathomorphological one or a dysfunction, or a combination of both. In that case there is the further decision as to which disturbance is currently the more relevant. Errors in diagnosis may arise; in such cases inflammatory, metabolic, or neoplastic diseases may be involved. For this reason laboratory tests should always be carried out (including blood count and erythrocyte sedimentation rate), and X-rays requested if there is the least suspicion. Pathological processes can often be difficult to diagnose clinically in the early stages, so that the practitioner can only prescribe pain relief. In cases such as these where it is not yet possible to arrive at a diagnosis, treatment of dysfunctions using today’s techniques involves no more risk than analgesics, which are indeed more likely to produce undesired side effects. The regular follow-up examinations given to patients during therapy mean that the warning comes from the course of the disease; the practitioner should be alert to warning signs such as repeated relapses, persistent failure of therapeutic measures to achieve much effect, and deterioration in the patient’s condition. However, it would be a mistake to overestimate the capacity of the test procedures used for these examinations. The practitioner should carry out testing directly after treatment to check the immediate effect; but it is wrong to suppose that a favorable finding, indicating success at this immediate stage, can be any proof that pathomorphological processes are not present. Even where there is pathomorphological disease, dysfunctions can develop and feed the symptoms at the moment when we are administering therapy. These may include restrictions and TrPs which it is quite legitimate to treat. This is an appropriate point to describe typical sources of error and how they can be avoided. If, despite repeated treatment and self-treatment, restrictions and identical TrPs repeatedly occur in the same segment, the cause is either internal disease in a location corresponding to that segment, or a correspondingly located tumor or other pathological
Diagnosis of dysfunctions of the locomotor system
process in the region of the spinal column. For example, in a young patient, recurrence of a sacroiliac restriction, if bilateral, suggests sacroiliitis. Recurrent back pain in postmenopausal women, especially if it occurs following physical stress, suggests osteoporosis.
4.21.2 Case studies Case study 1 A. F., carpenter, born 1915. This patient underwent surgery in 1959 for a painful tumor on the left thenar eminence, and for a Dupuytren’s contracture of the fourth finger on the left hand. In 1959, he began to experience pain in the back of the neck, with stiffness. The pain became increasingly severe and the patient was admitted to a neurological hospital at the beginning of 1961. A contrast study of the spinal column (myelography) yielded no particular findings, and the patient was therefore referred to us for manual therapy in May 1961. By the autumn of that year he had received treatment four times, and each time the success was only temporary. Despite the absence of neurological symptoms, and simply on the basis of the course of the illness, we recommended that the contrast investigation be repeated. On readmission to the neurological hospital in October 1961, the patient was found to have stiffness of the neck and he was holding his head in a fixed position slightly bent forward and permanently rotated to the right. Erb’s point on the right was tender to pressure, as were the spinous processes of C2–C4. Mobility of the head was restricted in all directions, but especially left rotation. The one other finding was a static, evidently functional, tremor of the right hand. Pneumomyelography after injection of 30 ml of air by the lumbar route, with the patient sitting and the head in maximum anteflexion, showed a well-defined tumor at C2. Cerebrospinal fluid albuminocytological dissociation was found. Symptoms of a radicular lesion at C8 appeared for the first time following the pneumomyelography. This striking finding led us to a diagnosis of neurinoma at C2, partially intradural and located on the ventral aspect of the cord. The patient underwent operation and a neurinoma of the spinal root of C2 was removed. The unbearable pain subsided immediately following the operation. The conclusions to be drawn apply not only to other sections of the spinal column but also to restrictions in the craniocervical region with forced attitude of the head in the case of brain tumors with an occipital pressure cone; this behaves like an extramedullary tumor.
Chapter 4
Case study 2 F. M., born 1914. This female patient was an unskilled worker. From September 1961 she complained of occipital headaches, repeatedly accompanied by vomiting. She was examined as an outpatient at the neurological hospital in November 1961, when cervicocranial headache was diagnosed. Manipulation was performed and brought instant relief from the pain, lasting about a month. At the follow-up examination at the end of December 1961 there was intense pain at the nape of the neck and the spinous process of C2 was tender to pressure. This time, manipulation brought no relief; injection of procaine at the pain point was then tried, also without success. At the next follow-up examination in mid February 1962 the patient was holding her head in a forced attitude in anteflexion and inclined to the left. Passive mobility testing of the head did not find any typical restriction, but merely found resistance; overcoming this produced a reaction of nausea. This suggested forced attitude of the head as a result of increased intracranial pressure. Plain film X-ray of the head showed signs of increased intracranial pressure at the sella turcica. On hospital admission on 21st February 1961, the patient was entirely symptom free and the neurological findings and electroencephalogram (EEG) were normal. However, pneumoencephalography showed an occipital pressure cone. Only a very small amount of the air entered the third ventricle, and showed it to be displaced to the left. This finding led the hospital to perform angiography of the right internal carotid, which revealed a vascularized tumor in the right parietal region, located parasagittally and suspected to be a meningioma. Only after the pneumoencephalography did the beginnings of papilledema and slight disturbance in the EEG become evident. The patient underwent surgery in mid May 1962, and a falx meningioma of the right parietal region was removed. In this case an occipital pressure cone initially caused a very ordinary cervicocranial syndrome that responded well to manipulation. Later came the development of the forced attitude, and it was important for the manual practitioner to distinguish this from restriction (the typical hard end-feel is absent).
A restriction that is not resolved either spontaneously or in response to treatment, and/or relapses within a short time, suggests visceral disease in the corresponding segment, or a tumor.
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4.21.3 Common differential diagnoses Acute pain Chronic, relapsing symptoms are not the only type to give rise to differential diagnostic decisions; acute pain is another. This is especially so if the pain appears following accidents, and manual techniques can also be used to deliver first aid. The practitioner not only needs to be able to exclude fractures and dislocations, but also torn ligaments and joint capsules, hematomas, etc. Acute pain at the back of the neck, occurring together with severe headache, can be the result of subarachnoid hemorrhage. Since this is not a joint disturbance but an acute meningeal syndrome, the movement direction that is restricted is not rotation or side-bending but anteflexion of the head.
Herniated disk In the case of pain in the lumbar region, perhaps the most frequent question that needs to be asked is whether there is disk herniation. This problem is dealt with in more detail in Sections 7.1.5 and 7.8.2.
Psychosomatic disorders In patients whose main concern is pain, the practitioner very frequently has to decide to what extent psychological factors play a role; every instance of pain is also a psychological experience. Understandably, medical practitioners base their approach on the presence or absence of clinical signs in a condition that the patient describes as painful. Unfortunately, few doctors have the relevant specialist knowledge to diagnose and understand dysfunctions, which are the most frequent cause of pain. The key is this: if the patient is able to give a precise description and localization of the pain, and this information remains consistent on repeated questioning, it is unwise to dismiss it as merely psychological. In doubtful cases our guide is the course of the illness, based on observation over time and knowledge gained of the patient. These enable us to compare the clinical findings, and the changes that take place in them, with the patient’s own statements. In contrast, if the patient finds it difficult 164
to describe or localize the pain at all precisely, and there are frequent changes in the patient’s statements, it is likely that the pain is (mainly) of psychological origin.
Masked depression The problem posed by masked depression is an important one because it can indeed take the outward form of back pain and headache. This is because psychologically caused tension and tense posture do actually bring about painful dysfunctions, especially in the orofacial system and cervical region, and at the coccyx as a result of tension of the gluteal muscles and pelvic floor (levator ani). The diagnosis is hard to establish at the first examination; during the course of treatment it is found that after a short while the patient complains of fresh pain, and tension is found at the locations described. This should be a cue to ask targeted questions about whether the patient feels depressed or has experienced sorrow in the past. The most important question to ask is whether the patient suffers from disturbed sleep; the typical pattern of sleep disturbance is for the patient to fall asleep normally, but to wake in the (very) early hours of the morning and be unable to go back to sleep. A conclusive diagnosis is obtained by test prescription of mild antidepressive drugs.
Fibromyalgia syndrome There is an essential distinction to be made between muscle pain that occurs in most cases of back pain in the form of TrPs on the one hand, and fibromyalgia syndrome, which has been much explored in the literature. This is a chronic systemic disease affecting mainly women. The painful muscles are found bilaterally; they are numerous, and not confined to the trunk, but also found on the limbs. The pain is accompanied by fatigue, and there is morning stiffness similar to that in rheumatoid arthritis. Patients suffer from sleep disturbance, especially of non-REM sleep. The combination of chronic pain, fatigue, and sleep disturbance is associated with a mood of depression. On palpation, the muscles that are painful either behave like TrPs or feel hypotonic and doughlike. Tenderness in hypotonic muscles is a particularly characteristic finding in this disorder. The laboratory findings are not characteristic and the pathogenesis unknown. The cause is thought to
Diagnosis of dysfunctions of the locomotor system
lie in a lowering of the pain threshold in the central nervous system. Mild antidepressants and carefully judged physical exercise are recommended as treatment. In our experience, there is some benefit in light massage that the patient experiences as pleasant, administered over fairly long periods of time. The usual analgesics are not very effective.
Inflammatory conditions Inflammatory conditions also play a role. Rheumatoid arthritis is usually not difficult to recognize. This does not generally tend to affect the spinal column as often as it does the limbs, but this very fact makes it important to be aware of inflammatory, destructive lesions in the region of the atlas and axis. For this reason, where vertebrogenic symptoms appear in patients with existing rheumatoid arthritis, an X-ray should be performed. Another condition that should particularly be borne in mind is ankylosing spondylitis. This should be considered in cases where the patient’s symptoms first occurred around the age of 20, from then on taking a progressive course without lasting periods of remission. Characteristically patients report pain at night, which regularly wakes them at the same time in the very early hours of the morning and forces them to get up and move about. The first clinical sign is generally recurrent sacroiliac restriction, often bilateral. The restriction soon extends to the entire lumbosacral segment, then to rotation of the trunk, and especially stiffening of the thoracic cage, where springing pressure elicits no springing. Consequently there is clavicular breathing and exaggerated abdominal breathing. Laboratory findings are also important in the diagnosis of this condition. One such finding is the HLA-B27 antigen, which suggests a hereditary cause. The radiological findings are also significant; a positive finding in the X-ray of the sacroiliac joints
Chapter 4
shows the contours of the joints as ill-defined. In the early stages the joint space is widened, but later it may be ossified. On the spinal column, syndesmophytes develop and bridge the intervertebral disks, so that in the fully developed stage the anteroposterior film shows the spinal column as looking rather like a stick of bamboo. Typical as these radiological changes are, they may be absent. Diagnosis is especially difficult in female patients, because the disease often follows a milder course which does not then lead to stiffness. In males, progressive stiffness, gradually extending in the cranial direction, is the rule. This development can occur largely painlessly, in which case the impression is given that the disease did not begin until around age 40 or even later. The consequences are particularly severe for patients in whom the disease develops in the hip joints. In the early stage it is mainly the palpation findings that are characteristic. This fact makes it difficult to achieve early diagnosis, and calls for practice.
4.21.4 Conclusions Perhaps the main point to be made in conclusion is that diagnosis of dysfunctions of the locomotor system is a new field of clinical medicine, and a difficult one. In differential diagnosis we need to be aware that in most cases, including structural changes, the earliest clinical manifestation takes the form of disturbed function. Moreover, patients referred for pain due to ‘mere’ disturbed function are usually dealt with as outpatients, who cannot be examined as thoroughly as those in a hospital ward, where the technical facilities available are also greater. The practitioner in charge of such cases must remain constantly aware of the innumerable pitfalls; nothing is more dangerous than a sense of infallibility. This section on differential diagnosis should also serve as a warning.
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Chapter Five
Indications for and principles underlying individual treatment methods
Chapter contents 5.1 Manipulation . . . . . . . . . . . . . . . 168
5.1.1 Indications . . . . . . . . . . . . . 168 5.1.2 Contraindications . . . . . . . . . 169 5.1.3 Traction . . . . . . . . . . . . . . . 170 5.2 Soft-tissue manipulation . . . . . . . . . 171
5.2.1 Skin stretching . . . . . . . . . . . 171 5.2.2 Stretching a soft-tissue fold (connective tissue) . . . . . . . . . 171 5.2.3 Application of pressure . . . . . . 171 5.2.4 Restoration of deep tissue mobility 171 5.2.5 Treatment of (active) scars . . . . . 172 5.2.6 Relaxation of muscles . . . . . . . 172 5.3 Reflex therapy . . . . . . . . . . . . . . 172
5.3.1 Massage . . . . . . . . . . . . . . 5.3.2 Exteroceptive stimulation . . . . . 5.3.3 Local anesthesia – needling . . . . 5.3.4 Electrical stimulation . . . . . . . . 5.3.5 Acupuncture . . . . . . . . . . . . 5.3.6 Soft-tissue manipulation versus reflex therapy . . . . . . . .
172 173 173 174 174 174
5.4 Remedial exercise . . . . . . . . . . . . 175 5.5 Treatment of faulty statics . . . . . . . . 176 5.6 Immobilization and supports . . . . . . . 177 5.7 Pharmacotherapy . . . . . . . . . . . . . 178 5.8 Surgery . . . . . . . . . . . . . . . . . . 178 5.9 Lifestyle . . . . . . . . . . . . . . . . . . 178 5.10 The course of manipulative treatment . 179 5.11 Conclusions . . . . . . . . . . . . . . . 180
5
The indications for a particular treatment method should be established not only on the basis of the clinical diagnosis but also following an analysis of the pathogenesis so as to identify which lesion is most important at a given moment and is therefore likely to be the most effective object of therapy. Every therapeutic action should therefore result from a fresh examination, to keep up to date with the ongoing development of the patient’s condition. In this setting it is of the utmost importance to identify chain reaction patterns of dysfunctions and to pinpoint the most relevant link in the chain. In establishing the indications for a particular treatment, it follows that no therapeutic intervention should be applied before examination of the patient has been completed and the findings have been meticulously analyzed. If therapy is determined according to the principles set out here, it is likely to be effective and the condition of the patient should be found to have changed at follow-up examination. If the patient’s condition is unchanged, treatment was not adequate and should (generally) not be repeated. Critical assessment of the preceding treatment and ongoing audit and review are essential here. To reiterate: this is primarily a question of analyzing the factors contributing to the pathogenesis and not simply of conventional clinical diagnosis. This attitude rules out an indiscriminate routine approach (e.g. ‘a series of intradermal injections’ or ‘a series of infiltrations’), presupposes critical assessment of any preceding treatment, and thus also enables the treatment program to be corrected in light of the results obtained with preceding treatments (evidence-based strategy).
Manipulative Therapy
5.1 Manipulation 5.1.1 Indications Manipulative treatment is indicated if there is functional movement restriction (a pathological barrier) of a joint or spinal motion segment, and if this is considered relevant to the patient’s symptoms. In this setting, too, it should be emphasized that the decisive factor is not the clinical condition as such or even the clinical diagnosis (headache, dizziness, low-back pain), but rather the importance of the movement restriction for the pathogenesis. Once this concept has been fully grasped, definition of the action required in spondylosis, disk herniation, osteoporosis, or ankylosing spondylitis is a straightforward matter: these conditions in themselves do not form the object of manipulative treatment. Nevertheless, if it is felt that movement restriction is a factor in patients with these diagnoses, then the restriction should be treated with a manipulative technique that is appropriate in the given circumstances. Given the questionable importance of spondy losis for the pathogenesis, it is highly probable that diagnosis of a movement restriction will be the key finding. In disk herniation, concomitant movement restri ction may often cause the patient’s condition to deteriorate considerably and in such cases manipulation can be very successful. While it is far from easy to predict a successful outcome, it is always worth making an attempt with an appropriate technique. Scoliosis is certainly not an object for manipulation, as in itself the condition does not usually cause pain. If a patient with scoliosis feels pain, and movement restrictions are diagnosed, these are far more likely to be the cause of that pain and should be treated. Manipulation is indicated if movement restrictions interfere with remedial exercise. In both osteoporosis and juvenile osteochon drosis, stiffness (leading to immobility) will cause the patient’s condition to deteriorate. Adequate gentle mobilization techniques are therefore indicated to restore mobility. Spondylolisthesis and basilar impression cannot be influenced by manipulation, but in clinical terms they are more often than not symptom-free. Here, too, dysfunctions associated with movement 168
restrictions can be, and frequently are, the true cause of discomfort. In ankylosing spondylitis, movement therapy is indicated, and therefore (self-)mobilization tech niques are also appropriate; these have to be applied, however, to those segments that still show some degree of mobility. The reason why manipulation may be regarded as safely indicated in all these patient groups is that the methods advocated in this book are extremely gentle and very effective neuromuscular mobilization techniques. They utilize the inherent muscle forces of the patient rather than those of the practitioner; indeed the practitioner tends to function more in a ‘directorial’ capacity, instructing the patient what to do and frequently allowing the patient to perform self-treatment.
High-velocity, low-amplitude thrust techniques After gentle mobilization has been performed, the experienced practitioner will sometimes sense that the effect is still not entirely satisfactory; for example, a segment may still not be completely freed from several neighboring segments or, despite a measure of improvement, an area remains that still requires treatment. Preceding mobilization ensures that such a segment is well-prepared for a high-velocity, low-amplitude (HVLA) thrust. Following the work of Mierau et al (1988) we know that use of HVLA thrust techniques is followed by temporary hypermobility, and that a very intensive reflex response characterized by hypotonus or reduced muscle tone is achieved, which can be beneficial in radicular compression or entrapment syndromes (e.g. carpal tunnel syndrome). HVLA thrust techniques should be delivered with a minimum of force, and the cracking or popping sound within the joints should never be ‘enforced’ by the practitioner. If the segment has been well prepared for a thrusting maneuver, then the technique should succeed with consummate ease. This also applies to the situation in children who are too young to cooperate; here it is important to exploit the precise moment when they are relaxed. However, this presupposes excellent technical skill. In this connection it is worth quoting Stoddard’s (1961) system of recording degrees of joint mobility (Figure 5.1, Table 5.1).
Indications for and principles underlying individual treatment methods
Figure 5.1 • Schematic diagram for recording the
degree of movement restriction (Stoddard’s system). The degree of restriction is indicated in the various directions: 1 for side-bending and rotation to the right; 2 for retroflexion and rotation to the left. Hypermobility is indicated by the use of an arrow labeled with the number 3 and extending beyond the perimeter of the circle.
5.1.2 Contraindications The major technical advances achieved in the field of manual medicine in recent years have brought about a sea change specifically in the area of indica-
Table 5.1 Stoddard’s classification of joint mobility
Classification
Description
0
No mobility, ankylosis, not suitable for manipulative treatment
1
Severe movement restriction, only mobilization techniques to be applied
2
Slight movement restriction, both mobilization and thrust techniques can be used
3
Normal mobility, best left alone; however, if there is movement restriction in one direction, a thrust technique in the free direction can be useful (Maigne)
4
Hypermobility, all types of manipulative treatment should be avoided
Chapter 5
tions and contraindications. The situation can now be summarized concisely as follows: there is no real contraindication to manipulation and no possibility that patients will be harmed by it. What is contraindicated, however, is poor technique. Nowadays the basic approach comprises mobilization with neuromuscular techniques that primarily make use of the patient’s inherent muscle forces. This would be like forbidding the patient any spontaneous movements. HVLA thrust manipulation is employed to a very limited extent only and the ground is generally thoroughly prepared beforehand using mobilization techniques. The following cardinal errors must be avoided: • Over-frequent use of HVLA thrust techniques. • Delivering an HVLA thrust before the patient is properly relaxed and before the slack has been taken up. • Trying to enforce manipulation of any type against protective muscle spasm or in a direction that causes pain. • Performing cervical manipulation in retroflexion, side-bending, and rotation with traction, especially in cases where the patient does not tolerate this position. • Repeating HVLA thrusts at short intervals (i.e. of less than two weeks); in this context, even over-zealous examination of mobility in a painful direction may be contraindicated. In the debate surrounding contraindications, repeated reference is made to serious incidents and even fatalities, such as those reported by Dvorák & Orelli (1985), Grossiord (1966), Krueger & Okazaki (1980), Lorenz & Vogelsang (1972), and cited in the memorandum issued by the German Association of Manual Medicine (1979). Basing their calculations on the results of a questionnaire sent to members of the Swiss Association of Manual Medicine, Dvorák & Orelli (1985) computed the number of serious complications after manipulation (thrust techniques) to be 1:400 000. By far the most important cause of serious complications is undoubtedly injury to the vertebral artery, the wall of which may split longitudinally. Given the low incidence of vertebral artery damage and the rarity of such incidents, more recent publications (up to 2004) have suggested that these findings may be coincidental. Unfortunately, an almost constant feature of the literature cited is a failure to specify the particular technique that was held responsible for the complications in question: this is rather like discussing 169
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postoperative complications without giving details of the surgical technique used. One exception, however, is the publication by Dvorák & Orelli (1985), which includes the following highly characteristic account:
Case study A 35-year-old woman collapsed while attending a funeral and suffered from wry neck for three weeks afterward. Within the space of a few days she underwent HVLA thrust manipulation three times, administered by a qualified, experienced chiropractor. The patient was supine and manipulation consisted of passive rotation, reclination, and sidebending of the head. This was followed immediately by a short period of unconsciousness and later by tetraplegia. The patient was extubated after mechanical ventilation for 36 hours and administration of dexamethasone. After four months the patient was symptom-free apart from slight unsteadiness of gait. HVLA thrust techniques in acute wry neck are questionable in themselves, but to use the dangerous combination of ‘rotation, reclination, and sidebending’ is to court disaster. Another grave error was to repeat the thrusts in quick succession within the space of a few days because the patient’s condition did not show any improvement. In the few instances where detailed case reports are available, serious complications have indeed occurred most frequently when HVLA thrust techniques are repeated within a short space of time.
It should be emphasized here that HVLA thrust techniques are inappropriate for painful and severe movement restrictions, even if several adjacent segments are involved simultaneously. In such cases, HVLA thrusts are not only traumatizing but also ineffective, whereas neuromuscular techniques have proved outstandingly beneficial. For this reason, HVLA thrust techniques hardly ever form the initial component of therapy. The following contraindication may be inferred: if it is a mistake to perform thrust manipulation in the painful direction where there is major movement restriction, then use of this technique is also contraindicated where pain and gross movement restriction are present in all directions. In reversible functional movement restrictions, a distinction is made in any case between the direction of restriction and the direction of ease; movement restriction in all directions does not suggest dysfunction and therefore does not constitute an indication for manipulation. 170
For obvious reasons, manipulation of any kind is out of place in hypermobility. While this does not mean that no movement restriction should be treated in a hypermobile patient, it would be better to avoid thrust techniques because temporary hypermobility always follows any thrust maneuver. Other contraindications include destructive condi tions of an inflammatory or neoplastic nature. It is clear that no one would try to treat this type of pathology by manipulation; unfortunately, particularly in the initial stages of such conditions, diagnostic error is often unavoidable. The specialist usually sees such patients in hospital, at a later stage, when the putative diagnosis has already become clearer. Nevertheless, with modern-day techniques, these patients should come to no more harm than from the administration of analgesics. If, in a case of diagnosed tumor pathology, coexisting movement restriction is considered harmful to the patient’s condition, there is no reason why such a restriction should not be treated with an appropriate technique (see Case study 2 in Section 4.21.2). While working at the neurology clinic in PragueVinohrady, I deliberately gave manipulation at the craniocervical junction to a patient with a decompensating acoustic neuroma; he was then able to be referred to the neurosurgery clinic in a wellcompensated state. It is regrettable that a vertebral artery syndrome is considered to be a contraindication in this setting. Admittedly, treatment must only ever be given in a direction that is well tolerated, but there are few disorders where restrictions involving the craniocervical junction are more disastrous.
5.1.3 Traction Traction is essentially a form of mechanotherapy or manipulation, but unlike other methods of manipulation it is generally accepted in traditional medicine. Within the framework of manipulative techniques, traction of the cervical and lumbar spinal column has a specific role in radicular compression syndromes in those spinal regions and in disk herniation. In fact, traction can also be useful for diagnosis: if it relieves discomfort in the lumbar region, then the diagnosis of a herniated disk is corroborated. Traction is also indicated in acute wry neck and low-back pain. One important point must be emphasized, however: it is essential first to establish in each case
Indications for and principles underlying individual treatment methods
whether experimental traction brings the patient any relief. If no relief ensues, we must first seek to modify the technique so that discomfort is alleviated, and then desist if traction still fails. One reason for the failure of traction is restriction of movement, either at the craniocervical junction or in the lumbar spine. Once this restriction has been released, traction is often well tolerated, provided that it is implemented gently and with technical skill, preferably by hand.
5.2 Soft-tissue manipulation Soft tissue, in particular the deeper layers including the fascia and connective tissue, is intimately connected with the locomotor system, muscles, and joints. It is the function of soft tissue to be stretchable while yet able to resist stretch, and to be capable of being shifted while yet able to resist shifting. All this should take place in harmony with the locomotor system and may involve considerable ranges of movement. The same also applies for the viscera: there are no standard measures whatsoever for the degree to which the internal organs may also move. Changes in soft tissue have usually been considered to be reflex changes, that is secondary changes. This is not always the case, however, particularly in the chronic stage of painful conditions, and in endocrine and metabolic disorders. The tissue changes then form what is termed a ‘terrain’ (or constitutional factor). Clinically, a physiological and a pathological barrier can be detected in all soft tissue: both types of barrier constitute a possible indication for therapy, enabling disordered function to be corrected in precisely the same way as in restricted joints. If the soft-tissue changes are significant, they produce reflex inhibition of the locomotor system; it is then advisable to treat such softtissue lesions before performing joint mobilization, as the treatment itself may have a considerable mobilizing effect.
5.2.1 Skin stretching This technique is specific for hyperalgesic zones (HAZs). It has an effect similar to that of Kibler’s skin-fold rolling test (1958) and of connective tissue massage as advocated by Leube & Dicke
Chapter 5
(1951). However, it is absolutely painless and may also be used by the patient for self-treatment. The technique can also be applied to very small skin areas, such as the skin fold between fingers or toes, where HAZs may develop, especially in radicular syndromes radiating to the fingers or toes. HAZs are a useful sign of a radicular lesion and their treatment can be highly effective. Examination usually starts with a test for skin drag by gently stroking the skin surface with a fingertip. Skin drag in a HAZ is heightened due to increased moisture (sweating) and so permits rapid identification of the area where skin stretching should be performed.
5.2.2 Stretching a soft-tissue fold (connective tissue) The deeper layers of connective tissue can be folded and, after the barrier has been engaged, stretched. This technique is particularly effective for treating short or taut muscles and scars. The fold can be formed between the fingers or sometimes between the full length of the lateral edges of both hands. Stretching should never involve compression. Once the barrier is engaged, release is obtained spontaneously.
5.2.3 Application of pressure In cases where a tissue fold cannot be formed, the application of very light pressure can obtain tissue release. The pressure applied is just sufficient to sense the moment of increased resistance when the barrier is engaged. After a brief latency period, the resistance disappears and the practitioner’s finger spontaneously sinks more deeply into the tissue. This method is especially effective for deep-lying trigger points (TrPs) and scars, particularly in cases of painful resistance in the abdominal cavity.
5.2.4 Restoration of deep tissue mobility Where there is a pathological barrier, restriction of fascial mobility against bone is a characteristic finding, and restoration of normal mobility is indicated. As with fascia, this also applies to the scalp and its mobility against the underlying bone, to 171
Manipulative Therapy
the soft-tissue pad at the heel, and to the mobility of adjacent bones connected mainly by soft tissue, such as the metacarpal and metatarsal bones and the fibular head with the tibia. The situation is similar with regard to the mobility of subperiosteal tissue in painful periosteal points found especially at the attachments of tendons and ligaments. In most instances these are chronic changes to which the term ‘dystrophic’ may be applied, even though they may be reversible in functional terms.
5.2.5 Treatment of (active) scars Scars are located chiefly in the soft tissue, involving all its layers. Where healing is uncomplicated, a scar will be asymptomatic and all the layers involved will stretch and shift like those in the surrounding tissue. However, if healing is not straight forward, but more frequently for no apparent reason, many years later, a scar may become active in stressful situations and may even recurr after successful treatment. Examination will disclose resistance in some or all of the tissue layers penetrated by the scar. Such a scar is termed ‘active.’ Pathological barriers will then be found in all soft-tissue layers, and the patient will report pain when these are examined. Because a scar generally passes through several soft-tissue layers, it can be a particularly rich source of pathology, causing dysfunctions of muscles and joints. The process of scar examination begins with a test for skin drag, often the most rapid guide as to what is happening. However, the diagnosis can also be difficult. Following surgery the operative field may (for esthetic reasons) be at some distance from the surface wound. Because surgery is often performed only by laparoscopy or with a laser, it is frequently necessary to rely on findings elicited by deep palpation. The same is true for internal injuries without surface scarring, for example following a difficult childbirth. In this setting (compared with the situation in organic disease), palpation of the release phenomenon is of major diagnostic significance. Typically, the diagnosis here can be helped by the finding that locomotor symptoms had their onset shortly after surgery or trauma. Undiagnosed active scars cause problems that keep recurring until they have been treated; however, their treatment can bring surprising successes, described by their discoverer Huneke (1947) as the ‘instant relief phenomenon.’ Huneke himself 172
injected novocaine into scar tissue and attributed the resultant effect to this intervention. However, simple needling yields the same result. Nevertheless, therapy using soft-tissue techniques is far more precise because it is based on the diagnosis of all scar layers. The term ‘instant relief phenomenon’ emphasizes not only the immediate effect but also the fact that all symptoms disappear with a single intervention. This is generally over-optimistic; the soft tissue in the vicinity of a scar often requires repeated treatment, and not infrequently the scar is just one of a larger number of factors in the pathogenesis. It may itself also be prone to recur.
5.2.6 Relaxation of muscles Post-isometric relaxation (PIR) is the specific therapy for muscle tension with or without TrPs. Here, too, the first step is to take up the slack by lengthening the muscle so as to engage the barrier. This method, which will be described in detail in Section 6.6, has a similar effect to the spray and stretch method of Travell & Simons (1999) and is effective not only on TrPs in muscle, but also on the points where tensed muscles attach to the periosteum, and on referred pain in particular. PIR is painless and is suitable for use in a self-treatment setting. We routinely combine it with reciprocal inhibition (RI) achieved by antagonist stimulation. It should be emphasized here that the vast majority of TrPs can be treated via reflex mechanisms merely using minimal pressure and generally in the context of chain reaction patterns. However, chronic TrPs do exist; these need to be diagnosed and then treated with painful needling or with hard ‘traumatizing’ massage.
5.3 Reflex therapy This acts on the same structures as soft-tissue manipulative therapy, but is generally less specific and is consistent with the traditional methods employed by physical therapists.
5.3.1 Massage This term covers a broad spectrum of techniques that have developed from time immemorial; massage can be used to treat soft tissue and even periosteum. From the clinical standpoint, it should be used when
Indications for and principles underlying individual treatment methods
and where changes are found in the tissue, changes that manifest themselves primarily as altered tension. The experienced massage therapist will adapt the technique to these changes so as to release tension in the tissues where it is detected, and to bring relief. Deep massage may be applied to the periosteum, but this is painful. There are also some TrPs that do not respond to reflex methods and that require deep friction, a certain degree of traumatization. Bearing this in mind, it would seem that massage is a universal method that is potentially applicable in all reflex changes produced by pain (or nociceptive stimuli); and indeed that is the case. Massage is pleasurable, routinely brings relief and is therefore also very popular with patients. Unfortunately, the effect is usually only short-lived, whereas the procedure is very time-consuming. At the same time, some massage techniques can be quite painful. Massage is invariably a purely passive form of treatment, demanding no active involvement whatsoever from the patient. For this reason massage is indicated only as a preparation for other, more specific and hence more effective treatment modalities, and is not the therapy of choice for locomotor system dysfunction. The term ‘reflex massage’ is also used occasionally. It is sufficient to point out that any massage, any palpatory activity, triggers a reflex, depending on the tissue that is being massaged.
5.3.2 Exteroceptive stimulation Although this method does not exploit the barrier phenomenon, it is nevertheless appropriate for inclusion here because it is a manual method that is used in a targeted manner in response to specific findings. It is based primarily on stroking, which is indicated in circumstances characterized by minor changes in tactile perception. From a purely theoretical standpoint, afferent conduction is the prerequisite for control by the nervous system. Exteroceptive stimulation is one of the few methods to take account of this. It is used not for gross neurological disorders, but merely for dysfunctions that are comparable to a HAZ. These dysfunctions are most clearly evident on the soles of the feet where an asymmetrical response to stroking or brushing is often observed and patients also confirm that they are aware of the difference. With greater experience it is possible to discern that changes in muscle tone are also
Chapter 5
consistent with minor asymmetries in tactile perception. These asymmetries can be corrected by stroking. However, the practitioner must be able to sense the reaction during stroking. Stroking (our preference is to trace numbers and letters – proprioception) in asymmetric tactile perception on the soles of the feet is so effective that it is invariably indicated, and is performed on the side that is considered abnormal.
5.3.3 Local anesthesia – needling Local anesthesia and needling are among the most widely used methods of treating painful lesions. It may appear unorthodox to deal with these two methods together, and yet it should be recalled that one does not simply use local anesthetics to relieve pain for the short period during which the anesthetic has effect. The popularity of local anesthesia is due to the fact that its effect far outlasts the direct (pharmacological) action of the anesthetic. It has further been shown that the effect appears not to be dependent on the local anesthetic injected. In fact, Kibler (1958) used sodium bicarbonate, and Frost et al (1980), in a double-blind study, compared the effect of mepivacaine injections with that of physiological saline injections in the management of myofascial pain. It was shown that, if anything, physiological saline solution was more effective than the local anesthetic. The common denominator in all these methods is, of course, the use of the needle. The effect, however, does appear to depend very much on how precisely the needle touches the pain point. Needling is most effective when the needle is able to reproduce the patient’s spontaneously reported pain and its radiation pattern. In the case of TrPs, a twitch response should be provoked wherever possible, whether a local anesthetic is used or not. If the exact spot is successfully located, then analgesia can be produced immediately simply with a dry needle (Lewit 1979), both at TrPs and at other pain points. Injection of local anesthetics is, of course, necessary if the intention is to interrupt conduction in nerve structures, for example in nerve-root infiltration or epidural anesthesia. One special method of using local anesthetics is to raise intradermal blebs, although this technique is advisable only where administration is within a HAZ. Here, too, it is immaterial whether the bleb is produced using a 173
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local anesthetic, physiological saline, or distilled water (although the latter is more painful). It is interesting that, just as after manipulation (so, too, after successful needling or local anesthesia), the immediate relief obtained is often succeeded by a painful reaction lasting for a period of hours, or one or sometimes two days. It is only after this reaction has subsided that the therapeutic effect proper becomes established. For this reason such treatment should not be repeated before seven days have elapsed. Repetition is indicated if improvement has been achieved but there is still some residual pain.
5.3.4 Electrical stimulation This category includes a variety of methods that ultimately act on the same receptors and therefore produce comparable effects. Pain can be alleviated by reflex mechanisms in response to electrical impulses, diadynamic current or transcutaneous stimulation and many other similar modalities. They compete successfully with more traditional methods such as poultices, cupping, leeches, etc. All these methods, especially if they are used relatively gently, can help to alleviate pain.
5.3.5 Acupuncture This discussion of reflex therapies must touch briefly on acupuncture, one of the most venerable modalities in this category. Considerable difficulties arise the moment we attempt closer analysis of its mode of action. According to the orthodox view, acupuncture treatment is based on organ diagnoses and less on principles of pathogenesis, although some modern authors (Bischko (1984), for example) concede that acupuncture works primarily in cases of disturbed function rather than in structural pathology. The choice of acupuncture points is based on ‘meridians’ and is entirely empirical. From a theoretical standpoint, the most questionable issue surrounds the concept of ‘energies’ that are not at all susceptible to measurement. For scientific analysis, therefore, it will be necessary to examine the individual constituent elements that go to make up the system of acupuncture. One such element is the effect of needling: this was confirmed as medically effective in an older publication by Travell & Rinzler (1952), and I 174
myself (Lewit 1979) described the ‘needling effect’ in 312 pain points in 241 patients. There would seem to be sufficient clinical evidence to support the efficacy of this treatment. There appears to be a growing tendency among modern Chinese doctors to select their needle insertion points not only according to the traditional ‘meridians,’ but also on the basis of the segmental anatomy of innervation. Instead of needling, electrical stimulation has also been introduced (Chang 1979). Melzack et al (1977) have pointed out important analogies between the TrPs of Travell & Rinzler (1952) and traditional acupuncture points. Gunn et al (1976) found that of 100 acupuncture loci chosen at random, 70 were motor points in muscles. Other acupuncture loci are attachment points of tendons and ligaments; if these are tender, they can be treated by performing PIR on the muscles for which they serve as attachment points – for example the fibular head (TrP of biceps femoris or by mobilizing the fibular head), or the che-gu (4 equ L14) acupuncture point by PIR of the adductor pollicis brevis. Patterns of chain reactions (see Section 4.20) help us to understand functional relationships based on physiological principles and thus might provide a rational explanation for the phenomenon of ‘meridians.’ Careful examination often reveals that many acupuncture points can be tender at palpation and that increased tension can be felt at these sites. This is borne out, too, by the measurement of reduced electrical skin resistance in the vicinity of acupuncture points. A rational, scientific attitude to acupuncture is important because it might enable us to establish the indication more precisely in the context of dysfunctions; it would then be possible to identify those circumstances where acupuncture might be the treatment of choice.
5.3.6 Soft-tissue manipulation versus reflex therapy Soft-tissue manipulation techniques act on the same structures that are the targets for most other methods employed in physical (reflex) medicine. Technically, they are based on the diagnosis and correction (release) of a pathological barrier and thus form part of the canon of manual therapy. There is one fundamental difference between the human hand and all the other instruments at
Indications for and principles underlying individual treatment methods
our disposal: it provides us with information about the processes unfolding at every stage of therapy and offers feedback so that we can continually correct or modify our approach. Once the barrier has been engaged and release has been pursued to the very end, we can sense how the tension dissipates, and we then know that the patient’s pain has subsided – at least at the site in question. The difference between massage and soft-tissue manipulation is primarily that massage, with its relatively rapid rhythmic movements, does not take precise account of the barrier and release phenomenon. Despite the rapid movements involved, massage is far more time-consuming, diagnostic criteria are often lacking, and self-treatment is not really possible.
5.4 Remedial exercise Having discussed the indications for methods that are intended to act directly on painful dysfunctions, we will now turn our attention to methods targeted at the more complex functions. In this setting, remedial exercise has a prominent role to play. Two essentially different types of remedial exercise should be distinguished. In the first type, patients learn to use their own muscles to restore joint mobility, to relax their own TrPs and also to treat soft-tissue parts that they can reach themselves. These techniques will be described systematically in conjunction with the corresponding manual therapy techniques. The second type of remedial exercise is intended to correct faulty movement patterns (or stereotypes), which are associated with muscle imbalance and are frequently the true cause of painful dysfunction. The object of remedial exercise in such cases is to correct a faulty movement pattern that has been diagnosed and is considered relevant to the patient’s problem. Without this diagnosis of a faulty movement pattern and subsequent assessment of its relevance in terms of the pathogenesis, remedial exercise is simply a frustrating waste of time. It should be the role of the physician to make this diagnosis and assessment. The technical aspects are then the domain of the physiotherapist. A physician who is able to establish the correct indication for remedial exercise should also be able to assess the effect that the physiotherapist has achieved.
Chapter 5
The first criterion for establishing the indication, namely the diagnosis of faulty movement patterns and muscle imbalance, often presents an insuperable problem in the acute stage when pain distorts all movements and it is impossible to differentiate between a pain reaction and a faulty movement pattern. Moreover, the patient is also still unable to execute any normal movement patterns. The second criterion in determining whether remedial exercise is indicated is the relevance of the faulty movement pattern to the patient’s problem. Here the decision can be more difficult, for example, than in the case of a movement restriction or a TrP, because remedial exercise is far more time-consuming and laborious. Muscle imbalances are also common in asymptomatic patients and to embark on a course of remedial exercise in every case would be most unrealistic. Remedial exercise is therefore indicated where we are satisfied that the faulty movement pattern we have diagnosed is so important that, if left uncorrected, the patient’s condition is bound to recur. Indeed, specific remedial exercise is indicated precisely to prevent these frequent recurrences. Nevertheless, there are cases where the findings are so serious that there is no need to wait for recurrences. One criterion is the degree of muscle imbalance. In other cases we must consider the circumstances that trigger recurrences: for example if they routinely occur when a patient lifts a heavy object or bends forward. In such cases we study the patient’s forward-bending movement pattern and then demonstrate the correct way to bend forward and straighten up again, also while lifting. The same is true for carrying loads, sitting at the computer, etc. However, faulty breathing patterns are the most disastrous of all because they are intimately linked with the stability of the spinal column. To make remedial exercise as effective as possible, and to make it a routine procedure, it is essential to set clear and attainable goals. This means that we should not set out to achieve ‘ideal movement patterns,’ but instead we should concentrate on the fault that is the chief cause of the recurrent problem. When we do this, it is often possible to obtain results within a short period, after a few clear instructions have been given. However, if we try to achieve more than this, then remedial exercise therapy may take months. It is also essential to recognize the limits of what is possible. Unlike manipulation or needling, remedial exercise demands the active cooperation of the 175
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patient. Some movement patterns can be so deeply ingrained that it is difficult to modify them, especially if the patient is no longer young. And the problem of motivation is a hugely important issue. If patients are not really interested in improving their condition, then any attempt at rehabilitation is a waste of time. It cannot be sufficiently emphasized, however, that the art of the good physiotherapist consists not only in technical competence but also in an ability to motivate patients. The intelligence of the patient also plays a role. Here we would do well to recall the remarks made in Section 2.6 concerning patients who, from childhood, are incapable of forming optimal movement patterns and therefore find it difficult to implement corrections. This group also includes individuals gifted with high intelligence who are virtually ‘handicapped’ the moment motor skills are called for. The patient’s general physical condition must also be taken into account: cardiac function, circulation, obesity, generally weakened abdominal musculature after repeated surgery and/or childbirth, recurrent hernias or decompensating scoliosis in old age – any of these may present insurmountable obstacles from the outset. Despite these limitations, remedial exercise should constitute the most important modality implemented by the physiotherapist for dysfunctions involving the locomotor system. The importance and effectiveness of remedial exercise have increased considerably now that we have a better understanding of how specifically to treat the deep stabilization system of the trunk and feet. This is why it is so crucial to devote time primarily to these active methods of rehabilitation and to a lesser extent to passive procedures such as massage, and the many different forms of electrotherapy. Finally, there is the question of whether and under what circumstances these remedial exercise methods can be prescribed for preven tive purposes. This is a perfectly reasonable consideration given that, in our modern technically advanced world, patterns of harm are continuously inflicted on the locomotor system from childhood. Regrettably, a solution to this problem is difficult to find, mainly because group therapy is not easy to arrange. One possible solution might be to recommend yoga techniques (e.g. breathing exercises, ‘spinal’ techniques, etc.) or methods utilized in Chinese exercise systems (e.g. Tai Chi) and certain strategies advocated in back schools. 176
5.5 Treatment of faulty statics The diagnosis of faulty statics has been described in Section 3.1 and Section 4.2. Contributing causes often include muscle imbalance and external influences (e.g. ergonomic factors), and faulty statics need to be treated accordingly. We will take the opportunity here to deal with the correction of obliquity. Obliquity in the pelvic region and in the lower part of the lumbar spine can be compensated for with corrective footwear. Because such footwear is beneficial only if it is worn permanently, prescription of this interventional measure must be approached in a purposeful and responsible manner if it is to be effective. Considerable thought must be given to ensure that such an intervention is properly indicated. The decision is relatively straightforward if obliquity is due to fairly recent trauma, for example a leg-shortening injury or unilateral compression of the lumbar spine. Unilateral (asymmetric) flat foot as a further possible indication can be best identified on examination if the patient stands on the lateral margins of both feet, causing the pelvis to become horizontal while at the same time the pelvis which deviated to the higher side returns to the mid position. However, because pelvic obliquity in most cases gives rise to secondary compensa tion during growth, the decision then becomes far more complex. In such circumstances assessment is impossible without X-ray analysis, as described in Section 3.1. Ultimately, however, the decision must also be taken on clinical grounds. Clinically, static pain is a chronic, recurring phenomenon associated with excessive static loading, primarily on standing. Examination reveals pelvic deviation toward the higher side. When a board of suitable thickness is placed under the foot of the ‘shorter’ leg, the patient’s pelvis should become horizontal and lateral deviation should also be reduced. Since X-ray images demonstrate this result much more precisely, the indication for such correction should be established on the basis of the clinical and X-ray findings before and after placing the board under the patient’s foot. It is also important to be guided by the patient’s reaction. If a thin insert about 1 cm thick is placed under the foot of a normal subject with the instruction to distribute weight equally on both legs
Indications for and principles underlying individual treatment methods
without bending the knees, the insert will cause considerable discomfort. Where pelvic obliquity is present, one of three different responses may be expected: 1. The patient may find the insert positively comfortable. 2. The patient may feel that the insert makes no difference. 3. The patient may find the insert uncomfortable. In the first case we can expect the patient to tolerate the correction well and instructions should be given to wear the insert at all times, even in indoor slippers wherever possible. In the second case a degree of adaptation may be necessary and the patient should be allowed to become accustomed to the insert gradually. In the third scenario the patient should be advised to try wearing the insert for brief periods; however, if the patient fails to adapt, wearing the insert should not be rigorously enforced. The type of shoe correction implemented is important in itself. A heel insert fitted inside the shoe is practical, but has the disadvantage that the shoe fits less well. For this reason, it is better to lower (shorten) the heel on the shoe of the longer leg. However, this is practicable only where leg length difference is minimal. Where leg length difference is greater than 2 cm, the sole must be thicker on the shoe of the shorter leg, otherwise the foot would be uncomfortable. It is not necessary though to compensate fully for leg-length inequality. If there is no difference in leg length and the pelvis is level, but obliquity is detected in the lower lumbar spine, this will have implications during both standing and sitting. In this instance corrective compensation must also be provided when the patient is seated by placing a thin board under one ischial tuberosity. X-rays will be required to demonstrate the need for such measures. The most frequent and most serious fault in sitting is kyphosis due to hypermobility of the lum bar spine. In such cases a back support should be prescribed where the kyphosis peaks. If that is not possible, then it is recommended that the sitting surface should be tilted forward or that the patient should sit in the oriental manner with legs crossed, or on the heels (Japanese fashion), which causes the pelvis to tilt forward. A forward-drawn posture (see Section 4.20.3 and Section 7.1.7) is also very important in this context.
Chapter 5
5.6 Immobilization and supports In the acute stage of lesions involving the locomotor system, muscle spasm ensures immobilization. The same also applies after trauma, when healing makes immobilization imperative. However, immobiliza tion becomes highly problematic once a condition threatens to become chronic, and if the objective is full recovery, that is restoration of normal function, then immobilization presents an outright obstacle. For this reason immobilization should only ever be a temporary measure in circumstances where the aim is to restore normal function. Permanent immobilization signifies simply that there is no hope of functional recovery. Unlike immobilization, however, supports need not greatly interfere with mobility while protecting the patient against excessive static loading, an important consideration in sedentary occupations. And it is primarily hypermobile subjects with lax muscles and ligaments who find it difficult to adapt to excessive static loading, particularly when, as in most modern means of transport, jolting is a compounding factor. Automobile drivers and passengers should be recommended to use an inflatable cushion to support themselves at the point where their kyphosis peaks when they are sitting in a relaxed position. Many hypermobile subjects suffering from headache should wear a soft supporting collar when riding in automobiles or using other means of transport. Elderly, obese patients with weak abdominal musculature, or with scarring and hernias, need a firm lumbar belt. Patients with ligament pain in the pelvic region require a firm pelvic belt, as proposed by Biedermann (1993) and Cyriax (1978) (see Section 6.9). Most of these supports should be worn primarily under conditions of excessive static loading, and the pelvic belt should be worn at night.
Immobilization should be only as minimal and as brief as necessary. However, in light of the increasing incidence of excessive static loading, thoughtfully selected supports can often be recommended.
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5.7 Pharmacotherapy Since the main focus of this book is on dysfunctions of the locomotor system, it will be understood that pharmacotherapy can be effective only within certain limits. It is hardly likely that a restricted joint, an immobile fascia, or faulty motor patterns related to breathing or to carrying loads will respond to pharmacological correction. On the other hand, it is clear that disturbed function in itself is not synonymous with disease and pain. It is only with the onset of reflex changes, which are felt to be painful, that the patient will report symptoms. Then it is possible to employ pharmacological means to reduce the intensity of the reaction to nociceptive stimulation. Moreover, the pain threshold is a major factor and this can be influenced by pharmacotherapy. It is therefore sometimes useful to prescribe medicines that lower the response of the autonomic nervous system; in particular, non-steroidal anti-inflammatory drugs (NSAIDs) are suitable for this purpose. It is important to issue warnings concerning the misuse/abuse of all types of analgesics in the setting of chronic pain. Dependence may develop and it is no coincidence that reduction of the analgesic dose is often the first step taken when patients are admitted to pain clinics. Analgesics are frequently combined with muscle relaxants, and a great many combination products are available. Prescription of these products can be beneficial only in cases where general muscle tension has been demonstrated. However, the most commonly encountered patient category comprises constitutionally hypermobile individuals suffering from localized painful muscle tension. In such patients the combination of analgesics and muscle relaxants can serve not only to increase hypermobility and poor coordination, but also to complicate specific rehabilitation because fine muscle control tends to deteriorate. The most rewarding effects of pharmacotherapy are achieved where patients with locomotor pain and suffering from masked depression are treated with mild antidepressants – a scenario that is not at all uncommon. As a rule, treatment with corticosteroids is not indicated in locomotor system dysfunctions. Local application of corticosteroids should also only ever be implemented in exceptional circumstances. Pain points on the periosteum and
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at tendon and ligament attachments, as well as muscle TrPs, can generally be treated successfully using relaxation and soft tissue techniques, and by needling and local anesthesia. Corticosteroids should be prescribed only if these physiological methods have failed. Their administration should be repeated only if they elicit some improvement at the first attempt. However, corticosteroids are suitable for use where inflammatory changes are present.
5.8 Surgery If the patient’s clinical condition is due to disturbance of function alone, there should be no question of surgical intervention. However, disturbed function may be the consequence of structural changes that necessitate surgery. This scenario is encountered most commonly in radicular syndromes and other disorders associated with intervertebral disk lesions. Conservative measures primarily aimed at restoring function are frequently successful here. It is therefore not always straightforward to decide when still to adopt a conservative approach or when to intervene surgically (see Section 7.8.2). Spinal canal stenosis may also be a (contributing) cause of radicular compression or even of spinal cord compression. Cauda equina syndrome, a condition characterized by acute bladder and bowel paralysis and rapidly progressive muscle weakness, constitutes an indication for emergency surgery. Instability, for example in progressive spondylolisthesis or following trauma, may also provide an indication for surgery. Instability due to odontoid abnormality may also be dangerous. It should be noted here that the conservative management of instability has become far more effective in recent years.
5.9 Lifestyle Lifestyle questions probably play the most impor tant role of all in the context of treating and preventing dysfunctions in the locomotor system. Lifestyle issues have been left almost until last because they do not constitute a therapeutic method in the true sense of the word, and a separate chapter has been devoted to this subject (see Chapter 8).
Indications for and principles underlying individual treatment methods
One of the most important tasks facing the practitioner during history taking is therefore to discover the potential sources of trouble in the patient’s daily routine so that warnings can be given to steer clear of harmful lifestyle habits. Indeed, if we succeed in detecting these important clues, we should already be able to give very useful advice after the first examination. However, if patients refuse to desist from a clearly harmful lifestyle, then any therapy offered is destined to fail.
5.10 The course of manipulative treatment The clinical examination provides information about the entire locomotor system or, at least, all key regions. Only once the examination stage is complete is it possible to consider whether we are faced with a typical chain reaction pattern or with a set of individual disorders of dubious connection. In the former, more typical scenario, treatment should be given to the link in the chain that appears to be most relevant. Then all findings must be checked again. Ideally, the chain reaction will no longer be present and it is then clear what home exercise needs to be assigned to the patient: for example, if the key link was in the foot, rehabilitation will focus on the foot dysfunction. If a secondary finding is diagnosed, for example a painfully restricted acromioclavicular joint, then this can also be treated. However, if the chosen link turns out to be wide of the mark, then an attempt should be made using another link in the chain. And this is by no means uncommon because the first attempt at treatment is frequently used for diagnostic purposes; the diagnostic process proper ends with the first intervention. It is not unusual for this intervention also to be selected on diagnostic grounds so as to confirm the importance of a particular finding – something that applies especially with active scars. However, if no chain reaction pattern at all is detected, then the findings made should be treated, and if there is an effective form of self-treatment, then the patient’s home exercise can be assigned. The first follow-up examination about two weeks later then assumes special importance. On that occasion the working hypothesis from the first examination will be either verified or found to require revision. Depending on the outcome of the follow-up examination, the subsequent
Chapter 5
rehabilitation plan will be continued or reviewed and modified. If the findings have definitely improved and the patient’s home exercise is clear, then the interval between further follow-up examinations can be increased. Even if the initial results are favorable, patients with a longer history of such problems should be followed up for longer – ideally for several months – because the natural course of dysfunctions tends to be chronic and relapsing. If no improvement is reported at the first follow-up examination, the first question to ask the patient must be: Did your condition improve briefly or not at all? The first intervention sometimes produces a very marked but short-lived effect. The follow-up examination may reveal one of two fundamentally different situations: 1. The findings are unchanged. This means that treatment has produced no results or that there has been a rapid recurrence of the patient’s condition (which is not much better). 2. The original findings have been corrected but new factors are now producing similar symptoms. In the latter case the condition may actually be regarded as having improved even if the patient does not feel any better. In the cervical region in particular, a highly characteristic pattern may develop in which lesions tend to migrate in a caudal direction until they disappear. In the former case, however, we must ask ourselves whether the initial analysis was correct and whether we failed to identify the true cause. Alternatively, the underlying condition may be more serious than appeared at first sight and may in fact be caused by pathomorphological changes. A further reason may be that patients often perform their home exercise wrongly or skip it altogether, for example, a simple self-mobilization technique or relaxation of TrPs. If, despite the failure of treatment, there is a continuing conviction that the original diagnosis was correct, then the treatment may be repeated once more. If initial improvement is again promptly followed by recurrence, then the underlying cause of this must be sought. A clinical finding will often be made in the corresponding segment; in the thoracic outlet syndrome this is almost always reflected in clavicular breathing (i.e. lifting of the thorax during inhalation), with poor stabilization of the trunk, which then needs to be corrected.
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However, the dysfunctions themselves can also be extremely complicated and multiple chain reaction patterns may be present, each one competing with the others. In such cases rapid results are unlikely and the patient will need to be monitored for a prolonged period. Chronic recurrent conditions such as migraine are routinely associated with dysfunctions of the locomotor system and tend to improve once these dysfunctions are treated. However, they may recur after a relatively long interval, and then the patient will need to be treated again. Where manipulation was discussed in a preventive context (see Section 5.4), this should also be understood to include the prevention of recurrence: rehabilitation, which regularly follows on from our treatment, with patients themselves playing an ever-increasing role, is truly synonymous with the prevention of recurrence.
5.11 Conclusions The ability correctly to establish whether or not a particular therapeutic intervention is indicated is the practical result of the pathophysiological thinking outlined in the theoretical sections of this book. Because the patient’s symptoms are usually the result of many individual factors, the chief task of the practitioner is to single out on each occasion the factor that currently appears to be the most important and also the most accessible to treatment. In this regard the recognition of characteristic chains of dysfunctions has done much to define this process more precisely. If we are successful at the patient’s initial visit, then a different therapeutic approach will quite
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likely be required when we next see the patient. Our aim is not constantly to promote one particular type of therapy but to normalize function and hence to relieve the patient’s symptoms. To do this we select the method that appears to be most advantageous. Such a strategy makes it difficult to determine which method has been most effective: manipulation, remedial exercise, or needling of a pain point. It would not be easy to justify the indication for further manipulation if movement restriction is no longer present, or for continuing to needle a pain point if this can no longer be detected. It therefore becomes difficult to determine statistically which method was most successful. If a patient with acute appendicitis is cured and remains symptom-free after removal of the inflamed organ, the surgeon does not have to provide statistical proof that surgery was indicated. If a pain point or TrPs disappear after PIR, RI or needling in a patient with locomotor system dysfunction, or if a patient has learned how to normalize respiration and does not slip back into clavicular breathing (lifting the thorax during inhalation), then something has been achieved even if other lesions which still cause symptoms have yet to be treated. This approach may seem rather unusual and complex, but it is consistent with the multifactorial nature of locomotor system dysfunction. It also precludes a monotonous, routine modus operandi characterized by a propensity for series of injections, repeated manipulation of a spinal segment, or the courses of electrotherapy so beloved of physiotherapists. The journey is a demanding one, but the effort involved is worthwhile both for the patient’s well-being and for refining the practitioner’s skills.
Chapter Six
6
Therapeutic techniques
Chapter contents
6.5 Self-mobilization . . . . . . . . . . . . . 236
6.1 Manipulation . . . . . . . . . . . . . . . 182
6.1.1 General principles governing technical aspects . . . . . . . . . 182 6.1.2 Extremity joints . . . . . . . . . . . 187 6.1.3 The spinal column . . . . . . . . . 201 6.2 Indirect techniques . . . . . . . . . . . . 223
6.2.1 Johnston’s functional techniques 223 6.2.2 Strain and counterstrain . . . . . . 225 6.3 Exteroceptive stimulation . . . . . . . . 225
6.3.1 Tactile perception and muscle tone . . . . . . . . . . . . 6.3.2 Assessing altered tactile perception . . . . . . . . . . . . . 6.3.3 Normalizing tactile perception . . 6.3.4 Altered superficial tactile perception following surgery (due to scarring) . . . . . . . . . . 6.3.5 Individual characteristics of perception . . . . . . . . . . . . 6.3.6 Self-treatment . . . . . . . . . . .
225 226 227 227 229 229
6.4 Soft-tissue manipulation . . . . . . . . . 230
6.4.1 Skin stretching . . . . . . . . . . . 6.4.2 Stretching a connective tissue fold . . . . . . . . . . . . . . 6.4.3 Sustained application of pressure . . . . . . . . . . . . . 6.4.4 Shifting (stretching) the deep fascia . . . . . . . . . . . . . 6.4.5 Mutual shifting of metacarpal and metatarsal bones . . . . . . . 6.4.6 Painful periosteal points . . . . . .
6.5.1 Self-mobilization by stretching . . 6.5.2 Self-mobilization of the sacroiliac joints . . . . . . . . . . . 6.5.3 Self-mobilization of the lumbar spine . . . . . . . . . . . . 6.5.4 Self-mobilization of the thoracic spine and ribs . . . . . . . . . . . 6.5.5 Self-mobilization of the cervicothoracic junction and first rib . . . . . . . . . . . . . . . 6.5.6 Self-mobilization of the cervical spine . . . . . . . . . . . . 6.5.7 Self-mobilization of the extremity joints . . . . . . . . . . .
237 238 238 240 242 243 245
6.6 Post-isometric relaxation and reciprocal inhibition . . . . . . . . . . . . 246
6.6.1 Basic principles . . . . . . . . . . 6.6.2 Muscles of the head and neck . . 6.6.3 Muscles of the upper extremity . . 6.6.4 Muscles of the trunk . . . . . . . . 6.6.5 Muscles of the hip region . . . . . 6.6.6 Muscles of the lower extremity . .
246 248 255 261 270 272
230
6.7 Training weak muscles (facilitation) . . . 279
230
6.7.1 Muscles of the trunk . . . . . . . . 279 6.7.2 Muscles of the hip . . . . . . . . . 285
231
6.8 Re-training to correct faulty movement patterns . . . . . . . . . . . . 285
231 235 236
6.8.1 Standing on both feet . . . . . . . 6.8.2 Standing on one leg and walking . 6.8.3 Sitting . . . . . . . . . . . . . . . . 6.8.4 Anteflexion . . . . . . . . . . . . .
285 286 287 289
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6.8.5 Lifting the arms . . . . . . . . . . . 6.8.6 Carrying loads correctly . . . . . . 6.8.7 Breathing . . . . . . . . . . . . . . 6.8.8 The feet . . . . . . . . . . . . . . . 6.8.9 The shoulder blade and upper cervical spine . . . . . . . . . . . . 6.8.10 The hands . . . . . . . . . . . . .
290 292 293 294 296 296
6.9 Supports . . . . . . . . . . . . . . . . . 296
6.9.1 Cervical collar . . . . . . . . . . . 297 6.9.2 Inflatable cushion . . . . . . . . . 297 6.9.3 Pelvic belt (Biedermann and Cyriax) . . . . . . . . . . . . . 297 6.10 Local anesthesia . . . . . . . . . . . . . 298
In the preceding chapters we have outlined the diagnosis of locomotor system dysfunctions, their pathogenesis, and the reflex changes they produce. Building on that foundation, we then considered the indications for specific therapeutic methods. However, to describe them all would go beyond the scope of this book. This chapter will confine itself principally to manipulative techniques, including those for soft tissue and especially for muscles, and to rehabilitation in the setting of locomotor system dysfunctions.
6.1 Manipulation 6.1.1 General principles governing technical aspects The objective of manipulation is to restore normal mobility to joints, including joint play. In this context we distinguish between two types of manipulation: mobilization and high-velocity, low-amplitude (HVLA) thrust techniques.
The positioning of the patient The patient should lie or sit in such a way as to be relaxed. The patient’s lying or sitting position should be selected so that the joint to be treated is ideally centered, allowing maximal muscle facilitation and relaxation. The joint that is the object of treatment must be accessible, and one of the articulating 182
bones should be fixed either by the patient’s own position or by the practitioner. The height of the manipulation table must be adjustable; this is absolutely essential given the large number of techniques in which the patient is seated and the major height variations in patients and practitioners.
The position of the practitioner The position adopted by the practitioner relative to the patient is in many ways decisive for the technique that is to be used. The practitioner must be in a comfortable and stable position in order to be relaxed at all times. If the practitioner is not relaxed, the patient too will be unable to relax. When treatment movements are performed correctly, the practitioner’s hand and forearm always form an extension of the direction of motion. However, this in itself is not sufficient to ensure optimally gentle yet effective movement. Movement impulses should emanate from the practitioner’s whole body, with forces usually generated by the feet and legs, as when throwing the discus or putting the shot. Any practitioner who becomes breathless or perspires during manual therapy is doing it wrongly. It may reasonably be said that during manipulation, especially of the spinal column but also during diagnostic examination, the practitioner’s body forms a harmonious moving unit with the patient’s body, rather like a dancing couple. This harmony between the mover and the moved is the secret of a flowing, gentle and hence elegant technique.
Fixation When techniques are performed correctly, one of the bones articulating in the joint being manipulated is fixed while the other is mobilized. In extremity joints it is usually the proximal bone that is fixed, that is supported by the body of the practitioner or by the treatment table. For effective fixation the mobilizing force should not act across two joints. In this process the practitioner’s hands are close (but not too close) to the joint so as to avoid any lever action. In the spinal column, fixation is achieved by correct positioning where possible. In the seated position, good fixation of the caudal spinal segment via the pelvis can be obtained if the patient sits astride the treatment table.
Therapeutic techniques
The starting position of the joint and the direction of treatment Treatment of the joint is performed once the slack has been taken up but not in a position in which the joint itself is not overstretched. If it is in an extreme position, the joint will be locked and cannot be treated. This principle must also be adhered to when treating the spinal column. According to Kaltenborn (1989), the direction of movement during gliding mobilization depends on whether the concave joint surface is located on the proximal (fixed) articulating bone or conversely whether the convex joint surface is located proximally and the concave joint surface distally (see Figures 2.7 and 6.1). In the first instance, gliding of the distal partner occurs in the opposite direction to functional bone movement, whereas in the second case, gliding of the distal partner occurs in the same direction as functional bone movement. Accordingly, in the first case, the convex distal partner is mobilized primarily in the opposite direction to functional bone movement, whereas in the second case, mobilization occurs in the same direction as functional bone movement (see Figure 2.7). For this reason mobilization of the first phalanx relative to the metacarpal head, for example, should be mainly in a palmar direction.
Taking up the slack (engaging the barrier) Taking up the slack (engaging the barrier) represents the first and crucial phase of manipulation: it is the prelude to release in the context of mobilization and to an HVLA thrust when a thrusting technique is being used. In peripheral joints we attempt to take up the slack by approaching the limit of joint play, where possible with simultaneous distraction of the joint. In a normal joint this is never a hard or sudden action. A hard end-feel when the limit of joint play
Figure 6.1 • Schematic illustration of directions of joint play.
Chapter 6
is reached is characteristic of a movement restriction. Functional movement in the spinal column cannot always be distinguished from joint play because movements in an individual motion segment cannot be performed actively and therefore resemble joint play to a certain extent. We know that we have taken up the slack (engaged the barrier) the moment we sense the first slight resistance (indicative of the physiological barrier). This must be performed gently and cautiously, and once the barrier has been engaged we should wait. The commonest reason for error and failure is to misinterpret active resistance by the patient as a sign that we have taken up the slack. This invariably happens if the patient senses pain or feels threatened by a rapid, harsh examination technique. ‘Locking’ is an additional factor in the spinal column, especially when long levers are used (see Section 6.1.3). This term refers to techniques in which all spinal segments are ‘locked’ except the one that is being manipulated.
Manipulation After the slack has been taken up (the barrier has been engaged), there are two ways to restore normal mobility: 1. Either by a gentle springing movement, but more often simply by waiting, in order to obtain release and thus normalize the barrier. 2. Or, by delivering an HVLA thrust, once the barrier has been engaged and the patient is relaxed.
Simple mobilization Mobilization can be achieved by gentle rhythmic repetitive springing, or usually just by waiting at the barrier with minimal pressure in the direction of functional movement or joint play. When simply waiting for the release phenomenon to occur, the practitioner must be able to sense precisely when release has fully run its course, otherwise both practitioner and patient will be ‘robbed’ of success. If the practitioner opts for rhythmic springing at the barrier, care must be taken not to lose the end position, otherwise the springing action can become too coarse and painful. And pressure must never be increased during springing simply because the effect obtained is insufficient. On the contrary, springing will be 183
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suppressed if springing back is prevented by increasing the pressure exerted. It appears that the therapeutic effect depends on (spontaneous) springing back to the barrier at the initial end position. Rhythmic repetitive springing is especially effective in joints that, when restricted, are not directly fixed or moved by muscles. In particular these include the sacroiliac, acromioclavicular, and sternoclavicular joints. To some extent the same also applies in extremity joints where shaking mobilization has proved especially useful. In the spinal column, preference is usually given to the release phenomenon option, although in combination with techniques involving muscular facilitation and inhibition (neuromuscular techniques).
Neuromuscular mobilization techniques Here we may differentiate between techniques that act on specific individual muscles and others that have an effect on the locomotor system as a whole. A feature common to all of them is that they facilitate, potentiate, and automate the release phenomenon.
Post-isometric relaxation
Wherever possible, post-isometric relaxation (PIR) is supplemented by reciprocal inhibition (RI). According to Mitchell et al (1979), only a minimum of resistance is used here. After taking up the slack, the practitioner offers resistance for 5–10 seconds as the patient exerts minimal pressure in the direction opposite to mobilization, and then the patient is instructed to ‘let go’. After a short latency period, release (i.e. mobilization) occurs and the practitioner then waits for the patient to relax. Starting from the newly gained position, the process is repeated once or twice. It is important not to interrupt the patient’s relaxation prematurely. The longer relaxation lasts, the better the effect and the fewer repetitions needed. If the patient fails to relax during PIR, the simplest solution is to extend the isometric phase, even for up to 20 seconds. An important improvement was achieved by Zbojan (1984) with his introduction of gravity-induced relaxation: in this technique, where possible, the weight of the head or (part of) an extremity is isometrically raised a little against gravity and then relaxed as gravity takes over. This can be repeated three times. Zbojan recommends holding both the isometric phase and the relaxation phase for 20 seconds each. This exercise can be done at home by 184
the patient as a self-treatment method on a daily basis.
Reciprocal inhibition
Wherever possible, PIR may be supplemented with RI: here the patient exerts light pressure in the direction of mobilization while the practitioner applies rhythmic repetitive counterpressure using minimal force. Active rhythmic repetitive movement in the restricted direction against resistance from the practitioner or (following gravity-induced relaxation) as a single powerful movement, also in the restricted direction, achieves RI of the muscles that are restricting movement.
Rhythmic repetitive muscle contraction
In isolated situations, rhythmic repetitive muscle contraction can act to produce mobilization directly, for example rhythmic contraction of the scalenes with their attachment points at the first and second ribs, or of the psoas major at the thoracolumbar junction.
Respiration
(See also Section 4.15.3.) As a rule, inhalation has a facilitating effect and exhalation an inhibitory effect, especially on the muscles of the trunk. Therefore, it is usually appropriate to combine inhalation with isometric resistance and exhalation with relaxation. However, there are important exceptions to this rule: forced exhalation facilitates the abdominal muscles, and maximal exhalation in lordosis facilitates the erector spinae muscles and thus mobilizes the thoracic spine into extension. In kyphosis, in contrast, the thoracic spine is mobilized by inhalation. From gymnastics we are accustomed to associating inhalation with straightening up and exhalation with anteflexion (and with side-bending). Mouth opening is associated with inhalation and mouth closure with exhalation. Where movement in one direction is associated with inhalation, and in the opposite direction with exhalation, this phenomenon is known as respiratory synkinesis. One characteristic of respiratory synkinesis is that it is difficult to perform a particular movement during the respiratory phase that is not associated with it, for example to bend forward while inhaling. Of particular interest is the mobilizing effect of respiration during side-bending, as noted by Gaymans (1980). During inhalation or exhalation, different spinal segments are facilitated or relaxed in an alternating pattern. Broadly speaking, with the exception of the cervicothoracic junction, the even-numbered
Therapeutic techniques
segments are inhibited (fixed) during inhalation and relaxed during exhalation, while conversely the oddnumbered segments are inhibited (fixed) during exhalation and relaxed during inhalation. Other forms of respiratory synkinesis also serve to promote mobilization. During isometric traction, for example, we exploit the fact that neck muscles become tense during inhalation and relax during exhalation, resulting in stretching. During isometric traction of the lumbar spine in lordosis when the patient is prone, tension is increased during exhalation whereas relaxation occurs during inhalation. This happens because the lumbar erector spinae in lordosis contracts during exhalation.
Eye movement (visual synkinesis)
Eye movement facilitates movements of the head and trunk in the direction of gaze and inhibits movements in the opposite direction. While this does not hold for side-bending, looking up facilitates straightening into a neutral position and out of side-bending. Looking up facilitates inhalation and looking down facilitates exhalation – a respiratory synkinesis that should be taken into account for combination with respiratory techniques. However, according to Gaymans (1980), maximal excursion of the eyes has an inhibitory effect.
Zbojan’s use of gravity
Where possible, use can be made of Zbojan’s (1984) gravity-induced technique (see above): during the isometric phase it is sufficient to raise the head or leg a little, hold for 20 seconds and then relax for 20 seconds.
Combining techniques
It will be self-evident that these methods can be combined to excellent effect. This applies in particular to the combination of PIR, respiratory synkinesis, visual synkinesis, and gravity-induced techniques. As a result the isometric phase (resistance exerted by the patient) and the relaxation phase can be largely automated, thus enabling the practitioner to dispense with repeated instructions to the patient of the type: ‘When you press, use only minimal force’ and ‘Relax completely’. If rotation to the right is restricted, for example, the practitioner can instruct the patient to look left during the isometric phase and breathe in, and then to look right during the relaxation phase and breathe out. This is especially appropriate when we are dealing with patterns of respiratory synkinesis.
Chapter 6
For mobilization into side-bending, the practitioner tells the patient to look up during the isometric phase and to look down during the relaxation phase if it is the even-numbered segments (C0, C2, C4) that are involved. The use of gravity-induced techniques is particularly suitable for combination and for achieving automation. For this, the levers should be arranged so that the force involved is neither too great nor too small. The greater the number of elements, the greater the potential for optimal combinations and for self-treatment, for example self-mobilization of the atlas against the occiput (at the same time also relaxation of the SCM muscle) while supine with the head rotated (see Figure 6.96). In view of the wide-ranging possibilities, a warning is also appropriate concerning incorrect combinations. Looking up does not work in combination with exhalation and neither does looking down in combination with inhalation. We must also bear in mind that looking up facilitates straightening up (retroflexion) and looking down facilitates forward-bending (anteflexion). For mobilization into side-bending, for the even-numbered segments, it will be useful to proceed in the manner described in the preceding paragraph. For the odd-numbered segments (C1, C3, etc.), exhalation during the isometric phase should not be combined with looking up and inhalation during the relaxation phase should not be combined with looking down. Therefore the combination of respiration with eye movements should be avoided in this case. If visual synkinesis is to be combined with respiratory synkinesis, then the instruction to look in a particular direction must precede the instruction to inhale or exhale. At the cervicothoracic junction and also in the thoracic spine it is essential for the neck to be held in extension during mobilization into sidebending. It is therefore correct during the isometric phase to give the instruction ‘Look up and breathe in’ but not to say ‘Look down’ during the relaxation phase because the patient would then bend forward. Consequently, the instruction in the relaxation phase is ‘Let go and breathe out’. It is very important for the patient always to breathe in and out as slowly as possible so that both the isometric phase and the relaxation phase are sufficiently long. It is therefore useful, for example, first to say to the patient ‘Look to the right’ and then after a short latency period to add ‘And breathe in slowly’; and also to say ‘Look down’ and after a certain latency period to add ‘Breathe out’. If the patient finds it difficult to breathe in and out slowly, then it is very useful for the patient to breath-hold at 185
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the end of inhalation before the instruction is given to breathe out. However, if this also fails to solve the problem, then the patient has a significant faulty breathing pattern (assuming that an organic respiratory disorder is not to blame). Remedial exercises to correct this seriously disordered breathing pattern are then indicated. As a technical note, release may take considerably longer than the process of exhaling slowly. Therefore the best solution is simply to instruct the patient to carry on inhaling and exhaling until release is complete. Once release has started, it will automatically follow its course to the end no matter how the patient continues breathing. If our combinations are well thought out, the sum total of physiological stimuli involved will considerably enhance the effectiveness of our mobilization techniques, make them less time-consuming and render them largely suitable for self-treatment, which also considerably strengthens the treatment program. PIR can be routinely supplemented with RI, thus allowing a further goal to be realized: taken collectively, all these neuromuscular techniques mean that it is the patient’s own muscles that are increasingly used to achieve mobilization. It will come as no surprise that maximal use of the patient’s own muscles is more ‘physiological’ than the best manipulation techniques delivered by the practitioner.
(i.e. by releasing the slack that has been taken up), we give the patient time to tense up as a reflex anticipatory reaction. When that happens, manipulation fails or becomes unduly forceful. If the above conditions are met, HVLA thrust techniques are never forceful because the thrust corresponds to a weight of not more than 1000 g. However, there are also situations where highvelocity maneuvers are not even necessary, thus allowing an even gentler approach, as in distraction manipulation in the cervical and cervicothoracic region with the patient seated. Mierau et al (1988) have shown that HVLA thrust techniques are followed immediately by a state of hypermobility in which the barrier is temporarily overcome. This also explains both the very intensive reflex effect and the presence of a certain degree of risk because the barrier fulfils a protective function. Leaving to one side a small number of incidents that have been widely discussed, it is generally true to say that forceful and frequently repeated HVLA thrusts carry a risk of permanent hypermobility. Figures 6.2 and 6.3 illustrate the different effects achieved with mobilization and HVLA thrust techniques.
HVLA thrust techniques
Immediately after treatment, whether this consists of mobilization or manipulation, its effect must be checked by testing (see Section 4.17).
These techniques consist of a high-velocity but non-forceful movement of small amplitude, starting from the end position gained (i.e. after taking up the slack) and going in the direction in which the slack was taken up or mobilization was performed. In the process, a barrier seems to give way, and as a rule we hear the joint ‘pop.’ Immediately afterward we sense a considerable reduction in muscle tone and increased mobility. The following technical conditions must be observed: • While taking up the slack the practitioner must be able to sense the moment when the patient is completely relaxed. • The end position is reached (or the barrier is engaged) using a minimum of force. • The HVLA thrust must start from the end position already gained, that is we must never back off before delivering the thrust. And this is the typical error made by almost every novice because we are used to drawing back our arm before delivering a blow. Here, however, it is a crucial mistake because as we back off 186
Testing to check the effect
Record keeping The purpose of keeping records is to ensure detailed documentation of the examination and in particular of any therapeutic interventions so that data are available in case the material later needs to be written up for publication or for an expert legal report. This aspect should not currently pose any difficulties given the general use of computers for data storage.
Follow-up treatment and aftercare If we discount acute cases where we are in fact administering first aid and where patients should be invited to attend for follow-up within a week, it is generally possible from the case history to offer advice concerning any lifestyle aspects that may require correction. The patient is then given home exercises that can be used either as part of a selftreatment plan or as a basis for a clearly specified
Therapeutic techniques
Chapter 6
Figure 6.3 • Tension curve during joint distraction and the effect of ‘joint cracking’ (adapted from Roston & Wheeler Haines 1947). (A) Tension increase without joint cracking. (B) Sudden ‘give’ at the moment of cracking.
6.1.2 Extremity joints
Figure 6.2 • Distraction of the metacarpophalangeal joint using a force of 8 kg after mobilization (A, B) and after an HVLA thrust (C, D).
course of physiotherapy. The patient should be invited to attend a follow-up appointment within two to three weeks. Failure to issue such instructions and to set goals is professionally irresponsible and betrays a lack of understanding of rehabilitation. It is always advisable to inform the patient that treatment of any kind may often be followed by a painful reaction lasting for anything from one to three days, after which improvement sets in. If patients are not given such a warning, the inevitable result is that practitioners will be bombarded with telephone calls during the first 24 hours about conditions that are ‘worse now than they were before!’
The techniques used in the manipulation of extremity joints are aimed almost exclusively at restoring joint play. Because examination of joint play is technically identical with the mobilization of these joints, both will be described here simultaneously.
Joints of the upper extremities Interphalangeal joints Dorsopalmar shift, distraction, and laterolateral shift are used for mobilization (and examination). The practitioner fixes the patient’s proximal phalanx between the thumb and forefinger of one hand, supported either against his own body or the treatment table. Taking the patient’s distal phalanx between the thumb and second finger of the other hand, the practitioner mobilizes the distal phalanx in one of the above directions, always applying distraction at the same time. It is advisable to keep thumb 187
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and forefinger at right angles to the direction of movement.
Metacarpophalangeal joints Because these joints are almost spherical (ellipsoid), joint play is tested in all directions, including rotation and distraction, using a technique similar to that described for the interphalangeal joints. The practitioner fixes the patient’s metacarpal head between the thumb and forefinger of one hand, supported against his own body or the treatment table, and takes hold of the first phalanx between the thumb and forefinger of the other hand. Here too mobilization is always performed while applying distraction. Only the thumb and forefinger holding the phalanx can be at right angles to the movement only in the dorso-palmar direction. In this case, distraction in a palmar direction is effective; this can be performed as an HVLA thrust using the first phalanx of the forefinger as a fulcrum – and is often administered as first aid following sprains. The practitioner can also take hold of the first phalanx from above so that the hand and forearm hang down, and then perform distraction by shaking. These last two techniques can also be used in a self-treatment setting (see Figure 6.4).
The carpometacarpal joint of the thumb The trapezium is first located by palpating the styloid process of the radius. Distal to this there is a groove which corresponds to the scaphoid, which then articulates with the trapezium as the wrist broadens again. Fixing the trapezium between the thumb and forefinger of one hand, the practitioner
uses the thumb and forefinger of the other hand to take hold of the first metacarpal bone as close to the carpometacarpal joint as possible. Here too mobilization can be performed in a dorsopalmar and laterolateral direction, with the practitioner’s thumbs and forefingers positioned at right angles to the direction of movement. For distraction, the terminal phalanx of the patient’s thumb is grasped using the little finger of the practitioner’s mobilizing hand and a pull is exerted via the terminal phalanx. The following technique is suitable for postisometric traction and HVLA thrust manipulation: placing his right hand round the ulnar aspect of the wrist of the patient’s supinated right hand, the practitioner takes hold of the metacarpal between the thumb and forefinger of his other hand, so that the proximal phalanx of the forefinger forms a fulcrum close to the carpometacarpal joint dorsally (below), and the thumb, located a little more distally, performs gentle dorsal compression to achieve distraction. The practitioner can amplify this effect further by hooking his little finger round the distal phalanx of the patient’s thumb (see Figure 6.4A). Once the barrier is engaged, an HVLA thrust is now delivered. The patient can also be instructed to offer slight resistance to distraction, to relax after 5–10 seconds and then to repeat this. Afterward the practitioner takes hold of the patient’s pronated hand from the ulnar aspect using the opposite hand. Using the other hand he then grasps the patient’s first metacarpal so that the radial edge of the proximal phalanx of his forefinger forms a fulcrum close to the carpometacarpal joint on the palmar side (below) and the thumb
Figure 6.4 • Treatment of the carpometacarpal joint of the thumb (A) into supination with distraction and gentle dorsal compression and (B) into pronation with distraction and gentle palmar compression.
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performs gentle palmar compression to achieve distraction. Once again, this can be amplified by hooking the little finger round the distal phalanx of the patient’s thumb and engaging the barrier (see Figure 6.4B). An HVLA thrust is now delivered to achieve distraction or again the patient can be instructed to offer slight resistance to distraction, to hold for 5–10 seconds and then relax. This technique is then repeated. Both techniques are eminently suitable for use in self-treatment. An even simpler technique is to take hold of the proximal phalanx of the patient’s thumb from above, to allow the forearm to hang down, and to perform distraction by shaking.
The joints of the wrist It is important first to find the exact location of the radiocarpal joint and the carpometacarpal joints: when the wrist is dorsiflexed, the skin crease on the dorsal aspect is precisely at the location of the radiocarpal joint, and on palmarflexion the skin crease on the palmar aspect marks the location of the carpometacarpal joints. If palmar flexion is restricted, the practitioner must examine and mobilize the proximal row of carpal bones relative to the radius in a dorsal direction. With one hand the practitioner takes hold of the patient’s supinated forearm just above the wrist, and supports this on his knee or on the treatment table. With the other hand the practitioner takes hold of the patient’s wrist slightly distal to the radiocarpal joint, takes up the slack dorsally by exerting light pressure, and performs mobilization using rhythmic springing pressure (see Figure 6.5). Self-treatment follows the same principle. It is sufficient
Figure 6.5 • Dorsal shifting of the proximal row of carpal bones relative to the radius.
Chapter 6
for the patient to support her forearm on her thigh; she then uses her other hand to take hold of the hand to be mobilized, and treats it in pronation for the radiocarpal joint and in supination for the intercarpal joint, first in a dorsopalmar and then in a palmodorsal direction. If dorsiflexion is restricted, the practitioner must examine and mobilize the distal row of carpal bones relative to the proximal row, in a palmar direction. With one hand the practitioner takes hold of the patient’s pronated forearm just above the wrist and supports this on his knee or on the treatment table. With the other hand the practitioner takes hold of the patient’s hand at the level of the carpometacarpal joints, takes up the slack in a palmar direction by exerting light pressure, and performs mobilization using rhythmic springing pressure (see Figure 6.6). Self-treatment follows the same principle. It is sufficient for the patient to support her forearm on her thigh; she then uses her other hand to take hold of the hand to be mobilized, and treats it in supination for the radiocarpal and in pronation for the intercarpal joint, first in a palmodorsal and then in a dorsopalmar direction. If radial abduction is restricted, the principle chiefly involves dorsiflexion of the trapezium relative to the scaphoid (see Section 4.10.3). The technique is essentially the same as for restricted dorsiflexion, but with the difference that the mobilizing pressure is directed toward the radius. In contrast, if ulnar abduction is restricted, then joint play is primarily restricted in the radiocarpal joint (see Section 4.10.3). Consequently, the technique is essentially the same as for restricted palmar flexion, but with the difference that the mobilizing pressure is directed toward the ulna relative to the pisiform bone or the wrist is sprung in a radial direction relative to the forearm.
Figure 6.6 • Palmar shifting of the distal row of carpal bones relative to the proximal row.
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Figure 6.7 • Shifting individual carpal bones against their neighbor: (A) examination; (B) mobilization by pincer grip.
Where a very specific procedure is required, it is possible to examine and treat joint play between two neighboring carpal bones and also the relevant metacarpal bone. The practitioner fixes one carpal bone between the thumb and forefinger of one hand, while moving the other carpal bone with the thumb and forefinger of the other hand. In technical terms it is crucial to examine using the minimum of force, because even in movement restriction the resistance is so negligible that it will not be recognized at all if the examination is forceful. For mobilization proper it is advantageous to place both forefingers on the palmar aspect and both thumb tips on the dorsal aspect (or vice versa) of adjacent carpal bones before exerting pressure (pincer grip, see Figure 6.7). In conjunction with distraction, this technique is important in carpal tunnel syndrome. The pincer grip can also be performed with the thumb and forefinger of one hand, making this movement a candidate for self-treatment. The pisiform bone may also be painful and restricted in its movement. Taking it between the thumb and forefinger, this bone can be examined and mobilized very easily in a laterolateral or proximodistal direction. It is of course important to be able to locate the individual carpal bones. We have already seen how
to locate the trapezium when treating the carpo metacarpal joint of the thumb. And it is a simple matter to find the pisiform (on the triquetral bone). The capitate forms the most prominent point of the wrist on palmarflexion. The techniques described here can be used not only for the carpal bones themselves but also for the carpometacarpal and intermetacarpal joints. Technically it is most important to examine using a minimum of force; moreover, the practitioner’s fingers should not be too close together because they might then be pressing on the same bone. Conversely, if they are too far apart, too much mobility will be felt because two joints are being examined. In addition to the translational (gliding) techniques described, it is also possible to perform a distraction technique that is implemented mainly as an HVLA thrust. This is very effective and entirely innocuous. The practitioner sits in front of (and a little lower than) the patient, who is also seated. He takes hold of the patient’s pronated, downwardhanging hand in the region of the wrist, at the distal articulating partner of the joint where restriction has been found. Both thumbs are placed one on top of the other on the back of the patient’s hand, with both hands encircling the palmar aspect of the patient’s wrist (see Figure 6.8). The slack is taken
Figure 6.8 • Traction manipulation of the capitate relative to the lunate: (A) making contact; (B) taking up the slack and delivering the HVLA thrust.
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up by very gentle traction with slight dorsiflexion of the patient’s hand; once the barrier is engaged, an HVLA thrust is delivered along the axis of the patient’s downward-hanging arm but taking care to allow no further dorsiflexion. There are two errors to be avoided at all costs: first, excessive traction while engaging the barrier and then releasing it before the HVLA thrust; and second, further compressive dorsiflexion at the wrist during the HVLA thrust. Distraction can be performed as mobilization or self-mobilization. Using one hand, which is supported on his knee or on the treatment table, the practitioner takes hold of the patient’s pronated forearm above the wrist. With the other hand he grasps a carpal bone between thumb and bent forefinger and, after taking up the slack, performs springing distraction. The same effect can be achieved with the patient’s arm hanging down: the practitioner takes hold of the carpal bone in the same way and performs a shaking maneuver. The distal radioulnar joint will be the last wrist joint to be considered. Mobility can be examined between the distal end of the radius and ulna and mobilization can be performed. The technique is broadly similar to that already described for the carpal bones: the practitioner takes hold of the distal end of the radius with one hand and the distal end of the ulna with the other. He then shifts the two bones in opposite (dorsal or palmar) directions to take up the slack and performs springing. For mobilization it is better to use the pincer grip, as for the carpal bones. Examination is clinically important whereas mobilization is less so because the movement restriction is located in the vicinity of the elbow.
Chapter 6
Figure 6.9 • Distraction of the elbow joint.
the other hand he fixes the patient’s upper arm by exerting downward pressure toward the padded surface of the treatment table. Using the thumb as a fulcrum, pressure is exerted distally (see Figure 6.9). The practitioner performs traction using the hand on the patient’s forearm while simultaneously enhancing leverage at the elbow by exerting pressure with his shoulder against the patient’s forearm. For radial and ulnar springing (lateral gapping), the practitioner takes hold of the distal end of the seated or supine patient’s upper arm with one hand and grasps the patient’s wrist with the other hand. With the patient’s forearm supinated, a springing push is exerted at the level of the elbow, either from ulna to radius or from radius to ulna, depending on the direction in which movement is restricted. The patient’s forearm is fixed against the practitioner’s iliac crest (see Figure 6.10). The patient’s elbow must not be fully extended,
The elbow The elbow actually consists of three joints: the humeroulnar, humeroradial, and proximal radio ulnar articulations, with joint play affecting all three. However, treatment is most often directed at epicondylopathies (epicondylar pain). The most important treatment techniques are distraction as well as radial and ulnar springing (lateral gapping), in combination with relaxation of the muscles that insert at the elbow. Distraction is performed with the patient supine and the arm to be treated flexed at the elbow, with the supinated forearm supported against the shoulder. With one hand the practitioner fixes the patient’s forearm in the crook of the elbow, and with
Figure 6.10 • Springing the elbow in a radial direction.
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the practitioner takes up a position to one side of the patient and shakes the patient’s forearm rapidly in a radial or ulnar direction. Lateral springing (shaking) produces distraction of the elbow on the side to which pressure is directed. The following shaking technique with the patient seated or supine is also gentle and effective. The practitioner sits between the patient’s trunk and slightly abducted arm, takes hold of the forearm proximal to the elbow, and moves it into supination (see Figure 6.11). In this position the arm can be gently and rhythmically shaken into extension. (See also Section 6.5.7.)
The shoulder
Figure 6.11 • Shaking mobilization of the elbow joint into extension.
otherwise the joint will lock. After taking up the slack, which is achieved by slightly rotating the pelvic crest on which the patient’s forearm is fixed, the practitioner gives a push to spring the joint. This maneuver is used primarily for diagnosis and the findings should therefore be compared with those on the contralateral side. When repeated, the maneuver is utilized to achieve mobilization or as an HVLA thrust for manipulation. Most commonly,
Where a typical capsular pattern is encountered at the shoulder, mobilization techniques are virtually useless; in this clinical condition – which is known as ‘frozen shoulder’ – joint play is characteristically normal as long as abduction is still possible to some extent. However, post-isometric traction often relieves pain, evidently due to the presence of good muscle relaxation. For distraction it is best for the patient to be standing or supine. In the standing option, the practitioner places his corresponding shoulder under the patient’s axilla (i.e. right to right, or left to left), pressing against the patient’s thorax. With one hand he grasps the patient’s wrist and with the other hand takes hold of the slightly abducted arm just above the elbow (see Figure 6.12A). After taking up the slack using gentle traction, the practitioner
Figure 6.12 • (A) Shoulder distraction over the practitioner’s shoulder, in the direction of the long axis of the arm; the patient may sit or stand. (B) Shoulder distraction with the patient supine.
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performs PIR: he instructs the patient to resist for about 10 seconds using minimal force while breathing in and then to relax while breathing out. The technique can be used for self-treatment over the cushioned back of a chair. If the patient is shorter than the practitioner then it is preferable to perform traction with the patient supine. With the patient’s arm abducted, the practitioner sits in the patient’s axilla, thus fixing the position of the thorax. With one hand he grasps the distal humerus and with the other the wrist of the patient’s pronated arm (see Figure 6.12B). The slack is taken up by traction on the upper arm; the patient is instructed to offer light resistance, to breathe in slowly and breath-hold, and then to relax while breathing out. In this process, resistance (pressure) should be exerted only against the chest wall and not against the upper arm. If rotation is free and shoulder abduction only is restricted and/or a painful arc is present, then joint play with the arm abducted will routinely be found to be disturbed. In this context, it is usual nowadays to refer to an impingement syndrome. Joint play is restricted because, in order to achieve abduction, the head of the humerus has to glide caudally in the glenoid cavity. This is also usually the cause of disturbed abduction. For mobilization the patient is seated with arm abducted. The practitioner places the patient’s elbow on his shoulder so that the upper arm is horizontal. With the radial aspect of one hand he exerts light pressure against the head of the humerus and with the other hand against the glenoid cavity of the shoulder blade in the opposite direction (see Figure 6.13). Once the slack is taken up, mobilization is performed using a springing pressure. In the interplay of both hands the direction of mobilization can be adjusted as desired and the practitioner can
Chapter 6
Figure 6.13 • Translatory mobilization of the shoulder joint with the patient seated.
also switch hands so that the hand exerting pressure from below is now on the upper arm while the other is on the shoulder blade. Joint play is most frequently restricted in a craniocaudal direction.
The acromioclavicular joint To mobilize the acromioclavicular joint, with the patient supine, the practitioner gently places his (right) thenar eminence at the lateral end of the patient’s (right) clavicle not too close to the joint and performs dorsoventral springing against the acromion (see Figure 6.14A). Although fixation of the shoulder blade is guaranteed by the patient’s supine position, it is still recommended that the practitioner fixes the head of the humerus with his other hand. In technical terms it is important to take up the slack using the very minimum of force and then to deliver a light dorsal push and release the pressure immediately to allow the clavicle to spring back. The practitioner should be able to both feel and even see the rhythmic springing movement. This springing is
Figure 6.14 • Mobilization of the acromioclavicular joint by springing the clavicle relative to the acromion (A) ventrodorsally and (B) craniocaudally.
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absent where movement of the acromioclavicular joint is restricted, but after a few mobilizing pushes using minimal force the joint will spring normally. The same effect can be achieved if the practitioner takes hold of the seated patient’s shoulder in both hands from behind and uses both thumbs ventrally to exert lateral pressure on the clavicle. Craniocaudal springing is an equally important mobilization technique (see Figure 6.14B). The practitioner stands to one side of the supine patient, fixes the patient’s bent elbow from below with one hand, and places the thenar eminence of the other hand over the lateral end of the clavicle. He takes up the slack by gently pressing both hands toward each other and then mobilizes in the same direction using light alternating pressure from both hands. Here, too, the spontaneous action of springing back as far as the barrier is important for successful mobilization. The worst mistake with this technique is to increase the pressure if springing fails to occur immediately. Another useful technique is that of distraction performed by shaking. For this, the patient should be seated or (preferably) supine. The practitioner stands to one side of the patient and uses the fingers or thumb of one hand to fix the clavicle close to the acromioclavicular joint; with the other hand he grasps the patient’s abducted upper arm (in slight ventral flexion). Light traction is exerted to take up the slack and the arm is shaken in the given direction: this has the effect of producing traction characterized by rapid rhythm and minimal force (see Figure 6.15).
Figure 6.15 • Distraction mobilization of the acromioclavicular joint.
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The sternoclavicular joint and shoulder blade The clavicle with the shoulder blade moves about an axis that passes through the sternoclavicular joint. Simple movement restriction of this joint without osteoarthritis is relatively rare. The most effective mobilization technique is distraction to spring or gap the joint. For this, the patient should be supine. With hands crossed, the practitioner places one pisiform against the medial end of the clavicle from below, and the other pisiform against the manubrium of the sternum from above. The slack is taken up by slight pressure that pushes the hands apart (see Figure 6.16) and then the joint is sprung into distraction. As with the acromioclavicular joint, mobilization must be performed using a minimum of force and again the spontaneous action of springing back is crucial. Distraction with leverage can be performed as follows: with the patient supine, the practitioner takes up a position on the side of the restricted joint and fixes the clavicle close to the sternoclavicular joint from below using the thumb of one hand. With the other hand he takes hold of the patient’s forearm and engages the barrier with light traction in a caudal direction, using the fixing thumb as a fulcrum. Mobilization is performed by springing traction from the original end point of the barrier. However, this can be done even more effectively by rapid shaking in the same direction. The shoulder blade lies flat on the thoracic wall where it is freely mobile. The synovial bursae permit considerable movement and this can be examined and mobilized. With the patient prone, the practitioner grasps the patient’s shoulder and shoulder blade with both hands and performs
Figure 6.16 • Mobilization of the sternoclavicular joint with crossed hands.
Therapeutic techniques
Chapter 6
Figure 6.18 • Fan-wise spreading of the metatarsals.
Figure 6.17 • Mobilization of the shoulder blade
against the thoracic wall (also useful for mobilizing the upper ribs).
circling movements of the shoulder blade against the sternum (see Figure 6.17). By pressure on the shoulder blade from above, he mobilizes the ribs simultaneously. In terms of technique, it is important that the movement imparted by the practitioner should come from the trunk so that both hands operate in synchrony, and that the forearm of the mobilizing hand should be vertical to the shoulder blade. With the patient side-lying, the practitioner can use the finger pads of one hand to lift the inferior angle of the shoulder blade away from the thoracic wall, while using the other hand to deliver a push on the patient’s shoulder in a caudal direction.
Joints of the lower extremities Metatarsophalangeal joints The techniques for examining and treating the interphalangeal joints are identical to those described for the fingers (see p. 187). The most important maneuver for the metatarsophalangeal joints is distraction. The practitioner uses one hand to fix the metatarsal bone at the joint. With some plantar flexion he uses the thumb and flexed forefinger of the other hand to perform distraction, employing the first phalanx of his flexed forefinger as a fulcrum.
A technique that patients find particularly agreeable consists of fan-wise spreading of the metatarsal heads in a dorsal (or more rarely, plantar) direction. For this, the practitioner stands or sits at the foot of the treatment table while the patient sits on the table facing him with knees slightly bent and heels resting on the table. He then takes the patient’s metatarsals in both hands, with thumb and thenar above (on the dorsal aspect) and fingers below (on the plantar aspect). Using his thumbs, he spreads the dorsum of the foot over the fulcrum created by the fingers underneath (see Figure 6.18).
The tarsometatarsal and transverse tarsal joints The distal row of articulations between the metatarsus and tarsus is known as Lisfranc’s joints (tarsometatarsal joints) and the proximal row of articulations between the tarsal bones is known as Chopart’s joint (transverse tarsal joint). The functional movements possible here are pronation and supination, while joint play primarily takes the form of dorsoplantar mobility. Mobilization and examination are best effected using a dorsal push (Sachse’s method). The practitioner stands at the foot of the treatment table to one side so that he is facing the medial aspect of the foot to be treated. With the more cranial hand he fixes the dorsum of the patient’s foot (above Chopart’s and Lisfranc’s joints). With his other hand supinated and in ulnar abduction, he takes up the slack using light pressure 195
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Figure 6.20 • Mobilization (manipulation) of the tarsal and tarsometatarsal joints by rhythmic shaking; an HVLA thrust may also be used.
Figure 6.19 • Mobilization of Lisfranc’s and Chopart’s joints by moving the distal articulating bones dorsally.
away from the plantar aspect (see Figure 6.19). Mobilization is then performed by springing with the radial edge of the forefinger placed parallel to the joint to be mobilized. The thumb of this hand remains on the dorsum of the patient’s foot. The most precise technique, however, is to examine and mobilize the joints between individual metatarsal bones as well as the individual tarsometatarsal joints. The technique is the same as that for mobilizing the carpal bones. The patient is supine with the leg slightly bent at the knee and the heel supported on the treatment table. With the thumb and forefinger of one hand the practitioner fixes the proximal tarsal bone: he then examines the play at the joint with the distal articulating bone by performing a dorsoplantar shift between the thumb and forefinger of his other hand. The pincer grip is more appropriate for the purposes of mobilization. The practitioner places both thumbs on the plantar aspect and both forefingers on the dorsal aspect of two adjacent bones (tarsals or tarsal/metatarsus). He takes up the slack by slight pressure first in a dorsal and then in a plantar direction, and then mobilizes the joint by rhythmic springing (see Figure 6.7). For mobilization in the opposite direction, he reverses the position of thumbs and forefingers. While this is a universal technique, the most frequent sites of restriction are the second, third, and fourth tarsometatarsal joints. 196
For a similarly universal distraction technique, the patient should be prone, with the leg to be treated slightly bent at the knee. The practitioner stands at the foot end of the treatment table and places the fingers of both hands round the patient’s instep and both thumb pads on the plantar aspect of the distal articulating bone in the restricted joint (see Figure 6.20). With both thumbs he exerts pressure in a plantar and distal direction until the slack has been taken up. He then performs dorsoplantar shaking, consistent with the rhythm of the structure (this will be slower in longer feet than in shorter feet). Consequently, it is also slower in the vicinity of Lisfranc’s joints than in Chopart’s joint. Technically, it is important that the treating hand is relaxed so that the practitioner can sense the inherent rhythm of the foot and so as to prevent flexion and extension at the talocrural joint during shaking.
The subtalar and talocalcaneonavicular joints Here we are concerned with the articulation of the talus with the calcaneus and the navicular, and with the articulation of these bones with the cuboid. In essence, joint play here can be examined (and treated) by assessing the mobility of the calcaneus in all directions relative to the other articulating partners. It is useful to ease the strain on the joint by traction. The patient is supine with the foot to be treated protruding over the free edge of the treatment table. The practitioner cups one hand round as far as the medial aspect of the patient’s heel while spanning the patient’s instep with his other
Therapeutic techniques
Chapter 6
Figure 6.21 • Mobilization of the calcaneus against the talus and navicular by applying traction (A) medially and (B) laterally.
hand. Applying light traction, he moves the joint in all possible directions: supination, pronation, plantar flexion, and dorsiflexion of the foot (see Figure 6.21). A very effective distraction technique has been developed for the posterior part of the subtalar joint. The patient is supine with the foot to be treated protruding over the free edge of the table. The practitioner stands at the foot of the table and takes hold of the patient’s lower leg above the ankle for fixation. With his other hand he cups the patient’s heel medially and takes up the slack by exerting light traction in a distal and upward direction (see Figure 6.22). It is now possible to spring the joint distally, deliver an HVLA thrust, or shake the joint rapidly to achieve distraction.
The talocrural joint The relative anteroposterior mobility of this joint is examined and treated with the patient’s heel on the table and the knee slightly bent. With one hand the practitioner fixes the patient’s foot by grasping its plantar aspect and holding it at right angles to the lower leg. With his other hand he takes hold of the lower leg above the ankle from the front and, after taking up the slack, springs the joint distally (see Figure 6.23). This is followed by rhythmic springing to mobilize the joint. It can be helpful to perform this mobilization technique using a pincer grip, that is by clasping the patient’s heel in both hands and locating both thumbs on the patient’s tibia above the ankle. The joint is then mobilized by simultaneous rhythmic flexion of the fingers and thumbs, using the
Figure 6.22 • Gapping the subtalar joint by pulling on the heel.
Figure 6.23 • Examination and mobilization of the talocrural joint by springing the lower leg against the stabilized foot.
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Figure 6.24 • Traction manipulation of the ankle joint.
forearms to fix the patient’s foot at right angles to the lower leg. Flexion at the knee facilitates mobilization. Traction manipulation is also very effective. The patient is supine with the leg to be treated protruding over the free edge of the treatment table. The practitioner folds both hands over the patient’s instep with both thumbs flat under the sole to stabilize the foot approximately at right angles to the lower leg (see Figure 6.24). Minimal traction is used to take up the slack and then, from the end position, manipulation is performed with HVLA traction. The most common mistake here is to hold the foot in exaggerated dorsiflexion because that could lock the joint. An alternative technique is to grasp the forefoot with one hand and the heel with the other, and to perform traction after the slack has been taken up. However, in this case the subtalar joint is also treated.
Figure 6.25 • Mobilization of the fibular head against the tibia.
fibula against the tibia (see Figure 6.25). With his other mobilizing hand he takes hold of the fibular head between thumb and forefinger, and takes up the slack, first medially and dorsally, and waits for release. Once release in that direction is complete, that is once the normal barrier has been reached, he takes up the slack laterally and ventrally and again waits to obtain release. This technique is far more effective and precise than springing the joint or an HVLA thrust, evidently because it is the soft tissue between the fibula and tibia rather than the joint that plays the crucial role. Technically, it is particularly important that it is in fact the fibular head that is mobilized between the practitioner’s thumb and forefinger (which may be flexed) and not merely the soft tissue.
The tibiofibular joint
The knee joint
Because the fibular head is the attachment point for the biceps femoris muscle, restriction of its movement is clinically important. It is first necessary to assess its mobility against the tibia and to determine the degree of pain present. Here we are concerned not with anteroposterior mobility but with rotation around the tibia. For this, the patient is supine with knee flexed and foot resting on the treatment table. The practitioner sits so as to fix the patient’s toes with his buttocks, and fixes the upper end of the tibia as he mobilizes the
Using both hands, the practitioner starts examination and treatment by moving the patella on the joint surface with the femur in a laterolateral and craniocaudal direction; this permits detection of any resistance, unevenness, and roughness as he glides the patella over the underlying structures. It is therefore recommended that patellar movement be tested with one hand while light pressure of varying intensity is simultaneously exerted on it from above with the other. In this way, points of resistance and roughness can be sensed, although the
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Figure 6.27 • Lateral springing (gapping) of the knee joint. Figure 6.26 • Distraction of the knee with the patient prone.
patient may also feel some discomfort. The same technique is used to smooth out points of resistance and unevenness. Once this has been done, the patient’s pain will be relieved and the practitioner will sense improved mobility. This technique can also be taught to patients for self-treatment. The knee joint itself can be treated using distraction techniques. The simplest of these is performed with the patient prone on a mat on the floor. The practitioner stands between the patient’s legs at knee level and fixes the patient’s thigh just above the knee to be treated using his foot, takes hold of the patient’s lower leg with both hands just above the ankle, and bends the patient’s knee at right angles. Mobilizing traction is then exerted along the now vertical axis of the patient’s lower leg (see Figure 6.26). With the treatment table adjusted to a low setting, the practitioner can also fix the patient’s popliteal fossa from above with his knee. Laterolateral springing is then tested by gapping the joint first medially and then laterally. For medial springing, the practitioner stands alongside the supine patient and, with one hand, takes hold of the patient’s lower leg medially just above the ankle (lifting it slightly off the treatment table). With the heel of his other hand he exerts lateromedial pressure on the knee to take up the slack and test whether the joint springs medially (see Figure 6.27). For lateral springing, the practitioner sits sideways on the treatment table between the patient’s legs, takes hold of the patient’s lower leg with one hand, and tests for lateral springing with the other.
Mobilization can also be achieved by rhythmic springing, although currently we prefer using a rapid rhythmic shaking technique during which the joint springs spontaneously. Shaking is also the ideal method for self-treatment (see Section 6.5.7). Technically, it is important to extend the knee but to avoid overextending (locking) it.
The hip joint Because the hip joint is an almost perfect balland-socket joint that allows hardly any shifting movement, only traction techniques are worth considering. Traction may be carried out either along the longitudinal axis of the leg, or in the direction of the femoral neck. The former method is performed with the patient supine and the hip in the neutral position (10° flexion, 10° abduction, and 10° external rotation). In this position the practitioner takes up the slack by gentle traction with both hands above the patient’s ankle. Most commonly this is then followed by: • post-isometric traction. After the slack has been taken up, the patient uses minimal force to resist traction and breathes in slowly, breathholds, and relaxes while breathing out; the practitioner waits until release is complete. This process can be repeated once or twice. From the end position gained, shaking can also be performed to achieve distraction • traction with HVLA thrust. In this case it is preferable to fix the patient’s position using a strap or stabilizing post placed in the groin area. The practitioner can place a second strap around the patient’s lower leg just above the 199
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Figure 6.29 • Traction of the hip joint along the axis of the femoral neck, over the edge of the table.
Figure 6.28 • Traction of the hip joint along the long axis of
the leg: (A) stabilizing the patient with one strap; (B) applying the second strap.
ankle and around his own waist. He then takes hold of the patient’s leg above the ankle with both hands and applies a minimum of traction to take up the slack with the patient’s hip in the neutral position (see Figure 6.28). From the end position (with the patient relaxed) he then delivers HVLA traction in the same direction, generally producing a tiny thud. The most serious mistake is to apply excessive traction when taking up the slack and then to release this by backing off to deliver the HVLA maneuver. The technique is effective and devoid of risk but is normally not suitable for use in patients with osteoarthritis of the hip. For traction in the direction of the femoral neck, the patient is supine with flexed knee close to the side edge of the treatment table. The practitioner sits low 200
down near the foot end of the table, looking toward the patient’s head. The patient places the leg (bent at the knee) over the practitioner’s shoulder while the practitioner grasps the patient’s thigh with both hands clasped (or with the forearm) in the groin area and applies caudal and lateral traction, with the patient’s pelvis stabilized against the padded surface at the edge of the table (see Figure 6.29). For postisometric traction, the patient offers resistance to traction while breathing in by drawing the pelvis up in a cranial direction, a technique that generally has to be carefully taught. In most cases patients have a tendency to flex the hip, which detracts from effectiveness. After 5–10 seconds the patient relaxes and breathes out. This process can be repeated two or three times. It is highly effective using the same hold to perform shaking in the same direction of traction. Self-treatment is not really feasible, but once the patient has learnt how to resist while breathing in, and then to relax and wait for release, then any family member or friend can assist on a daily basis by simply placing their hands in the patient’s groin region or round the ankle as the patient offers resistance, breathes in and out, and relaxes.
If it is possible to use shaking techniques for mobilization, these are not only gentle and agreeable, but also particularly effective.
Therapeutic techniques
The temporomandibular joint For this joint, a simple distraction technique can be used. The practitioner stands in front of the patient, whose mouth is open for this technique. He takes hold of the patient’s lower jaw with the fingers of both hands and positions his thumbs (wearing single-finger gloves) as fulcrums on the patient’s molars on both sides, stabilizing his fingers on the patient’s chin. Downward traction is applied with both hands. In this process, whether supine or seated, the patient’s head is stabilized. PIR is then used as the patient offers resistance while breathing out and relaxes while breathing in. Here we are taking advantage of respiratory synkinesis, according to which the masticatory muscles become tense during exhalation and relax during inhalation. Mobilization can also be performed using laterolateral movements of the jaw. The practitioner stands behind the seated patient whose head is turned so that the painful side is stabilized against the practitioner’s chest and fixed with one hand. Instructing the patient to open the mouth a little (let the chin drop), the practitioner gently ‘cradles’ the patient’s lower jaw between two fingers (see Figure 6.30). Mobilization is achieved by moving the patient’s lower jaw toward the side of the lesion until the slack is taken up. The patient then offers gentle resistance, after which gently springing lateral
Figure 6.30 • Mobilization of the temporomandibular joint.
Chapter 6
mobilization is performed during the relaxation phase. Relaxation techniques for the masticatory muscles can also be used for the purpose of mobilization; these are described in detail in Section 6.6.2.
6.1.3 The spinal column General principles The general principles set out in Section 6.1.1 also hold true for the spinal column. However, it is not possible in this context to make such a sharp distinction between ‘functional movements’ and ‘joint play.’ Traction along the longitudinal axis of the spinal column and distraction of joints (gapping) clearly utilize joint play for their effect. This applies for rotation holds in the lumbar spine, and for a dorsoventral thrust in the thoracic spine or into the costal angle. There are several ways of achieving a specific effect. These include fixation of at least one articulating bone wherever practicable (e.g. in an extremity joint). Another way is to apply locking techniques, especially if long levers are used, for example when employing the head in order to manipulate the cervical spine, or the legs and pelvis in order to mobilize the lumbar spine. Locking is achieved when all segments not intended for mobilization are brought into an extreme position and hence ‘locked,’ except for the segment that is the object of mobilization (manipulation). The actual mechanism involved is either apposition of the joint surfaces or maximal tension of ligaments. Even here it should be noted that the slack first has to be taken up with minimal force and that mobilization – and especially HVLA thrust techniques – must be applied with only very little force, otherwise locking will be ineffective. The advantage of long levers is that even tiny forces can be effective; however, these then only have a specific effect if treatment is not unduly forceful. Locking is achieved mainly by a combination of side-bending and rotation, making use of coupled movements. Lordosis in the lumbar spine means that there is side-bending coupled with rotation to the opposite side; hence locking is achieved by rotation and side-bending in the same direction. In kyphosis, the opposite is the case. In the thoracic spine, there is also rotation and side-bending in the opposite direction and therefore locking involves side-bending and rotation in the same direction. According to Greenman (1984), however, this is 201
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not the case on maximal extension. In the cervical spine, there is always side-bending and rotation to the same side, and here we achieve locking by sidebending and rotation to the opposite side. Obviously, specific treatment can be given using contact holds. For example, a vertebra may be fixed in one direction by exerting lateral pressure on its spinous process, thus preventing rotation to the opposite side. When we exert springing pressure or deliver an HVLA thrust, we are acting in a specific, local manner. There is even a belief among chiropractors that they can achieve the same effect as a rapid hammer blow delivered to a single brick, causing it to fly from its place in the wall without the other bricks changing position at all. Accordingly, the maximum specific effect is achieved with techniques that combine direct contact, leverage, and locking. Here it is vital for locking and contact to be targeted at precisely the same point. It should also be stressed that good fixation with the contact hand is always more reliable than the best locking maneuver. From this it follows that the stabilizing hand that provides fixation exerts its force in a direction opposed to the direction of the mobilizing hand. However, there are also techniques in which the two hands exert their effect in the same direction. Here the vertebra that is one down from the treated vertebra is fixed by positioning, for example the patient sits astride the treatment table and thus fixes the pelvis and lumbar spine. This type of technique necessarily relies primarily on locking. These techniques are used most frequently in traction holds because they are without risk and less is at stake if they are not applied with pinpoint specificity. In order to avoid confusion it is important to distinguish between traction along the long axis of the spinal column and distraction of intervertebral joints (gapping). This distinction is clearest in the lumbar region, where traction along the long axis acts primarily on the intervertebral disks, whereas distraction of the joints is produced by rotation. In the cervical spine, on the other hand, traction along the long axis affects both the intervertebral disks and the joints.
The lumbar spine Traction techniques Of all the non-specific techniques, traction is the most important. Manual traction has proved 202
particularly effective in radicular syndromes and constitutes first aid in emergency cases. The patient is prone and provides fixation by holding on to the end of the treatment table. The practitioner grasps both the patient’s legs just above the ankle, and braces himself by placing a foot or knee against the treatment table. The manual technique is performed by applying rhythmic springing traction to both legs and causing the patient’s body to vibrate along its long axis (shaking). For this, the patient must be relaxed, something that can be recognized from the movement of the buttocks and free mobility at the knees and hips. Next it is important to establish the correct rhythm for intermittent traction, in order to localize the effect in the lumbar region. If the rhythm is too slow, the patient’s whole body will move slightly back and forth on the table. By quickening the rhythm the practitioner will find the point at which the patient’s legs and pelvis move at the set rhythm while the lumbar spine remains still, like a nodal point in a standing wave, so that the vibration can be clearly palpated there. It will also be noted that this rhythm, which corresponds to the patient’s inherent rhythm, requires the very minimum of effort. The force of rhythmic traction can be amplified as desired and an HVLA thrust can be delivered in time with the rhythm that has been set. It follows clearly that this technique can only be performed manually, a fact that is emphasized because every patient will have a different rhythm, depending on how tall they are. Rhythmic traction can be applied not only to both legs but also to one leg (using both hands), depending on what suits the patient better. Technically, it is important to avoid squeezing the patient’s ankles. Rhythmic traction must originate from the practitioner’s entire body and for this reason he should perform it leaning backward. Amplifying the force used and delivering an HVLA thrust are possible options but are not absolutely necessary; the patient should always be consulted during traction to establish what is most appropriate. If the patient expresses misgivings, an attempt should be made to modify the technique and if this does not bring success, traction should be discontinued. Of course, it is an essential prerequisite for this technique that the patient is comfortable lying prone. However, if the patient has adopted a kyphotic antalgic posture, as is often the case in the acute stage, intermittent traction must be carried out in kyphosis. According to Obererlacher (personal
Therapeutic techniques
Chapter 6
Figure 6.32 • Post-isometric traction of the lumbar spine during exhalation and inhalation.
Figure 6.31 • Traction of the lumbar spine in kyphosis.
communication), the patient should be supine with knees bent and feet flat on a treatment table adjusted to a low setting or on a floor mattress. The practitioner places one foot on the treatment surface and arranges the patient’s legs so that both popliteal fossae are over his thigh. He can then lever the patient’s lower legs over his thigh, thus lifting the patient’s pelvis from the padded surface with a rocking motion. Once the patient is freely rocking and relaxed (and reports pain relief in the process), the practitioner can rhythmically lever the patient up and down (see Figure 6.31). The mechanism of this traction is similar to that of Perl’s apparatus. Technically, it is important that the practitioner’s thigh is located under the patient’s popliteal fossae and not under the lower legs, otherwise the lever action would be painful. Another highly effective and gentle technique is post-isometric traction with respiratory synkinesis. The patient is prone with arms alongside the body and the practitioner exerts light craniocaudal pressure on both the patient’s buttocks (see Figure 6.32). As the patient breathes out deeply, increasing resistance will be sensed due to tension of the erector spinae with lordosis of the lumbar spine; inhalation is accompanied by relaxation and kyphosis of the lumbar spine and the buttocks move caudally. The process is repeated from the (new) starting position gained.
In view of the adaptability and simultaneous efficacy of manual traction, apparatus-based traction using special tables appears far less suitable. The one possible exception to this rule is the Perl apparatus. It is absolutely essential that the patient is able to tolerate traction well, and this fact must be established in advance on every occasion.
Mobilization and manipulation
The diagnostic springing test with the patient sidelying (see Figure 4.16) can be used to great advantage for PIR. The side-lying patient, with both hips and knees flexed at right angles, pushes the knees forward with minimal pressure against the practitioner’s thighs. The practitioner fixes the spinous process of the upper vertebra in the treated segment using the fingers of one hand, reinforced by the fingers of the other hand placed over it, and with arms straight. In the process, the patient is instructed to produce a small amount of kyphosis, and to breathe in and then breath-hold, before ‘letting go’ and breathing out. While the patient relaxes, the practitioner will sense the ventral movement (mobilization) of the fixed vertebra into lordosis. As the procedure is repeated, springing is performed during relaxation to confirm that mobilization has occurred. This technique is particularly gentle and this is why most practitioners begin with it. The most popular technique is probably that of rotation mobilization or manipulation with the patient side-lying in a neutral position, with the leg underneath (i.e. the one resting on the table) very 203
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slightly flexed at the knee and hip. The upper leg should be flexed at the hip and knee in such a way that the foot can be stabilized in the popliteal fossa of the leg underneath. The practitioner stands in front of the patient and places one elbow against the patient’s shoulder and one knee against the patient’s knee. It can be helpful if the patient hooks the corresponding arm through the practitioner’s arm at the elbow. With his other forearm the practitioner stabilizes the patient’s pelvis at the greater trochanter while using his fingers to fix the spinous process of the lower vertebra of the segment being treated (see Figure 6.33). With the thumb of the hand coming from the shoulder, the practitioner establishes contact with the spinous process of the upper vertebra in the segment to be treated. Obviously if this is the lumbosacral segment, it is sufficient for the hand passing over the patient’s hip to fix the pelvis alone. In order to take up the slack, it is best to tell the patient to look in the direction of mobilization
(i.e. to rotate to the side). The patient is next instructed to breathe in deeply: this automatically exerts light pressure against the practitioner’s arm. The patient is told to breath-hold and then, as far as possible, to look in the direction of mobilization and breathe out. From the newly gained position, the process is repeated two or three times, waiting for complete relaxation on each occasion. An HVLA thrust can be delivered from the rotation position gained on each occasion. It can be helpful to supplement the above technique by adding a rhythmic repetitive technique. The patient can be instructed to perform active rhythmic repetitive trunk rotation. As soon as the patient has properly understood the movement emanating from the head and is performing it correctly, the practitioner can let go of the shoulder. He continues to fix the patient’s flexed leg with his thigh and knee, and the pelvis with his forearm. He now fixes the spinous process of the lower
Figure 6.33 • (A) Rotation mobilization or (HVLA thrust) manipulation of the lumbar spine and (B) close-up of the segment to be treated.
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Figure 6.34 • Active rhythmic repetitive rotation mobilization of the lumbar spine (Gaymans’ technique).
vertebra in the treated motion segment using the fingers of both hands placed one over the other (see Figure 6.34). In terms of technique, it is best if the patient uses a minimum of force and tiny excursions to rotate back and forth in the extreme position. Rotation produces gapping of the upper intervertebral joint, and active rotation triggers reciprocal inhibition of the tensed muscles. One particularly important and gentle technique is mobilization into flexion, first where flexion is restricted but also on the side affected by radicular compression and/or an intervertebral disk lesion, because this technique is associated with widening of the intervertebral canal and spinal canal, and only very minimal rotation takes place but intensive traction occurs. For this, the patient is side-lying, with the leg underneath slightly flexed and the upper leg hanging over the edge of the table; the weight of this leg causes the pelvis to tilt forward. In this oblique position, the practitioner fixes the patient’s hanging leg with his thighs and the patient’s pelvis with his mobilizing hand. With his other hand he carefully pulls forward the arm underneath on which the patient is lying, so as to increase lumbar kyphosis still further while at the same time taking care not to straighten the patient’s pelvis. Using the arm that is closest to the patient’s head, the practitioner fixes the patient’s shoulder while hooking the patient’s upper arm through his own at the elbow. With the slightly flexed terminal phalanx of the thumb of that hand, he fixes from
above the spinous process of the upper vertebra in the segment to be treated. At the same time he tells the patient to look up at the ceiling, thus fixing the head and trunk. It is also helpful if the practitioner stabilizes the patient’s trunk in the kyphotic position using his thorax, and for this the treatment table will have to be adjusted to a high setting (see Figure 6.35). Using the fingers of his mobilizing hand, the practitioner takes up the slack by applying traction in the region of the transverse process of the lower vertebra, and especially by exerting pressure with his forearm on the patient’s pelvis in the direction of traction, rotation, and kyphosis. The patient is then instructed to offer slight resistance with the pelvis against the practitioner’s mobilizing hand and
Figure 6.35 • Mobilization and manipulation of the lumbar spine in kyphosis into flexion.
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with the hanging leg against the practitioner’s legs, to breathe in slowly and deeply, to breath-hold, and then to relax. During relaxation the distance between the fingers of the practitioner’s mobilizing hand and the thumb of his other hand will increase as an expression of distraction and kyphosis. The practitioner must wait until relaxation is complete and then, depending on the outcome, he can repeat the procedure or deliver an HVLA thrust using the hand placed on the pelvis. Technically, it is important that the fixing thumb does not exert pressure from above but rather that the interphalangeal joint ‘hooks onto’ the spinous process, something that is readily manageable in kyphosis. The same technique can also be used to stretch the frequently shortened thoracolumbar erector spinae, with the practitioner’s thumb fixing a spinous process at the thoracolumbar junction. Isometric resistance offered by the patient is followed not only by relaxation but also by active stretching. Here it is advantageous not only for the practitioner to stabilize the patient with his thorax but also to stretch the patient over his ribcage into kyphosis. This is indeed the most powerful (diagonal) traction technique. PIR of the lumbar erector spinae can also be used as a self-mobilization technique (see Figure 6.116). We have limited our descriptions to techniques that treat movement restrictions in anteflexion or retroflexion. Regarding the procedure to be used in cases where side-bending is restricted, it should be recalled that in the lumbar spine (see Figure 4.5) either extension is restricted on the side of the lesion or flexion is restricted on the opposite side. Of course, this does not hold true for the antalgic posture adopted in radicular compression.
The pelvis The sacroiliac joint The only pelvic joint that is treated by manipulation is the sacroiliac. Mobilization techniques feature prominently in this setting and should be performed routinely in two (almost) perpendicular planes. In the sagittal plane we are concerned with nutation of the sacrum in relation to the ilium (functional movement), and in the horizontal plane with joint play (gapping the dorsal part of the sacroiliac joint). As there are no muscles between the sacrum and the ilium to move or fix these bones, it is always possible to release functionally 206
reversible movement restrictions using gentle springing mobilization techniques that employ a minimum of force. For mobilization in the sagittal plane, we first use Stoddard’s crossed-hands position with the patient prone. The practitioner places one pisiform on the posterior superior iliac spine (PSIS) from below, and the other hand on the caudal tip of the sacrum. With his diverging forearms held straight, he exerts light pressure from above on both contact points, pushing them apart simultaneously to restore nutation of the sacrum in relation to the ilium (see Figure 6.36A). He engages the barrier by first taking the mobility of the skin and sub cutaneous soft tissue to its limit until bony contact is achieved (and this should be sufficient). After a few very gentle springing movements at the restricted joint the practitioner will sense how the two bony structures start to move apart. The commonest mistakes are increasing the pressure (before movement is felt) and not releasing the pressure to allow springing back. Neuromuscular techniques play virtually no role in this context because there are no muscles between the sacrum and ilium. Experience gleaned from chain reaction patterns has modified our thinking inasmuch as indirect connections apparently exist due to the sacrotuberous ligament and the attachment points of the ischiocrural muscles, pelvic floor, and piriformis, etc. As a result, the sacroiliac joint very often no longer requires treatment after the lower extremity, pelvic floor, and piriformis have been treated. The examination technique with the patient side-lying (see Figure 4.9) is suitable for mobilization in the horizontal plane and it can even be used for an HVLA thrust. The side-lying patient stabilizes the flexed upper leg on the edge of the treatment table. As the practitioner uses his forearm to apply oblique forward and downward pressure on the anterior superior iliac spine (ASIS), he produces gapping of the sacroiliac joint above. From the end position achieved, he can now perform rhythmic springing mobilization or even deliver an HVLA thrust in the same direction. With the thumb of his other (cranial) hand the practitioner can test the mobility of the PSIS in relation to the sacrum. In terms of technique, the pelvis should remain motionless and in particular should not rotate forward. For this technique it is immaterial whether the practitioner stands in front of or behind the patient.
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Chapter 6
Figure 6.36 • (A) Examination and mobilization of the sacroiliac joint, with crossed hands. (B) Springing mobilization of the upper part of the sacroiliac joint. (C) Springing mobilization of the lower part of the sacroiliac joint.
If it is primarily the upper part of the sacroiliac joint that is to be treated to restore nutation, then the patient should lie on the side not being treated, stabilizing the upper knee (or indeed both knees one above the other) flexed on the edge of the treatment table. The practitioner sits below the level of the flexed hips and turns to face the patient’s head (see Figure 6.36B). With one hand he takes hold of the ASIS and exerts light springing pressure against it in a dorsal direction. With the thumb of his other hand stabilized against the flexed fingers (or with
the middle phalanx of his forefinger stabilized over the thumb), he applies counterpressure below the PSIS and takes up the slack. Mobilization is performed by rhythmic springing against the ASIS, and absorbing this synchronously with the thumb (bent forefinger) of the other hand. If it is the lower end of the sacroiliac joint that is to be treated, the patient should adopt the same position as above; however, the practitioner sits above the level of the patient’s pelvis facing toward the foot end of the treatment table. With one hand 207
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he grasps the ASIS and with the ulnar aspect of his other hand he takes up lateral contact with the caudal end of the sacrum (see Figure 6.36C). Using a rotating, convergent movement of both hands and forearms, the practitioner mobilizes nutation of the sacrum in relation to the ilium. Another option (according to Sachse) is for the practitioner to tilt the ilium dorsally, as for mobilization of the upper part of the sacroiliac joint, and to use the ulnar aspect of his other hand to mobilize the end of the sacrum ventrocaudally to achieve counternutation. For the HVLA thrust technique described by Kubis (1970), which primarily involves the lower part of the sacroiliac joint, the patient lies on the side of the restricted joint, meaning that it is ‘underneath’. Locking of the lumbar spine is performed in rotation up to and including L5 using the rotation hold at the lumbar spine with the leg underneath in extension and the lumbar spine stretched. The practitioner then makes dorsal contact with his pisiform pressing on the caudal tip of the sacrum, and takes up the slack by applying pressure on the sacrum in a dorsoventral direction (see Figure 6.37). He then delivers an HVLA thrust in the same direction. This maneuver primarily produces gapping of the sacroiliac joint ‘underneath’ that is fixed in place by the weight of the pelvis. There are two important technical points to be noted: first, the thrust must be delivered precisely in a dorsoventral direction, and second, there must be no further rotation while the thrust is delivered. This means that the practitioner needs to lean right over the patient so that his forearm delivering the thrust is horizontal. For this, the treatment table must be adjusted to a low setting. Treatment of what Greenman and Tait call ‘outflare’ and ‘inflare’ (see Section 7.1.8) creates the
illusion of true repositioning of an anomaly. On the side where the ASIS is flattened and further away from the umbilicus (outflare), the practitioner should proceed as when testing for ‘ligament pain’ (see Figure 4.13). He grasps the knee of the leg flexed at right angles at the hip and performs adduction until the slack is taken up. He then instructs the patient (as in PIR) to offer resistance for 5–10 seconds, to breathe in slowly, to hold the breath, to breathe out again, and to relax into adduction. He waits for relaxation to be completed and then repeats a further two or three times. This is followed by RI in which the patient exerts pressure into adduction against rhythmic repetitive resistance at the knee. On the opposite side (inflare) the patient adopts the position as for Patrick’s test (see Figure 4.43) and the practitioner exerts light pressure on the abducted knee in order to take up the slack. The patient then offers light resistance into adduction, breathes in slowly, holds the breath, breathes out, and relaxes completely into abduction.This process is repeated two or three times. RI is performed using active abduction against rhythmic repetitive resistance. After this mobilization technique, the pelvis is routinely symmetrical, and muscle tone in the lower abdomen is balanced, as is internal rotation at the hip joint which is regularly greatly reduced on the side of inflare. The latter may explain the considerable clinical effect.
The coccyx In the vast majority of cases of a tender coccyx, PIR of the gluteus maximus muscles is the treatment of choice, and this can also be administered
Figure 6.37 • HVLA thrust manipulation of the sacroiliac joint (after Kubis) with contact at the tip of the sacrum.
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as self-treatment (see Section 6.6.5), which is also consistent with the pathogenesis (see Section 7.1.9). However, there are also cases where manipulation per rectum is necessary; even when every effort is made to proceed carefully and gently, this treatment is generally unpleasant for the patient. However, it is a very effective technique, even though the mechanism is still obscure. The articulation of the sacrum with the coccyx is a syndesmosis and not a true joint; consequently, there can be no movement restriction here whatsoever. For manipulation, the patient is prone with feet rotated inward; alternatively, the treatment can be given with the patient resting on knees and elbows. The practitioner inserts one forefinger into the patient’s rectum and palpates laterally for trigger points (TrPs) in the levator ani. PIR can be used to relax the levator ani. Moving the coccyx permits precise location of the sacrococcygeal syndesmosis. The practitioner then applies (usually painful) pressure with his forefinger (and thumb on the outside) or simply uses his forefinger to exert pressure in a dorsal direction. This is repeated two or three times. It should then be checked whether the tip of the coccyx is still tender.
Chapter 6
both knees (slightly apart) and with crossed arms against the wall, rests the head on the arms. The practitioner stands behind the patient, and places one hand or just one finger on a spinous process in the stiffened spinal segment to indicate to the patient where attention should be focused (see Figure 6.38). Next, he instructs the patient to relax into extension. When maximum extension has been reached, he tells the patient to press lightly against his fingers and to breathe in deeply and slowly, breath-hold, and then breathe out slowly and completely. While breathing out, the patient should be told to straighten up again and to go into extension at the point where the practitioner’s finger can be felt. If performed correctly with sufficiently deep
The thoracic spine Mobilization
For the thoracic spine there are no ‘pure’ traction techniques such as are used in the lumbar and cervical regions. There is one maneuver that is very popular among lay practitioners and corresponds approximately to traction manipulation. For this, the patient stands or sits with arms folded across the chest. From behind, the practitioner cups the patient’s right elbow with his left hand and left elbow with his right hand and presses the slightly kyphotic patient to his chest to take up the slack. From this position he straightens up and, delivering a thrust to the patient’s elbows, draws the patient upward and at the same time closer to his chest. This unsophisticated technique is quite innocuous unless the patient suffers from osteoporosis. Because kyphosis with a stiff, rounded back is a particularly common disorder in the thoracic region, mobilization into extension is the technique most frequently called for. In order to make full use of the patient’s own musculature, we do not employ standard PIR but instead utilize the active contraction of the erector spinae muscles during exhalation to achieve mobilization into dorsiflexion. Seated on a stool facing a wall, the patient stabilizes
Figure 6.38 • Mobilization of the thoracic spine into extension during exhalation, patient seated.
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exhalation, this technique produces powerful contraction of the erector spinae accompanied by an intensive mobilizing effect that the patient experiences as being slightly painful. As soon as the patient has understood and felt this, the technique can then be practiced (and repeated) as self-treatment on a daily basis. However, this very simple and effective technique has one major drawback: many patients with a kyphotic back have thoracolumbar hyperlordosis or at least hypermobility in that area and are unable to prevent themselves going into hyperlordosis there – something that must be avoided at all costs. Consequently, this technique should only be used in cases where the practitioner is satisfied that the patient is capable of extension, especially in the mid-thoracic part of the spinal column. Extension is frequently also rendered difficult because the erector spinae muscle is less well developed in the mid-thoracic region and most powerfully developed in the thoracolumbar segment. Therefore a more demanding technique is usually preferred, and this is described as a selftreatment method in Section 6.10.4. If the intention is to treat just one restricted segment, then the procedure is similar to that for examination with the patient side-lying with both hands clasped behind the head. The practitioner stands in front of the patient and with one hand grasps both the patient’s elbows brought together in front of the neck, while using the forefinger of his other hand to stabilize the spinous process of the lower vertebra in the restricted segment. Using his forefinger as a fulcrum, he moves the patient into retroflexion to take up the slack (see Figure 6.39). The patient then uses the elbows to exert light (isometric) pressure against the practitioner’s arm and breathes in. He next instructs the patient to breathe out as fully as possible. As exhalation reaches the maximum, the erector spinae tenses and the thoracic spine is mobilized into extension. Here, too, it is the synkinetic tensing of the erector spinae during maximal (active) exhalation that is utilized for mobilization. This is therefore not a straightforward relaxation phenomenon such as occurs in PIR. For mobilization into anteflexion, the technique used is the same as that described for examination (see Figure 4.22). To take up the slack, the patient is brought into kyphosis, with the peak of the kyphosis being at the level of the restricted segment. The patient is told to look up and breathe in, to breath-hold, and then to look down and breathe out. During slow exhalation, the patient relaxes and 210
Figure 6.39 • Mobilization of the thoracic spine into extension during exhalation, patient side-lying.
the thoracic spine becomes kyphosed. However, this kyphosis must be controlled so that its peak always remains within the treated segment. This mobilization procedure is repeated two or three times. Anteflexion restrictions are most common where the upper thoracic spine is flattened and they tend to be associated with tension (TrPs) of the erector spinae, usually on one side. Therefore mobilization can also be achieved by relaxing this muscle. The practitioner stands behind the patient who is seated on the treatment table; with one hand he grasps the patient’s head, placing his palm on the occiput on the side of the lesion (i.e. his left hand is used if the lesion is on the right) (see Figure 6.40). He moves the patient’s head into anteflexion, sidebending, and rotation to the opposite side to take up the slack. Using the thumb of his other hand, he fixes the spinous process of the lower vertebra in the segment to be treated. The patient is then told to look in the opposite direction (toward the side of the restriction) and breathe in, to breath-hold, and then to look in the direction of mobilization and breathe out slowly, during which anteflexion, side-bending, and rotation will be found to increase. This procedure can be repeated two or three times. For specific treatment, it is important to start with anteflexion until the restricted segment is reached (i.e. begins to flex), and only then to move on to head side-bending and rotation. For mobilization into side-bending we use the same technique as for examination (see Figure 4.23)
Therapeutic techniques
Figure 6.40 • Unilateral mobilization of the thoracic spine into anteflexion–rotation; the spinous process is fixed with the thumb.
the only difference being that the practitioner’s thumb is not used to palpate mobility at the interspace between two adjacent vertebrae but to fix the lower vertebra in the segment to be treated. Here we utilize the alternating facilitating and inhibitory effect of inhalation and exhalation described by Gaymans (1980); gaze direction can also be used in the even-numbered segments where inhalation has a facilitating effect (see Section 6.1.1). The practitioner stands behind the seated patient and, placing his hand on the opposite shoulder, bends the patient’s trunk sideways to take up the slack. With his other hand at the level to be treated, he stabilizes the ribs while using his thumb to brace the spinous process of the lower vertebra in the restricted segment. If an even-numbered segment is being treated, he instructs the patient during the isometric phase to look up, breathe in, and hold the breath. It will be noted how resistance to side-bending increases. The patient is then told to relax and breathe out; the practitioner waits
Chapter 6
until relaxation is complete. In the odd-numbered segments (excluding T1/T2), the patient is simply instructed to breathe in slowly and deeply, to breathe out, and then to breathe in slowly again; the practitioner will sense how resistance increases during exhalation and how relaxation occurs during inhalation. In principle, the patient should avoid looking down during relaxation because this would encourage anteflexion. Mobilization can be repeated two or three times. If counting the segments is too onerous, it is equally reliable to ask the patient to breathe in and out just to see what happens. It will be very apparent whether resistance in the segment in question increases or decreases. However, the difference becomes less clear in the caudal segments because inhalation has a stabilizing effect and the quadratus lumborum becomes tense during inhalation. Technically, it is critical to wait for the relaxing effect of inhalation on the one hand and of exhalation on the other; relaxation can occur at a relatively late stage during exhalation or inhalation. The practitioner’s stabilizing hand must also provide the patient with good support from the side to allow relaxation to take place; during side-bending the spinous process automatically moves closer to the fixing thumb due to simultaneous rotation of the thoracic spine. However, if the patient has very broad shoulders and the practitioner has small hands, it is possible to use the technique described in the context of examination (see Figure 4.24). The practitioner stands behind the seated patient on the side into which side-bending is to occur. He tells the patient to raise the upper arm on the opposite (far) side. Taking hold of the upper arm from the front, he uses the thumb of his other hand to fix the spinous process of the lower vertebra in the segment to be treated. With his hand on the patient’s upper arm, the practitioner brings the patient into side-bending and so takes up the slack. Depending on whether the segment is even- or odd-numbered, mobilization is performed in the appropriate way. It must be stressed that during this technique the practitioner needs to lean backward and bend his knees. It is also remarkable that during mobilization into sidebending the vertebrae move closer together on the side in question and thus exert a mobilizing effect on the interposed tubercle of rib. Mobilization where rotation is restricted: as already discussed in Section 3.4.1, restricted trunk rotation does not result from joint restriction but 211
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from increased tension (TrPs) in a shortened muscle chain, namely that comprising the erector spinae, quadratus lumborum, and psoas major on the side opposite to rotation. Consequently, the mobilization technique is not strictly specific. In this situation we use the same technique as for PIR of the erector spinae (see Figure 6.40). For mobilization in rotation, the patient sits (with hands clasped behind the neck) in a slightly kyphotic position astride the end of the treatment table. The practitioner stands behind the patient and passes one arm under the patient’s axilla to grasp the opposite shoulder. He places his other hand on the patient’s back to stabilize it. The patient is then told to look at an object in the examination room placed in such a way as to necessitate trunk rotation in that direction, thus taking up the slack. Next the patient is instructed to look in the opposite direction and to breathe in. The practitioner offers isometric resistance in the opposite direction against automatic rotation. After breathholding, the patient is again told to keep looking in the direction of mobilization and to breathe out. This can be repeated two or three times. RI is then performed by instructing the patient (in the newly gained rotation position) to offer resistance in the opposite direction against repeated pressure. Because the three muscles mentioned above form a chain, trunk rotation can also be restored by relaxation of the psoas major or quadratus lumborum.
HVLA thrust techniques First a specific technique for traction manipulation: the practitioner stands behind the seated patient with a firm cushion between his chest and the patient’s back, so that the top edge of the cushion fixes the spinous process of the lower vertebra in the motion segment to be treated. He threads one arm through the patient’s axilla and uses the palm of that hand to stabilize the patient’s head and neck on one side. With his other hand he reaches across the patient’s chest to grasp the patient’s far hand and draw it through the other axilla, at the level of the fixed spinous process (see Figure 6.41). By pulling in a dorsal direction on his arm through the patient’s axilla and on the patient’s hand in the other axilla, he takes up the slack into extension. The practitioner delivers an HVLA thrust as he straightens up, thereby exerting sudden traction. This is the most gentle HVLA thrust technique for treating the thoracic spine. 212
Figure 6.41 • Traction thrust technique applied to the thoracic spine, using a cushion, with patient seated.
Manipulation with the patient supine is effective and gentle at the same time. For this, the patient’s hands are clasped behind the neck, with elbows touching in front of the chin. As the practitioner stands beside the treatment table, he grasps both elbows (or forearms below the elbows) using the hand nearer to the patient’s head. He turns the patient toward him a little and lifts (see Figure 6.42). With middle and ring fingers flexed (see Figure 6.43), he places his other hand beneath the transverse processes of the lower vertebra in the restricted segment in such a way that the middle phalanx of his third finger is under the transverse process on the near side and his thenar eminence is under the transverse process on the far side. The spinous processes are accommodated in the groove between the practitioner’s middle finger and thenar eminence. He now rolls the patient over again so that the patient’s back is lying on his prepared contact hand. Using his other hand that is grasping the patient’s elbows, he now brings the patient into kyphosis so that the peak is located over his contact hand, thus taking up the slack. There are now two alternatives for performing manipulation: 1. Into extension: the patient (supine on the practitioner’s contact hand) is instructed to
Therapeutic techniques
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this may happen after an HVLA thrust has been delivered with the practitioner’s thorax over the contact hand). 2. Into flexion: the patient (again supine on the practitioner’s contact hand) is instructed to breathe in. However, the practitioner uses the patient’s grasped elbows (on which his own thorax is still leaning) to enhance anteflexion. While the patient exhales, the practitioner uses his thorax to deliver an HVLA thrust into flexion toward the stabilizing contact hand underneath.
Figure 6.42 • Manipulation of the thoracic spine.
Figure 6.43 • Position of the practitioner’s contact hand during manipulation of the thoracic spine.
breathe out slowly. At the same time, while holding the patient’s elbows, the practitioner moves his upper body back over the contact hand, using his thorax to gently increase the pressure via his hand on the patient’s elbows and thorax. This is usually sufficient on its own to make the joint ‘pop’ (alternatively,
It may be difficult for the patient with hands clasped behind the neck to bring the elbows into the desired position. In such circumstances the patient’s hands should be ‘semi-clasped’ (i.e. with fingertips only just touching), so enabling the elbows to meet in front of the chin. Another possible difficulty is that the pressure on the middle finger of the contact hand may become painful for the practitioner, especially if he cannot flex the terminal phalanx sufficiently. If that happens, he can insert a thin rubber eraser between the proximal and terminal phalanges of his third finger. If need be, the maneuver can also be performed in such a way that the contact hand (including the wrist) is positioned under the vertebra in question so that the spinous process is located in the carpal tunnel and the transverse processes have contact with the pisiform and thenar eminence. However, it is essential that the thumb is opposed, i.e. touching the little finger. Contact holds with the patient lying in the prone position are always popular because of their simplicity. No locking technique at all is involved, and no distinction is made between flexion and extension. The HVLA thrust must be directed at the lower vertebra in the restricted motion segment, because only this will result in gapping or distraction of the intervertebral apophyseal joints, which are almost in the frontal plane in the thoracic spine. After the slack has been taken up, the springing technique illustrated in in Figure 4.15 can be used and may also be employed for manipulation without an HVLA thrust. The following technique, which can also be used for mobilization, produces some rotation as well as extension. The practitioner stands to one side of the prone patient with his hands crossed at the level of the motion segment to be treated and places the pisiform of his more cranial hand on the 213
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Figure 6.44 • Treatment of the thoracic spine with hands crossed.
Figure 6.45 • Mobilization of the ribs in dorsiflexion during
transverse process of the lower vertebra, and the pisiform of his other hand on the transverse process of the upper vertebra (see Figure 6.44). After taking up the slack, the practitioner delivers an HVLA thrust (or performs springing mobilization) from his shoulders with divergent arms held straight while the patient breathes out. Thus the push into extension and rotation is delivered in the direction of the hand on the lower vertebra. In terms of joint mechanics, there is gapping of the articulation on the side toward which rotation is also restricted. This crossed-hands technique is also suitable for progressive caudal-to-cranial mobilization, described by Terrier (1958) as ‘mobilization massage.’ This begins at the bottom of the thoracic spine and progresses cranially in the rhythm of respiration, from one segment to the next. There are three important technical aspects here: the practitioner’s arms must be kept straight and yet relaxed; the thrust must be delivered from his upper body through the shoulders; and his hands must be divergent so that the transverse processes of the two vertebrae move apart.
The ribs Mobilization A side-lying technique similar to the diagnostic method described by Kubis (1970) (see Figure 4.25) is used for mobilization. After isometric tension, 214
maximal exhalation.
this technique exploits the contraction of the back muscles during maximal exhalation. Standing in front of the side-lying patient, whose upper arm is raised above the head with elbow bent, the practitioner takes hold of the elbow with his hand that is closer to the patient’s head, allowing the patient’s forearm to dangle loosely (see Figure 6.45). Using his other hand with the fingertips held closely together, he fixes the costal angle of the restricted rib. While breathing in slowly, the patient presses the elbow forward against the hand of the practitioner, who offers isometric resistance. During maximal exhalation as the patient relaxes, the practitioner takes the patient’s upper arm into retroflexion while his fingertips form a fulcrum at the restricted rib. Again, as in diagnosis, although the shoulder blade covers the ribs, it is no obstacle to the fixation of the rib during mobilization. The first rib, however, can be neither diagnosed nor treated with this method, while the second rib can be treated only with difficulty. The ribs to which this technique is most frequently applied are thus the second, third, fourth, fifth, and sixth. It is technically important to raise the patient’s arm vertically to obtain a pure movement of retroflexion and to avoid rotation. However, this is often difficult where shoulder pain is present, and for this reason treatment must start with the shoulder.
Therapeutic techniques
Pressure mobilization is recommended for the ribs in cases where the ‘overtake phenomenon’ is detected. The patient is supine and the practitioner stands at the top end of the treatment table, with both thumbs placed on the upper margin of the asymmetric ribs lateral to the sternocostal joint. At the ‘higher’ (restricted) rib he offers resistance while the patient breathes in and delivers a light push in a caudal direction while the patient breathes out. Afterward the position of the two ribs typically evens out and so the overtake phenomenon disappears. If we find, on comparing the two sides, that one rib is restricted during exhalation, the following technique advocated by Greenman (1979) is indicated: with the patient supine, the practitioner places his thumb laterally on the upper margin of the restricted rib and, with his other hand under the patient’s shoulders, lifts the patient slightly toward him into slight anteflexion to take up the slack. In this position he instructs the patient to breathe out; during exhalation he delivers a push with his thumb in a caudal direction, at the same time lifting the patient’s trunk even higher and bending it to the side. Where several ribs are restricted, the lowest should be mobilized because it acts as an obstacle to its more cranial neighbors during exhalation. If inhalation is restricted, Greenman makes use of muscle pull. In the region of the upper ribs he uses the pull of the scalenes, for the middle ribs the pectorals, and for the lower ribs the serratus anterior. With the patient supine, the practitioner takes
Chapter 6
up the slack in the relevant muscles by side-bending of the patient’s head (scalenes), abduction of the arm (pectorals), or maximal elevation of the arm (serratus anterior). During inhalation, the patient offers resistance with the head or upper arm in the starting position described. The practitioner stands on the side opposite to the restricted rib, bends the patient’s head or usually shoulder girdle toward the side he is standing on, and with the same hand, which is now placed under the patient’s shoulders, abducts the upper arm or elevates it as far as it will go. With the thumb of his other hand, the practitioner delivers a push in a cranial direction to the rib while the patient breathes in and resists the practitioner’s hand as it elevates or abducts his arm or side-bends his head. If several ribs are restricted, the uppermost rib should be mobilized because it acts as an obstacle to its more caudal neighbors during inhalation.
Manipulation with HVLA thrust techniques For the following manipulation technique the patient is supine, with hands crossed to the opposite shoulder and the arm on the restricted side lying uppermost. The practitioner stands beside the treatment table on the side opposite the lesion, takes hold of the uppermost arm, and turns the patient toward him. He then positions the thenar eminence of his other hand beneath the costal angle of the restricted rib (see Figure 6.46A). Now
Figure 6.46 • (A) Preparatory phase for rib manipulation as the practitioner turns the patient to face him and places his thenar eminence underneath the costal angle. (B) Position of the practitioner’s hands during manipulation, showing full opposition of the thumb.
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Figure 6.47 • Delivering the thrust through the patient’s upper arm vertically toward the thenar eminence placed under the costal angle.
Figure 6.48 • HVLA thrust manipulation of the ribs, with the patient prone.
taking the patient’s other upper arm (i.e. the one that was previously lying underneath), he turns the patient away from him again until the costal angle is resting on his thenar eminence. To do this effectively his thumb must be maximally opposed so that its muscles contract and form a firm contact (see Figure 6.46B). The practitioner then uses his thorax to exert light pressure on the hand holding the patient’s upper arm until the slack is taken up. Afterward he delivers a vertical HVLA thrust with his thorax in the direction of his thenar eminence (see Figure 6.47). A simple but harder thrusting technique with the patient prone has a similar effect. The patient’s head is turned to the side of the restricted rib. If this is one of the upper ribs, the patient’s arm on the side being treated hangs down over the edge of the treatment table in order to produce abduction of the shoulder blade. The practitioner stands next to the patient and places the pisiform of his contact hand on the costal angle. The contact hand can be reinforced by grasping it just above the wrist with his other hand. He takes up the slack by exerting light pressure and delivers an HVLA thrust from his trunk via both arms as the patient breathes out (see Figure 6.48). A restricted rib is usually also painful at the sternocostal junction, which is the attachment point for the pectoral muscles. This situation then necessitates relaxation of these muscles (see Section 6.6.4 and Figure 6.109). A suitable treatment for the lower ribs involves a technique for which the patient sits astride the end 216
of the treatment table, with hands clasped behind the neck. The practitioner stands behind the patient and threads one arm under the patient’s axilla to take hold of the shoulder on the opposite side so as to rotate the patient’s trunk sideways about a vertical axis. With the pisiform or thumb of his other hand, he takes up contact at the costal angle (see Figure 6.49). Using both hands he now rotates the patient until the slack has been taken up.
Figure 6.49 • Manipulation of the lower ribs using trunk rotation and pressure at the costal angle in the same direction.
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He then delivers an HVLA thrust from his trunk, transmitting it simultaneously to both hands (pulling on the patient’s shoulder with one hand and pressing with the other). This technique produces gapping of the costotransverse joint of the restricted rib.
Manipulation of a painful slipping rib The patient reports pain in the region of the abdominal cavity during pressure palpation of the inferior costal arch, especially of the tenth rib, between the practitioner’s finger ‘inside’ beneath the costal arch and his thumb on the surface ‘outside.’ Mobilization is performed with the practitioner’s fingers beneath the inferior costal arch and the heel of the hand on the outside surface of the lowest ribs, gently springing ventrally and laterally in a slow rhythm. The technique is always painful but brings immediate relief.
Figure 6.50 • Repetitive mobilization of the first and second ribs by isometric rhythmic contraction of the scalenes.
Treatment of the first rib As we noted for the diagnostic examination, the technique for treating the first rib also differs from that employed for all the others. In terms of function, the first rib forms part of the cervicothoracic junction, and for mobilization we make use of the attachment between it and the scalenes. The practitioner stands behind the seated patient and stabilizes the neck or shoulder from the side. He places his other hand against the side of the patient’s head and instructs the patient to press her head against this hand as he rhythmically intensifies and slackens its pressure (see Figure 6.50). Usually about 20 isometric contractions in a slow rhythm (two per second) will suffice, and this will also mobilize the second rib. This technique is also well suited for self-treatment, with the patient using her own hand to exert rhythmic pressure against isometric resistance from the head. In another technique the practitioner stands behind the patient who is seated on the treatment table and leans back against him for support. The practitioner can also use his knee to stabilize the side not being treated, while also steadying the patient’s head with one hand on the same side. Using the forefinger of his other hand, he takes up contact over the angle of the first rib from above, close to the patient’s neck (see Figure 6.51). He takes up the slack by exerting light downward pressure and achieves very effective mobilization by
Figure 6.51 • Manipulation (shaking) of the first rib from above.
rapid shaking; alternatively, he can use the edge of his forefinger to deliver an HVLA thrust in a caudal and slightly ventral direction. 217
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The cervical spine Traction Traction is essentially performed using manual and post-isometric techniques, but additionally taking advantage of respiratory synkinesis. In the supine technique, the patient’s head projects over the end of the treatment table while the practitioner simply cradles it in his palms; very little force is required (see Figure 6.52A). The patient is told to look up toward the forehead and to breathe in deeply. Once the practitioner sees that the sternocleidomastoids are contracting, he instructs the patient to breathhold and, after a brief pause, to look down toward the chin and breathe out slowly. This automatically
ushers in relaxation; he then waits until relaxation is complete before repeating. A similar procedure is followed with the patient seated. The practitioner stands behind the patient who is sitting on the treatment table. To facilitate relaxation, the patient’s back is supported against the practitioner’s chest. He takes the patient’s head in both hands so that his forearms are resting just in front of the patient’s shoulders, thus ensuring an upright posture. His thumbs are located on the patient’s occiput, with his other fingers placed laterally around the zygomatic bones in as soft a hold as possible (see Figure 6.52B). After gently taking up the slack with traction, he tells the patient to look up and breathe in deeply. If he senses increased resistance, he tells the patient to breath-hold, look down and then breathe out. He will then feel the patient relax; once this process is complete, the procedure can be repeated. Relaxation occurs automatically as a result of PIR supplemented by respiratory synkinesis, and for this reason this form of traction appears to be ideal. It acts primarily on the C2/C3 segment. Because it is commonly used for treatment in the acute stage, it is critical that the patient can tolerate the technique well. Consequently, any existing antalgic posture should not be corrected; instead traction with PIR should be performed in the position that best suits the patient. For this reason alone it is preferable to apparatus-based traction techniques. Traction must always be stopped if it proves to be uncomfortable for the patient. In particular, we would not advocate the use of Glisson slings with the patient seated because traction here primarily involves the chin without occipital stabilization (in contrast to the supine position); in such circumstances the patient tenses the flexor muscles of the neck, causing any effect of traction to be lost. Because patients find it particularly agreeable, we will also describe here a traction technique that is associated with a massage element. For this, the patient is supine with shoulders at the edge of the treatment table. The practitioner sits behind the patient’s head, supporting it on his knees. He places both hands under the patient’s shoulders and then leans back so that both hands slide cranially as far as the patient’s occiput, exerting traction and gentle pressure massage at the same time.
Jirout’s maneuver Figure 6.52 • Traction of the cervical spine (A) with the patient supine and (B) with the patient seated.
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A maneuver described by Jirout (2000) has proved particularly effective in acute dysfunction. In such
Therapeutic techniques
cases it is most usual for rotation to the right in the upper cervical spine to be restricted. The patient is supine with head in a neutral position. The practitioner uses his thumb to exert pressure on the patient’s left shoulder from above while the patient relaxes the shoulder and breathes out. The patient is then told to offer resistance with the shoulder against the practitioner’s thumb while he additionally stimulates the periosteum at the patient’s shoulder with his thumb. After breath-holding, the patient relaxes so that the shoulder moves in a caudal direction. In the considerably rarer cases where rotation is restricted to the left, the above procedure is adopted, but this time the right shoulder is treated. Because the patient’s neck is not touched at all, the technique is invariably well tolerated and it is often possible to begin with this maneuver in acute rotation restrictions of the upper cervical spine.
Mobilization Side-bending This can be carried out with the patient seated or supine. The procedure makes use of the phenomenon, described by Gaymans (1980), of alternating fixation and relaxation of neighboring spinal segments. In the even-numbered segments (C0, C2, C4, C6), resistance increases during inhalation and maximal facilitation can therefore be achieved by telling the patient first to look up and breathe in deeply, then to breath-hold and, after a brief latency period, to look down and breathe out (see Figure 4.26). In the lower cervical spine, however, it is preferable to have the neck extended with the patient seated, in which case it is better to tell the patient during the mobilization phase to let go and then to breathe out. In the odd-numbered segments it is sufficient merely to tell the patient to breathe out slowly and then to breathe in slowly. If the patient is supine, then the technique is as described for examination purposes (see Figure 4.29). The practitioner takes up the slack in the spinal segment to be treated; it will be noted how resistance increases in the initial phase only to decrease abruptly toward the end of the second mobilization phase, at which point the practitioner can still instruct the patient to let go. The most important thing is to wait: if the practitioner commits the cardinal sin of actively forcing side-bending, he will then cancel out the effect of automatic relaxation. This procedure can be repeated two or three times.
Chapter 6
Rotation For post-isometric mobilization the simplest approach is for the practitioner to fix the lower vertebra in the segment between thumb and forefinger, as for examination (see Figure 4.32), and with his other hand on the patient’s chin, to go into rotation as far as the end point (i.e. to take up the slack). He then instructs the patient first to look up and breathe in, then to look down and breathe out, and he will sense how rotation increases during relaxation. Looking first in the opposite direction and then in the direction of mobilization usually produces too much active tension and too little relaxation (Sachse & Berger 1986).
Side-bending mobilization at the cervicothoracic junction In this case, too, the technique for side-bending mobilization at the cervicothoracic junction is the same as for diagnosis (see Figure 4.30). Throughout the cervicothoracic junction increased resistance is noted during inhalation whereas relaxation/ mobilization is seen during exhalation. The practitioner takes up the slack by holding the patient in retroflexion, with side-bending to the side of the restriction and rotation in the opposite direction, and fixes the lower vertebra with the thumb of his other hand. He then instructs the patient to look up and breathe in slowly, to breath-hold, but then to let go and breathe out slowly. Because locking was achieved in retroflexion, etc., if the patient were told to look down, this would cause anteflexion, thus unlocking the cervical spine and locking the cervicothoracic junction. Technically, it should be emphasized that the fingers over the zygomatic bone have the (sometimes quite difficult) job of holding the patient’s head in retroflexion, side-bending, and rotation to the opposite side, while at the same time the thenar eminence of the same hand fulfils a lateral stabilizing role on the upper vertebra in the restricted segment. During mobilization, the thumb of the practitioner’s other hand is used merely to fix the spinous process of the lower vertebra. As relaxation progresses he will sense how mobility (springing) is restored between his thumb and the thenar eminence of the other hand. Throughout mobilization the patient must be supported in an upright position. Starting from the same end point after taking up the slack, it is also possible to deliver an HVLA thrust; however, this must come from the thumb at 219
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the lower vertebra. In the process the practitioner’s other hand fixes the upper vertebra. It is technically easier (although less comfortable for the practitioner) to carry out this mobilization with the patient side-lying. Here, too, the hold is the same as for diagnosis (see Figure 4.31). The practitioner stands opposite the patient’s head and cradles it between one hand and upper arm, with his elbow resting on the treatment table. Then, without lifting his elbow, he moves it forward on the treatment table and so takes up the slack by moving the patient’s head into side-bending, rotation in the opposite direction, and retroflexion. (The practitioner’s forearm has to adopt this position if his hand keeps hold of the patient’s head and he simply moves his elbow forward.) The heel of the same hand takes up contact at the upper vertebra in the segment to be treated. With the thumb of his other hand he fixes the spinous process of the lower vertebra, using the terminal phalanx of his thumb to ‘hook in’. Because the practitioner has to bend over the patient for this mobilization technique, his position will be far more comfortable if he supports his knee furthest from the head end on the treatment table. He next instructs the patient to look up to the forehead, breathe in deeply, breath-hold and, after a brief latency period, to let go and breathe out. As the patient exhales, the practitioner will notice how resistance is reduced and how he can advance his elbow further forward without resistance. After taking up the slack, he can deliver an HVLA thrust by pushing his elbow forward rapidly, while the thumb of his other hand firmly holds the spinous process of the lower vertebra.
Rotation at the cervicothoracic junction
The following technique can be used for mobilization: with the patient seated on the treatment table adjusted to a low setting, the practitioner stands behind and takes hold of the patient’s head between his upper arm and forearm, with the patient’s chin in the crook of the elbow. He rotates the patient’s head in the direction of mobilization to take up the slack, with his little finger spanning the vertebral arch and the spinous process of the upper vertebra in the segment to be treated. With the thumb of his other hand he fixes the spinous process of the lower vertebra from the opposite side (see Figure 4.35). The patient is told to look in the opposite direction and breathe in, and to breath-hold while the practitioner offers isometric resistance to the patient’s 220
movement. After a brief latency period, he instructs the patient to look in the direction of mobilization and to breathe out slowly, thus causing mobilization to proceed automatically. Using the same technique, after taking up the slack, he can perform an HVLA thrust as follows: the hand cradling the patient’s head delivers the thrust while his other hand with its thumb against the spinous process fixes the lower vertebra.
Traction HVLA thrust at the upper vertebra in the restricted motion segment The patient is supine, with head and neck protruding beyond the edge of the treatment table. The practitioner rests the patient’s head on his forearm and cradles the patient’s chin with his fingers. He locates his other hand at the transverse process of the upper vertebra in the restricted motion segment (see Figure 6.53A). He side-bends the patient’s head just a little toward the side of the contact hand so that it does not slip off from its position. In order to perform longitudinal traction with both hands, he stands to one side level with the patient’s head. However, if the upper partner is the atlas or the occiput, side-bending is not necessary because, in these cases, contact is taken up with the transverse processes of the atlas (which jut out further) or with the mastoid process. The practitioner rotates the patient’s head slightly away from him; however, this rotation should be only minimal so as to avoid locking the segment to be treated. In this position, once the patient is completely relaxed, the practitioner takes up the slack with both hands simultaneously using minimal traction and delivers an HVLA thrust. The critical factor here is that both hands must operate as a single unit. Therefore the thrust must come from the whole trunk. When treating the atlanto-occipital segment, the patient’s head is rotated more to the side so as to lock the atlantoaxial segment (see Figure 6.53B), and contact is taken up at the mastoid process.
Traction low-velocity thrust applied to the lower cervical spine and the cervicothoracic junction The patient is seated on the treatment table with hands clasped behind her head and elbows wide apart. The practitioner stands behind the patient and threads his forearms through the triangle
Therapeutic techniques
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Figure 6.54 • (A) Traction manipulation of the lower cervical spine and cervicothoracic junction; (B) finger position.
Figure 6.53 • Traction manipulation of the cervical spine
with contact (A) at the transverse process of the upper vertebra in the segment to be treated, or (B) at the mastoid process.
formed on each side by the patient’s upper arms and forearms. With the middle fingers of both hands placed over the forefingers to reinforce them, he takes up contact at the spinous process of the upper vertebra in the restricted segment (see Figure 6.54). He now instructs the patient to relax and let her head fall forward as he simultaneously presses with his arms against the patient’s forearms. He takes up the slack by gentle pressure of his
fingers forward and upward against the spinous process, followed (in this case!) by a low-velocity thrust as he straightens up and increases the forward and upward pressure with his fingers. It is useful if the patient exerts slight pressure with her arms against the practitioner’s forearms. This technique is most easily applied to segments C4–C7, and sometimes it is even successful at C3 (where there is increased lordosis). Caudal to C7 the pressure exerted by the fingers is insufficient to be effective. They therefore remain positioned in the lower cervical spine and continue to apply distraction there; however, the practitioner delivers the thrust using the upper part of his breastbone (the manubrium sterni) against the spinous processes of T1–T3. Both techniques are gentle and safe. However, they are not absolutely specific: 221
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the thrust is delivered to the upper vertebra in the restricted segment, while the lower vertebra is not fixed. Traction may therefore affect some of the more caudal segments. The practitioner’s fingers in the cervical region also produce some distraction but this should be inconsequential.
Rotation HVLA thrust with the patient seated The patient is seated on the treatment table adjusted to a low setting and the practitioner takes up a position behind so that he is stabilizing the patient’s back against his chest. Using his mobilizing arm, he takes hold of the patient’s head between upper arm and forearm, so that the patient’s chin and face are in the crook of his elbow (see Figure 6.55). Leaning forward slightly, he spans the upper vertebra with the little finger of his mobilizing hand, while the thumb of his other hand fixes the spinous process of the lower vertebra laterally so as to keep it in a neutral position. The practitioner takes up the slack by carefully rotating the patient’s head while fixing the lower vertebra. He delivers the HVLA thrust with his mobilizing hand, mainly into rotation and traction.
Because the lower vertebra is fixed, this technique is highly specific. If fixation is correct, rotation is only minimal. Throughout manipulation the spinous process of the lower vertebra remains in a neutral position and the cervical spine undergoes kyphosis during traction in a cranial direction. Only if performed in this way is the technique safe and gentle. A similar, primarily mobilizing technique at the cervicothoracic junction has already been described (see Figure 4.34).
The craniocervical junction Mobilization of the joints at the craniocervical junction is performed using precisely the same techniques as those employed for diagnosis. In this segment (C0/C1), inhalation has a facilitating effect and exhalation an inhibitory effect in all directions.
Anteflexion After taking up the slack using the technique for examination (see Figure 4.37), the practitioner instructs the patient to look up toward the forehead, breathe in, and then breath-hold; he will clearly sense resistance against anteflexion and will often himself have to resist the patient’s automatic head retroflexion. He then tells the patient to look downward at the chin and to breathe out. Head anteflexion automatically follows. If facilitation is too pronounced on looking up at the forehead, it is sufficient (when repeating the procedure) simply to tell the patient to breathe in. The procedure can be repeated two or three times. This mobilization technique is the gentlest of all and therefore practitioners generally begin with it. The practitioner should check afterward whether the TrPs in the short extensors can still be felt.
Side-bending
Figure 6.55 • Rotation HVLA thrust of the cervical spine with the patient seated, under traction, in kyphosis.
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Using the technique for examination (see Figure 4.38), the practitioner takes up the slack with the patient’s head rotated and in side-bending. The patient is instructed to look up toward the forehead, breathe in slowly, and then breath-hold. The practitioner will sense increased resistance to sidebending. Afterward he tells the patient to look down toward the chin and breathe out: all resistance to side-bending will spontaneously disappear. The procedure can be repeated two or three times.
Therapeutic techniques
Retroflexion The practitioner takes up the slack with the patient’s head rotated and in retroflexion (see Figure 4.39). As the patient slowly breathes in deeply, resistance to retroflexion is felt to increase. After breath-holding, the patient is told to breathe out slowly and to allow her head to fall back. Toward the end of exhalation all resistance disappears and retroflexion clearly increases spontaneously. The procedure may be repeated once or twice. In this case, looking up to the forehead, that is into retroflexion, would be at odds with the increased resistance to retroflexion during inhalation, while looking downward would be inconsistent with the increase in retroflexion during exhalation. It is recommended not to rotate the patient’s head more than 60°, especially in the elderly, and it is also helpful simultaneously to lift the patient’s head, which protrudes a long way beyond the end of the treatment table. Because retroflexion increases considerably during exhalation, the practitioner needs to hold the patient’s head quite high up (at the crown) because otherwise his own hand would be an obstacle to retroflexion. Retroflexion must never be actively amplified; usually it increases spontaneously to such an extent that, if anything, the practitioner needs to hold it back. This is therefore the most effective of all mobilization techniques between the atlas and occiput. Recently we have started to use activation of the deep stabilization system to achieve mobilization. Stabilization in the craniocervical region is enhanced by carrying weights on the head. The following technique successfully exploits this principle: with the patient sitting upright, the practitioner places both hands on the crown of the patient’s head from both sides to exert very light, rapid, shaking pressure in the direction of the long axis of the cervical spine. It is important that the patient sits upright and that care is taken to avoid anteflexion–retroflexion and laterolateral flexion. This technique is ideal for self-treatment (see Figure 6.81C); it also acts on C1/C2 and possibly on C2/C3.
Side-bending between atlas and axis The examination technique (see Figure 4.29A) is used to take up the slack in side-bending between C1/C2 (‘side-nodding’). According to Gaymans’ (1973) rule, C1/C2 is an odd-numbered segment; consequently, resistance to side-bending automatically increases during exhalation. Deep exhalation
Chapter 6
is followed by slow, deep inhalation. Toward the end of inhalation there is an abrupt reduction in resistance in the restricted segment. Here it is especially important to wait for the precise moment of relaxation. The practitioner should ensure that sidebending is limited to the top part of the cervical spine; the patient’s head here should rotate about an axis that passes through the radix nasi (root of the nose). In terms of joint mechanics, side-bending in the top-most part of the cervical spine produces rotation of the atlas in relation to the axis and, after Jirout’s maneuver, it is the most effective technique for restoring such rotation.
Mobilization techniques utilizing respiratory synkinesis are so effective in the region of the craniocervical junction that relatively more hazardous HVLA thrust techniques are indicated there in exceptional cases only.
6.2 Indirect techniques This term is used to denote osteopathic techniques that are extremely gentle and yet effective at the same time; and it is these characteristics that justify their inclusion here. Use of the term ‘indirect techniques’ indicates that neither diagnosis nor therapy involves taking up the slack or engaging the barrier.
6.2.1 Johnston’s functional techniques Functional techniques seek to bring the patient into a position in which good relaxation and pain relief are obtained. Once this objective is successfully achieved, it is found that painfully increased tension gradually dissipates in other positions too. Functional techniques are based entirely on palpation and therefore it is difficult to capture their essence in writing. I will therefore do my best to help the reader to understand this concept. Palpatory examination may reveal increased tension (spasm) on one side of a lesioned spinal segment in the vicinity of the erector spinae; this appears as an area of prominence and it creates a palpatory illusion suggesting rotation toward the side of the area of prominence (increased tension). If a patient 223
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with such findings is now bent forward, backward, and to the side, the practitioner will feel that this increased tension, and hence asymmetry of muscle tone, becomes more apparent following movement in one direction, and more balanced following movement in another direction. In terms of joint mechanics, it should be borne in mind that on sidebending of the spinal column, the joint on the side of lateroflexion moves as it were into extension while that on the opposite side moves as it were into flexion (see Figure 4.5).
Treating the lumbar and thoracic spine When the lumbar and thoracic spine are being treated, the patient should be seated with both hands clasped behind the neck; with one hand/ forearm the practitioner stabilizes the patient, as illustrated in Figure 4.21. With his other hand he palpates with thumb and forefinger in the segment where the tension imbalance between the two sides is greatest, that is where there is a palpatory illusion of rotation. He next establishes whether the tension imbalance diminishes in anteflexion or retroflexion. When this happens the practitioner will experience the palpatory illusion that the spine is ‘de-rotating.’ For example, if tension becomes balanced in retro flexion, then it follows that side-bending toward the side of the spasm will have a beneficial effect; and conversely, if anteflexion restores balanced tension, then side-bending in the opposite direction will alleviate spasm, and this is generally associated with freedom from pain. In practice, the procedure is as follows: for example, if the practitioner finds that the tension imbalance is reduced in retroflexion, he should move the patient into maximum retroflexion with bending toward the side of the spasm. The patient’s trunk should be supported as effectively as possible so as to enhance relaxation. If tension in fact becomes balanced in this extreme position (wait to see if this happens), the practitioner slowly rocks the patient out of side-bending and maximum retroflexion and back into a neutral position. However, as soon as the tension reappears, he should return the patient to the relief position and make another attempt, taking care to progress slowly in this manner. As a rule, after a few rocking maneuvers back into the neutral position and some anteflexion, the tension will disappear with the result that, after a 224
few repetitions, even full anteflexion and bending to the opposite side are tolerated. The palpating hand will always indicate whether the practitioner has ventured too far, i.e. whether it would be right to go back a step or to proceed further. The same principle applies if anteflexion brings tension symmetry (‘de-rotation’). In this case the practitioner should work toward achieving a normal balance of tension in anteflexion (see Figure 4.22) and side-bending to the opposite side, and rock the patient carefully back to the neutral position and retroflexion until no further tension imbalance is evident on full retroflexion.
Treating the cervical spine A similar approach is adopted when treating the cervical spine. As he stands beside the seated patient, the practitioner uses one hand to move the patient’s head into anteflexion, retroflexion, and side-bending; between the thumb and forefinger of the other hand he palpates next to the spinous processes the muscles that lie behind the transverse processes. The following technique is even more effective: as he stands in front of the patient, the practitioner supports the patient’s forehead on his chest and palpates with both hands either side of the spinous processes (in this way he can use both hands to stabilize the patient’s head and neck). By raising or lowering his own ribcage, he then moves the patient’s head, taking it into anteflexion, retroflexion, and side-bending while simultaneously palpating the paravertebral muscles with his hands. Once again, the practitioner starts by identifying the side and the segment affected by increased tension and then tests whether this finding is accentuated or diminished in anteflexion or retroflexion. If tension decreases in retroflexion, he moves the cervical spine into retroflexion and side-bending toward the lesioned side, and waits in this position until all tension disappears. Then with gentle rocking movements, he reduces retroflexion and side-bending, always supporting the patient’s head against his chest. He repeatedly returns to the relief position as soon as he notices that increasing anteflexion causes tension to reappear, until finally full anteflexion and bending to the opposite side are well-tolerated. Conversely, if tension is relieved on anteflexion, he performs the treatment the other way round (i.e. anteflexion and side-bending to the
Therapeutic techniques
opposite side, followed by retroflexion and sidebending to the lesioned side). This method is extremely gentle and safe and is always most agreeable to the patient. However, it is not easy to illustrate and teach with words alone because it depends entirely on the palpation skills of the practitioner.
6.2.2 Strain and counterstrain This method has much in common with Johnston’s functional techniques in that it does not engage the barrier and seeks out positions that afford pain relief. The best experiences with strain and counter strain techniques are obtained in acute lesions where most other traditional methods have failed. Indeed L H Jones, the originator of the strain/counterstrain method, tells how he was called to treat an emergency case involving a patient who was unable to straighten up from flexion because of psoas spasm and could not find any relief position. On examination, however, Jones found that relief could be obtained when the patient was brought into a position of 45° of rotation and 30° of lateral flexion. He then went away to treat another patient. When he returned to his emergency case, he found that the patient was able to straighten up completely. In his original publication, Jones (1964) explained the rationale for his method, and this corresponds to the situation that is frequently observed in acute lesions: the patient picks up an object lying on the floor, usually bending forward to one side, and then straightens up (too) quickly out of anteflexion–rotation. It is conceivable that during this brisk movement something becomes caught or trapped. If we now help the patient to go back into the original flexed position and exaggerate this a little, then wait in this position before very slowly returning the patient into a neutral position, we give the impinged tissues the opportunity to slip out from their entrapment. An essential prerequisite is to find the position of relief – information that is frequently volunteered by the patient. However, Jones noted objectively that this process can be used to eliminate the most varied pain points in the muscles, on the thorax close to the midline, and on the abdomen usually more to the left side. Once the patient has been slowly brought into the relief position thus found, it can be exaggerated a little, provided that the patient tolerates this. The patient then remains in
Chapter 6
this position for 90 seconds. Afterward the patient is allowed to return (slowly!) to a neutral position. As a routine method this technique is timeconsuming and cumbersome. However, in a simplified form it is to be highly recommended in emergencies; and sometimes it is the only treatment method that is of help to the patient. It is employed most frequently in acute low-back pain and to treat radicular pain. For this, use is made of the positions (in anteflexion and retroflexion) that the patient adopts when performing McKenzie exercises (see Section 6.5.3). However, in each case, the position must be held for 90 seconds. A similar procedure may also be followed in acute cervical myalgia, that is the left-sided rotation and bending into mild flexion that is usually present can be slightly exaggerated and held. This technique has proved especially useful in instep pain where no movement restriction or TrPs are found and which develops sometimes on pronation and sometimes on supination of the foot. In such cases maximal supination or pronation in the direction of relief is the treatment of choice. On each occasion the position must be held for 90 seconds, followed by a slow return to a neutral position.
6.3 Exteroceptive stimulation (by H Hermach)
6.3.1 Tactile perception and muscle tone Even though an unborn child in the womb already reacts when its mother’s abdomen is touched, tactile perception can properly be said to develop only after birth. In the very early stages a large part of a baby’s body surface area is in intimate contact with the floor or other support surface. Soon, however, growing babies start to support themselves on their arms and legs and on only limited areas of their trunk, until finally they stand up and support themselves only on the small surface area of the soles of their feet in contact with the ground. In adults, however, it is more common for the caudal end of the trunk to be the main support structure! Tactile contact over large areas of the body, for example caressing and stroking, has a pleasant and 225
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calming feel to the child. However, if the child reacts to stroking by crying, this is a warning sign of unfavorable motor development. It can be a sign of increased tension in impending spasticity. The size of the support surface of a child or adult will indicate whether muscle tone is increased, normal, or reduced. Starting from the contact area and our ability to use this, we develop the ability to push off from the support surface and return to it. The way in which individuals react to their surroundings in response to contact with their body surface indicates whether they accept this or reject it, how they interpret it, and whether their reactions to environmental stimuli are appropriate or not. Our skin plays a major role in the processing of information we receive from the world about us; and it is on the basis of this information that we form an image of the space surrounding us and also of our own bodies. Pre-eminently it is our skin and sense of touch that enable us to differentiate between ‘self ’ and ‘non-self ’ out there. How much room does ‘self ’ take up? A disordered or inadequate tactile sense disturbs our orientation in space and our understanding of the position that we occupy in it. And this necessarily has repercussions in the sphere of movement, that is in the locomotor system. What we feel is closely related to our psyche. What we feel is interpreted, understood, grasped. And this interpretation also shows how we perceive the world, whether as agreeable, friendly and open (so that we open ourselves up to it in turn), or as disagreeable and hostile as we come into contact with it. If we feel that touch or contact on our skin is agreeable, then contact with the world around us is welcome and we seek it out. Of course, the converse also applies. Hence our sense of inner security and our feelings of insecurity in a spatial sense when moving about are interconnected. The more precisely we perceive, the better able we are to discriminate. The ability to discriminate precisely bears testimony to precise perception, and our tactile discriminatory skills tell us where we are. Reactions are shaped and behavior develops depending on the quality of our perceptive skills and how we interpret what we perceive. Our skin’s sensation of touch also has implications for our locomotor system. These implications are so immediate because the sensitivity of our skin is linked to its tension, which in turn is connected 226
with the tension of the subcutaneous connective tissues and of the muscles. Increased skin sensitivity is generally associated with increased tension in all tissues, including the muscles, while reduced sensitivity is linked with hypotonus. However, because sensations in the individual can be widely different, the symptoms can also be different. This explains why the skin may also be tense when sensitivity is reduced. Such a phenomenon may be the consequence of a reaction by the body as a whole to inadequate stimuli (information). It is therefore extremely important that we are able to intervene at the level of the sense of touch. Our skin has the capacity to learn how to perceive more or less, or even how to perceive better. And we can do this by altering the tension of the skin, subcutaneous tissues, and muscles. All of the above can be put to good use in the setting of treatment. Appropriate, discriminating sensation goes hand in hand with normal skin and muscle tone. The capacity of a muscle to alter its tension in a discriminating way is an expression of good coordination. Good tactile perception goes hand in hand with well-coordinated movements. If we succeed in the course of treatment in achieving well-balanced tactile perception, then it is no exaggeration to claim that the patient’s movements will then be optimal – coordinated and with good spatial orientation. In order to capitalize on this, we need to learn how properly to examine the tactile sensibility of the skin.
6.3.2 Assessing altered tactile perception The assessment of tactile perception has much in common with neurological sensibility testing. Our prime assessment tools are our fingers and the dorsal surface of our thumb nail. In the process, we assess how the patient reacts, whether the response is appropriate, and how the patient behaves. We can stroke or scratch, only lightly or even intensively, depending on the part of the body being examined. It is a good idea to begin abruptly so as to provoke a clearly discernible reaction. After a few repetitions, the reaction will change as the skin adapts to the stimulus. Failure of adaptation to materialize is a sign of hypersensitivity. The response to a stimulus may be merely local or it may also be generalized. A reaction may also be absent. In general, the more intense the general
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reaction, the less appropriate it will be. Absence of a local reaction is indicative of reduced tactile perception. The reaction may also be appropriate, or it may be exaggerated, as a sign of hypersensitivity. This may manifest itself as ticklishness, and even as pain. Paradoxical reactions may also be encountered: instead of pulling the sole of the foot away when tickled, the patient may breath-hold and tense the thoracic muscles. Sometimes a patient will develop goose bumps merely at the mention of tickling the soles of the feet. The most telling signs of a generalized reaction are altered respiration and sweating. These are indicative of instability in the organism as a whole, and the changes in respiration can also affect motor activity. Due consideration must also be given to the patient’s personality and cultural background and to whether current stress might be a factor. There are moments when all of us may react in an exaggerated manner.
6.3.3 Normalizing tactile perception Sensitivity for tactile stimuli is anything but constant; it alters and adapts rapidly. Sensitivity in response to stroking may also alter in the long term. This means that the skin learns to feel and to discriminate, and as a result the patient learns to interpret. The effect of a great many massage techniques is also based in part on tactile stimulation, and they can be applied with this in mind, provided that they are gentle and primarily have a surface effect. Brushing is another method that can safely be used in patients with diminished tactile sensitivity. In patients in whom altered tactile perception is expressed as algodynia or hypersensitivity, we must seek to use a technique that is agreeable to the patient or is at least felt to be tolerable. If treatment is felt to be disagreeable, it will provoke a defense reaction that will preclude any successful outcome. Treatment in patients with altered tactile perception begins in principle with slow and gentle stroking over large areas of the body. Tickling must be avoided. Our hand will provide feedback because it will ‘pick up’ changes in the tension of the skin, subcutaneous tissues, and muscles. As long as the findings improve, we may continue. If this is not the case, then we have failed to understand our
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task correctly or else the stimulus was too weak. If improvement fails to materialize, we must stop, review the diagnosis and decide whether the stimulus was the correct one. Stroking is generally performed along the long axis of the body, but may also be transverse to the long axis at the buttocks, or diagonal on the abdomen. If the skin is hypersensitive, we have two options: we can continue stroking through a fine fabric or else the patient can self-stroke for a few minutes each day until the touch of the practitioner’s hand can be tolerated. If the skin is hyposensitive, we can intensify the stimulus by stroking more quickly, changing pressure and direction, or using a hedgehog ball, brush, or towel. However, we should understand that good tactile perception permits a response to tiny stimuli that can never be achieved with coarse stimuli. In order to achieve good coordination, a muscle must be able to interact with other muscles as soon as tension changes. Heightened or diminished muscle tonus should not persist anywhere. Each muscle should be capable of relaxing and adapting to modified circumstances. If we have successfully altered muscle tonus using any method, then this means that well-coordinated movement has resulted without the need for special exercises and the correction they bring. If our own experience suggests that we have successfully normalized the tone of the muscles and subcutaneous tissue simply by stroking, then coordination will also improve, along with locomotor system function in every respect.
6.3.4 Altered superficial tactile perception following surgery (due to scarring) When assessing the tactile perception of the skin, we must also take account of any active scars that may be present. To determine the sensitivity of a scar, we ‘fold’ it a little. If the patient feels pain when we do this, hypersensitivity is present. If sensitivity remains unchanged after stretching and mobilization (see Section 5.2.2), then the pain point is more deep-seated. It is not sufficient to assess the sensitivity of the scar alone. Surgery may also damage cutaneous nerves, in which case hypesthesia will be present, but sometimes also paradoxical hypersensitivity. In both cases we should attempt to improve sensibility. 227
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As long as this is abnormal, then the tone of connective tissues and muscles will remain abnormal, as will their reactions. This tactile perception deficit may be indicative of muscle spasm, which means that the patient has insufficient muscle control. Hypersensitive skin may also be associated with paresthesia and even pain (sometimes referred pain). Hypersensitivity can be so intense that the patient cannot even bear contact with clothes. This condition is known as ‘clothing sensitivity,’ and the patient may also demonstrate a powerful emotional reaction. In such cases we should perform stroking through a sheet of fabric, or the patient should be encouraged to self-stroke daily until being touched by someone else’s hand becomes tolerable. And even if the sensitivity of the scar has been restored to normal, the patient must repeat the stroking as soon as hypersensitivity returns. The muscles beneath the active scar are usually hypertonic and painful. These aspects too may also improve as soon as normal cutaneous tactile perception is restored. Cutaneous tactile perception differs not only from person to person but also depending on body region and age. Infants recognize objects and first touch them with their mouths, and only later with their hands. Soon, however, they also use their feet to feel objects until they stand up and start to toddle. In that phase the foot serves as a support but it is by no means passive: the body reacts to the surface on which its stands to adopt an erect posture. As is well known, the tongue, mouth, hands (especially the thumbs), and feet are served by large areas of the sensory cerebral cortex. They play a pre-eminent role in tactile perception, and therefore changes in sensibility in those regions result in changes to overall behavior.
The tongue and mouth The tongue tends to be examined in exceptional cases only. However, it must be examined in young children with behavioral abnormalities: the findings often reveal a restless or, on the contrary, an immobile tongue. Examination is also necessary in cases where the mandible and lips are restless or the patient’s mouth is constantly open. A moistened finger is used for the examination. Where hypersensitivity is present, the tongue will react with a twitching defense movement or else gagging is provoked simply when the tip of the patient’s tongue is touched. In the case of a tongue where there is 228
no reaction, indicative of reduced sensitivity, the tongue, lower jaw, and oral cavity can be stroked with a moistened finger. Adult patients may do this for themselves; for toddlers and children, the parents should be instructed how to do this. It is necessary to proceed with caution owing to the ever-present risk of vomiting.
The hands It is not easy to assess the sensitivity of the hands. This is probably because the hands themselves are constantly touching objects and working on them. For the examination, the patient is seated in a relaxed position with palms facing upward. In this position, tension of the flexors is the dominant feature. Therefore the fingers are generally in slight flexion. The practitioner should surprise the patient by suddenly scratching one palm. Usually the patient will rapidly jerk the fingers away before returning them to their original position. One sign of hypersensitivity is finger extension, especially if this recurs when the test is repeated. The most effective therapy is stroking or a repetitive activity such as moving the fingers in a bowl of rice, kneading dough, or model-making with Plasticine®. Patients with hypersensitive hands are generally creative but they need to learn to relax their hands.
The feet An assessment of the sensitivity of the feet should form part of the routine patient examination. The feet play a key role in human upright posture and they are significant for the function of the spinal column. For the examination, the patient should be supine, with legs slightly flexed over a pillow placed behind the knees. Without warning the patient, the practitioner uses his fingernails to simultaneously stroke the soles of both the patient’s feet, from heel to toe in the direction of the big toe. Where tactile perception is normal, the patient will attempt to move away a little from this touch, by slightly increasing knee and hip flexion, dorsiflexing the feet, and flexing the toes a little. It is not uncommon for the observed reaction to be asymmetrical, and this is clinically important. When asked, the patient will also report asymmetric sensitivity. If the patient does not react at all, this indicates that the foot is not capable of responding appropriately during standing and walking because it is
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unable to receive information from the terrain. An exaggerated reaction, for example involving the whole body, shows that the foot is not able to adapt to the floor or ground because it is processing the information incorrectly. Therapy consists of stroking and a combination of superficial and proprioceptive stimuli as the practitioner traces numbers and letters on the patient’s soles. Patients can stroke or brush their own soles and walk barefoot on the lawn at home or on a shingle beach. If the practitioner detects asymmetric sensitivity of the feet, he should also screen for asymmetries in other body regions – lower legs, thighs, abdomen, thorax, arms, and face. In this way it will be possible to identify asymmetry involving the whole body, something that occurs particularly when one side of the body is markedly dominant. Such asymmetry will affect the locomotor system as a whole. The patient then needs to become aware of the ‘forgotten side of the body’ and learn to use it too. Once again, therapy consists of stroking the less sensitive body side (and the patient can also do this indepen dently). However, it is important to establish with certainty whether and when symmetry is restored.
may be found in unloved children, even persisting into adulthood. Differing sensitivity on one side of the body means that the patient has a false perception of body center and hence of the immediate surroundings. Objects seem to some extent less real on the side of diminished sensitivity, explaining why the patient may bump into things more often on that side. This sensitivity imbalance is often associated with emotional lability. As soon as the patient learns to be aware of the whole body and to use the side on which sensitivity was originally diminished, there will be an increase in self-confidence. Normal sensitivity of the feet is also a prerequi site for good balance and hence for a sense of security. Where such security is absent, the patient will seek to maintain balance through exaggerated activity of other muscle groups, for example in the pelvis and lumbar region, diaphragm, thoracolumbar junction, shoulder girdle, and those involved in mastication. These disturbances of muscle function generate characteristic chain reactions. Individuals with hypersensitive hands are often excessively neat and tidy, with a tendency toward perfectionism.
The abdomen
6.3.6 Self-treatment
Ticklishness, especially on the abdomen, is also a sign of hypersensitivity. This usually goes hand in hand with increased muscle tension. As a result, coordination, respiration, and spinal function are also disturbed. Ticklishness is linked with nociception and therefore also with TrPs. It is a precursor of pain.
6.3.5 Individual characteristics of perception The reactions of all patients also need to be assessed in the context of their personality. What appears to be exaggerated may be entirely normal in a highlystrung person. In someone with a very calm temper ament, what seems to be normal may already be an indication of hypersensitivity. The practitioner needs to listen to the patient very precisely – the patient’s own words will betray the underlying attitude toward pain – and simultaneously observe the patient’s behavior. Thus, an unusual reaction may ensue following simple skin contact because there is a disturbance at the emotional level, something that
Patients can use the following self-treatment techniques to restore a balanced pattern of skin sensitivity: • Stroking themselves with their fingers. • Stroking themselves with a towel. • Rolling a soft rubber ball or tennis ball with their feet. • Walking on pebbles or hot charcoal. • Wriggling their fingers in a bowl of rice or peas, etc. • Lying on a mattress filled with small plastic balls, chestnuts, or other nuts; children may play with balls or chestnuts in a bath containing just a little water. • Brushing to stimulate the skin. The prime goal of therapy is to reintegrate the region of diminished or heightened sensitivity into the overall body pattern. There are right-handed people who need to learn how to use their left hand too. Many patients have to re-learn how to walk barefoot or how to roll down a grassy slope (‘rolypoly’ fashion), and others have to be made aware of their thorax. 229
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6.4 Soft-tissue manipulation As with joints, we examine mechanical function in order to assess elasticity, mobility relative to other structures, and mutual patterns of displacement. The importance of soft tissue is evident from the simple facts that the locomotor system as a whole is embedded in soft-tissue layers, that connective tissue elements are also present in muscles themselves, and that the mutual mobility and displacement of all these structures is made possible by soft tissue. Indeed, motion of the locomotor system proper would not be possible if, starting with the skin, all the aforementioned structures and tissues were not freely mobile or capable of relative shift and stretch. The same applies to the visceral organs, especially in the abdominal cavity. Some of these movements involve quite considerable excursions. Consequently, soft-tissue function needs to be examined diagnostically and treated. The technique is characteristically uniform for all soft tissue, but differs from most forms of massage in that on each occasion, whether we wish to stretch or shift, we first take up the slack (engage a barrier), and then, without much change in pressure (pull), release occurs after a brief latency period. Release itself may take from a few seconds to half a minute or longer. The practitioner’s role is to sense this. If the release process is cut short prematurely, we will be depriving ourselves of the best possible treatment outcome. During this period of release it may be helpful to slightly modify both the direction and the intensity of pressure (pull). It must never be forceful, and the patient should never feel pain.
If muscles and joints are to move, then the surrounding soft tissue also needs to shift and stretch with them. This capacity for concomitant movement may be disturbed, with adverse repercussions for the locomotor system as a whole.
6.4.1 Skin stretching As explained in Section 4.3.2, a small area of the skin can be stretched between two fingertips; larger skin areas can be stretched between the practition230
Figure 6.56 • Skin stretching.
er’s thenar eminences or between the ulnar aspects of his palms with hands crossed. Stretching should be performed with a minimum of force, so as to take up the slack. Under normal circumstances a springing resistance will be felt. If there is a hyperalgesic zone (HAZ), the slack is taken up sooner and there is much less spring. If the skin is then held in this end position, resistance weakens after a brief latency period until the physiological barrier is reached and normal springing is restored (see Figure 6.56). The HAZ is then usually no longer detectable. If the HAZ is the cause of pain, this stretching method is quite as effective as needling, electrostimulation, and similar treatments. Moreover, it is painless and well suited for self-treatment. The effect can even be measured. The method is particularly suitable for small skin areas where a fold cannot be formed, for example between fingers and toes, in radicular syndromes, or in the region of the carpal tunnel if the skin there is taut.
6.4.2 Stretching a connective tissue fold Folds of soft connective tissue are usually formed between the thumb and forefinger of the practitioner’s two hands; in this way he can produce pull or stretch (but never compression!) and take up the
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Figure 6.57 • Stretching a connective tissue fold.
slack. The stretch is held and, after a brief latency period, he will notice that the tissue fold stretches (relaxes) until the physiological barrier is reached (see Figure 6.57). This technique is appropriate for treating HAZs in the subcutaneous tissue and especially for scars with active interference zones (pain points). It is particularly suitable for stretching taut muscles where the connective tissue element is shortened. In the case of large muscles, such as the ischiocrural group, the fold is produced between the palm of one hand and the fingers of the other. This is probably the most effective way of obtaining muscle stretch while avoiding the stretch reflex (‘cross-stretching’).
6.4.3 Sustained application of pressure In locations where a fold cannot be formed, pressure may be exerted with fingers, thumb, or even the elbow (see Figure 6.58). Here, too, the practitioner takes up the slack using the very minimum of pressure, and after a brief latency period he will notice that the tissue starts to yield and his finger sinks into the deep layers until a new barrier is reached. In the process both the intensity and direction of pressure can be modified slightly. This method is most effective for eliminating TrPs, for example in the erector spinae and the gluteal muscles; it can also be applied by a pincer movement between two fingers, for example in the sternocleidomastoid. The sustained application of pressure is also useful in treating deep, contracted scars where it is impossible to form a skin fold.
Figure 6.58 • Applying sustained pressure.
6.4.4 Shifting (stretching) the deep fascia The most important task of soft-tissue manipulation appears to be restoration of the normal mobility of the fascia. Once again, the technique is similar to those described above: after taking up the slack, the practitioner waits until release occurs and the tissue can be shifted in relation to the structure beneath. Many of these techniques were originally elaborated by R Ward (personal communication, 1989). It is worth emphasizing here that restrictions in the mobility of the deep fascia are a sign of a chronic disease stage.
Shifting the deep lumbar fascia caudally The practitioner takes up a position to one side of the patient, who is prone with feet protruding over the end of the treatment table. He starts by comparing the extent to which the soft tissue can be shifted caudally on both sides. He then instructs the patient to press the toes on the side to be treated against the edge of the table, to stretch out the arm on that side as far as possible with fingers splayed, and to turn the head so as to look toward the side being treated (see Figure 6.59). The practitioner next uses one hand to exert pressure on the gluteal muscles in a caudal direction while his other hand fixes the thoraco231
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Figure 6.59 • Shifting and stretching the deep lumbar fascia caudally.
lumbar area from above. Once the slack has been taken up, he instructs the patient to breathe out (thus increasing resistance to the pressure being exerted caudally), then breath-hold, and breathe in slowly. Inhalation is accompanied by release, caudal shifting of the lumbar fascia, and stretching. The procedure is repeated three or four times. If satisfactory release fails to occur, it can be helpful if the patient gives a cough. After this treatment the shifting qualities of the lumbar fascia on both sides will be symmetrical and the practitioner will notice a blush sign at the treated site. The movement restriction need not necessarily be on the painful side.
Shifting and stretching the dorsal fascia cranially The practitioner takes up a position to one side of the patient who is prone with feet protruding beyond the end of the treatment table. He starts by comparing the extent to which the soft tissue can be shifted cranially on both sides. He then instructs the patient to press the toes on the side to be treated against the edge of the table, to stretch out the arm on that side as far as possible with fingers splayed, and to turn her head toward the practitioner. With one hand placed at the level of the shoulder blade, the practitioner shifts the soft tissue cranially to take up the slack, while 232
his other hand fixes the soft tissue in the thoracolumbar region using downward pressure toward the treatment table (see Figure 6.60). He next instructs the patient to breathe in deeply, breathhold, and then breathe out slowly. Release occurs while the patient is breathing out. The procedure is repeated several times. If release is not satisfactory, the situation can be helped by asking the patient to cough.
Stretching the fascia on both sides of the trunk This technique is indicated where side-bending is restricted due to muscle shortening. For diagnosis and treatment, the practitioner takes up a position behind the patient, who is seated. On the side to be treated, the patient raises her arm above head height and bends it at the elbow. The practitioner takes hold of the elbow with one hand while his other hand fixes the patient’s hip from above. He takes the patient into side-bending over his thigh, which is supported on the treatment table, until the slack has been taken up (see Figure 6.61). He then tells the patient to look up and breathe in deeply, breath-hold, and then look down and breathe out. Stretching occurs after a brief latency period. The procedure is repeated two or three times.
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Figure 6.60 • Shifting and stretching the dorsal fascia cranially.
Figure 6.61 • Stretching the lateral fascia (muscles) of the trunk.
resistance, usually on one side, and makes a comparison with the other side. In the direction in which he feels resistance (a pathological barrier), he takes up the slack during inhalation and senses the release during exhalation. During mobilization, it is helpful for the practitioner to guide the patient’s hand with his own so that the patient can feel the barrier and release first hand, and then continue the (always agreeable) self-treatment at home (see Figure 6.62B). Clinically, this dysfunction is especially common and significant in the setting of pain in the region of the shoulder and shoulder blade. In a similar way, in patients experiencing pain in the inguinal region, the shifting qualities of the soft tissue relative to the pubic bone may be reduced. In all such situations, the treatment is fundamentally the same: the practitioner takes up the slack in the direction of increased resistance. This is then held, after which release is obtained and the barrier is restored to normal. The same also applies for the shifting quality of the buttocks in a caudal-to-cranial direction: the practitioner takes up the slack on the side of increased resistance by exerting pressure in a cranial direction and then, after a brief latency period, release is obtained.
Rotational shifting of the fascia around the thorax
The scalp
With the patient supine, the practitioner examines and mobilizes the soft tissue around the thorax, particularly on the lateral surface, in a ventromedial direction (see Figure 6.62A). He palpates for
In clinical terms, the scalp behaves like a deep fascial layer. Restricted scalp mobility may cause headaches as well as vertigo in conjunction with the cervicocranial and mandibulocranial syndrome. 233
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applying a rotational movement around the long axis of the neck. The practitioner stands behind the seated patient, places one hand round the patient’s neck from behind, and applies a rotational movement to detect increased resistance in one direction (see Figure 6.63). He takes up the slack in that direction and, after a brief latency period, release is obtained as the patient breathes out. Treatment may be applied in the direction of the thumb or of the fingers; treatment in the direction of the thumb is more specific while that in the direction of the fingers covers a larger surface. With his free hand the practitioner fixes the patient’s head. At the cervicothoracic junction, the same technique can be employed if the patient is extremely slim; in most cases, however, the practitioner will need to take hold of the cervicothoracic junction with both hands and rotate the soft tissue around a vertical axis. Here it is also possible to perform a wringing action with one hand against the other. In each case, the barrier is engaged and then release is obtained. Treatment of the extremities proceeds in a similar fashion. Soft-tissue rotation about a longitudinal axis can be tested and treated; once the (pathological) barrier has been reached, a wringing
Figure 6.62 • Shifting the fascia laterally around the thorax: (A) performed by the practitioner; and (B) performed as selftreatment.
For diagnosis, the practitioner examines the mobility of different scalp areas in different directions in relation to the skull beneath and compares the two sides. Here, too, pathological barriers can be identified: once the slack has been taken up, the typical release phenomenon follows. Examination is generally performed using the pad of a single finger although this may easily slip off the patient’s hair. The practitioner supports the patient’s head with his non-palpating hand.
Fascia at the neck and the extremities The soft tissue (fascia) at the neck and in the cervicothoracic region can be examined and treated by 234
Figure 6.63 • Rotational movement of the soft tissue (fascia) at the neck.
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movement is performed with both hands in opposite directions. The commonest pathological barriers are detected around the elbow, wrist, knee, and ankle.
Heel pain In cases of painful calcaneal spur, it may be found that at least in one direction the soft-tissue pad at the heel is less readily shifted than on the other side. As soon as the practitioner detects the pathological barrier, he takes up the slack and then overcomes the resistance to restore normal tissue mobility. Usually it is necessary to apply strong (lateral) pressure in the immediate vicinity of the bone using both thumbs while fixing the heel with the other fingers (see Figure 6.64). In cases of heel pain around the attachment point of the Achilles tendon, the soft tissue between the tendon and the bones of the lower leg is tender to the touch. In such cases, this tissue must be folded and stretched between the fingers. For this, the patient is prone with the knee flexed. The practitioner stabilizes the patient’s lower leg against his body. He applies pressure with the finger of one hand just above the heel and with the thumb of his other hand a few centimeters further proximally. He then repeats the procedure in the opposite direction (see Figure 6.65). For this, it is necessary to position the thumb flat because there is only minimal space between the Achilles tendon and the tibia. After the slack has been taken up, the fold will stretch during release.
Figure 6.65 • Folding and stretching the soft tissue between the Achilles tendon and the tibia (A) laterally and (B) medially.
6.4.5 Mutual shifting of metacarpal and metatarsal bones
Figure 6.64 • Shifting the soft-tissue pad at the calcaneus.
In radicular syndromes radiating to the fingers (or toes), stretching is not limited only to the skin between the fingers (toes); generally there is also increased resistance (‘bind’) if we try to move one metacarpal (metatarsal) bone against the next, in a dorsopalmar (dorsoplantar) direction. This resistance does not stem from any joint but from the soft tissue between the individual bones. As soon as the practitioner detects increased resistance compared with the other side, he uses a pincer hold (see Figure 6.7) to engage the barrier, and once the slack has been taken up, he waits for release. 235
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The restricted fibular head can be treated in the same way and for the same reasons (see Section 6.1.2, Figure 6.25).
6.4.6 Painful periosteal points Pathological barriers are also encountered at painful periosteal points, most frequently in the vicinity of attachment points of ligaments and tendons; these barriers are characterized by restriction of subperios teal tissue on shifting, in at least one direction. It is always necessary to make a comparison with a symmetrical painless area on the non-affected side. Thus, on examination of the epicondyles, it is normally possible to shift the soft tissues easily in all directions; however, when pain is present, shifting is generally restricted in at least one direction. This signals the presence of a pathological barrier, which is indicated by an abrupt end-feel that is devoid of springing. Once the barrier has been engaged, release can be obtained after a brief latency period. After mobilization, the patient experiences relief from pain. Shifting always occurs in a tangential direction and is therefore painless. Pressure is never applied directly to the periosteal point itself (see Figure 6.66). This technique is also important, for example, in cases where the spinous processes are painful, particularly in the lower lumbar region in hypermobile patients. It is worth emphasizing that the pain point on the spinous process is never precisely in the midline, but always slightly to one side. On the side of painful tenderness, deep pressure ventrally (i.e. parallel to the spinous process) will encounter greater resistance than on the non-painful side. These areas
Figure 6.66 • Shifting the subperiosteal soft tissue at painful periosteal points.
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represent painful attachment points of the short intervertebral muscles. Accordingly, the practitioner takes up the slack using downward pressure applied with a fingertip; as the pressure is held, release is obtained. In the very frequently encountered condition where the spinous process at the axis is tender, the pain point is also located to one side; this is revealed by axis rotation following side-bending of the patient’s head to the non-painful side. In this case it is usual for the mobility of soft tissue to be clearly restricted in a caudal or cranial direction. Therefore the practitioner fixes the patient’s head in side-bending, with his free hand palpates the pain point lateral to the spinous process, and takes up the slack in the direction of the restriction. Release is obtained after a brief latency period. The procedure is repeated and the pain is usually found to have been alleviated. Another extremely common pain point is at the PSIS, a lateral projection on the iliac crest that runs obliquely in a ventral direction. Soft-tissue mobility in this direction is tested and treated tangentially. A similar procedure may be followed for the pes anserinus and the styloid process of the radius, etc.
6.5 Self-mobilization A crucial factor contributing to the successful outcome of manual therapy and, in the broader sense, of rehabilitation is the patient’s active cooperation in the therapy. It is in this setting that predominantly passive therapy is transformed into a learning process. Even in the neuromuscular mobilization techniques, the patient’s role is not merely a passive one; however, the patient’s activity unfolds in response to the precise instructions and prompting of the practitioner. The next step on from this emerges with compelling logic: what patients can do in response to the practitioner’s instructions, they should surely be able to learn to do for themselves. And here we have the seamless transition from therapy to rehabilitation. Ultimately, the locomotor system is the organ of active movement, and for that reason alone, normal and painless active movement is the key criterion for treatment success. It is, of course, nothing new to use our own muscles to stretch and limber up if we are feeling stiff. Engaging in forceful, non-specific movements is frequently problematic and may do more harm
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than good. Movement restriction is routinely associated with muscle spasm that specifically protects the lesioned motion segments. Forceful movement suddenly applied to those segments is likely only to increase spasm, with the actual end result being that the normal and even the hypermobile segments are mobilized, while the lesioned segments are fixed even more firmly by muscle spasm. Self-mobilization techniques must therefore be gentle and slow (as in passive techniques after the slack has been taken up) and as specific as possible. Precise diagnosis (location) is mandatory, as is careful work to establish the indication for treatment.
6.5.1 Self-mobilization by stretching It is entirely possible for the patient to stretch an area of skin, and to fold and stretch the subcutaneous tissue, provided that the HAZ is within reach of the hands. It should also be possible for the patient to rotate or wring the deep fascia at the extremities, and around the neck and thorax. The scalp and heel are other areas that are accessible to self-treatment. The same is true for periosteal points. However, self-treatment of the deep fascia on the back is problematic. The literature contains accounts of a wealth of stretching exercises (Anderson, 1980), and good fixation is an absolute prerequisite for these. Two such techniques will now be described. To stretch the lateral fascia on the trunk, the patient stands with legs apart and one arm raised and flexed behind her neck. With her other hand she takes hold of the raised elbow behind her neck and draws her entire trunk into side-bending to take up the slack (see Figure 6.67). She then looks up and breathes in, causing resistance to side-bending to increase. After breath-holding she looks down, breathes out, and simultaneously increases sidebending by pulling on her elbow. This procedure can be repeated. A similar technique is also suitable for the cervical region. The seated patient stabilizes herself with one hand holding the edge of the treatment table or a chair to fix her shoulder; with her other hand she reaches over the top of her head and, tilting it slightly forward, draws it sideways to take up the slack (see Figure 6.68). She then looks up, breathes in, and breath-holds for a short time, causing the tension to increase. She then looks down, breathes out, and draws her head further sideways.
Figure 6.67 • Stretching the lateral fascia and muscles of the trunk.
Figure 6.68 • Stretching the lateral soft tissue of the neck, including the trapezius.
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6.5.2 Self-mobilization of the sacroiliac joints Sachse’s technique for self-mobilization The patient is on all fours close to the edge of the treatment table. One of her knees hangs over the edge of the table, and her instep on that side is hooked over her other leg just above the heel. In this position, if she is properly relaxed, the weight of the overhanging leg with the pelvis brings pressure to bear on the supporting knee and, via the thigh and hip joint, causes the slack to be taken up in the sacroiliac joint on the supported side (see Figure 6.69). The moment the well-relaxed patient senses tension in the region of her sacroiliac joint, she makes a very small downward springing movement with her knee hanging over the edge of the treatment table, moving in a vertical direction, thus amplifying the feeling of tension in the sacroiliac joint when she moves up. This mobilizes the sacroiliac joint on the supported side. In terms of technique, it is important that the patient lifts only very little so as to avoid trunk rotation.
Self-mobilization in the side-lying position The patient is side-lying on her non-lesioned side with her underneath leg extended and her uppermost leg flexed approximately at right angles at the hip and knee (which is resting on the padded surface
Figure 6.70 • Self-mobilization of the sacroiliac joint in the side-lying position.
of the treatment table). She now places the heel of her upper hand on her ASIS and exerts light pressure in the direction of mobilization to take up the slack (see Figure 6.70). Self-mobilization is now performed in exactly the same way as if it were being done by the practitioner, that is using rhythmic springing pressure in a ventrocranial direction using minimal force at a rate of about two per second. Even though this technique appears to be straightforward, it is often difficult to make the precise direction of the hand movement clear to the patient. For anatomical reasons alone it is not possible for her to align her forearm with the direction of springing pressure. It can therefore be helpful if she uses her other hand to reinforce the action of the hand originally placed on the ASIS, and if it is explained to the patient that the direction of springing is in fact along the line of the forearm of the reinforcing hand. It has further been shown that self-mobilization by the patient is only achieved if she contracts her brachial biceps, that is if she flexes the elbow of the arm that is uppermost.
6.5.3 Self-mobilization of the lumbar spine Self-mobilization of the lower lumbar spine into anteflexion and retroflexion
Figure 6.69 • Self-mobilization of the sacroiliac joint on the side of the supported knee (Sachse’s method).
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The patient sits back on her heels with arms stretched forward and supporting herself on her hands resting on her knees. By contracting her gluteal muscles, she raises her pelvis, producing
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the motion segment to be treated using the radial edge of the forefingers of both hands; or she may fix the lower vertebra of the motion segment to be treated using the tips of her thumbs. Using the fixation point of her hands as a fulcrum, she then very specifically performs rhythmic repetitive movements into retroflexion or side-bending (see Figure 6.72). Fixation from above (by the forefingers) is indicated if there is hypermobility above the segment to be treated, and from below (by the thumbs) if there is hypermobility below the segment to be treated. Therefore the lumbosacral segment (L5/S1) is always fixed from above, and the thoracolumbar junction is always fixed from below. Forceful movements of large range must be avoided.
Self-mobilization of the lumbar spine (McKenzie techniques)
Figure 6.71 • Self-mobilization of the lumbar spine: (A) anteflexion; (B) retroflexion.
kyphosis of the lower lumbar spine. When she relaxes, her pelvis tilts forward, producing lordosis at the lumbar spine (see Figure 6.71). This exercise (raising the pelvis using the gluteal muscles) is also very helpful as preparatory training for standing correctly.
Self-mobilization of the lumbar spine into retroflexion and side-bending Fixation is absolutely crucial for this exercise. The patient may either fix the upper vertebra of
Techniques elaborated by McKenzie (1981) can be used here in simplified and modified form; these are especially effective in intervertebral disk herniation, irrespective of whether we are dealing merely with low-back pain or with radicular pain. Only the simplest techniques will be described here because, in our opinion, these are the only ones that can be mastered by patients in a selftreatment setting. Of fundamental importance here is the frequency with which the patient needs to exercise: sets of ten repetitions, ten times daily for exercises into extension, and sets of ten repetitions but only five times daily for exercises into flexion. For the exercise into extension, the patient is prone and raises his trunk with arms straight while moving his pelvis up as little as possible from the treatment table (once his arms are straight, he stops; see Figure 6.73A). If the pain is acute, he should raise his trunk only as far as is bearable. However, if he is comfortable in the lordotic posture with arms straight, he can intensify the effect by exhaling deeply (synkinetic contraction of the erector spinae muscles during exhalation in lordosis). He can also practice retroflexion in the standing position, as in Figure 6.72A, the difference being that he fixes his buttocks with the palms of both hands. For the exercise into flexion, the patient is seated on a chair in such a way that on anteflexion he takes hold of a chair leg with both hands between 239
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Figure 6.72 • Self-mobilization of the lumbar spine, with fixation from above (A) into retroflexion and (B) into side-bending; and with fixation from below (C) into retroflexion and (D) into side-bending.
his own spread legs. Then, by flexing his elbows, he rhythmically and repetitively daws himself down into anteflexion (see Figure 6.73B). It is important to take due note of McKenzie’s instructions, especially in the event of radicular syndromes: according to McKenzie, pain during and after the exercise should not project into peripheral regions, that is from the gluteal region distally. However, the patient may continue if the pain is ‘centralized’ from the periphery, that is if it is projected proximally. 240
6.5.4 Self-mobilization of the thoracic spine and ribs Retroflexion self-mobilization The patient is seated upright with arms abducted and flexed at the elbows. Sitting absolutely upright – including her head – she rotates her upper arms dorsally with the help of her forearms, producing extension of the mid-thoracic spine without
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Chapter 6
Figure 6.74 • Retroflexion self-mobilization of the thoracic spine.
Figure 6.73 • Self-mobilization of the lumbar spine
(McKenzie technique): (A) into extension and (B) into flexion.
dorsal flexion of the thoracolumbar segment (see Figure 6.74). In this position, she slowly breathes in and then out as far as she can, thus activating her abdominal muscles and forming a fixed point around the xiphoid process that prevents any retroflexion of the trunk. She can also perform the exercise standing and leaning against a wall, pressing her pubic symphysis forward in the process. At this point, it will be helpful to recall the technique used to mobilize the thoracic spine in the seated position (see Figure 6.38). This may be used for self-treatment but is only indicated if thoracolumbar hyperextension does not occur simultaneously.
Anteflexion self-mobilization on inhalation The patient sits on her heels and lays her upper body forward over her knees so that her forehead
Figure 6.75 • Anteflexion self-mobilization of the thoracic
spine on inhalation, with the patient sitting on her heels and in maximum anteflexion.
is resting on the padded surface of the treatment table. Her arms are held straight at her sides (see Figure 6.75). In this position, the patient consciously breathes into her back: she will quickly learn how to direct her breathing specifically into the restricted segment. This can first be checked by the practitioner by inspection or palpation and then by the patient using her own fingers.
Self-mobilization of the upper ribs on inhalation Where there is movement restriction (stiffness) of the upper ribs, the patient sits bending forward and turns her head toward the side to be mobilized, while 241
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backward, together with the spinal segment that is above this fulcrum (see Figure 6.77). In this setting, it is important that the movement is not performed like anteflexion or retroflexion but that the patient’s head moves horizontally forward and backward. In terms of mobilization, it is only the backward movement that is important; the forward movement should be only minimal.
Figure 6.76 • Self-mobilization of the upper ribs on inhalation with head rotated.
looking up as far as she is able to (see Figure 6.76). She lets one arm hang down between her knees (which are slightly apart) while the other hangs down at her side. In this position, the upper ribs on the side to which the patient’s head is turned bulge slightly and the slack is taken up. The patient performs mobilization by breathing specifically into those ribs.
Self-mobilization of the thoracic spine in rotation This technique is identical to the relaxation selftreatment method for the thoracolumbar erector spinae, quadratus lumborum, or psoas major, which are in a chain reaction pattern (see Section 6.6.4).
6.5.5 Self-mobilization of the cervicothoracic junction and first rib Forward and backward movement of the upper thoracic spine and cervicothoracic junction The seated patient leans against a chair back in such a way that the lower vertebra of the restricted motion segment to be treated is fixed in a stable position. She then moves her head forward and 242
Figure 6.77 • Self-mobilization of the upper thoracic spine
and cervicothoracic junction by (A) forward and (B) backward movement of the head, with the back supported at the lower vertebra of the segment to be treated.
Therapeutic techniques
Rotation self-mobilization at the cervicothoracic junction (according to Gaymans) Internal and external rotation of the arms outstretched to the sides has some mobilizing effect on the cervicothoracic junction. This effect is considerably enhanced if the two arms are rotated in opposite directions, that is one from supination into pronation and the other from pronation into supination. However, this alone is not enough. The exercise becomes very effective if the head is also rotated simultaneously, in the same rhythm as the arms and preferably toward the hand that is rotating into pronation (thumb pointing downward). Care must be taken not to lift the shoulders, and for this reason the patient’s arms should not be horizontal but slope down at a slight angle (see Figure 6.78). This technique is performed energetically and is not well tolerated by patients with a flat (hypermobile) upper thoracic spine.
Figure 6.78 • Rotation self-mobilization at the
cervicothoracic junction, by a combination of arm rotation in opposite directions and head rotation in the direction of the pronated forearm.
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Self-mobilization of the first rib The technique for self-mobilization of the first rib is identical to the mobilization technique according to Gaymans (1973) (see Figure 6.50). The patient offers isometric resistance with her head against the gentle repetitive lateral pressure delivered rhythmically by her hand at a rate of two pushes per second.
6.5.6 Self-mobilization of the cervical spine Side-bending self-mobilization The patient is seated upright. Using her hand on the side toward which she intends to bend as a fulcrum, she reaches over her head to the opposite side and side-bends her head with a minimum of force to take up the slack. She then looks up and breathes in slowly, holds her breath, looks down while breathing out, and relaxes into side-bending. For RI she side-bends actively against repetitive
Figure 6.79 • The patient sits upright and bends her
head with her left hand to the right over her right hand as a fulcrum. She first looks up and breathes in, breath-holds, then looks down and relaxes into side-flexion.
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Figure 6.80 • The patient side-bends actively against repetitive moderate resistance by her hand.
moderate resistance applied by her own hand (see Figures 6.79 and 6.80).
Anteflexion and retroflexion self-mobilization between occiput and atlas For the atlanto-occipital joints the exercise involves a nodding movement. Standing or sitting upright, the patient turns her head to the side so as to lock the cervical spine. In this position she executes a nodding movement by dropping her head toward her larynx and then lifting it (see Figure 6.81A and B). As soon as she has engaged the barrier (taken up the slack) in one or other direction, she facilitates an additional brisk nodding movement downward by looking down and exhaling quickly, or upward by looking up and inhaling quickly (through her nose). PIR of the sternocleidomastoid is also recommended (see Figure 6.96). The following very effective and simple technique is based on activation of the deep stabilizing muscles of the upper cervical spine: the patient is seated upright and places her two hands from either side on the crown of her head. She then exerts slight but very rapid, centered pressure on her head in the direction of the axis of the cervical spine. Care must be taken to avoid anteflexion– retroflexion and laterolateral flexion: there should be only slight vertical springing (see Figure 6.81C). 244
Figure 6.81 • Self-mobilization of the craniocervical
junction with head rotated to the side using a nodding movement (A) into anteflexion and (B) into retroflexion. (C) Self-mobilization by slight but fast shaking pressure of both hands with the arms abducted in the direction of the axis of the cervical spine.
Therapeutic techniques
6.5.7 Self-mobilization of the extremity joints Obviously, the patient can also perform self-mobilization of peripheral joints, especially in the lower extremities, because both hands are free. This possibility has already been alluded to in Sections 6.1.2 and 6.1.3 for some patient categories. Only a few instances will therefore be outlined here.
Self-applied traction of the carpal bones The patient sits with her legs crossed and fixes her forearm on her thigh. With her free hand she takes hold of one carpal or metacarpal bone (depending on which she wishes to treat) between her thumb and forefinger and performs traction in a distal direction (see Figure 6.82).
Traction of the fingers Using the little finger of her other hand the patient grasps the distal phalanx of the finger to be treated,
Figure 6.82 • Self-applied traction of the carpal bones.
Chapter 6
while with her thumb and forefinger she takes hold of the first phalanx or the first metacarpal bone. This technique can be used both for traction as well as for mobilization of metacarpophalangeal joints II–V and of the carpometacarpal joint of the thumb.
Self-mobilization of the elbow in a radial direction The standing patient grasps the edge of the treatment table, with her arm held vertically and stretched in supination so that her thumb lies parallel with the edge of the table. Her other hand grasps her elbow from the ulnar side and produces mobilization there by gentle rhythmic springing or by a fast shaking movement in a radial direction (see Figure 6.83).
Self-applied traction at the shoulder Traction at the shoulder can also be performed as PIR over the padded back of a chair, provided that the chair back is softly padded and supports the side
Figure 6.83 • Self-mobilization of the elbow in a radial direction.
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longitudinal axis of the arm until the slack is taken up. She then resists her own traction, breathes in slowly, breath-holds, and then relaxes as she breathes out. This procedure can be repeated at least three times.
Self-mobilization of the knee The patient is seated on a low chair or stool and stabilizes her slightly abducted leg on her foot, which is first in external rotation and then in internal rotation. When the foot is in external rotation, the patient takes hold of her knee with her opposite hand placed medially, takes up the slack using light lateral pressure, and shakes her knee in a lateral direction (see Figure 6.84A). When her foot is in internal rotation, she takes hold of her knee with her hand on the same side placed laterally. After taking up the slack using pressure directed medially, she performs shaking mobilization in a medial direction (see Figure 6.84B). Shaking should never be forceful but should be at a frequency that produces rapid, rhythmic, spontaneous springing of the joint.
6.6 Post-isometric relaxation and reciprocal inhibition 6.6.1 Basic principles
Figure 6.84 • Self-mobilization of the knee by shaking
(A) laterally with the foot in external rotation, and (B) medially with the foot in internal rotation.
of the patient’s thorax and not the axilla. Using her non-lesioned hand, the patient takes hold of her other forearm and applies light traction along the 246
Post-isometric relaxation (PIR) techniques as well as reciprocal inhibition (RI) have already been alluded to in the context of mobilization techniques in Section 6.1. The method forms a connecting link between therapy and rehabilitation: it is simultaneously the specific therapy for muscle spasms, especially of TrPs, but always presupposes activity on the part of the patient. All the techniques presented in this section have been selected because they may also serve as self-treatment methods. It has already been mentioned that Mitchell et al (1979) use muscle facilitation and inhibition in their muscle energy technique for joint mobilization. Nothing was therefore more logical than to use the method in muscle dysfunctions. However, this is at variance with what Mitchell et al originally wrote: ‘When isometrics are used for joint mobilization, maximal contractions are not desirable since they tighten, or freeze, the joints. Moderate
Therapeutic techniques
contractions are much more appropriate for joint mobilization … However, when a muscle or its fascia must be stretched, powerful isometric contractions are useful …’ Experience indicates, however, that the use of a minimum of force during isometric contraction is also much more advantageous in the treatment of TrPs. Therefore, as for relaxation, we proceed as follows: the muscle is first stretched only as far as is possible without meeting any resistance. In the (extreme) position thus gained, the patient is instructed to resist with a minimum of force and (in the case of the muscles of the trunk) usually to breathe in. This resistance is held for 5–10 seconds, after which the patient is told to let go and breathe out slowly. After a brief wait, the practitioner will sense that the muscle is de-contracting or lengthening, thus allowing a new end position to be reached. This phenomenon can be utilized for as long as the muscle continues to lengthen purely due to the patient’s own relaxation. This phase may last for 10 seconds, but also for longer than 30 seconds. The process should never be cut short because it is crucial for the therapeutic effect. If relaxation proves to be unsatisfactory after the isometric tension phase, the isometric phase can be prolonged, sometimes to as much as half a minute. However, if good relaxation is achieved at the first attempt, the isometric phase may be shortened. The procedure can be repeated depending on how well the patient relaxes. If relaxation is good, the practitioner will sense how the tension ‘melts away’ so to speak.
It is not possible for the practitioner to relax the patient; this is something that the patient must do. In this process the muscle also stretches (spontaneously). As soon as the muscle is being stretched by the practitioner, it is no longer legitimate to call it relaxation (PIR).
Wherever possible, PIR should be enhanced by methods that utilize inhalation and exhalation, direction of gaze, and gravity for resistance (as advocated by Zbojan (1984)). At this point we would reiterate what has already been said concerning the combination of mobilization techniques. Instructions that determine direction (e.g. of gaze, pressure) should precede breathing instructions, so as to prolong the process. When gravity-induced
Chapter 6
relaxation is used alone, the contraction and relaxation phases should each last for 20 seconds. This approach can be used as self-treatment right from the outset. When combining PIR with inhalation and exhalation, it is important that both inhalation and exhalation should be of sufficient duration, if possible 10 seconds or longer. To achieve this it is recommended that once inhalation (and sometimes also exhalation) has ended, the patient should breath-hold to slow the respiratory rhythm. PIR is routinely combined with RI. For this there are two options: one involves the technique developed by Ivanichev (1997) in which the patient performs a forceful movement of maximal excursion in the direction into which relaxation is intended. In the other option, the patient makes a movement using only a minimum of force against rhythmic repetitive resistance from the practitioner. Maximal forces are also undesirable here because they can easily lead to a ‘duel’ between patient and practitioner in which the practitioner may actually come off worse. Rhythmic repetitive resistance achieves the same inhibiton as one-off maximal resistance. The effect of treatment can be ascertained not only in the muscle (TrP) treated, but also at its attachment point as well as at the attachment points of ligaments which transmit the tension. Often the discomfort in question will be referred pain, which has a tendency to react favorably. TrPs that are significant for the pathogenesis also give rise to chain reaction patterns (see Section 4.20) involving multiple TrPs and movement restrictions, and hence treatment can have a significant distant effect. The method is also highly specific: in broad, fanshaped muscles the forces need to be directed precisely at the muscle bundles that harbor TrPs, and also at the attachment point that belongs with the muscle bundle, for example where the attachment point of the pectoralis muscle to a rib is painful. Hence one common reason for failure is insufficient specificity. This method is inappropriate where there is no increased muscle tension (e.g. at painful hypotonic pain points in the fibromyalgia syndrome). The same naturally applies in situations where the treated TrP itself is a secondary phenomenon and its cause remains untreated. With regard to the theory underlying this physiologically highly effective method of muscle relaxation, it is suspected that what we are dealing with here is not simple Sherrington-type inhibition. 247
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The latency periods are far too long for this. The patient is responding after all to verbal instructions. This is also the case with Kabat inhibition, which is why a simple spinal reflex is hardly worthwhile considering. As described here, the effect of PIR may be due to the fact that:
• when minimal force is used, only those muscle fibers contract that have a low stimulus threshold, as is the case in muscle TrPs • and consequently, we avoid the stretch reflex, which always comes into play with passive stretching – even of a gentle variety.
It may even happen that the patient experiences some pain during relaxation, even though the range of movement increases during relaxation, for example during PIR in ligament pain. Despite this, the pain disappears once PIR is complete. PIR impressively demonstrates how tension is associated with pain, and relaxation with the absence of pain. PIR is also comparable with the ‘spray and stretch’ method of Travell (1952) but places greater emphasis solely on relaxation while refusing to accept any stretching (even of a gentle variety). The cold spray evidently causes transient inhibition of the stretch reflex and therefore stretch is not an interfering factor here. Indeed, stretch is by no means an essential component of relaxation, as demonstrated by many techniques that utilize gravity, and in relaxation of the gluteus maximus muscles (see Section 6.6.5). It has been found that stretch need not necessarily occur at all; it serves rather as clinical proof of successful relaxation. Passive stretching is indicated in situations where the connective tissue element of the muscle is shortened, that is where the muscle sheaths – the connective tissues encasing the muscle bundles and fascia – are involved. PIR acts on the contractile elements in muscle. This effect has been documented in 351 muscle groups in 244 patients (Lewit & Simons 1984); an immediate analgesic effect was detected in 330 muscle groups, while no effect at all was recorded in 21 patients. As stated previously, some TrPs do not respond to methods that operate using reflex pathways, and also fail to respond when chain reaction patterns are treated. These would appear to be no longer functionally reversible. In such cases treatment then consists of traumatizing massage or needling in which it is important to ‘hit’ the maximally painful points and, where possible, also to produce a twitch 248
response. Usually these are not just single points, for which reason we do not recommend injecting local anesthetics. With needling it is possible to ascertain with the needle still in situ that the TrP has been eradicated and is no longer painful. The following sections provide precise descriptions of techniques that can be used to diagnose and treat functionally reversible TrPs in the individual muscles.
6.6.2 Muscles of the head and neck Masticatory muscles Increased tension in the masticatory muscles is present if the patient is unable to insert three knuckles between the upper and lower rows of incisors with mouth wide open. Tenderness of the temporomandibular joint (TMJ) is also routinely found on palpation. TrPs in the temporalis can be palpated in the temporal region, those in the masseter through the cheeks, those in the internal pterygoid behind the ramus of the mandible, and those in the external pterygoid inside the mouth above the wisdom teeth. TrPs here are particularly common and intensely painful. PIR to relax all of these muscles is performed as follows: the patient is supine with her head at the end of the treatment table. The practitioner fixes the patient’s forehead with one hand and places her other hand on the patient’s chin. She takes up the slack by opening the patient’s mouth to a moderate degree (see Figure 6.85). The following respiratory synkinesis is then used: during (slow) exhalation
Figure 6.85 • PIR (RI) of the masticatory muscles.
Therapeutic techniques
there is an automatic increase in resistance to mouth opening. At this point, however, the patient is told to take a deep breath while energetically opening her mouth wide, as when yawning. The procedure is repeated two or three times. In this instance active mouth opening also provokes RI.
Self-treatment For self-treatment the patient sits at a table, with one elbow on the table and the same hand supporting her forehead; the fingers of her other hand are resting on her lower incisors (see Figure 6.86). After opening her mouth to take up the slack, she first breathes out; during deep inhalation she then opens her mouth as wide as possible. The hand at her forehead should prevent anteflexion of her head, which would interfere with maximum mouth opening. However, her head should also not tilt backward.
Chapter 6
by shifting the thyroid cartilage from side to side; resistance is greater on the side where the digastricus is tense. If tension is marked, then deviation of the cartilage to the tense side may even be visible, as may a depression in the floor of the mouth on the tense side and a flattening on the other side. For PIR the patient should be supine; with one hand placed below the patient’s chin the practitioner should resist mouth opening while the thumb of her other hand is placed laterally against the patient’s hyoid and palpates resistance (see Figure 6.87A). During the isometric phase the
Digastricus The main antagonists of the masticatory muscles are the muscles at the floor of the mouth, principally the digastricus. Examination is most readily performed
Figure 6.86 • PIR (RI) of the masticatory muscles (self-treatment).
Figure 6.87 • PIR of the digastricus: (A) treatment; (B) self-treatment.
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patient opens her mouth against the resistance applied by the practitioner’s hand under her chin, breathes in, breath-holds, and then relaxes and breathes out. In this process the patient’s mouth will close and the practitioner will sense how lateral resistance at the hyoid subsides. It is therefore necessary prior to PIR to palpate the hyoid bone. While she must be able to feel the tension and relaxation, the practitioner must never poke about with her thumb at the hyoid.
Self-treatment For self-treatment of the digastricus the patient is seated with one elbow supported on a table and her chin cupped in the same hand. The thumb of her other hand lies lateral to the hyoid on the tense side (see Figure 6.87B). Against the resistance of her chin against her hand, she opens her mouth, breathes in, breath-holds, and then relaxes while breathing out. The procedure is repeated two or three times.
Mylohyoid If there is increased tension in the mylohyoid muscle at the floor of the mouth, the following selftreatment method is indicated. The patient presses the tip of her tongue against her hard palate, breathes in, and lets her tongue drop back while breathing out.
External pterygoid For specific treatment of the external pterygoid muscle the patient is supine with her mouth only slightly open. From above, the practitioner places both thumbs on the patient’s chin (see Figure 6.88A). The patient is then told to push her chin forward and breathe in while the practitioner offers resistance at the chin. She is next instructed to hold her breath, let go and then breathe out.
Self-treatment For self-treatment the patient places her thumbs on her chin (see Figure 6.88B). She then pushes her chin against the resistance of her thumbs and breathes in. After holding her breath, she relaxes as she breathes out. 250
Figure 6.88 • PIR of the external pterygoid: (A) treatment; (B) self-treatment.
Short extensors of the craniocervical junction Palpatory examination of these muscles is possible only with the patient supine and her head slightly raised. For treatment, the practitioner stands behind the seated patient and places both thumbs behind the patient’s head below the occiput, with her fingers up over the zygomatic bones. The patient is then told to look up and breathe in deeply as the practitioner resists the (automatic) retroflexion of the head (see Figure 6.89). Afterward the patient is instructed to hold her breath, look down, and breathe out slowly. This must not produce anteflexion of the entire cervical spine but merely a nodding movement. Consequently, the practitioner allows the patient’s supported head and upper body to drop slightly back and down without letting the
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Chapter 6
Figure 6.89 • Treatment of TrPs in the short extensors of
the craniocervical junction: (A) resistance with upward gaze; (B) forward nod with downward gaze.
head fall forward. The procedure is repeated from the newly gained position. For RI the patient is asked to nod her head forward as the practitioner offers rhythmic repetitive resistance.
Self-treatment For self-treatment the seated patient stabilizes her occiput from below with her fingers and her zygomatic bones from above with her thumbs. Using both hands she makes a slight nodding movement to take up the slack (see Figure 6.90A). She then looks up and breathes in, holds her breath, then leans back against the back rest of the chair, looks down, breathes out, and gives a forward nod while doing so (see Figure 6.90B).
Levator scapulae The typical TrP lies in the angle between neck and shoulder. Further pain points are located at the
Figure 6.90 • Self-treatment of TrPs in the short extensors of the craniocervical junction: (A) resistance with upward gaze; (B) forward nod with downward gaze during retroflexion.
superior angle of the shoulder blade and on the lateral surface of the spinous process of the axis. For treatment, the patient is supine with her head at the top end of the treatment table and the elbow of her flexed arm raised beyond her head. The practitioner exerts pressure on the patient’s shoulder 251
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blade by pressing in a caudal direction against the elbow, fixing the elbow in this position with the thigh in order to take up the slack in the levator scapulae. Using both hands the practitioner moves the patient’s head to the opposite side until light resistance is encountered. This is felt sooner on the side of increased tension than on the other side. The practitioner then simultaneously raises the patient’s head a little and turns it to the same side (see Figure 6.91A). The patient is instructed to look toward the side that
is being treated and slowly breathe in, then to hold her breath, let go and breathe out. During the ensuing relaxation the practitioner moves the patient’s head to the opposite side until light resistance is again encountered. The procedure is repeated. If, as is not infrequently the case, the patient cannot raise her arm as the above technique requires, then the practitioner may employ the method described by Sachse, which can also be used to test for muscle shortening. With the patient supine, the practitioner uses the palm of one hand to draw the patient’s shoulder caudally so as to fix it and positions her fingertips at the attachment of the levator scapulae at the superior angle of the shoulder blade. She places her other hand round the patient’s neck, raises the head into anteflexion, and produces side-bending above C4 to the opposite side until she feels tension at the muscle attachment point (see Figure 6.91B). The patient is then instructed to look toward the side of the tense muscle and breathe in slowly, hold her breath, then let go and breathe out. The procedure is repeated.
Upper part of the trapezius Painful TrPs can be readily palpated along the entire length of the upper part of the trapezius. For treatment (and for examination), the patient is supine: the practitioner fixes the patient’s shoulder from above with one hand, while side-bending the head and neck with her other hand to take up the slack (see Figure 6.92). She then instructs the patient
Figure 6.91 • Examination and PIR of TrPs in the levator
scapulae (A) with fixation of the shoulder blade via the patient’s elbow pushed caudally by the practitioner’s thigh, and (B) with fixation of the shoulder using Sachse’s method.
252
Figure 6.92 • Examination and PIR of the upper part of the trapezius.
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to look in the direction of the stabilizing hand and breathe in slowly, then breath-hold, let go and breathe out. During relaxation the practitioner takes the patient’s head further into side-bending until the slack is taken up again, and the procedure is repeated. For RI the patient exerts pressure with her head toward the side of the tense muscle while the practitioner offers rhythmic repetitive resistance.
Self-treatment For self-treatment of both the levator scapulae and the upper part of the trapezius, gravity-induced PIR is most effective. The patient sits against a low chair back with both arms hanging down over and behind it, to ensure as upright a posture as possible. In this position she looks up, raises her shoulders, breathes in (see Figure 6.93A), holds her breath and looks down, lets her arms drop, and breathes out slowly (see Figure 6.93B). This procedure is repeated several times. For RI the patient exerts downward pressure with both arms toward the floor.
Scalenes While tension of the scalenes causes minimal direct pain, it is of great clinical significance. As a rule the scalenes are involved in tension of the other upper fixators of the shoulder girdle; they play a decisive role specifically in the faulty clavicular breathing pattern that is characterized by lifting of the thorax during inhalation. Tension in the scalenes leads to tension in the pectorals with pain points in the region of the sternocostal joints. This is often accompanied by a sensation of tightness that subsides after the scalenes have been treated. In restriction dysfunction of the first rib the scalenes develop reflex tension and this is one contributing cause of the thoracic outlet syndrome (see Section 7.5.2). The site of the typical TrP in the scalenes corresponds to Erb’s point and usually responds to PIR. Tension in the scalenes causes restriction of retroflexion of the rotated head to the opposite side. If there is marked cervical lordosis, tension of the scalenes may even restrict side-bending of the head, simulating increased tension in the trapezius. For examination, as for treatment, the practitioner stands behind the seated patient, using her body to support the patient’s shoulder on the side to
Figure 6.93 • PIR of the levator scapulae and the
trapezius: (A) with shoulders raised, looking up, and breathing in; (B) with shoulders relaxed, looking down, and breathing out.
be examined (treated), and with one hand fixing the upper ribs on the same side. With her other hand she tilts the patient’s head (turned to the opposite 253
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Figure 6.94 • Examination and PIR of the scalenes.
side) slightly backward so as to take up the slack (see Figure 6.94). The patient is then told to look up and to the side and to breathe in. As the patient breathes in, the practitioner offers powerful resistance with her hand placed on the patient’s ribs, while her other hand at the side of the patient’s head offers only minimal resistance. As the patient breathes out, she looks to the opposite side and allows her head to drop into retroflexion. Considerable relaxation generally occurs spontaneously with the result that it is rarely necessary to repeat the procedure.
Self-treatment Self-treatment of the scalenes is possible provided that the faulty clavicular breathing pattern characterized by thoracic lifting is not being treated simultaneously. For this the patient lies on her side, raising her head from the padded cover of the treatment table, and breathes in slowly (see Figure 6.95A). She then holds her breath, allows her head to sink back (under gravity) to the treatment table while breathing out, and then repeats the exercise (see Figure 6.95B). For RI the patient exerts strong pressure with her head against the padded cover.
Sternocleidomastoid TrPs are almost invariably detected (using a pincer grip) along the course of this muscle in dysfunctions of both the cervical region and the orofacial region; these are associated with pain that is referred to the cranium and face. There is frequently also a 254
Figure 6.95 • Self-treatment of the scalenes: (A) with head raised, looking up, and breathing in; (B) with head on the treatment table, looking down, and breathing out.
pain point at the transverse process of the atlas; painful attachment points may be detected medially at the clavicle and at the mastoid process. The muscle develops TrPs in response to most disturbances involving the head, neck, and even the cervicothoracic region, and it is a good indicator of untreated dysfunctions in this whole territory. To treat this condition, use is made of gravityinduced PIR and respiratory synkinesis. The patient lies supine, with her head rotated and resting over the edge of the treatment table, so that her chin and mastoid process are (gently) supported by the edge of the table. In this position the patient is told to look up at her forehead and to breathe in slowly and deeply. As she does this the sternocleidomastoid muscle automatically contracts, causing the patient’s head to lift slightly with a side-nod (see Figure 6.96A). After holding her breath, the patient looks toward her chin and breathes out slowly, causing the sternocleidomastoid to relax and her head to be lowered (see Figure 6.96B). The act of looking up and down facilitates inhalation and exhalation, and the
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attachment point pain around the che-gu point well known to acupuncturists. Its relaxation is important in the setting of reflex therapy. For treatment by PIR, the practitioner abducts the patient’s thumb to engage the barrier. The patient is then instructed to adduct her thumb as the practitioner resists with minimal force and to let go after 5–10 seconds (see Figure 6.97A). The procedure is repeated. This is followed by RI in which either the patient performs maximum abduction herself or the practitioner (or the patient herself) offers rhythmic repetitive resistance to abduction.
Self-treatment The patient uses her other hand to resist adduction (see Figure 6.97B).
Figure 6.96 • Gravity-induced PIR of the
sternocleidomastoid: (A) with head turned to the side, the patient looks up at her forehead and breathes in, automatically contracting the sternocleidomastoid; (B) she looks down at her chin and breathes out, relaxing the sternocleidomastoid, and letting her head drop.
contraction and relaxation of the sternocleidomastoid occurs in the context of respiratory synkinesis. The patient repeats the exercise several times. This technique serves not only to relax the sternocleidomastoid muscle. It is also a very effective self-mobilization technique for movement restriction at the atlanto-occipital joint because it encourages side-nodding. In the exceptional cases where respiratory synkinesis is insufficient, the patient may also deliberately raise her head slightly.
6.6.3 Muscles of the upper extremity Adductor pollicis The attachment point for this muscle is at the second metacarpal. The TrP in this muscle causes
Figure 6.97 • PIR of the adductor pollicis: (A) the
practitioner uses her fingers to resist adduction of the thumb; (B) self-treatment.
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Radial epicondylopathy Alongside movement restriction at the elbow, TrPs may be present in the supinator, the forearm extensors, and the biceps and triceps brachii. The presence of a TrP in the supinator is confirmed by restricted pronation compared with the non-lesioned side. For treatment, the patient should be seated in front of the practitioner or supine. The practitioner places one hand laterally to fix the patient’s elbow, which is flexed at right angles. With her other hand she takes the patient’s forearm at the wrist into pronation to take up the slack (see Figure 6.98A). She then instructs the patient to resist with minimal force in the direction of supination, holding this for 5–10 seconds and then letting go. As the patient breathes out, pronation should increase markedly. The procedure is repeated from the newly gained pronation position. For RI rhythmic repetitive resistance is offered against pronation performed by the patient.
Self-treatment The procedure for this is self-evident but care must be taken to ensure that the patient keeps her elbow against her trunk and does not move it forward away from her body (see Figure 6.98B). For RI the patient forcefully performs maximal pronation resisted by her other hand.
Finger and hand extensors TrPs in the finger and hand extensors cause movement restriction, which can be tested very accurately by approximating the patient’s fingertips as far as possible toward the palmar aspect of her forearm, and comparing with the fingers of the other hand (see Figure 6.99A). This test involves simultaneous flexion of the wrist and fingers. The TrPs can be readily palpated in the forearm. For PIR the practitioner places her thenar eminence or fingers over the back of the patient’s hand and fingertips, so as to approximate them to the forearm; the result can be measured by using the fingers of her other hand. The slack is taken up in this way. The patient next resists the pressure of the practitioner’s hand for 5–10 seconds and then lets go. During relaxation there is a measurable increase in flexion. For RI the patient flexes her fingers while the practitioner offers rhythmic repetitive resistance against flexion. 256
Figure 6.98 • PIR of the supinator muscle: (A) treatment and testing for TrPs; (B) self-treatment.
Self-treatment Here, too, the procedure for self-treatment is obvious. The main difference is that the patient mainly places her thenar eminence over the fingertips of the hand being treated and uses her fingers to flex the wrist of the treated hand (see Figure 6.99B).
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Biceps brachii When TrPs are present in the biceps brachii it will be found that extension at the elbow is somewhat restricted. Treatment involves gravity-induced PIR. The seated patient supports her extended elbow on one knee, then bends the elbow a little and holds her forearm slightly raised for 20 seconds (see Figure 6.100A). She then allows her forearm to drop back to its original position and relaxes for 20 seconds (see Figure 6.100B). The exercise can be repeated two or three times. For RI the simplest method is to perform maximal active extension at the elbow.
Figure 6.99 • PIR of tensed finger and hand extensors: (A) examination and treatment; (B) self-treatment.
The patient can also perform RI by rhythmically and repetitively resisting the flexion of the treated hand.
Figure 6.100 • Treatment of TrPs in the biceps
brachii: (A) with the forearm slightly raised; (B) during relaxation the forearm rests in extension on the patient’s knee.
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Triceps brachii When TrPs are present in the biceps brachii they are also routinely found in its antagonist, the triceps brachii. According to Krobot (1994), primary TrPs in the triceps brachii cause axillary pain. They can be palpated in the long head of the triceps close to the axilla and the patient reports pain on extension of the elbow joint under pressure (e.g. when doing press-ups). Treatment involves gravity-induced PIR. The patient is seated and raises her arm vertically, flexes it at the elbow, and places her hand on the top of her head. She then lifts her forearm a little and holds it there for 20 seconds (see Figure 6.101A). Afterward she lets it fall again to her head and relaxes for 20 seconds (see Figure 6.101B). The exercise can be repeated two or three times. For RI the patient exerts forceful pressure with her hand on her cranium.
Ulnar epicondylopathy In this condition TrPs are present in the digital flexor muscles on the ulnar side. For treatment, the patient is seated in front of the practitioner with elbow fully flexed and forearm in supination. The practitioner takes hold of the patient’s dorsiflexed hand from the radial edge and supports the back of the hand with her thumb. The patient’s hand is then taken into dorsiflexion and pronation to take up the slack (see Figure 6.102A). The patient resists with light pressure toward flexion and supination. After 5–10 seconds she relaxes in the direction of pronation and dorsiflexion. The procedure can be repeated two or three times. For RI the patient exerts pressure toward pronation while the practitioner offers rhythmic repetitive resistance into supination.
Self-treatment With the hand to be treated in the same position as above, the patient places the fingers of her other hand on the palm of her dorsiflexed hand from the ulnar side, while supporting the back of the hand with her thumb. She takes up the slack into supination and dorsiflexion and then offers isometric resistance in the direction of pronation and flexion (see Figure 6.102B). After 5–10 seconds she relaxes and dorsiflexion and supination are amplified. This exercise is repeated three times. 258
Figure 6.101 • Treatment of the triceps brachii: (A) with forearm slightly raised; (B) during relaxation the patient’s hand rests on her head.
Supraspinatus TrPs in the supraspinatus muscle are found in the fossa supraspinata. On abduction against resistance the patient typically feels pain at the greater
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Figure 6.103 • PIR of the supraspinatus: (A) examination and treatment; (B) self-treatment.
Figure 6.102 • PIR of the hand and finger flexors: (A) examination and treatment; (B) self-treatment.
tubercle. For treatment, the practitioner stands behind the patient and supports her. She brings the patient’s flexed arm medially into adduction in front of her chest, to take up the slack (see
Figure 6.103A). In this position she tells the patient to exert slight counterpressure into abduction while breathing in, and then to relax as she breathes out, causing adduction to increase. The procedure is repeated from the newly gained position. For selftreatment the patient does exactly the same, using her own hand (see Figure 6.103B). For RI the patient exerts forceful adduction of her arm resisted by her other hand.
Infraspinatus The infraspinatus is a common source of shoulder pain. TrPs here are palpated in the fossa infraspinata. 259
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Figure 6.104 • PIR of the infraspinatus. The patient’s
arm, abducted at right angles and flexed at the elbow, is in internal rotation: (A) with forearm slightly raised; (B) with forearm lowered during relaxation.
External rotation against resistance provokes pain at the attachment point with the greater tubercle. Gravity-induced PIR is used both for treatment and self-treatment. The patient is supine with her arm in abduction over the side of the treatment table and her elbow bent at right angles so that her forearm points toward her hip (i.e. her shoulder is in internal rotation). The effect of gravity causes the muscle slack to be taken up (see Figure 6.104A). The patient next lifts her forearm about 2 cm, holding it in this position for about 20 seconds. She then relaxes for at least 20 seconds and lets her forearm drop (see Figure 6.104B). From the newly gained position the procedure is repeated two or three times. The patient can perform this exercise as self-treatment several times a day. For RI the patient exerts downward pressure with her hand.
Subscapularis If the subscapularis muscle goes into spasm (contracts), the result is adduction and internal rotation, 260
that is the ‘frozen shoulder’ position. It appears that there is indeed a close relationship between the subscapularis and frozen shoulder, and that TrPs in the subscapularis may accompany frozen shoulder from the outset through all its stages. For diagnosis it is necessary to palpate the TrPs directly. For this, the patient is supine with her arm abducted at about 60°. In this position the practitioner takes hold of the patient’s forearm and exerts light latero caudal traction along the axis of the patient’s arm. With the fingers of the other hand, the practitioner slips over the edge of teres major and latissimus dorsi deep into the axilla on the ventral aspect of the shoulder blade to palpate the exquisitely tender TrPs of the subscapularis. Frequently, however, the pain is not consistent with that of frozen shoulder where pain radiates as far as the wrist. The pain may simply be felt in the shoulder, shoulder blade, or thorax; if this pain occurs on the left side, it may also present as cardiac pain or dyspnea with respiratory limitation due to costal restrictions. These conditions are frequently associated with TrPs in the subscapularis. The subscapularis should therefore always be palpated in cases of pain of unknown origin involving the shoulder and thorax. Here, too, gravity-induced PIR is used for (self-) treatment, with the patient positioned as described for the infraspinatus (see above), the difference here being that her forearm is pointed cranially (see Figure 6.105A and B). However, it is likely that a patient with a frozen shoulder will not be able to abduct the arm at right angles and that external rotation will also be restricted. In such circumstances the patient should abduct the arm just a little in order for there to be sufficient external rotation for gravity to enhance external rotation still further. It is necessary in such cases for the patient to perform the exercise while side-lying on the painful shoulder (see Figure 6.105C and D). For RI the patient exerts active pressure with her forearm into external rotation.
Latissimus dorsi and teres major These two muscles constitute a functional unit. In combination with the pectoralis major they adduct the arm. On their own they permit retroflexion of the arm. They clearly play an important role in the synkinetic movement of the arms during walking and also probably during trunk rotation. TrPs in
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Figure 6.105 • PIR of the subscapularis: (A) with forearm slightly raised; (B) with forearm lowered during relaxation. Gravityinduced PIR of the subscapularis in frozen shoulder: (C) side-lying, with forearm slightly raised; (D) during relaxation.
these muscles are palpated in the axilla and further down the back. Pain radiates from the shoulder down the ulnar aspect of the arm. For treatment, gravity-induced PIR is most practical. The patient is side-lying, with her back close to the edge of the treatment table. The arm to be treated is abducted at 135° and flexed at the elbow (see Figure 6.106A). The patient next takes her arm further into abduction, breathes in slowly, holds her breath, then relaxes while breathing out and lets her arm fall against her head (see Figure 6.106B). For RI she exerts pressure with her upper arm against her head.
6.6.4 Muscles of the trunk Pectoralis major Increased tension (TrPs) of the upper (subclavicular) part of the pectoralis major results in a forward-
drawn position of the shoulders. Beneath the clavicle the tendon protrudes on abduction like a ‘false clavicle’ and is tender to palpation. For examination, with the patient supine, the practitioner brings the patient’s arm as far as possible into abduction in order to detect any shortening of the pectoralis major (see Figure 6.107A). Gravity-induced PIR is useful for treatment, with the patient in the same position as for examination. She relaxes her arm (which is abducted over the edge of the treatment table) until the slack is taken up. She then raises her arm about 2 cm and breathes in slowly, holds her breath, relaxes and breathes out slowly, while her arm sinks down again (see Figure 6.107B and C). The procedure is repeated two or three times. For RI the patient exerts forceful pressure with her arm toward the floor. Where the sternocostal part of the pectoralis major muscle is tense (TrPs), full elevation of the 261
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Figure 6.106 • PIR of the latissimus dorsi: (A) with upper arm raised; (B) with upper arm lowered to rest on head.
arm is restricted and the tendon in the axilla is taut as well as tender to palpation. For the examination, the patient is supine. Placing her forearm on the patient’s sternum, the practitioner fixes the thorax from above, while with her other hand she brings the patient’s arm into maximum (oblique) elevation without applying any force and identifies any muscle shortening (tension) (see Figure 6.108A). TrPs can be palpated here by a pincer movement beneath the axilla as the practitioner slips her fingers between the ribs and the flat pectoralis major, while her thumb palpates through the overlying skin, eliciting a twitch response. Gravity-induced PIR is useful for self-treatment. Like the practitioner previously, the patient performs the same elevation movement with her arm over the edge of the treatment table, then lifts her arm just a very little, breathes in slowly, holds her breath, and then relaxes slowly while breathing out (see Figure 6.108B and C). For RI the patient herself performs maximal forceful elevation. 262
Figure 6.107 • (A) Examining the subclavicular part of the pectoralis major for shortening. (B) PIR of the pectoralis major, with arm raised during inhalation. (C) Arm lowered during exhalation.
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Figure 6.109 • PIR targeted specifically at the muscle
bundles of the pectoralis major that attach to the painful periosteal point.
For treatment, the patient can be supine or side-lying. The practitioner brings the patient’s arm into abduction, producing contraction of the fiber bundle that is causing the painful pressure point. This tension must be palpated precisely (see Figure 6.109).
Pectoralis minor
Figure 6.108 • (A) Examining the sternocostal part of the pectoralis major. (B) PIR of the pectoralis major, with arm slightly raised. (C) Arm lowered during exhalation.
Painful attachment points on the ribs These pain points are found in the axillary line and often in the vicinity of the sternocostal joints. They are commonly associated with thoracic pain, for which differential diagnosis is essential. The structures in question are attachment points of individual fiber bundles of pectoralis major (in the axillary line, serratus anterior).
Tension (TrPs) of the pectoralis minor manifests itself as a pain point below the clavicle, corresponding to the coracoid process, and as painful attachment points at the ribs. It further produces forward-drawn shoulders and increases thoracic kyphosis; moreover, it can be one contributing cause in the thoracic outlet syndrome (Hong & Simons 1993). For treatment (relaxation), we use gravity-induced PIR. The patient is supine close to the edge of the treatment table with her arm hanging down over the edge. She raises her shoulder while breathing in slowly (see Figure 6.110A), holds her breath, and then lets her arm drop while she breathes out and relaxes (see Figure 6.110B). The procedure is repeated three times. For RI the patient exerts pressure with her arm toward the floor.
Serratus anterior In tension of the serratus anterior there are TrPs close to the costal attachment points. For examination, the patient is side-lying, with her underneath leg (i.e. the leg on the treatment table) stretched 263
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practitioner, the patient raises her arm, breathes in, holds her breath, and lets her arm fall again to take up the slack as she breathes out (see Figure 6.111B and C). For RI the patient exerts forceful pressure in the direction of extension.
Diaphragm
Figure 6.110 • PIR of the pectoralis minor: (A) shoulder
of the arm hanging down over the edge of the table, in the raised position; (B) shoulder lowered during relaxation.
out while her uppermost leg is bent at the hip to stabilize the side-lying position. The practitioner brings the patient’s upper arm cranially into abduction with retroflexion to engage the barrier. With the thumb of her other hand she simultaneously fixes the painful attachment point at the rib (see Figure 6.111A). The direction of abduction can be established accurately because, if the patient’s arm is guided correctly, the tension is transmitted precisely to the location of the practitioner’s thumb (pain point). As she breathes in, the patient offers resistance and after holding her breath she relaxes as she breathes out. The procedure can be repeated.
Self-treatment For self-treatment, gravity-induced PIR is useful. Adopting the same position as for treatment by the 264
For palpatory examination of the diaphragm the patient is seated in slight anteflexion and the practitioner stands behind him, supporting his trunk against her own. With the fingers of both hands flexed, she performs palpation beneath the inferior costal arches from below and upward and moves her fingers laterolaterally (see Figure 6.112). If TrPs are present, marked resistance will be felt and the patient will experience some pain. PIR and RI are regularly effective. The patient breathes in a little, then with mouth closed he pinches his nose and tries to breathe in against isometric resistance. He holds this for 5–10 seconds and then breathes out slowly. He is able to last out because he has breathed in a little to start with. For repeats and for subsequent self-treatment the patient learns to perform isometric resistance not by pinching his nose, but by closing his glottis, as when pronouncing the consonant ‘K.’ After two or three repeats the patient performs RI by actively breathing out as far as possible. The method is so effective that any painful resistance that persists is not a TrP but in all probability is attributable to the gall bladder, spleen, or stomach. The major clinical significance of these TrPs is that the diaphragm is one of the most important muscles in the deep stabilization system. It is the starting point for extensive chain reaction patterns and for pain that is referred particularly to the thoracic and cervical regions and to the head. Examination of the diaphragm is therefore recommended as a routine procedure. Despite its simplicity and effectiveness, TrP relaxation here is of secondary importance compared with active exercising and strengthening of the deep stabilization system as a whole, which is discussed in Section 6.8.7.
Erector spinae Increased tension and TrPs are very frequent in all parts of the erector spinae because this muscle
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Figure 6.111 • (A) Specific PIR of the tense serratus anterior with the slack taken up in the direction of the TrP at the rib. (B) Arm raised for self-treatment. (C) Arm lowered during relaxation.
often also reacts in response to disturbances in any spinal segment. There is one simple gravity-induced technique that can be used along the entire course
of this muscle on both sides. For this, the patient is prone with her head hanging over the end of the treatment table. She raises her head and breathes in (see Figure 6.113A), then holds her breath and, while breathing out, she relaxes into the starting position (see Figure 6.113B). If the patient lifts her head only a little, she then contracts and relaxes only the upper parts of the erector spinae; the higher she lifts her head, the further caudally the muscle is contracted. This procedure is repeated.
Thoracic region
Figure 6.112 • Palpation of the diaphragm.
Generally, tension is detected predominantly on one side. In such cases it is more specific to treat with a combination of anteflexion, side-bending, and rotation. In the cervicothoracic and thoracic region, the practitioner stands behind the seated patient and fixes the shoulder or costal angle on the painful side with one hand, using the thumb of that hand 265
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Figure 6.114 • Treatment of the cervicothoracic and thoracic part of the erector spinae.
Figure 6.113 • PIR of the erector spinae: (A) with head raised; (B) with head lowered again during relaxation.
to fix the muscle paravertebrally just below the TrP. With her other hand she brings the patient’s head into anteflexion, side-bending, and rotation toward the opposite side until she has taken up the slack (see Figure 6.114). Now the patient is instructed to look toward the lesioned side and up, to breathe in deeply (as the practitioner resists the automatic counterpressure), and then to hold her breath, look toward the non-lesioned side, and breathe out. This procedure is repeated. For RI the patient continues to look toward the non-lesioned side, while the practitioner rotates the patient’s head against resistance toward the restricted side.
Thoracolumbar region When treating the erector spinae in the lower thoracic and upper lumbar region, the practitioner 266
stands behind the patient, who is seated in slight kyphosis with hands clasped behind her neck. The practitioner threads one arm under the patient’s axilla to reach round to her shoulder on the side to be treated and tells the patient to look toward the non-lesioned side until the slack has been taken up in rotation (see Figure 6.115). She then asks the patient to look toward the lesioned side and to breathe in while she resists the patient’s efforts to turn in this direction. The patient is then instructed to look as far as possible in the direction of the non-lesioned side and to breathe out, which results in an increase in rotation. This procedure is repeated. For RI the practitioner rhythmically and repetitively resists rotation toward the non-lesioned side.
Lumbar region Relaxation of the erector spinae in the lower lumbar region is performed using gravity-induced PIR coupled with inhalation and exhalation. Because the position for this technique is identical to that used when mobilizing the lumbar spine into flexion (see Figure 6.35), this technique can also be used for self-mobilization of the lumbar spine into flexion.
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Figure 6.115 • Examination and PIR of the thoracolumbar part of the erector spinae; simultaneously with rotation mobilization of the spinal column.
The patient is side-lying in kyphosis, her underneath leg flexed at the hip and knee, and her uppermost leg hanging over the edge of the treatment table, bringing her pelvis into a forward-tilted position. She looks up at the ceiling (i.e. she rotates her head and shoulder in the opposite direction from that of the pelvis). In this position the patient relaxes and the weight of her leg hanging down is sufficient to take up the slack of her lumbar erector spinae (i.e. to bring the lumbar spine into anteflexion and rotation). The patient then lifts her hanging leg slightly, breathing in slowly (see Figure 6.116A), holds her breath, and then relaxes as she breathes out, allowing her leg to fall again (see Figure 6.116B). This procedure is repeated three times. This technique is also effective in the treatment of pain at the spinous processes, in which case the more painful side must lie uppermost.
Self-treatment The following technique is effective for self-treatment of the entire erector spinae (apart from the most caudal segment) while seated: with one hand on the top of her head, the patient brings her head and therefore her trunk first into a position of
Figure 6.116 • PIR of the lower lumbar erector spinae:
(A) the leg hanging over the side of the table is slightly raised during inhalation; (B) the leg is allowed to fall again during relaxation and exhalation.
anteflexion, and then into side-bending and rotation so that the peak of the curve is at the level of the painful TrP (which the patient will feel during anteflexion; see Figure 6.117). After taking up the slack, she looks in the opposite direction from rotation, breathes in slowly, and uses the hand placed on her head to resist automatic rotation in the direction of her gaze. She holds her breath and then looks in the direction of mobilization and breathes out, taking her head and trunk into rotation, anteflexion, and side-bending as far as the (new) barrier.
TrPs in the horizontal part of the trapezius Here the typical pain point is medial to the superior angle of the scapula; it is characterized by a 267
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Figure 6.117 • Self-treatment of the erector spinae, with the patient seated (see text).
radiating pain pattern, and is encountered especially in radicular syndromes and acute cervico brachial pain in the upper extremity. For diagnosis, the practitioner takes up the slack in the muscle by bringing the scapula into maximal abduction: to do this she takes the patient’s upper arm as far as possible toward the opposite shoulder, thus causing the muscle to protrude like a taut cord that is painful on snapping palpation. For treatment, the practitioner stands behind the seated patient and brings the patient’s elbow toward the opposite shoulder to take up the slack (see Figure 6.118A). She instructs the patient now to give slight counterpressure with the elbow against her hand and to breathe in, hold her breath, and then relax as she breathes out. The patient’s elbow will then come even closer to the opposite shoulder. This procedure is repeated two or three times. For RI the patient exerts pressure with her hand in the same position against the practitioner’s hand, which rhythmically and repetitively increases springing counterpressure.
Self-treatment For self-treatment the patient uses her own hand in exactly the same way as the practitioner does 268
Figure 6.118 • PIR of the horizontal part of the trapezius: (A) examination and treatment; (B) self-treatment.
above (see Figure 6.118B). Gravity-induced PIR is especially helpful for self-treatment. The patient is side-lying close to the edge of the treatment table and allows her uppermost arm to hang vertically
Therapeutic techniques
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For RI the patient pushes her hand forcefully toward the floor.
Quadratus lumborum
Figure 6.119 • Self-treatment of the horizontal part of
the trapezius: (A) with the upper arm raised; (B) with arm hanging down during relaxation, and pushing it toward the floor for RI.
over the edge. The weight of her hanging arm produces abduction of the shoulder blade and the slack is taken up (see Figure 6.119A). The patient then raises her hanging arm a little and breathes in, holds her breath, relaxes as she breathes out, and lets her arm drop again (see Figure 6.119B).
When trunk rotation is restricted, the quadratus lumborum is routinely found to harbor TrPs. These are palpated at the waist. The patient may be prone or supine for comparison of the two sides. However, it can be difficult here to distinguish the quadratus lumborum from the oblique abdominal muscles. For precise palpatory examination it is better if the patient is side-lying. With one hand she holds the top end of the treatment table and lets her uppermost leg hang down over the edge of the table behind her, so as to create as much room as possible for palpation between the iliac crest and the inferior costal arch. Using a pincer hold, the practitioner palpates by forefinger pressure caudally beneath the iliac crest and cranially beneath the inferior costal arch in the direction of the attachment points of the muscle. Tension in the quadratus lumborum can be treated both by gravity-induced PIR and using respiratory synkinesis. The patient stands with her legs apart and relaxes into side-bending. If she is completely relaxed (her head must also be hanging sideways), looking up and breathing in slowly and deeply will be sufficient to raise her trunk (see Figure 6.120A). The patient then holds her breath, looks down, relaxes, breathes out slowly, and sinks to a (new) end position (see Figure 6.120B). This procedure is repeated two or three times. For RI, after the slack has been taken up, the patient actively pushes her downward-hanging arm toward the floor. Due to the chain reaction pattern linking the quadratus lumborum with the psoas major and erector spinae muscles, relaxation of the quadratus lumborum normalizes restricted rotation of the trunk. If this exercise is poorly tolerated, the patient can assume the same side-lying position as for examination, raising the leg while breathing in and letting it fall again beyond the edge of the treatment table while breathing out (see Figure 6.125).
Rectus abdominis TrPs in the rectus abdominis may give rise to referred pain simulating visceral disease. They may also be associated with pain at the attachment 269
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points with the pubic symphysis, xiphoid process, and the adjacent parts of the costal arches. Examination routinely reveals tenderness at the attachment points and it is also possible to diagnose the TrPs using rapid snapping palpation. Clinically, there is frequently a characteristic forward-drawn posture with tension of the neck and back muscles, as well as restriction of retroflexion that the patient experiences as low-back pain. For treatment (and self-treatment), gravity-induced PIR is most effective: the patient is supine with her buttocks resting at the end of the treatment table and her legs hanging over the edge. She rests the foot of the non-treated side on a low stool, and a pad is inserted under the buttock on the other side to tilt her pelvis slightly to one side. In this position she relaxes her freely hanging leg to take up the slack. She then lifts the knee of that leg a little and breathes in (see Figure 6.121A); afterward, as she breathes out and relaxes, she lets her leg fall again to a (new) end position (see Figure 6.121B). This procedure can be repeated twice. For RI the patient actively presses her hanging foot down toward the floor. If the intention is more to relax the upper part of the rectus abdominis, she should raise her head, hold this for about 20 seconds, and then let it sink back to the padded surface of the treatment table. For RI she can then press her head against the padded surface. This technique is not commonly used because TrPs in the rectus abdominis generally occur secondarily as a result of movement restrictions involving the fibula, the feet, and even the pelvic floor.
6.6.5 Muscles of the hip region Iliopsoas
Figure 6.120 • PIR of the quadratus lumborum: (A) looking up during maximal inhalation; (B) looking down, relaxation and exhalation.
270
Intensely painful TrPs are palpated through the abdominal wall: at the psoas major by parallel pressure from the side against the spinal column; and at the iliacus, parallel to the inguinal ligament, by pressure in the direction of the ilium. For treatment, we employ gravity-induced PIR. The patient is supine with his buttocks at the end of the treatment table. He flexes his non-lesioned leg at the knee and hip and, with his hands clasped around the tibial tuberosity, he draws the leg up toward his chest, thus fixing the pelvis. He then lifts the knee of his hanging, lesioned leg a few
Therapeutic techniques
Chapter 6
Figure 6.122 • PIR of the iliopsoas: (A) with knee raised Figure 6.121 • PIR of the rectus abdominis: (A) the
during inhalation; (B) with knee lowered during relaxation and exhalation, pushing it toward the floor for RI.
leg hanging freely over the edge of the table is raised during inhalation; (B) the leg is allowed to fall again during relaxation, pushing it toward the floor for RI.
Ligament pain (pelvic region)
centimeters while breathing in (see Figure 6.122A), holds his breath, and then lets it fall again as he relaxes and breathes out (see Figure 6.122B). This procedure is repeated about three times. For RI the patient exerts pressure in the direction of his hanging foot toward the floor.
Where contraction of the ligaments in the pelvic region provokes pain, increased resistance and (on range of motion measurement) restricted adduction are invariably encountered on the side where pain is present. Of course, this resistance cannot derive from the ligaments themselves and therefore can only be of muscular origin. 271
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remain constant while his other hand performs PIR (see Figure 6.123B). For RI he can also rhythmically and repetitively resist adduction.
Gluteus maximus and levator ani A tender or painful coccyx is generally attributable to attachment point pain due to increased tension in the caudal part of the gluteus maximus and TrPs in the levator ani. Treatment consists of PIR of the gluteus maximus and levator ani. For this, the patient is prone, with his heels rotated outward to relax the buttock muscles. Standing by the patient’s legs, the practitioner crosses her hands and places one hand on each buttock. As she exerts light pressure she will feel the increased muscle tension (see Figure 6.124A). She next tells the patient to clench his buttocks together with minimal force, to maintain this pressure for about ten seconds, and then to let go. During the protracted (!) relaxation phase the practitioner feels her hands going deeper as the tension in the muscles diminishes. This procedure is repeated several times until it seems as if tension is no longer diminishing. The practitioner then checks to establish whether the coccyx is still painful. Figure 6.123 • PIR in ligament pain: (A) examination and treatment; (B) self-treatment.
For treatment, the practitioner flexes the patient’s knee and hip to the point where resistance, and simultaneously the pain response, are greatest on adduction. This technique applies equally for the iliolumbar ligament and for the sacroiliac ligaments. In this position the patient exerts light pressure against the practitioner’s examining hand and holds this for 5–10 seconds (see Figure 6.123A). During the relaxation phase, the practitioner brings the patient’s thigh further into adduction provided that no resistance develops. In the process the patient will generally experience some pain but this is of no significance provided that the patient is still able to relax. This procedure is repeated from the newly gained position. For RI the patient offers resistance into abduction against the rhythmic repetitive pressure on his thigh.
Self-treatment For self-treatment, the patient is supine with his two hands beneath his buttocks and his feet rotated inward; gravity-induced PIR is also used (see Figure 6.124B). The patient now tenses his gluteals a little and holds this for 20 seconds before relaxing for 20 seconds. This procedure is repeated three to five times. A painful coccyx is caused by tendomyopathy of the gluteus maximus and levator ani muscles, and post-isometric muscle relaxation therapy is consistent with the pathogenesis. Only in exceptional cases where there is no increased tension is there an indication for the (standard) therapeutic approach per rectum.
6.6.6 Muscles of the lower extremity
Self-treatment
Hip abductors
For self-treatment, the patient uses the hand on the same side to ensure that hip and knee flexion
Tenderness at the greater trochanter is due principally to tension of the hip abductors, primarily the
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treatment table, with his underneath leg flexed at the knee and hip and his uppermost leg hanging over the end of the table in adduction. The patient lifts his leg horizontally (see Figure 6.125A), holds for 20 seconds, and then relaxes for a further 20 seconds (see Figure 6.125B). This procedure is repeated two or three times. This technique also relaxes the quadratus lumborum at the same time. For RI the patient exerts forceful pressure with his leg against the padded cover of the treatment table and practices this exercise daily. It may be helpful to adopt an even more precise procedure here: if the TrPs are located primarily in the gluteus medius, the uppermost leg should perform the exercise in extension. However, if the TrPs are primarily in the tensor fasciae latae, the uppermost leg should be flexed a little at the hip.
Figure 6.124 • PIR of the gluteus maximus for a tender and painful coccyx: (A) examination; (B) self-treatment.
gluteus medius and the tensor fasciae latae. Active abduction is then also frequently painful. However, the same pain points are also found in osteoarthritis of the hip. When TrPs are present in the gluteus medius (palpated using a pincer grip), the inferior margin of the iliac crest is also tender. TrPs in the tensor fasciae latae are palpated just above the greater trochanter and pain points are also found simultaneously along the course of the fascia lata on the lateral aspect of the thigh. Gravity-induced PIR is used to treat these muscles. The patient is side-lying at the end of the
Figure 6.125 • PIR of the hip abductors (this technique
can also be used for PIR of the quadratus lumborum): (A) with uppermost leg raised; (B) with leg lowered during relaxation, pushing it toward the floor for RI.
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Hip adductors As in osteoarthritis of the hip, Patrick’s sign is positive and the attachment points at the pubic symphysis and pes anserinus are painful, causing the patient also to experience knee pain. TrPs can be palpated in all the muscles belonging to the hip adductor group. The adductors are closely associated with diseases of the hip, they may give rise to pain that is referred to the pelvis, and they are often coupled with TrPs in the pelvic floor. The position for Patrick’s test is used for examination and to take up the slack: the patient is supine and flexes one leg at the knee and hip so that his heel is touching the medial aspect of his other outstretched leg just below the knee. Gravity-induced PIR is used for treatment. After taking up the slack, the patient raises his knee a little for about 20 seconds (see Figure 6.126A) and then lets it fall again while he relaxes (see Figure 6.126B). After a further 20 seconds, this procedure is repeated two or three times from the newly gained position. For RI the simplest option is maximal active abduction.
The ischiocrural group of muscles The basic function of the ischiocrural group of muscles is to fix the pelvis in an upright position. These muscles extend the hip and flex the knee. TrPs can be palpated along the course of these muscles and produce pain in the thigh and at the muscle attachment points, especially at the ischial tuberosity. For treatment (and self-treatment), the patient is prone with his pelvis at the end of the treatment table so that both legs hang down (his feet may even be resting on the floor). The gravity-induced technique is used for PIR. The patient raises one outstretched leg a little from the floor (see Figure 6.127A), holds for 20 seconds, and then lets it sink back to the floor as he relaxes (see Figure 6.127B). After a further 20 seconds, this procedure is repeated two or three times. For RI the patient exerts forceful pressure with his foot against the floor.
Rectus femoris To examine for TrPs, the practitioner uses pincer palpation along the course of the rectus femoris; the diagnosis is usually made by applying the femoral 274
Figure 6.126 • PIR of the (short) hip adductors: (A) with
thigh raised; (B) relaxation, pushing it against the table for RI.
nerve stretch test. Tension in the muscle is therefore generally increased in dysfunction of the L4 segment and in the L4 radicular syndrome. For treatment and self-treatment, we use gravityinduced PIR. The patient is supine with one leg outstretched so that the lower leg hangs over the edge of the treatment table. Flexing his non-lesioned leg at the hip and knee, he draws it up toward his trunk using his hands, which are clasped round the tibial tuberosity. The patient then extends the knee of the leg to be treated and holds it for 20 seconds
Therapeutic techniques
Chapter 6
Figure 6.128 • PIR of the rectus femoris: (A) with knee extended and raised; (B) relaxation with knee flexed.
Figure 6.127 • PIR of the ischiocrural muscle group:
(A) with one leg raised; (B) relaxation with foot resting on the floor, and pushing it against the floor for RI.
(see Figure 6.128A); he next relaxes and allows it to drop back down for 20 seconds (see Figure 6.128B). This procedure is repeated two or three times. For RI he flexes his knee powerfully in the same position.
Piriformis The TrP in the piriformis muscle is palpated as painful resistance above and medial to the greater trochanter. Given this location, it is hardly surprising that spontaneous discomfort here causes the patient to complain of ‘hip pain’ and is an obstacle to sleeping on the painful side at night. This TrP is generally linked with dysfunction of the motion segment L4/ L5 and with the L5 radicular syndrome.
For treatment, the patient is prone: he flexes his knee at right angles on the side to be treated and allows his lower leg to fall outward. He then turns on to his side so that his lower leg is lying horizontal on the treatment table. The patient now raises his foot and lower leg by about 2 cm (see Figure 6.129A), holds this position for 20 seconds, then lets them drop back down to the table surface (see Figure 6.129B) and relaxes in that position for a further 20 seconds. This procedure is repeated three times. For RI the patient exerts forceful pressure with his lower leg against the padded surface of the treatment table.
Biceps femoris Pain at the fibular head is the result of TrPs in the biceps femoris. For treatment, the practitioner stands at the foot end of the treatment table on the patient’s non-painful side. The patient is supine. 275
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Figure 6.129 • PIR of the piriformis: (A) with lower leg
raised; (B) relaxation with lower leg resting on the padded surface of the treatment table, and pushing it against the table for RI.
With her right hand the practitioner grasps the patient’s right foot (or with her left hand his left foot), with her thumb at his heel and her little finger at his little toe, so as to rotate his foot inward. She then raises the patient’s stretched leg, bringing it simultaneously into internal rotation and adduction to take up the slack (see Figure 6.130A). In this position the practitioner tells the patient to exert light pressure with his foot into external rotation against her resistance and to hold this for 5–10 seconds. During the subsequent relaxation phase she increases rotation, straight leg raising and adduction. This procedure is repeated two or three times.
Figure 6.130 • PIR of the biceps femoris for tenderness
Self-treatment
of the fibular head: (A) examination and treatment; (B) selftreatment.
For self-treatment, the patient stands with feet apart: the foot to be treated is rotated inward with its outer edge propped against a table leg, for example. To take up the slack the patient moves a step
forward with his free foot and bends his knee, producing an increase in the inward rotation of the foot and in the tension of the ischiocrural muscles
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(see Figure 6.130B). He then presses his foot (isometrically) against the table leg and holds this for 5–10 seconds. While he relaxes, knee flexion and foot rotation increase. This procedure is repeated two or three times. This technique is awkward, which explains why mobilization of the fibula is generally used in practice.
Foot and toe extensors Increased tension (TrPs) of the extensor muscles on the ventral aspect of the lower leg manifests itself primarily as fatigue pain. For treatment, the patient is seated. The practitioner sits next to him and places the lower leg to be treated across her thigh. With one hand she fixes his lower leg, and places her other hand dorsally over his forefoot and toes, simultaneously performing plantar flexion of the toes and foot to take up the slack (see Figure 6.131A). She then tells the patient to resist for 5–10 seconds before instructing him to let go until the slack is taken up again. This procedure is repeated two or three times. For RI the patient offers resistance against rhythmic repetitive extension of the flexed toes.
Self-treatment For self-treatment, the patient is seated and uses his opposite hand to flex his toes and forefoot (see Figure 6.131B). The subsequent details are as described for the procedure performed by the practitioner.
Painful Achilles tendon Pain at the Achilles tendon and at its attachment to the calcaneus is caused by TrPs with increased tension in the soleus muscle. For treatment, the patient lies prone with the knee on the lesioned side flexed. With one hand the practitioner takes hold of the patient’s foot and brings it into dorsiflexion and, depending on whether the tendon is tender on the medial or lateral side, either into pronation or supination to take up the slack on the painful side (see Figure 6.132A). She then tells the patient to resist using counterpressure of minimum force for about 10 seconds. During the subsequent relaxation phase, the patient is instructed to actively enhance dorsiflexion (= RI). This procedure is repeated with the goal of increasing dorsiflexion.
Figure 6.131 • PIR of the foot and toe extensors: (A) examination and treatment; (B) self-treatment.
Self-treatment Gravity-induced PIR is used for self-treatment. The patient stands in front of a table, supporting himself against it on his hands. He steps forward with the foot being treated and flexes his leading leg at the knee until the slack is taken up at the talocrural joint (see Figure 6.132B). The patient resists with his foot in the direction of plantar flexion for 20 seconds, after which he relaxes for a further 20 seconds in dorsiflexion. This procedure is repeated three times.
Painful calcaneal spur A painful calcaneal spur is caused by increased tension (TrPs) in the deep short toe flexors, which have their points of attachment there. For treatment, the patient is prone and flexes the knee of the leg to be treated. The practitioner places one hand 277
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Figure 6.132 • PIR of the soleus for a tender Achilles tendon: (A) examination and treatment; (B) self-treatment.
round the patient’s heel and with her other hand takes hold of the patient’s forefoot; she next brings the forefoot and toes into dorsiflexion relative to the heel to take up the slack (see Figure 6.133A). The patient is then told to flex his toes and forefoot relative to his heel, making his foot ‘hollow’; the practitioner offers light resistance to this flexion movement. As far as possible, all plantar flexion 278
Figure 6.133 • (A) Examination and treatment of increased tension in the plantar aponeurosis for a tender calcaneal spur. (B) PIR with accentuation of the plantar arch during isometric contraction. (C) Flattening of the arch during relaxation.
Therapeutic techniques
must be avoided. During the ensuing relaxation phase there is an increase in the dorsiflexion of the toes and forefoot relative to the heel. This procedure is repeated three times. RI takes the form of dorsiflexion of the toes, against which the practitioner offers rhythmic repetitive resistance. In chronic cases, there may be an indication for needling the TrP on the sole of the foot.
Self-treatment Gravity-induced PIR is used for self-treatment. The patient is standing or seated with his feet on the floor. During the isometric phase he accentuates the arch of the foot by drawing his toes in and he holds this position for 20 seconds (see Figure 6.133B). He then relaxes again for 20 seconds (see Figure 6.133C) and this procedure is repeated three times. In view of recent experience with the stabilization system of the feet, it seems both simpler and more effective to train automatic toe flexion by forward inclination during standing (see Section 6.8.8 and Figure 6.157).
6.7 Training weak muscles (facilitation) In general, true paresis is absent in our patients; their muscle weakness is instead the result of inhibition and neglect or disuse. Our task is therefore to teach the patient how to use these neglected muscles correctly again. This goal can be achieved using a variety of facilitation methods, which will be described below. The common feature shared by all these methods is that the patient must become aware of the inhibited muscles. This means that for a certain period the patient must learn consciously to control these muscles until correct function becomes automatic again. Facilitation implies creating ideal conditions for the weakened muscles. In this setting, posture has an especially important role to play. A bent posture intensifies the activity of the phylogenetically older, predominantly tonic muscles, whereas an upright posture with the extremities in slight abduction and external rotation facilitates the phylogenetically younger, phasic muscles with their tendency to become weak and inhibited. Exteroceptive stimulation in the form of specific judicious stroking
Chapter 6
also has a part to play here, enabling muscle tone to become balanced on both sides of the body.
6.7.1 Muscles of the trunk The deep flexors of the neck These muscles belong to the deep stabilization system and are therefore extremely important. Head anteflexion against resistance can be practiced very simply: the patient is seated at a table, with elbows on the table and chin cupped in both hands. She now pushes against the resistance of her hands. The exercise is effective but not specific for the deep neck flexors. The following exercise is more specific and highly effective. The seated patient bends backward over the low back of a chair and in that position makes a nodding movement by drawing her chin down to her neck (see Figure 6.134). The exercise is repeated daily. Backward bending serves primarily to inhibit the sternocleidomastoid. The exercise can also be performed supine with the head retroflexed over the end of the treatment table; however, this modified version is very strenuous. Using a pressure sensor inserted under the neck in the supine position, Jull (2000) discovered that patients following cervical spine injury are unable to exert pressure on the sensor with their neck
Figure 6.134 • Training the deep neck flexors by nodding
the head forward at the craniocervical junction with the thoracic spine in retroflexion; the diagram illustrates the sequence of movements into maximal dropping of the chin (‘nodding’) and then back to the starting position.
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Figure 6.136 • Training the lower part of the trapezius.
Figure 6.135 • Training the deep neck flexors: the patient
exerts pressure with his fingers against the cervical spine as it exerts counterpressure against his fingers; at the same time he palpates his sternocleidomastoid.
without sternocleidomastoid contraction. This fact is exploited when exercising the deep neck flexors. The patient is supine (or standing against a wall) and places two fingers laterally under his cervical spine, while with his other hand he palpates the sternocleidomastoid on the opposite side (see Figure 6.135). He then presses his fingers on his cervical spine and exerts counterpressure with his spine, but only for as long as the sternocleidomastoid does not contract. He then learns to increase the pressure against his own fingers using the deep neck flexors in such a way that the sternocleidomastoid does not contract.
The lower part of the trapezius This muscle has a key role in the fixation of the shoulder blade. The following exercise should be carried out to facilitate contraction: the patient sits on her heels and bends her upper body and head forward to rest her forehead on the padded surface of the treatment table in front of her. As she does this she may lift her buttocks off her heels. Her 280
hands are on the crown of her head, and her elbows are flexed and resting loosely on the treatment table roughly level with her ears (see Figure 6.136). Throughout the exercise her elbows should not be pressed down on to the padded surface. In this position the medial border of the shoulder blade diverges from the spinal column in a caudal direction. The patient is then told to draw her shoulder blade in a caudal direction, thus bringing the medial border of the shoulder blade parallel with the spinal column. The shoulder blades must not be drawn together in this process. To begin with, it is recommended that the practitioner touches the patient to indicate which muscle she should contract. It can often be helpful if the patient herself uses the thumb of her opposite hand to monitor the contraction of the lower part of the trapezius. Once the patient has mastered this exercise in the facilitation position, she should learn to perform it in the prone position, with her arms by her sides in internal rotation. Immediately she manages to contract the lower part of the trapezius, the upper part will relax owing to reflex inhibition. Once the patient has mastered the contraction of the lower part of the trapezius in the prone position, she will also be able to do it upright, whether seated or standing. She can always use the thumb of her opposite hand to monitor the contraction of this muscle. This exercise plays a crucial role in good fixation of the shoulder blade.
Serratus anterior This muscle, which also fixes the shoulder blade from below and is connected to the oblique abdominal muscles, can be tested and exercised using the
Therapeutic techniques
following method. The patient is on all fours with head held horizontally. Her weight is mainly on her hands, which are in internal rotation so that the fingers are pointing toward each other (see Figure 6.137A). She then performs a press-up so that her center of gravity is shifted forward and her elbows are pointing outward as she exhales. Her forehead is now pointing at the floor (see Figure 6.137B). During this movement the contraction of her abdominal ‘muscle corset’ should fix her trunk. Her shoulder blades are kept maximally apart, and the muscles between them must show only eccentric contraction. One very important aspect is the contraction of the upper quadrants of the abdominal muscles because only then will the patient’s back remain as straight as a board. In lordosis the serratus anterior is unable to fix the shoulder blade and a winged scapula is seen (see Figure 6.137C). A comparable effect is achieved with the following exercise in which the patient, again on all fours,
Chapter 6
Figure 6.138 • Patient on all fours with a book on her
occiput, to train the serratus anterior and the lower part of the trapezius.
has a book resting on her occiput. It, too, trains the correct fixation of the shoulder girdle by contraction of the serratus anterior muscles and the lower part of the trapezius (see Figure 6.138). In this instance it is important that the patient supports herself radially on her thenar eminences. At the same time there should be coordinated contraction of the flexors and extensors of the cervical spine. The upper part of the trapezius remains relaxed and the abdominal muscles are contracted. The back and neck should be as straight as a board.
Rectus abdominis
Figure 6.137 • Training the serratus anterior: (A) starting position; (B) press-up with arms flexed, correct position; (C) faulty position with lordosis.
The simplest test for this muscle is for the patient to sit up from the supine position and to lie back down again. In this process her legs remain bent at the hips and knees and her feet should not lift up from the mat. In order to practice coordination even more precisely, the patient may actively contract her knee flexors to press with her heels against an object solidly placed behnd her heels (see Figure 6.139A). It would be a major error to fix her feet from above (see Figure 6.139B). If the patient is unable to sit up in this way, and provided that her lumbar erector spinae is not too short, then she may train her abdominal muscles as follows: the patient is seated with legs flexed at the hips and knees, and then lies back slowly with her spine in kyphosis so that her lowest lumbar vertebrae touch the table first, followed in sequence by her other vertebrae up as far as the shoulders (eccentric contraction). The exercise must be stopped the moment the patient’s feet are lifted from the table or if lumbar kyphosis cannot be maintained. Only once the patient has learnt to lie down in this way from 281
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Figure 6.140 • Drawing in the navel.
Figure 6.139 • Strengthening the rectus abdominis by lying down from a sitting position and sitting up from a recumbent position: (A) correct and (B) faulty.
the sitting position should she attempt to sit up from the supine position by the same method in reverse. Nowadays it is more common practice to exercise the deep stabilizers rather than the rectus abdominis.
this system is of major importance and even today it represents uncharted territory. The simplest way to start is for the patient to draw in his navel (see Figure 6.140). Here it is important for the abdominal wall laterally at the waist and for the lower abdomen to contract simultaneously (or autonomously). This primarily involves the transversus abdominis, but also the obliquus internus abdominis. There is a special reason for this contraction at the waist: it involves eccentric contraction of the abdominal wall coupled with concentric contraction of the diaphragm, unless the two are being exercised separately (see Figure 6.141). Kolárˇ’s tests, as outlined in Section 4.20.5, can also be used for the purposes of exercise: by raising his head and chest in the prone and/or supine position the patient learns to contract not only his abdominal or back muscles, but also the lateral part
The deep stabilizers of the lumbar spine and pelvic floor In principle this group comprises the muscles of the pelvic floor, deep abdominal region, diaphragm, and the multifidus muscles. It is very important to note that the individual muscles form a chain so that the others also react when one is successfully facilitated. For practice, this is of major significance because not all these muscles are equally accessible to therapy; thus Hides (2004) principally advocates exercising the multifidus muscles, with visual feedback provided by ultrasound imaging. While we endeavor to use methods that are more accessible in a clinical setting, we share the view of that Australian physiotherapy team that the function of 282
Figure 6.141 • Testing for and stimulation of isolated contraction of the lateral abdominal wall.
Therapeutic techniques
of the abdominal wall. The same applies for flexion of the bent legs against resistance, whether supine or sitting upright against gravity. If the patient is performing the exercise alone, it is always possible for him to use his own hands to check what is happening at the waist.
Transversus abdominis Once the patient has mastered the previous exercises he can perform the following exercise himself, as developed by Wohlfahrt et al (1993). Lying supine, he raises and flexes his legs as if cycling and in so doing exerts pressure on a sensor placed beneath his lumbar spine. Then, instead of the pressure sensor, the patient inserts both hands (palms facing down against the padded table surface) and, by flexing his fingers, exerts pressure against his lumbar spine while simultaneously applying counterpressure against the backs of his hands (see Figure 6.142). To prevent any discomfort, the patient may cover the backs of his hands with a soft material. This exercise can only be performed correctly if the patient has learnt to contract the lateral part of his abdominal wall and his lower abdomen; otherwise, in this exercise that is targeted specifically at the transversus abdominis, he will make his abdomen protrude.
Chapter 6
floor, particularly the coccygeus muscle. For this it is necessary to distinguish the TrP and its significance here from the TrP in the levator ani that causes attachment point pain at the coccyx. Palpation of the TrP in the coccygeus has been described in Section 4.5.8 (see Figure 4.12). The exercise begins with the side-lying patient drawing in his navel (the principle is illustrated in Figure 6.140). Once he is able to do this, he places the fingers of one hand flat over his anal region and attempts in a similar manner to draw this in (see Figure 6.143). The practitioner may ask the patient whether he can feel this happening. The problem is that there is no direct means of con firming contraction of the pelvic floor. The patient is therefore instructed to pinch his nose with his other hand and to breathe in against resistance with his mouth closed. The resultant suction will enable the patient to be considerably more aware (perhaps for the very first time) of pelvic floor contraction. In both scenarios it is possible to tell that the patient is actually contracting his pelvic floor.
Coccygeus The following exercise is designed to help the patient learn both to contract and relax his pelvic
Figure 6.142 • Training the transversus abdominis.
Figure 6.143 • Training the pelvic floor, especially the coccygeus.
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This exercise is repeated two or three times. The practitioner then checks whether palpation of the pelvic floor is still painful and to what extent the usually numerous additional TrPs and restrictions linked with the pelvic floor are still present. If the outcome is satisfactory, the patient can perform the exercise several times daily in the seated position, simultaneously drawing his navel in. He can also do this while at work without anyone noticing. The patient should be instructed always to perform the exercise slowly, otherwise relaxation will fail to materialize. The exercise also shows that relaxation of the coccygeus takes place in an entirely different manner from relaxation of the levator ani. In the exercise to educate the levator ani and gluteus maximus, the patient clenches his buttocks together and also contracts his sphincter. In the present case, however, the buttocks are relaxed and the patient does the exercise while imagining that he is sucking something in. All this illustrates the two very different functions of the pelvic floor: first, as a component of the deep stabilization system, and second, in connection with sphincteric function.
The ‘cradle’ The patient lies supine, drawing her knees up to her chest and holding them there with her arms clasped. She then lifts her pelvis and brings her lumbar spine into kyphosis by contracting her gluteal muscles (hip extension), causing her arms around her knees to come under tension. At the same time she lifts her head and chest and breathes out, thus producing maximal contraction of her abdominal muscles. By rhythmic pressure of her knees against her clasped arms, she rocks herself up into a sitting position, before rolling on her lumbar kyphosis back to her starting position (see Figure 6.144A and B). At a later stage she may perform this exercise without the help of her arms, which she holds out in front of her. The purpose of this exercise is to strengthen and improve coordination between the abdominal and gluteal muscles and to relax the erector spinae.
The ‘pelvic see-saw’ The patient is supine with knees bent and feet placed flat on the treatment table. Breathing calmly and regularly, she brings her lumbar spine into lordosis by 284
Figure 6.144 • The ‘cradle’: (A) knees drawn up to the thorax the chest; (B) hip extension against resistance at the knee.
contracting her erector spinae (see Figure 6.145A), and then relaxes the erector spinae while contracting her abdominal and gluteal muscles, thus flattening her lumbar spine against the treatment table. Once the patient has mastered this phase, another element is added to the exercise. As before, she presses her entire lumbar spine flat against the treatment table without her calm breathing becoming irregular in any way. She then presses her knees together and, in a caudal-to-cranial sequence, raises first her pelvis, then her (kyphosed) lumbar spine, and finally her thoracic spine away from the treatment table while ensuring that her lumbar spine kyphosis is not reduced. Her knees remain pressed together and finally she clenches her buttocks to straighten her pelvis slightly more dorsally. Then in reverse sequence (thoracic spine, lumbar spine, pelvis) she lowers her back down on to the treatment table (see Figure 6.145B). The purposes of this exercise are to control pelvic movement, to coordinate the abdominal and buttock muscles, and to strengthen the gluteals in particular.
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tilt – probably their most important postural function. For this, there is an especially effective exercise that is also used for self-mobilization of the lower lumbar spine (see Figure 6.70). In the routine activities of daily living the gluteus maximus contracts primarily when a person rises vertically from a squatting or sitting position, that is the individual must not bend forward in the process. This can be practiced if the patient rises vertically from a chair and palpates her gluteus maximus on the side of the weakened buttock muscle.
Gluteus medius Figure 6.145 • The ‘pelvic see-saw’: (A) bringing the
lumbar spine into lordosis; (B) raising the pelvis and lying back on the padded surface of the treatment table, with the lumbar spine in kyphosis.
As a minor modification, and from the same starting position, the patient can press her lumbar spine flat against the treatment table while simultaneously stretching one leg (resting on its heel), but only so far that her lumbar spine does not diminish its pressure against the treatment table. The extent of this stretch will increase with practice.
6.7.2 Muscles of the hip Gluteus maximus If this muscle is found to be weak, that is if it is flaccid or displays only minimal activity during hyperextension of the hip (see Figure 4.47), the most effective and simplest facilitation technique is for the patient to lie prone and perform hyperextension with her leg in external rotation. However, if this is insufficient, the patient can consciously contract her buttocks and hold this contraction during hyperextension of the hip in the prone position. In patients with hyperactive erector spinae and hyperlordosis, lordosis can be reduced by placing a cushion under the patient’s abdomen. She then again consciously contracts her buttock muscles and raises her extended leg very slightly so as not to lordose her lumbar spine or contract her erector spinae. Once she has mastered this she can learn to use both gluteus maximus muscles to reduce pelvic
The following method has proved most effective for facilitating the gluteus medius: the patient is sidelying and, because the gluteus medius is weak, she performs ‘false abduction’ chiefly using the tensor fasciae latae and the hip flexors (see Figure 4.48). The practitioner then passively performs maximum abduction correctly, and from that position suddenly and unexpectedly lets go of the patient’s leg. This will cause her gluteus medius to contract automatically. This maneuver is repeated, with the practitioner palpating first how the gluteus medius contracts (and later encouraging the patient to palpate this for herself). This will make the patient aware of her own gluteus medius. Once she has learnt to identify gluteus medius contraction, she can check this with her fingers. Within the space of a few exercises she will learn how to abduct her leg correctly – in the frontal plane – using the simultaneous and coordinated contraction of both the tensor fasciae latae and the gluteus medius.
6.8 Re-training to correct faulty movement patterns 6.8.1 Standing on both feet An important criterion for standing posture is that it should be stable. Furthermore, the muscle activity required to maintain balance should be as minimal as possible. However, there is always some activity at the level of the feet, and this fact is consistent with the decisive role of the feet in this context. This is no mere coincidence: the major role played by the feet, together with the hands and mouth, is reflected in their extensive representation in the 285
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motor region of the cerebral cortex and in the fact that they have the highest density of sensory receptors. This is commensurate with the importance of the feet as stabilizers of upright posture. However, this function is constantly compromised by wearing shoes, which causes a certain degree of sensory deprivation. First and foremost, therefore, it is necessary to activate the feet. In the ‘Chinese stance’ the patient stands with her legs slightly apart, her feet parallel to each other and knees slightly bent. This position greatly facilitates the activity of the foot flexors, enabling the patient to ‘grip’ the surface on which she is standing. Obviously, this is easier to do without shoes. The stability of this type of standing can be tested very simply by giving a gentle unexpected push to the patient’s trunk from in front or behind. If she is standing in the conventional way with her feet in external rotation, she is likely to lose her balance. Her stability is greatly enhanced if she stands with legs slightly apart, feet parallel in slight internal rotation and knees bent. This, however, is not the only effect: the pelvis will automatically be in a neutral position, thus greatly improving body statics and posture.
6.8.2 Standing on one leg and walking Because these are asymmetric functions, asymmetric exercises are used to bring about correction. The ability to stand correctly on one leg is also a prerequisite for a normal gait pattern because
walking entails alternate standing on one leg (see Figure 4.77). However, a certain degree of asymmetry is normal, and this is why we distinguish the supporting leg from the free leg. The supporting leg is the one a person puts more weight on when standing at ease. The asymmetry should not be too marked, however. In both standing and walking, it is essential to pay attention to the activity of the feet, and of the toes in particular. In standing, the knee should be bent very slightly and the toes should be pressing against the floor. In walking, the heel strikes the ground first, then the foot rolls on to its lateral edge and its arch should not sink down medially. Pronation does not occur until toe-off; that is toe-off is achieved by the metacarpal bone of the hallux and flexion of all toes.
Understanding and correcting pelvic obliquity The supine patient is instructed to push one leg and the corresponding side of her pelvis away from her in the direction of its long axis (see Figure 6.146). At the same time she is told to make the opposite movement with her other leg, thus producing pelvic obliquity due to contraction of her non-tense quadratus lumborum. While this is happening, her lumbar spine is firmly fixed against the treatment table by contraction of the abdominal musculature. Her other muscles are relaxed. The purpose of this exercise is to help the patient understand how pelvic obliquity occurs and how she can correct this.
Figure 6.146 • Alternate pushing away and drawing back of the legs, patient supine.
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Figure 6.147 • (A) External rotation and (B) internal rotation of the hip, patient side-lying with uppermost leg abducted.
Rotation of the hip The side-lying patient abducts (raises) her extended uppermost leg and (as in the preceding exercise) pushes it away from her. She then performs external and internal rotation of her foot (see Figure 6.147). In the process the position of her pelvis is fixed by her abdominal and buttock muscles. The purpose of this exercise is to re-educate the hip muscles while the pelvis and lumbar spine are fixed in position.
Flexion and extension of the leg As for the preceding exercise the patient is sidelying with her uppermost leg slightly raised (abducted) and flexed at the knee. This leg is then flexed at the hip (see Figure 6.148A) and extended (see Figure 6.148B). Her pelvis and lumbar spine are fixed in position. Flexion of all leg joints is accompanied by moderate kyphosis of the lumbar spine via the pelvis. The abdominal muscles and hip flexors are involved in this movement. In the second phase of the exercise, as the leg is extended, all the extensor muscles of the leg contract, and the lumbar spine participates in this movement only by going into moderate lordosis. Correct contraction of the abdominal muscles should prevent hyperlordosis during extension. The exercise can be made easier if the practitioner
offers light resistance at the knee against flexion and at the heel against extension. The purpose of this exercise is to re-educate the hip stabilizers and abdominal muscles, and to relearn the coordinated movement pattern as in walking where movement is controlled not by the hip but by the lumbar spine. It has proved effective to have the exercise performed side-lying, that is in an exercise position that is ‘unusual’ for the patient.
6.8.3 Sitting See also Section 4.15.1.
Sitting erect with trunk rotation The patient is seated on the floor, resting back on her ischial tuberosities. Her knees are parallel and slightly flexed, and her hands are clasped over her occiput (see Figure 6.149A). The coordinated contraction of her abdominal muscles holds her spinal column erect in a neutral position. In the second phase of the exercise, the patient rotates her trunk from her hips up to and including her head (see Figure 6.149B). The movement must be performed smoothly from bottom to top and back again. The patient’s spinal column must be kept vertical, avoiding all anteflexion, retroflexion, and side-bending. 287
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Figure 6.148 • (A) Flexion and (B) extension of the slightly abducted uppermost leg, patient side-lying.
This exercise is demanding because the patient’s pelvis is not fixed. Therefore it should be practiced initially with the patient sitting astride a chair or treatment table, thus fixing the pelvis. Good facilitation can be obtained if the patient looks toward the side of rotation and up a little, breathing in during rotation to the side and breathing out as she returns to a neutral position. All this holds true for trunk rotation while standing with legs apart.
Lateral movement of the thorax
Figure 6.149 • (A) Sitting erect on the floor. (B) Trunk rotation.
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The patient is seated on a chair with her feet supported on the floor, and preferably in front of a mirror so that she can correct her position. Her arms are held in abduction at 90°. She then moves her thorax to one side, as if someone were pulling her arm horizontally. If the patient contracts her abdominal wall correctly, her thoracic spine will move sideways without itself curving laterally (see Figure 6.150A and B). During this sideways movement the patient’s body weight will shift on to one buttock and the leg on the same side. The exercise can be facilitated if the practitioner effects light
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Figure 6.150 • Laterolateral horizontal movement of the thorax with the patient seated: (A) correct and (B) faulty.
resistance against the patient’s ribs, first from one side and then from the other. The purpose of this exercise is for the patient to become aware of how to compensate for scoliotic posture and how to control the oblique and deep abdominal muscles that are so important in this context.
Correction of pelvic tilt while seated The patient sits on a stool or on her heels facing a mirror. She first intentionally relaxes her abdominal muscles, bringing her lumbar spine into lordosis. She then slowly contracts her abdominal and gluteal muscles to cause lumbar kyphosis. Her shoulders should move as little as possible during this exercise.
The purpose of this exercise is for the patient to achieve ‘dynamic sitting’, something that can be practiced particularly well on an exercise ball.
6.8.4 Anteflexion It is well-known that a stooped or forward-bent posture can be indicative of underlying pathology. However, anteflexion is an entirely normal function of the locomotor system that should not be avoided but carried out correctly.
Straightening up from anteflexion The patient is seated on her heels, resting her hands on the floor in front of her knees. As she breathes 289
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Figure 6.151 • Uncurling from anteflexion with patient sitting on heels: (A) with hands on the floor; (B) straightening up.
calmly, her lumbar spine is in kyphosis (see Figure 6.151A). On coordinated contraction of her abdominal and back muscles and with her pelvis fixed by her gluteals, the patient lifts her hands from the floor and her lumbar spine and thoracic spine straighten up (see Figure 6.151B). The purpose of this exercise is to prepare the patient for subsequent exercises.
Anteflexion and retroflexion of the trunk with pelvis upright Standing erect, the patient contracts her abdominal and gluteal muscles, and begins anteflexion of the head and neck followed by her thoracic and lumbar spine. Her pelvis should remain upright, which means that anteflexion is never extremely pronounced. The patient never touches the floor with her hands, and usually cannot reach further than her knees. From this position she straightens up in reverse sequence (lumbar spine, thoracic spine, head) and continues seamlessly into retroflexion, contracting her gluteal muscles and pushing her pelvis forward. She then straightens up again to her starting position. The purpose of this exercise is for the patient to learn how to control the position of her pelvis and to master the smooth straightening of her thoracic and lumbar spine. 290
Lifting an object In a standing position, the patient places one foot forward, simultaneously bending her trunk and the knee of her forward leg to pick up the object (see Figure 4.72). In this way the load is evenly distributed between leg, pelvis, and trunk. She then straightens her trunk, simultaneously extending her forward leg and righting her pelvis using her gluteal and ischiocrural muscles, while her abdominal and back muscles control the (successive) uncurling of her spinal column. Facilitation of the abdominal muscles can be enhanced by the patient either breathing out against resistance or pressing her outstretched fingers toward the floor. Contraction of the abdominal muscles should be maintained as the patient straightens up and subsequently also during forward-bending, and she can check this using her fingers. She should also keep her trunk as close as possible to her thighs, which in turn prevents leverage. Her body’s center of gravity is over the advanced knee and is supported to some extent.
6.8.5 Lifting the arms The critical constants here are correct fixation of the shoulder girdle and hence relaxation of the cervical spine.
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Lifting the sideways-extended arms The patient is prone, with arms relaxed and extended sideways and her forehead resting on the exercise mat. Her arms are in internal rotation with palms facing upward (see Figure 6.152A). Her pelvis is fixed by the abdominal and gluteal musculature. The practitioner brings the patient’s shoulder blade passively into the correct starting position by raising her shoulders and moving her shoulder blades caudally. In this process the patient’s arms go into external rotation and her palms are now flat on the floor. In this position the patient now actively fixes her shoulders. She then raises her forehead slightly and moves her outstretched arms up toward the level of her head, rotating them further externally and lifting them only so far that her forearms are still touching the exercise surface while her shoulders remain higher than her hands
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(see Figure 6.152B and C). In this process the lower fixators of her shoulder girdle remain contracted, while the upper fixators are relaxed. This exercise can be performed on one side initially, and later on both sides. The purposes of this exercise are to enhance coordinated rotation at the shoulder while the upper shoulder blade fixators are relaxed, to achieve coordinated fixation of the trunk, to stretch the pectoralis, and to strengthen the lower shoulder blade fixators.
Raising and lowering the shoulders The patient is seated erect on a chair, preferably in front of a mirror, with arms hanging down. As forcefully as she can, she fixes her shoulder
Figure 6.152 • Lifting the sideways-extended arms, patient prone: (A) first phase; (B) second phase; (C) third phase; (D) faulty.
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Figure 6.154 • Lifting the arms above the head: (A) correct and (B) faulty.
Figure 6.153 • Raising and lowering the shoulders: (A) relaxed starting position; (B) faulty.
blades using the lower shoulder blade fixators (see Figure 6.153A). Now chiefly using the levator scapulae, she lifts her shoulders, leaving the upper part of the trapezius as relaxed as possible while activating the lower part (see Figure 6.153B). If only one side is being exercised, the patient can check the lower part of the trapezius with her other hand. The purpose of this exercise is for the patient to learn to feel the relaxation of the upper fixators of the shoulder while consciously contracting the lower fixators.
Lifting the arms above head height The patient is seated erect on a chair and performs a routine movement, bringing one hand up to her head (e.g. as when combing her hair). It is important that the shoulder blades are fixed properly, the neck muscles are relaxed, and head posture is correct. The levator scapulae and upper part of the trapezius should also remain relaxed (see Figure 6.154A). The exercise can be performed on one side only, and if done on both sides, the two hands do not need to be lifted equally high.
Head rotation The patient, who is seated on a chair, is instructed to rotate her head. There should be rotation of the 292
cervical and upper thoracic spine, and the shoulder blades should remain fixed from below, with the upper shoulder blade fixators relaxed (see Section 4.15.1, Figure 4.75). There should be no side-bending and the rotational movement should be around the vertical axis of the body. The purpose of this exercise is to train properly coordinated head rotation with the upper shoulder blade fixators relaxed.
6.8.6 Carrying loads correctly For correct load-carrying, the proper fixation of the shoulder blades is just as essential as during lifting of the arms. Here, however, special attention must be paid to relaxing the subclavicular part of the pectoralis major so as to avoid drawing the shoulders forward. The coordinated contraction of the interscapular muscles is also important. Once the patient succeeds in holding her shoulders back behind the body’s gravity line, the upper fixators of the shoulder girdle remain relaxed and the load being carried is not transmitted to the cervical spine (see Figure 4.76). It is no less important to keep the head back, otherwise the shoulders are again drawn forward. It is also necessary to relax the hands when carrying something and not to actively flex the fingers, instead holding a handle by the terminal phalanges, whenever possible. In fact, the terminal phalanges flex automatically thanks to the same mechanism that enables rock-climbers to hold on to the rock face without actively flexing their fingers. This also helps to prevent epicondylopathy.
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6.8.7 Breathing The most serious fault here is clavicular breathing in which the thorax is lifted during inhalation (see Figure 4.78). When this occurs, the tensed scalenes take over the activity of the diaphragm, which means that the deep stabilizers are no longer able to function as they should. In this faulty breathing pattern, not only is the cervical spine constantly overloaded, but the thorax also moves away from the pelvis with every breath taken, causing the diaphragm to tilt and abolishing any fixation of the thorax from below by the abdominal wall. The first step is to restore coordinated activity between the diaphragm and the deep abdominal muscles. As preparation for this it is also helpful to relax the scalenes (see Figure 6.94). During normal breathing there is eccentric contraction of the transversus abdominis as a result of the concentric contraction of the diaphragm during inhalation, which can be easily palpated at the waist and lateral abdominal wall. To teach this to the patient, the practitioner places his hands with the radial edge of his forefingers at the waist and tells the patient to apply pressure against the fingers at the waist. After a little stimulation with the hands, this will be learned in most cases. However, if this fails to work, the patient should exercise using one of the tests described in Figures 6.140 to 6.143, which are designed to contract this muscle group. Once the patient is able to contract the lateral abdominal wall, he is asked to lie supine. The practitioner stands at the head of the treatment table and places both hands over the patient’s lower thorax. As the thorax is usually fixed in an inspiratory position, the practitioner first mobilizes the thorax in a caudal direction during exhalation and then stimulates the lateral abdominal wall with his forefingers (see Figure 6.155). The patient is instructed to breathe out. As he then breathes in, the practitioner uses his hands to prevent the patient’s thorax from moving cranially and simultaneously stimulates the lateral abdominal wall so that the patient feels how to fix his thorax himself using his own muscles. This process helps to coordinate the concentric contraction of the diaphragm and the eccentric contraction of the transversus abdominis in particular. After taking a few breaths, the patient will learn to fix his thorax himself using his abdominal muscles. The practitioner next insists that the patient also contracts his lower abdomen, thus
Figure 6.155 • Activation of thoracic fixation during
inhalation using co-contraction of the diaphragm and the transversus abdominis.
preventing his navel from moving cranially and his abdomen from protruding. Once the patient is breathing properly in the supine position, he is invited to sit on a chair. He should be erect and not leaning back, stabilizing himself with both legs in slight abduction and feet rotated externally; he can check his position in the mirror. In this position the practitioner starts by placing his hands on the patient’s waist while simultaneously checking the lower abdomen with his fingers. As soon as he notices that the patient is contracting his lateral abdominal wall and lower abdomen, and that his thorax is widening instead of lifting as he breathes in, then the practitioner places the patient’s hands on his waist so that he can feel with the radial edge of his forefingers for himself the contraction of the lateral abdominal wall and palpate with his other fingers his lower abdomen. He can also watch his clavicles in the mirror to check that these are not lifting during inhalation (see Figure 6.156). After a few repeats, the patient will be able to perform the exercise at home in front of the mirror several times a day. After 10–14 days he should attend a follow-up appointment where the main focus will be to establish whether and how he has practiced and what still needs to be corrected. It should also be clarified whether the exercise has helped the patient. Mastery of correct breathing technique is usually associated with restoration of deep stabilizer function. Actively exercising the deep stabilizers and their function during breathing has the following astounding effect: TrPs and movement restrictions, including 293
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Figure 6.156 • Training correct breathing in front of a
mirror: the patient uses his hands to check contraction of the lateral abdominal wall and lower abdomen.
chain reaction patterns, are routinely resolved in the same way as after PIR, RI, and manipulation (mobilization). It is impossible to overestimate the importance of the activity and cooperation of the patient here.
6.8.8 The feet In our earlier discussion of the key regions in the locomotor system, we already emphasized the absolutely crucial role played by the feet. This is reflected in the simple fact that the feet have the highest density of sensory receptors, and is also commensurate with their very significant level of representation in the sensorimotor part of the cere bral cortex. Clinically, this is manifested among other things in the unusually frequent chain reaction patterns that have their origin in the feet. It 294
was clearly stated earlier (see Section 4.20) that the deep stabilizers are the source of the commonest chain reaction patterns, and the same claim can be made emphatically for the feet. The latest research findings indicate that the feet form a functional unit with the deep stabilizers, as illustrated by the following: the feet play a prominent role in maintaining balance, especially in the sagittal plane. As is well known, when we stand ‘at ease’ our muscles are constantly having to compensate for the oscillations of our body in all directions in order for us to keep our balance. If the feet are functioning well, then the greatest muscle activity occurs in the muscles of the lower legs and feet. It has also been emphasized that one of the characteristics of the deep stabilizers (e.g. the transversus abdominis or the muscles of the pelvic floor) is that we do not generally move them consciously; therefore we have to learn how to control them deliberately. A similar situation occurs with the autochthonous muscles of the foot; it is difficult consciously to accentuate the arch of the foot using the deep plantar flexors or to abduct the hallux. However, one special characteristic of the feet – something that is not as evident anywhere else in the locomotor system – is their tactile sensitivity and, in this connection, it is possible to use afferent impulses to achieve clinical effects. Although it is repeatedly stressed that the nervous system is an information-processing organ, our knowledge is insufficient to achieve rehabilitation. However, amazing successes in this respect have been recorded with the feet. And here, too, it can be seen especially clearly how sensitivity is linked with changes in muscle tonus (see Section 6.3). This sensitivity of the soles of the feet to exteroceptive stimuli may also be linked to the fact that the feet are shielded by footwear from a host of physiological stimuli and are suffering from constant sensory deprivation. The following treatment option may therefore be inferred: if we notice during stroking (light scratching) that the patient’s reaction is not symmetrical on both sides and/or the patient informs us that stroking is sensed differently on both soles (and neurological disease has been excluded), we can be satisfied that tonus differences are present in the soles of the feet. If this is the case, then the most effective therapy for TrPs and movement restrictions in the feet and for chain reaction patterns emanating from the feet (most typically on leaning forward) is exteroceptive stimulation of the sole
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of the foot on the side with the clinical abnormality. The technique that has proved most effective is to trace numbers and letters on the sole and to ask the patient to identify them. Not only is superficial sensitivity addressed but also proprioception, and because the patient focuses attention on deciphering the numbers/letters, the technique is better tolerated in the event of ticklishness.
Functional pes planus (flat foot) Rehabilitation per se is primarily directed at ‘functional’ pes planus, a condition in which the arch of the foot collapses during the gait cycle, irrespective of whether the foot is normal or flat in purely morphological terms. And here again it has proved useful to exploit afferent impulses. In the gait cycle, after heel-strike, the foot normally rolls first on to its lateral edge, then goes into pronation on toe-off, before completing toe-off in pronation by pushing off with the toes, especially the hallux. Therefore, if pronation occurs prematurely, that is if the foot does not remain on its lateral edge and collapses, then the patient should be instructed when walking to perceive or sense the lateral edge of the foot. If pes planus is not extreme, then the longitudinal arch will momentarily hold far better. The patient then needs to be told constantly to cultivate this ‘awareness’ when walking, regardless of whether barefoot or wearing shoes. Functional pes planus is also commonly characterized by diminished tonus. As well as extero ceptive stimulation, gentle pressure along the longitudinal axis of the toes has also proved beneficial, that is pressure that is transmitted to the interphalangeal and metacarpophalangeal joints and constitutes a proprioceptive stimulus.
Splay foot Splay foot is primarily a weakness of the foot and toe flexors in terms of their postural function. Patients are generally able to flex their toes strongly without difficulty but are unable to utilize this in the toe-off phase of the gait cycle. This is indicated by the fact that the toes are unable to perform the test devised by Véle (personal communication). For this, the barefoot patient shifts his body weight forward without lifting his heels from the floor. Normally, this movement automatically produces flexion of the toes, probably as they seek to prevent
Figure 6.157 • Véle’s test: when the patient’s body weight is shifted forward, normal reflex flexion of the toes is visible (left) but absent (right).
the person falling forward. Véle has shown that this reaction is absent on the lesioned side in the S1 radicular syndrome. However, it is very much more common for this sign to be positive in functional faulty movement patterns of the foot stabilizers, that is when toe flexion is absent (see Figure 6.157). For rehabilitation, the patient learns to achieve automatic and sufficiently strong toe flexion by rocking back and forth on both feet slowly, and relaxing when rocking back. Recent experience has shown that this rocking technique is the most effective method of mobilization and relaxation for the treatment of restrictions and TrPs in the feet and of chain reaction patterns related to foot dysfunction (e.g. forward-drawn posture). This is true regardless of whether the reaction of the toes on forward rocking is abnormal or entirely normal. This exercise, together with gait training in which the patient learns awareness of the lateral edge of the foot, eliminates TrPs and movement restrictions in the same way as when exercising the deep stabilizers of the trunk – further evidence that the feet are also a component part of the deep stabilization system. Where pain due to splay foot is present, it is often the metatarsophalangeal joint of the fourth toe that is worst affected, with pressure from a plantar direction being extremely painful. In these circumstances, counterstrain is often instantaneously effective: for this, the patient applies dorsal pressure on to the transverse arch of the foot at the level of the metatarsal heads, fixes the first and fifth metacarpal bones, and holds this pressure for 90 seconds. Padded shoe inserts are also effective, 295
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especially when placed under the fourth metatarso phalangeal joint.
Abductor pollicis brevis and hallux valgus Weakness is often also detected in another postural muscle, the abductor pollicis brevis, especially if hallux valgus is developing. The patient must then learn to abduct the big toe or perform fan-wise abduction of the toes, including the little toe. This, too, is a predominantly postural function, a fact that explains why some time is generally needed before the patient masters it. However, motivation to persist should stem from the experience that active abduction brings immediate relief from the pain of hallux valgus.
Dorsiflexion The form of weakness most commonly encountered is that involving dorsiflexion of the foot, with the big toe usually being most affected. Among a wide spectrum of possible causes, the commonest is a radicular lesion at L5. In terms of rehabilitation, it is especially effective and simple to utilize the great extent to which the big toe is represented in the sensorimotor cerebral cortex. Rather than advising patients to practice dorsiflexion as assiduously as possible, they should instead be counseled to think of their big toe as often as possible, especially when walking – even when wearing shoes.
6.8.9 The shoulder blade and upper cervical spine The muscles which stabilize the shoulder blade play a similar role for the upper extremities to that played by the deep stabilizing system of the trunk for the lumbar spine. The most important muscles here are the lower (ascending) part of the trapezius and the caudal part of the serratus anterior. If these muscles are weak, active caudal movement of the shoulder (shoulder blade) with the patient prone does not produce the normal caudal and slightly medial movement of the inferior angle of the shoulder blade; instead the inferior angle of the shoulder blade protrudes like a hook toward the spinal column. This movement can be easily resisted if the 296
practitioner catches the lower angle of the scapular wing between thumb and forefinger. In contrast, the normal movement in a caudal and slightly medial direction cannot be resisted at all. Training the correct function of the lower fixators of the shoulder blade is described in Section 6.7.1 (see Figure 6.136). The patient learns to palpate the contraction of the lower part of the trapezius, first in the position of facilitation and then sitting. The patient next trains the fixators of the shoulder blade (see Figure 6.137). Immediately after this exercise it frequently happens that there is a marked improvement in TrPs and restrictions in the upper extremity, for example in epicondylar pain and painful shoulder. Current experience indicates that, in painful conditions of the upper extremity, the stabilizing muscles of the shoulder blade play an even greater role than the cervical spine, which itself is stabilized by the shoulder blade. The extremely labile craniocervical junction is stabilized mainly by the short extensors and the deep flexors. In ancient times, people used to carry heavy loads on their heads, thus improving their posture. While this practice can certainly be recommended even today, it is not readily accepted. Clinical experience has shown that rapid, shaking, vertical pressure in the direction of the axis of the cervical spine with the patient upright engages the deep stabilizing system of the cervical spine and has a strong mobilizing effect on restrictions and relaxes TrPs (see Sections 6.1.3 and 6.5.6 and Figure 6.81C).
6.8.10 The hands Probably the most common disorder is cramping of the hands and the hypertonus associated with it. Once again, stroking along the axis of the fingers and metacarpals is indicated here. Helpful selftreatments include wriggling the fingers in a bowl of uncooked rice or peas, or playing/exercising with a soft rubber ball. For hypertonus of the hands, axial pressure via the fingertips is indicated, placing the interphalangeal and metacarpophalangeal joints under pressure.
6.9 Supports So far this chapter has been devoted to techniques that restore normal mobility and function; it is
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Figure 6.159 • Inflatable support cushion for lumbar Figure 6.158 • A simple (home-made) cervical collar.
kyphosis.
beyond the scope of this book to deal with immobilization techniques. However, it will be useful to discuss some simple supports that do not necessarily entail immobilization and can often be acquired by patients themselves.
to provide support at the point where the kyphosis peaks when the patient is sitting relaxed (see Figure 6.160A). The practitioner can be satisfied as to the correct placement of the cushion if he first supports the patient with his fist as he sits erect and tells him to relax (see Figure 6.160B).
6.9.1 Cervical collar A simple cervical collar made of latex foam can be very effective (see Figure 6.158). As soon as the soft material is placed round the neck to form a tube, it is sufficiently firm to support the cervical spine. Such collars are chiefly prescribed to protect patients from jolting and jarring their neck during road and rail journeys. However, wearing a cervical collar should not become a permanent habit.
6.9.2 Inflatable cushion If they are able to lean against a chair back, hypermobile patients with a tendency to sag into kyphosis when seated should carry an inflatable cushion, fixed by braces or a belt, especially for use during car journeys (see Figure 6.159). The cushion should be only slightly inflated, and should be fitted
6.9.3 Pelvic belt (Biedermann and Cyriax) Use of a pelvic belt is indicated in patients with a ‘loosened’ pelvis, especially after childbirth. This is a leather belt that is 8–10 cm wide and has a padded lining on its inner surface. The belt should be worn below the iliac crests and above the greater trochanters (see Figure 6.161). To achieve sufficient tension, it is recommended that the belt be fastened below the pelvis at thigh level and then pulled up over the greater trochanters. It should be worn for at least six weeks, particularly at night but may also be worn through the day. A pelvic belt may also be prescribed for patients with extensively weakened abdominal muscles in whom rehabilitation is a lost cause. This is not uncommonly the case in obese patients who have undergone multiple surgical procedures and in multiparous women. A key consideration here is that 297
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Figure 6.161 • Pelvic belt (after Biedermann and Cyriax).
6.10 Local anesthesia
Figure 6.160 • Locating the correct support point:
(A) pinpointing the peak of kyphosis when the patient is sitting relaxed; (B) using the fist to check for optimal support function.
the belt should be worn so that it supports the (overhanging) lower abdomen from below and does not compress the abdomen. 298
Within the scope of this volume it is not possible to cover the innumerable treatment methods that employ reflex mechanisms. The method that is probably most popular is local anesthesia. As already emphasized in Section 5.3.3, there is no essential difference between the effect of local anesthesia and of dry needling (Frost et al 1980). The critical factor is technique. The needle must touch the point where pain is maximal. It is not enough for the patient to feel pain; this pain must be sufficiently intense for the patient to react involuntarily, and wherever possible, the pain thus provoked should reproduce the patient’s spontaneous pain. Only when the most painful point in the pain zone is touched will needling achieve immediate alleviation (frequently elimination) of pain, affording relief that is just as intense as that of a local anesthetic, a fact that the patient can also corroborate instantly. The advantage of dry needling is that the position of the needle can be corrected if an analgesic effect is not obtained immediately. If the most painful point is not touched by the needle in local anesthesia, the effect is considerably diminished as soon as the local anesthetic wears off. If, however, the object is to achieve conduction anesthesia (e.g. of a painful nerve root or a peripheral nerve) or epidural anesthesia is required, then the administration of a local anesthetic is indispensable.
Therapeutic techniques
The treatment of TrPs involves the use of methods that employ reflex mechanisms: PIR, RI, minimal pressure, mobilization and/or manipulation of joints and often even of chain reaction patterns arising as a result of treatment of other, often remote TrPs and other dysfunctions. However,
Chapter 6
there are some TrPs that are not (or no longer) entirely reversible, where needling or traumatic massage are necessary. In such circumstances, however, needling is not so much a form of reflex therapy but more a form of traumatization (microsurgery).
299
Chapter Seven
7
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
Chapter contents 7.1 Pain in the lumbar spine and pelvic region . . . . . . . . . . . . . . . 302
7.1.1 Low-back pain due to muscle and ligament overload . . . . . . . 7.1.2 Painful or tender coccyx . . . . . . 7.1.3 Painful hip joint (coxalgia) . . . . . 7.1.4 Restrictions in the lumbar spine and sacroiliac joints . . . . . . . . 7.1.5 Low-back pain due to disk herniation . . . . . . . . . . . 7.1.6 Pelvic distortion . . . . . . . . . . 7.1.7 Forward-drawn posture . . . . . . 7.1.8 Inflare and outflare (Greenman) . . . . . . . . . . . . . 7.1.9 The coccygeus and pelvic floor . . . . . . . . . . . . . 7.1.10 Low-back pain due to restricted trunk rotation . . . . . 7.1.11 Combined lesions . . . . . . . .
303 303 305 306 309 311 311
7.5 Entrapment syndromes . . . . . . . . . . 325
7.5.1 Carpal tunnel syndrome . . . . . . 7.5.2 Thoracic outlet syndrome . . . . . 7.5.3 Ulnar nerve weakness . . . . . . . 7.5.4 Nocturnal meralgia paresthetica . . . . . . . . . . . .
326 327 328 328
7.6 The cervicocranial syndrome . . . . . . . 329
7.6.1 Headache . . . . . . . . . . . . . . 329 7.6.2 Disturbances of equilibrium . . . . 333 7.7 Active scars . . . . . . . . . . . . . . . . 338
313 314 315 316
7.2 Pain in the thoracic spine and thorax . . 317
7.2.1 Slipping rib . . . . . . . . . . . . . 317 7.3 Pain in the cervical spine . . . . . . . . . 318
7.3.1 Muscle imbalance . . . . . . . . . 318 7.3.2 Acute wry neck . . . . . . . . . . . 319 7.4 Referred pain and other pain types . . . 320
7.4.1 Fibular head restriction . . . . . . 7.4.2 Painful patella . . . . . . . . . . . 7.4.3 Knee joint dysfunction . . . . . . . 7.4.4 Painful foot . . . . . . . . . . . . . 7.4.5 Painful heel . . . . . . . . . . . . .
7.4.6 Shoulder pain . . . . . . . . . . . 322 7.4.7 Pain in the elbow region . . . . . . 324 7.4.8 Pain at the wrist . . . . . . . . . . 325
320 321 321 321 321
7.7.1 Diagnosis . . . . . . . . . . . . . . 338 7.7.2 Therapy . . . . . . . . . . . . . . . 339 7.8 Structural diseases associated with locomotor system dysfunction . . . 339
7.8.1 Basilar impression and spinal canal narrowing . . . . . . . . . . 339 7.8.2 Radicular syndromes . . . . . . . 341 7.9 Vertebrovisceral inter-relationships . . . 348
7.9.1 General principles . . . . . . . . . 7.9.2 Tonsillitis . . . . . . . . . . . . . . 7.9.3 The lungs and pleura . . . . . . . 7.9.4 The heart . . . . . . . . . . . . . . 7.9.5 The stomach and duodenum . . . 7.9.6 The liver and gall bladder . . . . . 7.9.7 The kidneys . . . . . . . . . . . . . 7.9.8 Importance of the psoas major and rectus abdominis . . . . . . .
348 349 349 350 351 352 352 352
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7.9.9 Gynecological disorders and low-back pain . . . . . . . . . . . 353 7.10 Post-traumatic states . . . . . . . . . . 354
7.10.1 Cranial trauma . . . . . . . . . . 354 7.10.2 Trauma to the extremities . . . . 357 7.11 The clinical picture of dysfunctions in individual motion segments . . . . . 357
7.11.1 The temporomandibular joint (TMJ) . . . . . . . . . . . . 358 7.11.2 Atlanto-occipital segment . . . 358 7.11.3 Atlantoaxial segment . . . . . . 358 7.11.4 Segment C2/C3 . . . . . . . . . 358 7.11.5 Segments C3/C4–C5/C6 . . . . 358 7.11.6 The cervicothoracic junction (C6/C7–T2/T3) . . . . . . . . . . 359 7.11.7 Thoracic segments T3/T4–T9/T10 . . . . . . . . . . 359 7.11.8 Restricted trunk rotation (segments T10/T11–L1/L2) . . . 359 7.11.9 Segment L2/L3 . . . . . . . . . 359 7.11.10 Segment L3/L4 . . . . . . . . . 359 7.11.11 Segment L4/L5 . . . . . . . . . 360 7.11.12 Segment L5/S1 . . . . . . . . 360 7.11.13 The sacroiliac joint . . . . . . . 360 7.11.14 The coccyx . . . . . . . . . . . 360 7.11.15 The diaphragm and pelvic floor 360 7.11.16 The hip joint . . . . . . . . . . 360 7.11.17 The foot and fibular head . . . 361 This chapter will illustrate how the theoretical principles and the diagnostic and therapeutic methods set out in previous chapters are applied to specific clinical entities and symptoms involving the loco motor system. It should be remembered that famil iar clinical pictures such as back pain, shoulder pain, and headache have rarely been considered systemati cally from this point of view and consequently there is little on the subject to be found in the literature (Brügger, Cyriax, Gutmann, Mennell, Simons, Trav ell, etc.). All the more reason therefore to demon strate the importance of what has been discussed in earlier chapters as it ‘touches down’ in everyday clinical practice. It is of great consequence for medi cal theory that this new approach has yielded major and unsuspected new insights into these seemingly familiar clinical entities. This has been made possible because of the efficacy and specificity of the new therapeutic measures we use. Nevertheless, they can 302
only be called upon and applied to best advantage if the functional diagnosis is as accurate and compre hensive as possible. And as the number of practition ers working with these methods is increasing rapidly, the body of clinical data is also growing apace. In back pain, the significant role played by the spinal column is established beyond all reason able doubt. However, the problem is traditionally treated mainly or even exclusively as a morphologi cal issue, which creates the impression that all we have to do is to find the underlying inflammatory, degenerative, or metabolic disease or gross mechan ical lesion, such as a herniated disk. We first have to satisfy ourselves that such a disease or lesion is indeed present and to what extent it is of key rel evance. Once patients have been ‘pigeon-holed,’ the largest group left over cannot be assigned to any category, that is these are patients ‘without any spe cific diagnosis’ whose symptoms are produced by locomotor system dysfunctions. Because the field of pathomorphological diagno sis is amply covered in textbooks of orthopedics, rheumatology, and neurology, we will deal here only with issues relating to differential diagnosis. For a discussion of how to take the patient’s history, read ers are referred back to Section 4.1. The present chapter will consider not only the mechanical aspects of the problem, but also the impact on the autonomic nervous system of fac tors such as menstruation, infection, meteorological changes, hormonal disturbances, or psychological stress. Because the term ‘back pain’ is altogether inadequate for a proper clinical understanding, it will be imperative to focus close attention on each individual section of the spinal column.
7.1 Pain in the lumbar spine and pelvic region The majority of lumbar and sacral dermatomes con verge in the lumbar region, which comprises the lower lumbar spine and sacrum (see Figure 4.3). Furthermore, the most powerful muscles have their attachments at the pelvis: this is the site of greatest mobility and is where the movements of the lower extremities are transferred to the trunk. All of this explains the great vulnerability of this region, har boring as it does a vast number of potentially path ogenic factors that have to be assessed for relevance in every case. The most important dysfunctions
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
causing different types of low-back pain will now be reviewed, together with their respective specific therapies. The term ‘low-back pain’ also includes pain radiating laterally toward the hips or groin, and referred pain that is felt in the lower extremities.
7.1.1 Low-back pain due to muscle and ligament overload In this type of low-back pain, morphological lesions may be absent and the spinal column as such may not necessarily be altered, at least at the outset. However, since this first pain category is not homo geneous, some further definition is required. The cause may be exogenous, for example heavy physical labor. More frequently, however, pain is the result of faulty posture and excessive static strain caused either by external factors or by faulty movement patterns. Poor posture may be attribut able to adverse static development, for example leg length inequality, or to juvenile osteochondro sis. In most cases, however, postural abnormalities are due to muscle imbalance arising in the context of adverse movement patterns, hypermobility, or obesity. All these sets of circumstances are char acterized by signs of excessive strain on locomotor system structures.
Chapter 7
on the other. The individuals most commonly affected are constitutionally hypermobile patients who experience ‘ligament pain’ involving the ilio lumbar and sacroiliac ligaments (see Section 6.7.1). An extremely common finding in these patients is insufficiency of the deep stabilizer system, which is linked with the compensatory development of large numbers of TrPs, principally in the long muscles (e.g. erector spinae, quadratus lumborum, or rectus abdominis). Tender pain points are also frequently found at the inferior lumbar spinous processes and the posterior superior iliac spines (PSISs). If there is marked postural asymmetry, pain points may be detected on the iliac crests and the lowest ribs on the same side, especially where there are TrPs in the quadratus lumborum. Baastrup’s phenomenon (osteochondrosis of the spinous processes) is com monly regarded as a cause of tenderness involving the spinous processes. In practice, tender spinous processes are encountered in hypermobile adoles cents without radiological evidence of degenerative changes. And in cases where Baastrup’s phenome non yields typical radiological signs suggestive of a pseudarthrosis between the spinous processes, the patient usually feels no pain at all.
Therapy
Fatigue sets in, usually in the form of trigger points (TrPs) with attachment point pain, and this increases to become pain during postural and/or dynamic loading. Often the symptoms are more the result of postural strain than of movement per se. Thus, any posture or position that the patient is required to hold for any length of time is registered as unpleas ant strain. Patients therefore feel the need to change their position, even in bed. In this context morning stiffness is often reported, and while this is gradually overcome, it can manifest itself later as pain associ ated with fatigue and excessive strain.
Where pain is due primarily to external factors pro ducing excessive strain, the first-line approach is to correct posture and dynamic overexertion patterns (see Section 8.3). However, if the underlying cause is faulty statics and muscle imbalance, the guidelines set out in Sections 5.4 and 5.5 should be followed (correction of statics and use of a remedial exercise program). In hypermobile patients exposed to situ ations of excessive static loading, attention should focus on the deep stabilizer system, with recom mendations for appropriate supports (see Section 6.9) to be used especially during road or rail travel. Acute pain should be relieved by treating TrPs (with post-isometric relaxation (PIR) and reciprocal inhi bition (RI)) and soft tissue, especially the fascia. If necessary, needling or local anesthesia can be used.
Clinical signs
7.1.2 Painful or tender coccyx
The typical imbalance in the lumbosacral region is characterized by weakness of the abdominal and gluteal musculature on the one hand, and by hyperactivity of the hip flexors and erector spinae
A painful or tender coccyx is the result of muscle dysfunction involving the gluteus maximus and levator ani and their points of attachment to the coccyx.
Symptoms
303
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Symptoms In the majority of cases where the coccyx is tender to palpation, patients report pain not in the coccyx itself but in the lower back. In low-back pain, on the other hand, about one-fifth of patients experience coccygeal tenderness on palpation. The opposite is also true: reports of coccygeal pain may in fact be attributable to painful lower sacroiliac joint dysfunc tion, a painful ischial tuberosity, a TrP in the coccy geus muscle (pelvic floor), or exceptionally even pain referred from the hip. In such cases, however, ten derness does not involve the tip of the coccyx itself but rather one side of the coccyx only. Falls on to the coccyx play a negligible role in chronic coccygeal pain. History taking in our patients revealed that only about one-fifth had experienced any previous falls on to their coccyx. In particular, patients complain of low-back pain when seated. There may sometimes be constipation and patients may report dyspareunia.
Clinical signs In obese patients, in particular, examination dis closes a hyperalgesic zone (HAZ) in the form of a small fat pad on the sacrum. Another important sign is hypertonus of the gluteal muscles, and some times a TrP in the iliacus or piriformis. Most char acteristically, however, there are TrPs in the levator ani but these can only be detected on examination per rectum. Patrick’s sign and the straight-leg rais ing test may also be mildly positive. However, the pathognomonic sign is an exquisitely tender (pain ful) tip of the coccyx, in response to even the slightest touch. Palpation must include the ventrally curved end of the sacrum. The true pain point will never be located if palpation covers only the dor sal surface of the coccyx. Sacral palpation may be difficult not only due to hypertonus of the gluteus maximus but also because the patient resists by clenching the buttocks. A painful coccyx is always curved ventrally; a coccyx that is straight and points caudally is never painful.
Therapy The treatment of choice is PIR of the gluteus maximus, during which the levator ani also contracts and relaxes at the same time. The conventional approach per rectum is used only exceptionally if there is no hypertonus of the gluteal muscles but 304
instead hypotonus with the patient, so to speak, sit ting on the coccyx without the ‘cushioning’ of the buttocks. The patient can practice PIR of the glu teus maximus regularly at home, several times daily (see Figure 6.124). Based on clinical experience and on therapeutic results it can be assumed that tension in the gluteus maximus and the levator ani is the main cause of a tender coccyx, that is it represents a tendomyop athy of these muscles. Contraction and relaxation of the gluteus maximus (PIR) are coupled with PIR of the levator ani. Increased tension in these muscles is associated with psychological tension, and relaxa tion of these muscles leads not only to a reduction in coccygeal pain but also to psychological relaxa tion. Finally, in the patient with low-back pain, it is important never to miss a tender coccyx, otherwise any treatment given may be doomed to failure.
Case study R J; male; born 1922; civil servant.
Medical history Pain in lower back and buttocks since 1977, permanently troublesome since Spring 1982. Pain worst on getting up in the morning or after sitting for lengthy periods. Coughing sometimes provoked stabbing discomfort. The patient’s medical record showed that he often suffered from tonsillitis in boyhood (tonsillectomy performed at age 10 years). He had also had typhoid fever and pneumonia. Sports activities: skiing, ice-skating, tennis, horse-riding. No record of accidents.
Clinical findings Examination on 11 June 1983 revealed some limitation of retroflexion, atlanto-occipital movement restriction on both sides, and a painful coccyx.
Therapy Mobilization of C0/C1 into anteflexion, and traction manipulation. PIR of gluteus maximus muscles. Home exercise for self-treatment: gluteus maximus relaxation. At the follow-up examination on 4 July 1983 the patient’s low-back pain had improved, occurring now with reduced frequency and intensity. If he stood for longer periods, he noticed pain in the region of his sacrum. On examination his coccyx was no longer painful; the key finding now was extreme weakness of the abdominal muscles, with separation of the rectus abdominis. He was advised to wear a lumbar belt.
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
7.1.3 Painful hip joint (coxalgia) In a series of 59 patients with a painful hip joint with no or very slight osteoarthritis of the hip, lowback pain was the most frequent complaint (Lewit 1977). Conversely, signs of a painful hip are com mon in patients with low-back pain. It is therefore justifiable to discuss the painful hip in this section because the hip also needs to be considered in the setting of low-back pain.
Symptoms Patients complain of pain on prolonged walking, especially when climbing hills and stairs or on hard paved surfaces, when standing for long periods, and when lying on the painful hip. However, pain is relieved by lying down for extended periods. The pain is usually felt in the low back, hip, and groin and it may radiate in segment L4 toward the knee, causing patients often to complain of knee pain. Sometimes pain localized at the knee is the first and only sign of (incipient) osteoarthritis of the hip: the pain is experienced on climbing stairs but not when descending.
Clinical signs On examination, Patrick’s sign is strongly positive, and when passive mobility is tested, the extreme limits of movement, especially internal rotation, are painful, particularly if a light springing force is applied in the extreme position. In osteoarthritis of the hip there is movement restriction consist ent with the capsular pattern described by Cyriax (1977, 1978) (internal rotation is most severely limited, see Section 4.10.5). Active abduction is also painful. The characteristic pain points are found at the femoral head palpated in the groin, at the insertion points of the adductors at the pubic symphysis, and at the pes anserinus of the tibia (which is also interpreted as knee pain). Further pain points include the greater trochanter (which provides attachment for the abductors) and the iliac crest. Increased tension of the hip flexors is responsible not only for pain at their attachment point, the lesser trochanter, and for TrPs in the tensed muscles, but also for flexion at the knee
Chapter 7
and hip in osteoarthritis of the hip. This results in the characteristic posture typified by exces sive lumbar lordosis. The PSIS is also frequently painful.
Therapy The choice of treatment depends largely on the stage of osteoarthritis of the hip and to what extent any anatomical changes permit functional improvement. It is beyond the remit of this vol ume to discuss the full range of therapeutic options available in the fields of physical medicine and surgery. The most important form of con servative therapy is traction. Where anatomical changes are not (yet) detectable, traction with a high-velocity, low-amplitude (HVLA) thrust can be instantly effective. Otherwise, traction with PIR constitutes the treatment of choice in this set ting (see Section 6.1.2). The effect can be further enhanced by shaking. The efficacy of this tech nique is probably attributable to the relaxation of all the muscles that place the hip joint under pressure. It is evidently the most effective form of conservative treatment and it should be performed daily, as far as possible. Because self-treatment is not really practicable, the following procedure can be adopted: once the patient has learned how to relax during therapy, then anyone in regular contact with the patient (family member, friend, colleague) can perform resistance by placing their hands in the patient’s groin. The patient then does the rest. If there is a muscle imbalance, it is usually the abductors that are weak and the hip flexors and adductors that are hyperactive. This is often apparent in the Trendelenburg test (the hip drops during standing on one leg); more usually, how ever, it is lifted, causing the center of gravity to shift over the standing leg, thus relieving the weakened abductors. In this case the hyperactive, shortened muscles should be relaxed and also pos sibly stretched, and the weakened muscles should be strengthened. Lifestyle advice is particularly important. Patients should avoid prolonged periods of walk ing (especially on hard pavements or asphalt) and standing. Soft heels and soles should be encour aged, and in severe cases the use of a walking stick (on the healthy side) is recommended. Weight loss is imperative in patients who are obese. 305
Manipulative Therapy
Case study S Z; male; born 1922; university professor.
Medical history At the initial examination on 7 May 2002 the patient complained of pain in his right thigh that woke him at night; he had no pain on walking, and no back pain, only slight stiffness in the neck.
Clinical findings and therapy On examination the patient was found to have reduced fascial mobility in the cervical region, restricted movement of the fibular head, and restricted movement in Lisfranc’s joint on the right side. He received treatment for these. At the follow-up examination on 22 May 2002 the patient reported that he was free from pain at night, his neck was not as stiff, and he had only minimal pain intermittently in his thigh. The patient was seen again on 27 April 2004. While he had no recurrence of his original discomfort, he now had pain at the back of his thigh and sometimes a stabbing pain on walking. He was now found to have reduced spinal anteflexion, retroflexion, and side-bending without pain, increased tonus in the thoracolumbar erector spinae, and a positive femoral nerve stretch test on the right side, consistent with a movement restriction between L3/L4. L3/L4 were mobilized, after which the femoral nerve stretch test was negative, and the patient practiced the McKenzie technique in the prone position for self-mobilization into extension. At a follow-up examination on 18 May 2004 the patient reported considerable improvement, but climbing stairs was still painful. Patrick’s sign was now positive on the right side, internal hip rotation was largely restricted on the right side and was possible only up to 20° on the left side. Dorsiflexion at the hips was also limited. Internal rotation of the right hip improved to 20° following isometric traction with shaking. X-rays revealed narrowing of the joint space in the right hip and a translucent area at the right acetabulum. The patient and his wife were trained so that they could perform self-treatment regularly.
Case summary This patient presented initially with quite uncharacteristic symptoms. Then in 2004 important findings were made in the lumbar spine at L3/L4 for the first time; when these were treated, improvement ensued. It was not until after this disorder was 306
treated that the first signs of osteoarthritis of the hip were diagnosed; these typically responded to traction. This case also illustrates the close connection between the L3/L4 segment and the hip.
7.1.4 Restrictions in the lumbar spine and sacroiliac joints These conditions share common ground in terms of their etiology, clinical features, and therapy. Mobi lizing therapy constitutes the first-line approach for movement restrictions in the lumbar motion seg ments.
Symptoms In the acute stage mobility is severely restricted, and straightening up (extension) usually presents more difficulty than flexion. Often there is pain on coughing and sneezing. In more chronic cases there is usually stiffness after longer periods of sit ting and/or bed rest, and this improves on move ment. Retroflexion is generally more restricted than anteflexion, and the most characteristic complaint is pain on straightening up after anteflexion. Sidebending is also often painful and as an early sign there is no rotational synkinesis during this move ment (normally, the upright pelvis rotates in the direction opposite to side-bending). Pain is usually asymmetrical and may radiate to the hips, buttocks, lower abdomen, groin, and lower extremities, and cranially toward the thoracic spine (referred pain).
Clinical signs and therapy Typical signs of movement restriction are found. One early sign is the absence of rotational synkine sis of the pelvis during side-bending. The specific symptoms in the individual motion segments are listed in Table 7.1. What used to be designated as ‘movement restriction of the thoracolumbar junc tion’ is now termed ‘movement restriction on trunk rotation’ (see Section 3.4.1). Movement restriction of L2/L3 is a rarity. It should be noted that a positive straight-leg raising test is caused by spasm (TrP) of the ischio crural muscles while a positive femoral nerve stretch test is caused by spasm of the rectus
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
Chapter 7
Table 7.1 Clinical signs in movement restriction of the lumbar spine and sacroiliac joints
Clinical sign
Trunk rotation
L3/L4
L4/L5
L5/S1
Sacroiliac joints
Absence of rotational synkinesis
−
+
+
+
++
Straight-leg raising test: ischiocrural muscle spasm (TrPs)
−
−
+
+
+
Femoral nerve stretch test: rectus femoris spasm (TrPs)
−
+
−
−
−
Patrick’s sign: adductor spasm (TrPs)
−
+
+
+
+
Spasm (TrPs) of thoracolumbar erector spinae
++
−
−
−
−
Spasm (TrPs) of lumbar erector spinae
−
+
+
+
−
Spasm (TrPs) of quadratus lumborum
++
−
−
−
−
Spasm (TrPs) of psoas major
++
−
−
−
−
Spasm (TrPs) of piriformis
−
−
+
−
−
Spasm (TrPs) of iliacus
−
−
−
+
−
Painful iliac crest
+
+
−
−
−
Painful greater trochanter
+
+
+
−
−
Pain at PSIS
−
+
+
+
+
Referred pain in L4 segment
−
+
−
−
−
Referred pain in L5 segment
−
−
+
−
−
Referred pain in S1 segment
−
−
−
+
+
Pain at pubic symphysis
+
−
−
−
+
Pain in upper part of sacroiliac joint
−
−
−
+
++
Pain in lower part of sacroiliac joint
−
−
−
−
++
femoris. Patrick’s sign is positive when there are TrPs in the adductors. The characteristic TrPs for the individual motion segments are very important for the clinical diagnosis: TrPs of the psoas major, quadratus lumborum, and erector spinae for rota tional restriction, and TrPs of the rectus femoris for segment L4, of the piriformis for L5, and of the ili acus for S1. The TrPs in the psoas major are respon sible for pseudovisceral pain on restricted trunk rotation, and TrPs in the rectus femoris for thigh and knee pain that mimics a painful hip (‘pseudohip’). In the case of TrPs in the piriformis, pain occurs laterally in the buttocks, making side-lying
painful and causing patients to report hip pain. A TrP in the iliacus muscle is experienced as pain in the lower abdomen, or sometimes in the groin, pos sibly simulating some gynecological complaints and, when it occurs on the right-hand side, appendicitis. The typical pain emanating from the lumbosacral and sacroiliac joints cannot be differentiated. TrPs in the iliacus muscle are more likely to indicate a dysfunction at L5/S1. Sacroiliac joint restriction occurs far more often as a secondary phenomenon than was previously assumed. It commonly reflects muscle fixation due to movement restriction of the fibular head with 307
Manipulative Therapy
TrPs in the biceps femoris, or due to restrictions of L4/L5 as a result of TrPs in the piriformis and in the pelvic floor. When these disorders are treated, normal function of the sacroiliac joints is restored. However, since none of these muscles directly con nects the ilium with the sacrum, this restriction is not strong; consequently, minimal force is always sufficient when mobilizing the sacroiliac joints, and HVLA thrust techniques are superfluous. There is one condition, however, in which sacroiliac joint restriction plays a major role: namely osteoarthritis of the hip, and even as a sequel to hip replacement surgery. In such cases sacroiliac joint mobiliza tion can greatly relieve the patient’s pain. Indeed, sacroiliac joint restriction after hip replacement surgery may be the frequently unrecognized cause of persistent symptoms.
At the follow-up examination on 24 August 2004 the ranges of movement on standing were completely normal, just slightly uncomfortable, and the restriction at L4/L5 was mobilized without difficulty and with an HVLA thrust into flexion, after which the patient was pain-free and required no further treatment.
Case summary Jones’ counterstrain technique in the pain-free direction was helpful as an initial step, and then careful mobilization into flexion was possible. The deep stabilizers were also exercised as breathing was corrected. About 14 days later a minor residual restriction was released easily. The possible role of an intervertebral disk lesion was considered.
Case study Case study V M; male; born 1979; professional dancer.
Medical history
M J; male; born 1967.
Medical history The patient had been experiencing low-back pain and subscapular pain since 2002. The pain was worse at night. A general medical assessment was inconclusive.
The patient sustained a lifting injury while dancing in March 2004, producing ‘a cracking sound’ in his lower back. The intense pain subsided after a few hours but returned in June 2004. By then the pain was very severe and could only be relieved if the patient was supine with knees flexed; in the mornings he had difficulty getting up and dressing, and he also experienced considerable pain when seated. However, he had no pain when he coughed or sneezed.
At examination on 2 August 2005 there were TrPs on the right side in the thoracolumbar erector spinae, psoas major, and quadratus lumborum. Trunk rotation to the left was restricted. Retroflexion was also painfully restricted.
Clinical findings and therapy
Therapy
When he was examined standing on 11 August 2004, anteflexion, retroflexion, and side-bending were possible to only a minimal extent, and even seated anteflexion was restricted. When he was prone, however, retroflexion in a straight-arm press-up position was possible. Therefore counterstrain was applied in the press-up position in lordosis for 90 seconds. Afterward, seated anteflexion was possible to some extent. Next, a flexion restriction at L4/L5 was diagnosed and carefully mobilized. Furthermore, there were still active TrPs in the erector spinae and these were found alongside TrPs in the coccygeus (pelvic floor). The deep stabilizers were activated to encourage diaphragm breathing instead of clavicular breathing. Self-mobilization of the lumbar spine (McKenzie method) and correction of the faulty breathing pattern were assigned as home exercises.
PIR of the quadratus lumborum on the right side while side-bending to the left with the patient standing: the patient performed side-bending to the left to take up the slack, then looked up and breathed in deeply, straightening up a little in the process. He then looked down, breathed out, and relaxed into side-bending. He repeated this three times and then actively and energetically performed side-bending to the left side. Afterward, not only were the TrPs in the quadratus lumborum released, but also those in the psoas major and erector spinae in the chain reaction pattern on the right side. Trunk rotation was symmetrical on both sides. The patient’s home exercise was therefore to perform PIR-RI of the quadratus lumborum on the right side on a daily basis. At the follow-up examination on 16 August 2005 the patient stressed that he was pain-free for the first time since 2002, but on closer questioning he
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Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
admitted that slight pain was still present at the level of the lumbosacral junction. The extent of trunk rotation and retroflexion were normal, but retroflexion was still rather painful. TrPs were detected in the rectus abdominis on the left side and its attachment at the pubic symphysis was slightly tender; the left fibular head was restricted with a TrP in the biceps femoris; there was also a TrP deep in the left sole with movement restriction of the second tarsometatarsal joint. After shaking mobilization of the foot, all TrPs disappeared, including the TrP in the rectus abdominis. Retroflexion was now also completely pain-free and we recommended the patient to use a foot roller for his left foot.
Case summary Typical low-back pain due to restricted trunk rotation with TrPs in the psoas major, quadratus lumborum, and erector spinae muscles. As a secondary finding, there was a TrP in the rectus abdominis on the left side with a tender attachment at the pubic symphysis, rendering retroflexion painful (due to stretching of the rectus abdominis), and this is always interpreted as low-back pain (!). This TrP forms a chain reaction pattern with TrPs in the biceps femoris and sole of the foot, with the foot being the dominant point.
Chapter 7
to manage is bending forward (even slightly), as over a wash basin, because in this position contrac tion of the erector spinae is maximal and therefore the pressure on the disk is at its greatest. The ‘pain ful arc’ described by Cyriax (1977, 1978) also gen erally manifests itself in this position. Pain when turning over in bed and when getting up is also highly characteristic.
Clinical signs In acute cases there is a characteristic antalgic (or relieving) posture that is also adopted in response to radicular pain. The most typical antalgic pat tern is lumbar kyphosis with the pelvis displaced toward the side of the lesion (and deviation of the trunk to the opposite side; see Figure 7.1).
7.1.5 Low-back pain due to disk herniation The subject of this section is disk herniation with out radicular compression. It is essential to know when disk herniation should be suspected in sim ple low-back pain. The conditions described thus far have been functional disorders. Here, however, we are faced with a defined pathological lesion with a correspondingly serious prognosis. It must be remembered that many instances of disk herniation are completely devoid of clinical relevance, and for this reason the prognosis is favorable even with con servative therapy. At the same time, dysfunctions play an important role here.
Symptoms If we discount acute attacks, the clinical course as a rule is more severe than in straightforward func tional disorders, that is to say attacks last longer and the condition has a greater tendency to relapse. Coughing and sneezing are generally very painful. The posture that is particularly difficult for patients
Figure 7.1 • Typical antalgic posture in acute intervertebral disk herniation.
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Anteflexion while standing is generally severely limited and the straight-leg raising test is posi tive (except in lesions at L3/L4 where the femoral nerve stretch test is positive). All movement that is at odds with the antalgic posture is painful. There need not be any movement restriction in the seg ment affected by disk herniation. When movement restriction is present simultaneously, springing of the lumbar spine continues to elicit pain even after the restriction has been released. Conversely, an (experimental) traction test may bring marked pain relief. In the more chronic stage, anteflexion is lim ited while standing, but normal when the patient is seated (with knees flexed). Another very typical sign is the painful arc described by Cyriax (1977, 1978) (see Section 4.6.1). Here, too, the straightleg raising test and the femoral nerve stretch test in segment L3/L4 are positive, much more so than when there is only joint restriction. A most valu able diagnostic sign is pain on springing the lumbar spine, irrespective of whether restriction is present or not.
Therapy Manual traction taking account of antalgic pos ture may be attempted in the acute stage. In other words, if the antalgic posture is in kyphosis, then traction is performed with the patient supine over the practitioner’s knee, but if the antalgic posture is in lordosis, then traction is performed with the patient lying prone. If traction is well tolerated it may procure immediate relief. Counterstrain to exaggerate the antalgic posture is also highly effec tive. This might be termed ‘manipulative first aid.’ If these techniques fail to bring immediate relief, epidural anesthesia and bed rest in the antalgic posture should be considered, as should analgesic medication. However, bed rest should be kept as brief as possible because energetic (‘aggressive’) therapy in the acute stage is the most important step in preventing chronicity. Traction may also be helpful in the chronic stage, provided that the patient finds it agreeable and improvement is detected afterward. In every instance it is important to proceed in a manner that is consistent with the clinical findings, and this approach presupposes a fresh examination at every follow-up visit. In this process, chain reaction pat terns should be sought in order to shed light on the pathogenesis. Current knowledge indicates that the 310
commonest causes are to be found in the deep sta bilizer system (in conjunction with faulty breath ing), the feet, faulty movement patterns, active scars, movement restrictions, and TrPs in the key region as well as the fascia. No less important are general measures: these include avoiding situations that routinely trig ger recurrences, and protecting the lumbar region against chill after perspiring.
Case study B J; male; born 1930; professor of clinical medicine.
Medical history The patient was seen on 11 March 2004 complaining of low-back pain radiating primarily to his left thigh. The pain was worse at night and the patient had difficulty getting up in the mornings. He also reported pain on coughing and sneezing. His lowback pain had started after a hiking tour in the mountains. For two years he had also had pain in his right arm, the mobility of which was limited. When he was younger he had no history of pain whatsoever. In February 2004 he sustained a fall on to his coccyx. A tonsillectomy had been performed when he was 11 years old.
Clinical findings Examination revealed pes planus on both sides, but more pronounced on the right. When standing, the patient’s right knee was slightly flexed. He had a kyphotic posture and retroflexion was extremely limited. In relative terms, extension in his right knee was more limited than flexion. Joint play in the knee was restricted. A TrP was present in the iliacus muscle on the left side. There was also a hard restriction in segment L5/S1 and the springing test was extremely painful. There was limited mobility of the deep lumbar fascia.
Therapy We first performed mobilization for the fascia, followed by rhythmic traction, and then mobilization of L5/S1 into rotation to the right, followed by mobilization into flexion to the left. After this the TrP in the iliacus could no longer be palpated and the patient was assigned a home exercise to practice extension (McKenzie technique) while supine. A lumbar belt was prescribed for rectus abdominis diastasis. At the follow-up examination on 20 April 2004 the patient felt that his condition had improved. He sometimes had pain radiating to his legs but this
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
improved on walking (despite osteoarthritis of the knee). Even then the springing test was painful. On this occasion the patient was trained how to practice retroflexion while standing. On 28 June 2006 the patient was symptom-free.
Case summary The repeatedly painful springing test, the relief of pain after traction, the pain on coughing and sneezing, the only moderate improvement, and the difficulty experienced with the McKenzie exercise in the supine position are suggestive of disk herniation in the setting of simple low-back pain with referred pain – but without neurological abnormalities.
7.1.6 Pelvic distortion Pelvic distortion is always a secondary symptom (see Section 4.5.3). The clinical picture is there fore dependent entirely on the condition in which pelvic distortion is (also) detected and which is also the object of therapy. If treatment is correct, pel vic distortion also disappears. It is encountered far more frequently in children and adolescents than in adults, and it is generally a consequence of a restric tion at the craniocervical junction. Adolescent girls with pelvic distortion also frequently present with dysmenorrhea. Here, too, the true cause is prob ably a dysfunction at the lumbosacral junction with a TrP in the iliacus. In the final analysis the Rosina test (see Section 4.5.5) also indicates that pelvic distortion in patients with normal sacroiliac joints can be provoked by head rotation and that this is a palpatory illusion, as has been confirmed radiologi cally.
7.1.7 Forward-drawn posture Symptoms Because this disorder affects posture as a whole, symptoms may occur at every level of the locomo tor system, although they are strikingly common in the cervical region. The following pathological mechanism in par ticular is responsible for low-back pain: TrPs in the rectus abdominis produce attachment point pain at the pubic symphysis and prevent retroflexion of the trunk. This is perceived as low-back pain and can be eliminated directly by relaxing the abdominal mus cles or by local anesthesia of the pubic symphysis.
Chapter 7
Clinical findings In this dysfunction an (apparent) asymmetry is palpated at the pubic symphysis and at the ischial tuberosities. Inspection from the side reveals a for ward shift of the pelvis relative to the patient’s feet, of the shoulder girdle relative to the pelvis, and of the head relative to the shoulders (see Figure 7.2). TrPs in the rectus abdominis are a typical finding, with the abdomen often drawn in and not participat ing in respiration. The attachments of this muscle at the pubic symphysis and at the inferior costal arch with the xiphoid process are tender. Hypertonus of the gluteal region is also found, with increased resistance of its soft tissue against shifting in a cra nial direction. Further TrPs are located in the biceps femoris with restricted mobility of the fibular head and, when the chain reaction pattern is complete, there are TrPs and restrictions at the feet, often with asymmetric tactile perception on the soles of the feet. A forward-drawn posture is also always associated with increased tension (hypertonus) of the erector spinae throughout the back and neck. The most important clinical test is to sit the patient down. If hypertonus disappears, especially in the neck, then we know that the disorder origi nates not from above but from the feet (in cases where the chain reaction pattern is complete). The underlying pathological mechanism is as follows: where TrPs are present in the biceps femoris, the postural fixation of the pelvis via the ischial tuber osity and the sacrotuberal ligament is impaired, and it is held in place by compensatory tension of the abdominal and gluteal muscles. On the side where the rectus abdominis has its insertion and hypertonus exists, palpation reveals that the symphysis is higher, and on the side of the tensed biceps femoris it is found that the ischial tuberosity is lower. Interestingly, these differences are only ever detected with the patient in the prone position, and never standing. There are numerous osteopathic techniques by which this asymmetry can be corrected, but nothing in the radiological appearance is altered. What does change is the posi tion of the palpating fingers (‘palpatory illusion’; see Figure 4.11). In our experience this finding has nothing to do with the sacroiliac joints.
Therapy If increased tension in the dorsal muscles disap pears on sitting down, treatment of the most caudal 311
Manipulative Therapy
Figure 7.2 • Forward-drawn posture (A) before and (B) after treatment.
lesion is indicated, where possible at the feet (key region), or in the event of negative findings there, at the fibular head. Forward rocking (see Section 6.8.8 and Figure 6.157) causing reflex toe flexion is cur rently the most effective and indeed the simplest form of (self-)treatment. Findings at the buttocks and abdomen are almost always secondary, and they may have their origin in the deep stabilization sys tem, especially in the pelvic floor. It must be stressed that forward-drawn posture is a very common disorder: we saw 90 cases over a two-year period. Treatment in patients with for ward-drawn posture is so effective that restricted mobility at the craniocervical junction, for example, is also released.
If a patient with headache and restricted mobility in the cervical region is found to have a forwarddrawn posture, and if the neck muscles are tensed on standing but become relaxed on sitting, then any treatment that is limited to the cervical region alone is bound to be unsuccessful.
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Case study B K; female; born 1985.
Medical history The patient was seen on 22 February 2005 complaining of headache. In December 2004 she had been struck by an automobile and knocked to the ground. She had landed on her back and occiput, was briefly unconscious, and was admitted to hospital. Her headaches did not start until a few days later and were now constant. The patient also reported flickering in front of her eyes and dizziness when performing certain movements; when this occurred she had a tendency to stagger to the right. Since 2003 she had also experienced low-back pain occasionally in the mornings and during her menstrual periods. She underwent surgery for an umbilical hernia at the age of 11 years and she suffers from bronchial asthma.
Clinical findings Examination disclosed hypermobility; the patient had a typical movement restriction at C0/C1 with TrPs in the sternocleidomastoid muscle and the short extensors of the upper cervical spine, a restriction at
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
T1/T2 on the left side with a restriction of the first rib on the left side, TrPs in the diaphragm and the pectoralis major (right side), quadratus lumborum (right side), erector spinae, gluteus medius, and in the pelvic floor (right side), in the thigh adductors (right side), at the right fibula with TrPs in the biceps femoris, TrPs in the soleus, and restricted movement in Lisfranc’s joint with TrPs in the sole and on the dorsum of the right foot.
Therapy Activation of the deep stabilizers, first in the supine position, then by lifting the knees while seated; the patient palpated contraction of the lateral abdominal wall with her own hands. Then clavicular breathing was corrected in front of a mirror: during inhalation she palpated for contraction of the lateral abdominal wall and the lower abdomen while simultaneously checking in the mirror to see whether her thorax was lifting. After repeated exercise, all TrPs and restrictions were eliminated. Her home exercise was to practice breathing correctly in front of the mirror. At the follow-up examination on 15 March 2005 the patient was virtually pain-free. Correct fixation of the thorax during breathing was verified and she was recommended to continue with regular exercises to activate the deep fixators.
Case summary The case of this patient illustrates how dysfunctions of the deep stabilizers provoke chain reaction patterns in all sections of the locomotor system and how all TrPs and restrictions can be eliminated by activating (exercising) this system. The umbilical hernia, for which the patient underwent surgery at the age of 11 years, is a further indicator of a major weakness in this system.
Chapter 7
the history is a factor here. Our experience indicates that this disorder is highly relevant although the true pathological mechanism is far less clear. Nevertheless we know today that movement restriction of the hip is a routine finding on the side of inflare and that this disappears immediately after therapy.
Clinical findings Inflare and outflare are in fact characterized by pelvic asymmetry (as described by Greenman & Tait 1988): on one side (usually the right) the anterior superior iliac spine (ASIS) appears to be more lateral and flat tened, while on the other side (usually the left) the ASIS appears to be more medial and ventral. As a result the triangle formed by the right and left ASIS and the umbilicus is pulled out of shape (see Figure 7.3). These findings create the impression that one half of the pelvis is tilted outward and the other half inward. Hypotonus (reduced muscle tone) is pal pated on the side of the flattened ASIS, while relative hypertonus is palpated in the lower abdomen on the opposite side. It appears to be important that internal rotation at the hip on the side of the prominent ASIS is routinely found to be clearly restricted compared with the other side (Lewit & Olšanská 2005). This asymmetry is readily visible in slim patients; in obese patients, however, this possibility must be remem bered and palpated for. Unlike Greenman, we are of the opinion that there is generally no sacroiliac joint dysfunction.
7.1.8 Inflare and outflare (Greenman) Symptoms In our experience these conditions frequently take the form of low-back pain and radicular pain with a severe clinical course, and they are also encoun tered in patients with residual discomfort follow ing intervertebral disk surgery. In the vast majority of cases the patient’s history contains evidence of a fall on to the buttocks and/or coccyx. This fact, coupled with the often very favorable effect of ‘repositioning,’ awakens the suspicion that trauma in
Figure 7.3 • Outflare (patient’s right side) and inflare (patient’s left side).
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Therapy For specific therapy, on the side where the ASIS appears flattened (outflare) and with the patient’s knee and hip flexed at right angles, the practitioner adducts the patient’s thigh (as when testing the ilio lumbar ligament, see Figure 4.13) until the slack is taken up. He then tells the patient to resist adduc tion for 5–10 seconds and breathe in, then to relax and breathe out. PIR is repeated two or three times, and then the patient adducts the thigh flexed at the knee and hip against repetitive resistance (RI). On the other side (inflare), the practitioner takes up the slack on the thigh abducted at the knee and hip (as when testing for Patrick’s sign, see Figure 4.43). The patient resists abduction for about 5–10 seconds and breathes in, and then relaxes into abduction while breathing out. PIR is repeated two or three times, and then the patient performs abduction against repetitive resistance or else abducts the thigh maximally (RI). Afterward, the practitioner checks whether the ASISs are sym metrical, whether muscle tone in the lower abdo men is now balanced, and whether internal rotation at both hip joints is now identical.
Case study R D; male; born 1946.
Medical history The patient was first seen on 14 June 2005. He had been involved in a road traffic accident in August 2004, following which he had been unconscious for almost a week. On his left side he sustained several fractured ribs and a fractured lower leg. He was a professional downhill skier and recalled having fallen on to his coccyx on numerous occasions. He had experienced back pain for the past 18 years related to his sporting activity, and had suffered one or two headaches every week since adolescence. The symptom that actually prompted him to consult us was pain in the left groin that radiated into his thigh and on account of which he had to remain standing in order to get moving again.
Clinical findings On examination, lumbar spinal mobility with the patient standing was normal, head rotation was limited in both directions, there was restricted mobility of C1/C2, restricted mobility of the fibular head with a TrP in the left biceps femoris, outflare on the right side 314
and inflare on the left, and the femoral nerve stretch test was positive on the left side. Internal rotation at the hip joint was 25° on the left and 45° on the right. Dorsiflexion in the right talocrural joint was restricted (80° compared with 100° on the left side).
Therapy Treatment involved ‘repositioning’ the pelvis. After this treatment all findings became normal, apart from the right talocrural joint, which was also mobilized. At follow-up examination on 12 July 2005 the patient was able to walk normally, but he felt slight pain in his left lower leg on running. Over the intervening four-week period the patient had had only two headaches. The findings now comprised a movement restriction at C1/C2. The fascia on his left lower leg showed poor mobility relative to the underlying bone, a sign of an active scar following the accident, and there was a TrP in the adductors on the left side. After treating the fascia of the left lower leg, there was no longer a TrP in the adductors, and the movement restriction at C1/C2 was also released. The findings at the pelvis and hips were symmetrical.
Case summary The principal symptoms associated with claudication were abolished following treatment of outflare and inflare, and the findings in the cervical region were also improved immediately after treatment, as reflected in the reduced frequency of headaches. The pain in the patient’s left lower leg was a residue from a comminuted fracture with an active scar; after these were treated there was normalization of the TrPs in the adductors and of the movement restriction in the upper cervical spine. The movement restriction in the right talocrural joint was not linked with the other dysfunctions; it may have been the result of excessive strain caused by an antalgic posture adopted by the left lower leg after fracture.
7.1.9 The coccygeus and pelvic floor The coccygeus forms part of the deep stabilization system and can be understood only in the context of the locomotor system as a whole. We should fur ther recall the role of the levator ani in conjunction with the sphincters and the gluteus maximus. Here we are dealing with an entirely different func tion of the pelvic floor, which contributes to erect posture and respiration; disturbances of this func tion are announced by a TrP in the coccygeus. The
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
palpatory technique for this TrP is described in Section 4.5.8 (see Figure 4.12).
Clinical findings The numerous chain reaction patterns originating in the deep stabilizers, and in the pelvic floor in partic ular, are described in Section 4.20. One especially characteristic finding is a usually very clear TrP in the thoracic erector spinae; mechanical stimulation of this TrP produces not only an observable, local twitch response but also contraction of the lumbar erector spinae with brusque dorsiflexion of the pel vis. This phenomenon was described by Silverstolpe (1989) and Skoglund (1989) who termed it the ‘S reflex.’
Therapy Relaxation of this TrP can be obtained by release achieved using simple sustained pressure (as for diagnosis). However, this is felt to be painful by the patient and, what is worse, relapses usually develop quickly. We have therefore elaborated a relaxation technique that the patient can practice on a daily basis (see Figure 6.143). However, the process begins with activation of the entire deep stabilizer system and involves exer cising the concerted action of the diaphragm, the deep abdominal muscles, and the pelvic floor. This has been described for the rehabilitation of breath ing in Section 6.7.7 (see Figures 6.155 and 6.156). Interestingly, this activation relaxes not only the TrPs in the pelvic floor and diaphragm, but also gen erally all other TrPs linked with them. The patient is then instructed to exercise actively with the aim of normalizing respiratory movement patterns and the deep stabilizer functions of the trunk. However, if the TrP in the coccygeus persists, the patient needs to practice its relaxation.
7.1.10 Low-back pain due to restricted trunk rotation
Chapter 7
visceral pain. TrPs in the erector spinae may also be responsible for pain felt underneath the shoul der blades. The pain here may have an acute onset, particularly on picking up an object placed to one side of the patient, causing lifting to occur with a rotating movement. This mechanism is also impor tant in evolutionary terms: only humans generate maximum forces by trunk rotation, for example as when throwing the discus. Farfan et al (1996) have emphasized that the intervertebral disks in par ticular are not well adapted to powerful rotational movements.
Clinical findings Trunk rotation is widely regarded as a function of the thoracolumbar junction because, on anatomi cal grounds, it has been claimed that the joints of the lumbar spine do not permit rotation and that the ribs pose an obstacle to rotation, at least of the upper and middle thoracic spine. It has already been shown in Section 3.4.1 (see Figure 3.19) that this is an erroneous view and that coupled move ment associated with scoliosis and rotation can be regularly observed in the lumbar and thoracic spine: side-bending (scoliosis) produces rotation, and rota tion produces side-bending. On clinical examina tion, patients with restricted trunk rotation are found to have TrPs in the thoracolumbar erector spinae, the psoas major, and the quadratus lumbo rum on the side opposite to the lesion. In this con text it is sufficient to treat one of the three muscles in this chain to restore trunk rotation. Compared with these three powerful muscles, the joints do not appear to play a major role here. It should also be recalled that vertebral frac tures are most commonly encountered at T12 and L1, especially in osteoporosis. In such patients trunk rotation is indeed considerably restricted, at least on one side. Careful neuromuscular mobiliza tion (using only visual and respiratory synkinesis) achieves instantaneous pain relief here in a very gentle way.
Therapy Symptoms Patients complain of low-back pain, apparently due to painful attachment points of the erector spinae and quadratus lumborum dorsally on the iliac crest. TrPs in the psoas major may cause pseudo
Treatment takes the form of PIR and RI of one of the three muscles in the chain, namely, the erector spinae (see Figure 6.115), the quadratus lumborum (see Figure 6.120), or the iliopsoas (see Figure 6.122). 315
Manipulative Therapy
As a relatively recent phylogenetic function, trunk rotation is very commonly restricted and often occurs in a chain along with many other dys functions. The link with restricted rotation of the cervical spine appears particularly important. In such cases, restricted trunk rotation should be treated first. Usually it is then no longer necessary to treat the cervical spine.
Case study H K; female; born 1919; professional translator.
Medical history The patient came to us on 1 July 2003 complaining of pain in her cervical and lumbosacral regions. Cervical pain had been present since 1998, and lowback pain since the onset of puberty at the age of 13 years. She had experienced low-back pain both during menstruation and during three pregnancies. Her most recent episode of low-back pain had occurred in May 2003, but by early July it was cervical pain that was dominant. Her occupation as a translator involves keyboard work at a computer. She reported having undergone a hysterectomy and ovarectomy in 2000.
Clinical findings and therapy Examination revealed a slight movement restriction to the left at C4/C5, TrPs in the diaphragm on the right, and in the psoas major, quadratus lumborum, and erector spinae on the left. Trunk rotation was 30° to the right and 45° to the left. Therefore the quadratus lumborum was treated using gravity-induced PIR coupled with visual and respiratory synkinesis. After this, not only trunk rotation but also head rotation was completely normal; moreover, the TrP in the diaphragm on the right side was no longer palpable. The patient’s home exercise consisted of PIR and RI for the quadratus lumborum. At the follow-up examination on 30 July 2003 the patient made a point of saying how much the exercise program was helping, but she still had low-back pain and right shoulder pain as a legacy from tidying up on the previous day. The principal finding on examination was a painful subscapularis on the right side, which was treated using PIR and RI; otherwise the examination yielded no abnormalities.
Case summary In elderly patients, in particular, low-back pain is frequently associated with restricted trunk rotation and is also typically coupled with slight restriction of head rotation. The latter resolves immediately 316
following treatment of trunk rotation. The focus therefore simply needs to be on correcting trunk rotation. This was reflected in the exercise prescribed for the patient at home. The subscapularis muscle is a common source of shoulder/arm pain, especially after exertion.
7.1.11 Combined lesions Needless to say, the individual forms of back pain described above rarely occur in isolation. Usually they present as mixed or combined lesions, with the clinical picture being dominated by a different factor in each case. And this does not happen by chance. All the structures involved in the etiology of low-back pain are somehow interconnected, and many are closely linked in a chain reaction pattern. Movement restriction at L4/L5 often fixes the sacroiliac joint via the piriformis, the sacroiliac joint itself is closely connected to the hip, and this in turn to segment L3/L4, while the pelvic floor has a special relationship with the adductors, and also with the biceps femoris and fibular head.
Case study J F; female; born 1906.
Medical history Our patient since 1962, she was obese with a slouched posture consistent with lumbar hyperlordosis and weak abdominal muscles. Low-back pain started in 1957, often occurring when the patient bent forward.
Clinical findings and therapy Initial examination revealed movement restriction in segment L5/S1 and pelvic distortion, and subsequent examination showed a painful coccyx (this relapsed twice). Later the clinical picture came to be dominated by hip pain (without osteoarthritis), then again by lumbosacral movement restriction and a painful coccyx, followed by pain at the L5 spinous process, and (since 1968) sacroiliac restriction. The patient’s condition improved slowly in response to remedial exercise and weight reduction, but she continued to require treatment periodically.
Case summary It is certainly uncommon to encounter such a wide range of pelvic lesions in an individual, not concurrently but occurring in alternating sequence over a
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
number of years. Despite the often close anatomical relationships, it is important to differentiate the individual dysfunctions precisely so that they can be treated in a targeted manner and so that remedial exercises can be prescribed as specifically as possible.
7.2 Pain in the thoracic spine and thorax The thoracic spine is the least mobile section of the spinal column. Because of this stability it is only rel atively rarely the site of the primary lesion in dys functions. On the other hand, pain in the thoracic region is often referred pain from the viscera, and it is here that vertebrovisceral inter-relationships are most clearly apparent. A special warning against diagnostic error is particularly apposite in this region. One important condition that manifests itself prima rily in the thoracic spine is juvenile osteochondrosis, the commonest cause of kyphosis in adolescents. Stiffness of the kyphosed thoracic spine has to be compensated for by lumbar hyperlordosis, and it is there that pain is most commonly felt. Patients complain mostly of pain between or below the shoulder blades. Here, again, pain in the dorsal region may be the result of excessive strain due to external factors or to muscle imbalance and excessive static loading. One particularly common culprit is a kyphotic sitting position associated with working at the computer. The typical muscle imbal ance is shortening of the pectoralis major and weak ness of the interscapular muscles and of the lower fixators of the shoulder blade. Major stiffness is detected especially at the point where the kyphosis peaks. On the other hand, hypermobility can also be linked with pain, generally in a flat back in the upper thoracic region. Movement restrictions may be present not only in the apophyseal joints between the individual vertebrae but also at the joints between vertebrae and ribs, and they produce very similar symptoms. Deep breathing can be painful in both scenarios. Of course, this is particularly the case with rib lesions, where it is useful to distinguish between pain on inhalation and pain on exhalation. It is essential for the differential diagnosis to exclude pleural disease. The techniques for diagnosis and therapy have been discussed in the appropriate sections in Chap ters 4 and 6, with regard to both movement restric tions and TrPs. The deep stabilization system with
Chapter 7
TrPs in the diaphragm and pelvic floor also plays an important role here. Patients with restricted trunk rotation suffer not only from low-back pain but also from pain between or beneath the shoulder blades (attachment points of the iliocostal muscle). Therapy and self-mobilization (see Figure 6.74) simultaneously serve to strengthen the interscapular component of the erector spinae. Where painful ten der points are present at the sternocostal joints, spe cific relaxation of the bundles of the pectoralis major with insertion there has proved effective (see Fig ure 6.109). While highly effective, self-mobilization (see Figure 6.38) is indicated only if lordosis in the thoracolumbar region does not occur in the process. Less frequently than in the lumbar and cervi cal spine (where acute low-back pain and acute wry neck are common conditions), acute episodes of pain may occur in the thoracic spine, due especially to rib dysfunction. Such episodes can be even more dra matic than acute low-back pain or neck pain, because patients are unable not only to move but also even to breathe without pain. Manipulation and mobiliza tion are complicated by the fact that mere contact at the rib is excessively painful; on the other hand, local anesthesia at the transversocostal joint is easy to per form because the structure is superficial. However, a similar acute pain on respiration may also be pro duced in the very early stage of pneumonia (before the typical rise in temperature).
7.2.1 Slipping rib Symptoms Here attention will be drawn to a clinical condition that is by no means rare but is only seldom recog nized. Slipping rib presents as intense pain localized in the lower thorax and upper abdomen, sometimes associated with pain on respiration and coughing (or sneezing). Large, forceful movements of the upper extremity on the side of the lesion may also be pain ful. Generally, suspicion falls on a wide variety of diseases of the thoracic and upper abdominal organs, and these patients usually undergo a great many vis ceral examinations (which all prove negative).
Clinical findings A simple maneuver can be valuable in confirming the diagnosis. With the patient seated or supine, 317
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the practitioner hooks her fingers under the last ribs at the upper end of the patient’s abdominal cavity (similar to the situation shown in Figure 6.112) and exerts pressure on the ribs with her fin gers underneath against her thenar eminence above. At that moment the patient experiences sharp pain. This response clinches the diagnosis of slipping rib (Heinz & Zavala 1977). Interestingly, we have encountered slipping ribs relatively frequently in women with pain following breast cancer surgery.
Therapy Therapy consists of mobilization using the fingers hooked beneath the inferior costal arch to exert repetitive springing pressure ventrally and later ally. This mobilization is always painful but gener ally brings instantaneous relief. Only in exceptional cases is local anesthesia necessary at the inner mar gin of the tenth rib, while surgical removal of the painful rib may be considered as a last resort. Treat ment of the spinal column or of the costovertebral joints is ineffective in this condition and the true pathogenesis is unknown.
Case study C M; female; born 1929.
Medical history First seen by us on 4 June 2002 complaining of burning pains in the thorax, usually occurring at rest and apparently without any provoking factors. Onset of pain just one month previously. The patient had undergone surgery in 1992 to remove her left breast, after which she experienced transient swelling of the feet; no symptoms at all prior to surgery.
Clinical findings and therapy Restricted movement at C3/C4 to the left side, TrPs in the diaphragm on the left side, the thoracic fascia on the left side showed reduced mobility relative to the underlying structures, and the fifth sternocostal joint was painfully tender. The fascia was treated and the attachment point of the pectoralis at the fifth costotransversal joint was released. The restriction at C3/C4 was also treated, after which the TrP in the diaphragm could no longer be palpated. At follow-up examination on 25 June 2002 the patient reported no major improvement. She also still complained of ‘spasm-like back pain.’ On this occasion a slipping rib (left side) was diagnosed and 318
treated. Following further examination on 4 July 2002 the patient’s condition was considerably improved, and she reported feeling only slight tension in the axilla. The serratus anterior was found to be shortened; this was relaxed and stretched. Relaxation of the serratus anterior was then assigned as her home exercise.
Case summary The slipping rib was found to be crucially important for the symptoms experienced by this patient. The far more typical findings made at the initial examination proved to have little relevance.
7.3 Pain in the cervical spine The clinical features of neck pain per se are rela tively straightforward by comparison with low-back pain. By contrast, the clinical features of vertebro genic disorders in the cervical region, the so-called ‘cervical syndrome,’ are far more complex than those of lesions of the lumbar spine and pelvis.
7.3.1 Muscle imbalance Pain may result from excessive strain due to exter nal factors or from muscle imbalance. Most com monly, static overload due to long periods of working with the head bent forward plays a promi nent role. A similar effect is produced by a for ward-drawn posture as a result of faulty statics (see Figure 3.39). The typical signs of muscle imbalance have been described in Section 4.20.3.
Symptoms Initially, signs of fatigue occur, followed by pain, most frequently after working at the computer with head bent forward or in a fixed position. Jolting in automobiles and other types of vehicle may elicit similar pain.
Therapy Wherever possible, long periods spent with the head bent forward should be avoided and fixed positions should be corrected. Remedial exercises should be employed to correct any muscle imbal ance. Clavicular breathing, a faulty respiratory
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
pattern characterized by thoracic lifting (without widening) during inhalation, is a particularly com mon expression of a disorder of the deep stabiliza tion system, and this requires treatment. Any TrPs and movement restrictions found should be treated. Later, during the rehabilitation phase, muscle imbalance is corrected, paying par ticular attention to clavicular breathing as the most common manifestation of this. In terms of lifestyle advice, correct positioning in bed at night is especially important (see Section 8.3.1).
7.3.2 Acute wry neck Symptoms The pain often has its onset after rest in bed (in an unsuitable position), after a sudden jerk of the head, or after an automobile journey with the win dow open. The patient complains of neck pain, frequently on the right side and radiating toward the shoulder and/or occiput, and of stiffness. Auto nomic symptoms such as nausea or drowsiness may also be present.
Clinical signs The patient’s head is rotated to one side, more usu ally to the left. Rotation to the right and inclination to the left are restricted, but anteflexion and retro flexion also suffer. Segment C2/C3 is most commonly involved, and in exceptional cases C1/C2 or C3/C4. However, in the acute stage it can be dif ficult to localize the dysfunction precisely. Further, it is important to realize that another segment is usually restricted, for example C5/C6, as well as a segment at the cervicothoracic junction. Simulta neously, numerous TrPs are present in the area of the short extensors at the craniocervical junction, and in the sternocleidomastoid, levator scapulae, and trapezius. A very characteristic finding is a pain point on the lateral aspect of the spinous process of the axis (during the examination the practitioner should not forget to bend the patient’s head to one side!). A pain point in the horizontal part of the tra pezius close to the shoulder blade is an important prognostic indicator: finding this TrP suggests that a cervicobrachial syndrome or even a radicular syn drome may be imminent.
Chapter 7
Therapy The first step is post-isometric traction (see Figure 6.52): this must be performed in the direction that is most agreeable to the patient and in which the patient also finds it easiest to relax. One alternative is a simplified version of Jirout’s maneuver (2000): for this, the patient is supine with the cervical spine precisely in a neutral position. If rotation to the right is restricted (as is usually the case), the prac titioner’s thumb takes up contact with the patient’s left acromion, which must not be elevated, stimu lates this a little with the thumb and instructs the patient to offer (isometric) resistance against this pressure and then to let go again. This procedure is repeated two or three times. In those exceptional cases where head rotation to the left is restricted, resistance is offered on the right-hand side. This technique has the advantage that no contact at all is made with the painful neck region. The acute mus cle spasm is usually corrected after this maneuver, as after post-isometric traction. Only after this step is complete can the remain ing restrictions or TrPs then be treated specifically; possible chain reaction patterns from other areas of the locomotor system can also be diagnosed and treatment can be continued as appropriate.
Differential diagnosis It is important not to confuse the common form of wry neck with spasmodic torticollis, a mistake that can be easily made because in the initial attack pain is the dominant clinical feature of both. However, although pain diminishes with each relapse, the fixed position in spasmodic torticollis continues to deteriorate. The powerful spasm of the sternocleidomastoid on one side and of the splenius capitis on the other will then be noted, but without the typi cal signs of true movement restriction. Meningeal bleeding must also be considered in the differential diagnosis. This may also begin with acute neck pain radiating to the head, and here too the patient will avoid movement and jolting. How ever, the movement that is primarily restricted is anteflexion, although here it is a meningeal sign. Side-bending and rotation are not affected. If the pain is not acute, then neck pain is just one of many signs of what is termed the ‘cervical syndrome.’ It is unusual for neck pain not to be com bined with either headache or shoulder pain, that is 319
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pain in dermatome C4. Among other sources, pain is also referred to this segment from the diaphragm. There is often also a HAZ posterior to and below the mastoid process, which is suggestive of restric tion at the craniocervical junction.
7.4 Referred pain and other pain types The lower extremities (see 7.4.1–7.4.5) It will be useful at this point to review the material on the subject of referred pain presented in Sec tion 2.11. Table 7.1 lists those spinal segments where individual movement restrictions produce referred pain. As in true radicular syndromes, in the pseudoradicular (or reflex) syndromes provoked by movement restrictions we encounter referred (or radiating) pain exclusively in segments L4, L5, and S1. In the L4 pseudoradicular (reflex) syndrome, pain radiates down the ventral aspect of the thigh toward and even below the knee; in the L5 syn drome, pain radiates down the lateral aspect of the thigh and lower leg to the lateral malleolus; and in the S1 syndrome, pain radiates down the dorso lateral aspect of the lower extremity toward the heel. In the L4 syndrome, the femoral nerve stretch test is positive (TrP in the rectus femoris), while in the L5 and S1 syndromes, the straight-leg raising test is positive (TrPs in the ischiocrural muscles). Besides the referred pain, there may also be paresthesia. The TrPs in the key muscles were listed in Table 7.1. It may also be helpful to consider which other structures are also capable of triggering the same patterns of referred pain. The referred pain in L4 may stem not only from a lesion in the motion seg ment L3/L4 but also from the hip joint, and for this reason it may be difficult to distinguish a pain ful hip with (minimal or) no osteoarthritis from an L3/L4 lesion. Pain at the knee may even be caused by both these lesions, especially where TrPs in the adductors produce pain at the pes anserinus on the tibia. A mildly positive Patrick’s sign may also be elic ited in the L4 pseudoradicular syndrome if there are TrPs in the adductors. The femoral nerve stretch test is probably the most useful tool for differenti ating between the two lesions. 320
In the L5 pseudoradicular (reflex) syndrome, a TrP in the piriformis plays a major role and this may even persist after the movement restriction at L4/L5 has been released. The piriformis may also cause fixation of the sacroiliac joint, and for this reason restrictions at the sacroiliac joint are quite often found concurrently with restrictions at L4/ L5. Where a TrP is simultaneously present in the biceps femoris, a restricted and sometimes painful fibular head may also be encountered. The S1 pseudoradicular (reflex) syndrome is caused not only by lesions of the L5/S1 motion seg ment but also by lesions of the sacroiliac joint. The sacroiliac ligaments and the ischial tuberosity may also give rise to pain in this segment. The TrP in the iliacus is generally consistent with the movement restriction at L5/S1. Further findings in this seg ment may include TrPs in the ischiocrural muscles and movement restriction at the fibular head. The structure that may complicate all three pseudoradicular (reflex) syndromes is the coccyx. A painful coccyx may be associated with a positive Patrick’s sign, a mildly positive straight-leg raising test, and TrPs in the iliacus and even in the piri formis and gluteus maximus. In exceptional cases a painful coccyx may even simulate hip pain.
The upper extremities (see 7.4.6–7.4.8) Referred pain is not the exclusive preserve of the lower extremities. Dysfunctions are often found that have their origin in the upper extremities; they may be complications of vertebrogenic and even of radicular syndromes. In the upper extremities, too, it is common to find pain that is referred from lesioned structures in the cervical spine. Here, however, unlike the lower extremities, referred pain does not exactly follow the individual segments/dermatomes. Instead, the pattern is consistent with that produced by TrPs in the individual muscles close to the cervical spine and cervicothoracic junction, with pain characteris tically referred to the shoulders, elbows, and hands.
7.4.1 Fibular head restriction Movement restriction involving the fibular head is closely linked with faulty statics (see Figure 6.25). Locally, it may give rise to lateral pain at the knee
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
and cramping in the calf. Often it is a secondary finding in dysfunctions involving the foot. Fibular head restriction is regularly associated with TrPs in the biceps femoris, a muscle that plays a criti cal role in the anatomical fixation of the pelvis. Where pelvic fixation by the biceps femoris is inad equate, there is a compensatory response by the rectus abdominis together with the gluteal muscles, and then TrPs are found principally in the rectus abdominis, causing a forward-drawn posture.
7.4.2 Painful patella In true knee pain (not pain that is referred to the knee) it is most important not to overlook a painful patella. A healthy patella should move freely on the articular surfaces of the femur and tibia. It should therefore be checked whether the patella is freely mobile in all directions and whether gentle pres sure on the patella during mobility testing produces grinding resistance and pain. The technique for this is described on page 198 and can often bring instan taneous relief. Attachment point pain at the upper margin of the patella may be caused by TrPs in the rectus femoris, but also by increased tension in the tensor fasciae latae.
7.4.3 Knee joint dysfunction Dysfunctions of the knee (tibiofemoral) joint are characterized by a capsular pattern in which flexion is gradually more restricted than extension. Lateral springing (gapping) and joint play on one or other side are also often restricted. Unlike the hip joint, the knee is most painful when the patient walks downstairs or downhill. In this case mobilization by rapid shaking is most effective, and this is also true in particular for osteoarthritis of the knee.
7.4.4 Painful foot The clinically important articulations in the foot are the ankle joint, the tarsal joints, and particularly the tarsometatarsal joints. Restrictions primarily involve Lisfranc’s joint, the second and third meta tarsophalangeal joints, the talocrural joint and, to a lesser extent, the talocalcaneonavicular and subtalar joints. The main TrPs are found in the deep flexors of the sole of the foot and dorsally between the metatarsal bones.
Chapter 7
The commonest complaint is foot pain that is often associated with cramps in the foot and calf and with paresthesia, although tunnel syndromes may be present in exceptional cases. What is far more important is that the feet constitute a key region in the locomotor system. The foot and its muscles are required to stabilize the almost spheri cal talocrural joint. Futhermore, the sole of the foot and the toes possess the highest density of proprioceptors and exteroceptors. The soles of the feet may be hypersensitive as well as relatively hyposensitive, and not infrequently the soles of the feet also react asymmetrically to exteroceptive stimulation (see Section 6.3). The consequence of all this is that the feet, like the deep stabilization system, are a source of very common chain reaction patterns involving the entire locomotor system; the most characteristic finding is a forward-drawn posture.
7.4.5 Painful heel When walking and standing, patients not infre quently complain of a painful calcaneal spur. This is quite simply pain at the attachment of the plantar aponeurosis, a structure that becomes painful when there is increased tension in the aponeurosis itself. This is chiefly the result of TrPs in the deep flex ors of the sole of the foot. At the same time there are generally also movement restrictions in the foot as well as dysfunctions in the lower extremities, including the fibular head. Dysfunctions are some times also found in the pad of soft tissue at the heel. Treatment takes the form of PIR of the foot flex ors (see Figure 6.132). Activation of the toe flex ors by rocking forward is even more effective (see Section 6.8.8 and Figure 6.157). Needling of TrPs has also proved most beneficial, yielding far better results than a series of local anesthetic infiltrations around the calcaneal spur. Another commonly encountered complaint is not only Achilles tendon pain itself, but pain where the Achilles tendon attaches at the heel. Here, too, treatment primarily takes the form of PIR-RI of the TrP in the soleus muscle; this is usually highly effective, with the result that needling is gener ally superfluous. Achilles tendon pain should be differentiated from pain in the underlying soft tis sue between the Achilles tendon and the tibia (see Figure 6.65). 321
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7.4.6 Shoulder pain This is the commonest form of referred pain radiat ing into the upper extremity and constitutes a clini cal problem as complex as that of low-back pain. This is probably due to the fact that the shoulder region corresponds to segment C4 and that numer ous structures refer pain to this segment, in partic ular the diaphragm with the phrenic nerve. Clinical experience suggests that any type of pain originating in the cervical spine, the cervicothoracic junction, or the upper ribs – and even in the visceral organs of the thorax and upper abdomen – is felt in the shoulder region.
A diagnosis of ‘humeroscapular periarthropathy’ merely betrays the incompetence of the person making it because this somewhat vague label in fact covers a number of quite specific dysfunctions.
Shoulder pain due to disturbed muscle function In the shoulder region pain can be caused by increased muscle tension with TrPs, especially where the patient is under excessive strain. The muscles most susceptible to painful increases in tension are the upper part of the trapezius, the levator scapulae, the sternocleidomastoid, the sub scapularis, the infraspinatus, the pectoralis major and minor, the diaphragm, and sometimes the deltoid. Symptomatic therapy here consists primarily of PIR and RI, and sometimes needling; over and above this, it is important to understand and treat the cause of excessive strain.
Pain referred from the spinal column This pain is most commonly evoked by a certain movement – or position – of the head. TrPs are then detected in the corresponding muscles, and move ment restrictions are diagnosed in the correspond ing spinal segments; these are then treated. Pain originating in the upper ribs radiates to the shoulder blade and shoulder. Lesions of the first 322
rib provoke only shoulder pain. At examination, with the patient’s shoulder blade abducted, a typi cal pain point is found at the costal angle. This pain point on the first rib is the articulated junction with the manubrium sterni. In the other ribs, too, there is often a pain point that can be palpated at the sternocostal joint – the attachment point for the pectoralis minor. Rib movement here is commonly restricted, and manipulation is indicated to cor rect this. However, where movement is restricted in several ribs, this is usually attributable to TrPs in the subscapularis and to impaired mobility of the thoracic fascia.
Frozen shoulder The clinical picture of frozen shoulder is in fact a pathological condition involving the scapulohumeral joint. It has been described in classic terms by Cyr iax, and is a phenomenon that is unique in arthro logy because it is caused by contracture of the joint capsule (Cyriax, de Sèze).
Symptoms The patients, more usually women and predomi nantly between 45 and 65 years of age, develop intense shoulder pain that radiates down past the elbow as far as the wrist. The pain is often at its most intense at night, preventing patients from sleeping, and tends to worsen when the arm hangs down, carrying a weight, or on moving the shoulder. At first there is only slight restriction of movement, but this rapidly increases. According to Cyriax (1977, 1978), three stages can be distinguished: 1. The first stage is characterized by extreme pain and rapid deterioration of the range of movement. 2. In the second stage the pain subsides but there is hardly any improvement in movement restriction. 3. In the third stage the movement restriction melts away (hence the name ‘frozen shoulder’). Each stage lasts for about three or four months, with the result that when the disorder follows its natural course the patient becomes symptom-free after about a year. However, this is not the case in secondary forms, for example following stroke or trauma.
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
Clinical signs Examination of range of movement reveals the typi cal capsular pattern as defined by Cyriax (1977) and corrected by Sachse (1995): with the shoulder blade fixed, abduction is most restricted, followed by external rotation, with internal rotation being least affected. Joint play may be normal provided that arm abduction is not already considerably restricted. This is further proof that we are not dealing here with movement restriction such as is familiar from other joints. Pain points are found at the attachment of the deltoid, and in the subscapularis and infrasp inatus. In severe cases there is muscle atrophy in the deltoid, supraspinatus, and infraspinatus. The pain may also be associated with autonomic symptoms, such as cyanosis and edema, especially involving the hands and fingers, and with algodystrophy.
Therapy In the acute stage the most important step is to alleviate pain using analgesics (by the intravenous route, where necessary). It is also important to treat all concomitant painful dysfunctions, for example in the cervical spine, cervicothoracic junc tion, and ribs. In particular, treatment of the T1/T2 segment often yields good results. It is important to relax tensed muscles with TrPs. Isometric traction is used for this (see Figure 6.12). Relaxation of TrPs in the subscapularis by means of PIR-RI, needling, or local anesthesia appears to be most important. It is worthwhile trying intra-articular injections of cortisone preparations. If this brings improvement, then administration may be repeated no more than once. It is advisable for the patient to wear the arm in a sling during the acute stage so that it does not hang down. Active exercises are not feasible until the second, less painful stage and should never be such as to provoke pain. Excessively energetic, painful exercise will merely delay improvement. Warnings should be issued against heat applications, especially in the acute stage.
Pain provoked by arm abduction (impingement syndrome) Patients who experience pain principally or exclu sively during abduction of the arm (but with nor mal external and internal rotation) are encountered more commonly than those with a capsular pattern. This fact may be attributable to the mechanism
Chapter 7
that allows the head of the humerus to slip through under the acromioclavicular ligament during abduc tion. The subdeltoid bursa together with the rotator cuff is the key player in this mechanism, and calci fications are detected around the bursa where this mechanism is disturbed. Degenerative changes are seen in the rotator cuff with tears, especially in the supraspinatus tendon, and alleged impingement.
Pathophysiology During abduction, the head of the humerus is required to glide caudally in the glenoid cavity. This movement is also reflected in the play of the joint. Any disturbance of this gliding motion is an obsta cle to abduction. Consequently, restoration of this gliding function is the therapy of choice.
Symptoms Pain may appear only on abduction or even spon taneously when the patient is at rest. Two types of impaired abduction are distinguished: either there is simple restriction of abduction by degrees or there is a painful arc, as described by Cyriax (1977, 1978). Where a painful arc is present, abduction initially proceeds normally up to the point where the head of the humerus engages the coraco-acro mial ligament. The patient feels a sharp pain, but as soon as this obstacle is overcome, abduction may continue through to its full extent without pain.
Clinical findings There is restricted abduction, or a painful arc only on abduction but which the patient can move through. Joint play is regularly absent (see Figure 4.42).
Therapy First and foremost there is mobilization to restore joint play (see Figure 6.12). This has an instanta neous effect in the vast majority of cases but may need to be repeated a few times. Surgery is super fluous. Rotator cuff tears have also been detected on ultrasound in clinically healthy individuals.
Painful long head of triceps brachii In 1994, Krobot described a pain that occurred on exercising the triceps brachii and that is felt in the shoulder, axilla, and shoulder blade. On examina tion, the patient is unable to raise the lesioned arm 323
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in front to ear level and experiences pain when doing press-ups. An extremely painful TrP is found in the long head of the triceps brachii just under the axilla. Therapy consists of PIR and RI of the triceps brachii (see Figure 6.101) or needling.
The acromioclavicular joint Dysfunction of the acromioclavicular joint is one of the commonest (and yet rarely diagnosed) causes of shoulder pain. A traumatic origin is especially common: any force acting on the shoulder from the side, for example following a fall, is first absorbed by the acromioclavicular joint.
Clinical signs Painfully restricted adduction of the arm across the chest toward the opposite shoulder is suggestive of the diagnosis. The joint space is tender to palpation.
Therapy Therapy consists pre-eminently of mobilization (see Figures 6.14 and 6.15). However, this must be performed using a minimum of force and it is help ful to supplement mobilization by shaking in the direction in which distraction is intended. The clinical course is more severe if there is radiological evidence of osteoarthritic changes or, more rarely, of joint space widening. In such cases the pain can be relieved using local anesthesia (not into the joint space!) and cortisone preparations.
The sternoclavicular joint Simple movement restriction here without osteo arthritis is rare. A painful sternoclavicular joint is a common finding in rheumatoid arthritis.
Symptoms The patient feels pain locally beneath the medial end of the clavicle, radiating into the shoulder, neck, and thorax; the pain is provoked by move ments involving the shoulder blade (e.g. lifting the arms). It is important to point out that pain origi nating at the medial end of the clavicle is not neces sarily a sign of a sternoclavicular joint lesion. The sternocleidomastoid muscle also has attachment at the clavicle, and close by is the articulation between the first rib and the manubrium sterni. True osteo arthritis of this joint is relatively rare. 324
Therapy Osteoarthritis and simple movement restriction should be treated with mobilization; in patients with osteoarthritis, mobilization needs to be performed repeatedly over an extended period (see Figure 6.16).
7.4.7 Pain in the elbow region Epicondylar pain is a very frequent complication of the cervicobrachial syndrome. It is encountered far more often at the lateral than at the medial epi condyle of the humerus.
Lateral epicondylar pain The epicondylar region provides the attachment points for those muscles involved in the prehen sile function of the hands. Excessive strain and increased muscle tension (TrPs) play an important role here. Although the lateral epicondyle is pal pated through the brachioradialis muscle, the latter is a bystander here. The muscles producing attach ment point pain at the lateral epicondyle are the supinator, the extensors of the fingers and wrist, the biceps brachii, and the triceps brachii. It is no coin cidence that tennis elbow and writers’ cramp share a common pathogenesis. In the first case the tennis player is unable to relax the grip between strokes, and compounds this error by not holding the racket sufficiently in radial abduction and extension at the wrist. In the second case the writer is tense and holds the writing implement in a cramped fashion.
Symptoms Pain at the lateral aspect of the elbow, radiating up and down the arm, and more intense when the hand grips something firmly. The pain may sud denly intensify to the point where patients often drop objects: breaking crockery is a common early sign of epicondylopathy.
Clinical signs Typically, there is a deep pain point where the supi nator is located and where the biceps tendon has its insertion. See Figures 6.97–6.100 for details concerning diagnosis of the individual muscles here. Joint play radially is also impaired. Because the normal movement between radius and ulna is restricted, there is also impairment of the lateral
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
abduction of the hand (this depends largely on the joint play between radius and ulna). Consequently, there is often concurrent pain at the wrist with restricted radial abduction, a painful styloid proc ess of the radius, and/or painful tendovaginitis, especially on the radial aspect. This is particularly also the case after Colles’ fractures because follow ing a fall on to the hand – irrespective of whether fracture ensues or not – the force of the impact is always transmitted via the radius to the elbow. In chronic cases the periosteum at the epicondyle is hyperalgesic and the patient reacts painfully even to the very lightest percussion.
Therapy This consists of relaxation of tensed muscles with TrPs using PIR and RI, mobilization, shaking free any restrictions at the elbow, and self-treatment. Soft-tissue techniques may be attempted where there is a pain point at the periosteum of the epi condyle (see Figure 6.66). If these measures are ineffective, needling, local anesthesia, or cortisone preparations may be tried. Repeated stroking has proved effective in chronic cases. Rehabilitation is essential in the long term, the goal being to over come the patient’s cramped tension. It is always vital to screen for dysfunctions in the cervical spine and insufficient fixation of the shoulder blade, where these are found, to identify their chain reac tion patterns and treat them accordingly.
Chapter 7
7.4.8 Pain at the wrist In wrist dysfunction, the structure most frequently found to be painful is the styloid process of the radius. As already mentioned in Section 7.4.7, this process is closely related to joint play at the elbow and between the radius and ulna. Radial abduction of the hand is regularly found to be restricted. Another structure that is frequently painful is the carpometacarpal joint of the thumb where osteoarthritic changes are found particularly fre quently. There may also be TrPs in the thenar emi nence. Here therapy is mainly directed at (self-) mobilization through shaking (see Figure 6.4). In patients with rheumatoid arthritis it is par ticularly common to find painful changes involving the wrist. In all the painful conditions of the upper extremity dealt with in Section 7.4, insufficient stabilization of the shoulder blade by the lower part of the trapezius and by the serratus anterior can play such a decisive role that, after scapular instability has been treated, the local symptoms may clear up without any local treatment. Patients should therefore be routinely examined for scapular instability (see Section 6.8.9).
A painful styloid process of the radius is generally associated with impaired radial abduction and movement restriction at the elbow.
Medial epicondylar pain Symptoms This condition is characterized by pain at the medial epicondyle.
Clinical signs The principal findings on examination are tension (with TrPs) in the flexors of the forearm and impaired springing of the elbow in a medial direction.
Therapy Therapy consists primarily of PIR and RI of the flexors (see Figure 6.101) and mobilization (shaking) in a medial direction; self-treatment is performed along similar lines. Here, too, severe cases may be characterized by hyperalgesia of the periosteum at the medial epicondyle; treatment for this is identi cal to that advocated for the lateral epicondyle.
7.5 Entrapment syndromes Entrapment syndromes have become fashionable especially in circumstances where the intention is to ignore the potential role of dysfunctions. It is then possible to explain pain in terms of trapped nerve structures. This view fails to recognize that pain is registered not in the nerve itself but in its receptors. In principle, neurology teaches us that peripheral nerves process not only pain but also other modali ties. Therefore if nerve compression causes pain at all, then alongside pain other modalities (includ ing motor activity) must also be impaired. Conse quently, if only pain is present without hypesthesia or weakness, we should never simply assume nerve compression or an entrapment syndrome. The entrapment syndromes of the upper extrem ity not infrequently occur in combination. 325
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7.5.1 Carpal tunnel syndrome This condition is attributed to compression of the median nerve in the narrow tunnel formed by the carpal bones and crossed by the transverse car pal ligament. Compression first affects the blood vessels supplying the nerve, and this explains the important role of ischemia.
Symptoms The patient complains chiefly of numbness and tin gling in the hand and fingers, and later also of pain. In the initial stages, these symptoms are felt only on waking up in the morning but later they are suf ficiently severe to waken the patient at night. In the more advanced stage, pins and needles and pain are felt even during the day, particularly on raising the arms. Pain may then also radiate up the arm as far as the shoulder. Relief is obtained when the arms hang down loose, while shaking the hands improves the blood supply. Heavy physical work exacerbates the symptoms.
Clinical signs In the initial stages, we have to provoke the symp toms for the purpose of examination; the simplest method is to instruct the supine patient to raise the arms vertically and then wait to establish whether paresthesia occurs. In the more advanced stages, pressure or percussion on the median nerve above the wrist may elicit a sharp tingling pain (Tinel’s sign). There is also constant hypesthesia in the ter ritory of the hand supplied by the median nerve and weakness with atrophy of the abductor pollicis brevis; this muscle must always be tested. Charac teristic thenar wasting is encountered only in the advanced stages of the disease. On the basis of our own experience we would stress that even in the early stages of carpal tunnel syndrome increased resistance is found when testing joint play between the carpal bones.
Therapy In the early stages, mobilization, carpal bone distraction and stretching of the transverse carpal ligament are indicated (see Figures 6.98–6.101) and self-applied traction is prescribed as a home exer 326
cise (see Figure 6.82). It has been found to be par ticularly helpful for patients to wear an orthosis or elasticated support at night to fix the wrist in mild dorsiflexion, the position in which intra-articular pressure in the carpal tunnel is least pronounced. If increased resistance is not detected when joint play is tested, local anesthesia or cortisone prepara tions may also be tried. In the stage characterized by incipient weakness and atrophy and by typical electromyography changes, surgery to release the transverse carpal ligament is usually indicated.
Pathogenesis The carpal tunnel is a channel that is formed by a large number of small bones that move in rela tion to one another. This channel must be able to accommodate its contents comfortably in response to every type of hand movement. It is easy to understand, therefore, that a disturbance of joint play will result in conflict between the walls of the channel and its contents, and that restoration of joint play constitutes a form of treatment that reflects the pathogenesis.
Case study K O; female; born 1936.
Medical history The patient first came to us on 24 June 2003 complaining of tingling in her right hand that kept her awake at night. To get rid of it she had to get up and shake her arm. The symptoms started on or about 10 June 2003 after she had been painting a fence.
Clinical findings Examination disclosed increased resistance on testing for joint play of the carpal bones and tingling was promptly elicited in the arm elevation test with the patient supine.
Therapy The individual carpal bones were mobilized and distraction manipulation was performed at the wrist. The patient was prescribed an orthosis to wear at night. The patient notified us by telephone on 7 July 2003 that she was symptom-free. She reappeared on 14 October 2003 with acute low-back pain and a lumbosacral mobility restriction. There had been no recurrence of tingling in her fingers, and she
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
complained merely of numbness in her fingertips. Her skin there had a typical glossy appearance (slight reddening, erasure of skin creases) and this responded excellently to skin stretching.
Case summary Typical carpal tunnel syndrome in the functionally reversible stage. This was diagnosed most elegantly using the arm elevation test with the patient supine; tingling was elicited after a brief latency period.
7.5.2 Thoracic outlet syndrome This syndrome is attributed to compression of the brachial plexus mainly in the gap between the anterior and middle scalenes and the muscle attach ments at the first rib, and in the region of the supe rior thoracic outlet. Principally, it causes paresthesia (numbness, pins and needles, pain) in the upper extremities, this being most intense on the ulnar aspect of the fingers. This syndrome is predominantly the result of dysfunctions involving the highly complex struc tures that constitute the superior thoracic outlet. The prerequisite for effective therapy is to identify any disturbances in these individual structures and their relevance in each case. In detail, these com prise increased tension (TrPs) of the scalenes, TrPs in the pectoralis minor (Hong & Simons 1993), increased tension of the upper fixators of the shoul der girdle, and TrPs in the diaphragm. Closely related to these muscle disorders, there may be movement restriction at the craniocervical junc tion, the cervicothoracic junction, and the upper ribs, in particular the first rib. The true cause of this increased tension (TrPs) is clavicular breathing (i.e. lifting the thorax during inhalation), which is associated with insufficiency of the deep stabilizer system. It is no wonder, in view of this complexity and the lack of understanding concerning dysfunctions, that surgical decompression procedures are per formed on the scalenes, the first rib, or a cervical rib, instead of pursuing the true cause, the treat ment of which is highly rewarding.
Symptoms The symptoms consist principally of paresthesia involving the upper extremity (including the hands), more apparent on the ulnar aspect, and typically
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becoming worse when carrying heavy loads. Because of the plethora of individual dysfunctions, the clini cal picture (especially the pattern of pain) is any thing but uniform; for example, headache may also be present due to movement restriction at the craniocervical junction. It is worth emphasizing that, by contrast with the carpal tunnel syndrome, severe weakness or atrophy rarely occur.
Clinical signs The following tests are useful for provoking the symptoms: • Adson’s maneuver: the pulse at the radial artery is weakened (or disappears) on bending the patient’s head back and turning it to the same side. • Hyperabduction test: the patient’s arm, bent at the elbow, is taken into maximal abduction and the radial artery pulse is palpated. • Pulling the arm downward, as when carrying a load, and feeling for the radial artery pulse. More important, however, is diagnosis of the indi vidual dysfunctions in the region of the superior thoracic outlet. Only in exceptional cases are there signs of neurological deficit. Cervical myelopathy is generally present where there is major weakness with atrophy and, of course, paresthesia.
Therapy Therapy depends on the analysis of the individual clinical findings forming the links in the chain. Given the unmistakable role of the scalenes, it is evident that clavicular breathing is the crucial fac tor in the pathogenesis, coupled with involvement of the deep stabilizer system.
Case study B I; female; born 1960.
Medical history First seen on 18 October 2000 complaining of pain in the cervical region with stiffness, headache, shoulder pain, and tingling in the fingers. Her symptoms started in the cervical region, and she had experienced tingling in her hands for the past two or three years, especially when working at the computer for long periods. Apart from an operation to correct hallux valgus, her other details were unexceptional. 327
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Clinical findings and therapy Examination disclosed thoracic dextroscoliosis, increased tension in the scalenes on both sides, and movement restriction of the first rib on both sides and of the cervicothoracic junction. The patient’s breathing was normal. Her first rib and cervicothoracic junction were treated and her scalenes were relaxed; self-mobilization of the first rib was assigned for home exercise. At the follow-up examination on 1 November 2000 the patient felt better, less stiff, and reported only occasional tingling in her hands. TrPs were now detected in the subscapularis and pectoralis major on the left side, and her thoracic fascia showed poor mobility relative to underlying structures. When the fascia were treated the TrPs disappeared; self-treatment of the thoracic fascia was recommended as a home exercise (see Figure 6.62b). The patient was seen again on 16 May 2001. She had been symptom-free up to the start of that month, but now her neck was painful again and she was experiencing tingling in her hands. She also complained of shortness of breath. TrPs were found in the diaphragm and again there was increased tension in the scalenes with restricted movement of the first rib on both sides. Her left fibular head was also restricted. Her diaphragm and scalenes were relaxed, the first ribs and cervicothoracic junction were treated, and her fibula was mobilized. As a home exercise we prescribed relaxation of the diaphragm and self-treatment for the first rib. On 5 June 2001 she had only transient tingling in her fingertips. Her pelvic floor was painful on the right side. Her pelvic floor was relaxed and her fingertips were treated using skin stretching. The patient was again symptom-free and appeared for a further examination on 9 May 2002. Since April 2002 she had been complaining of shortness of breath, with feelings of tightness in the left half of her thorax. Since the beginning of May she had also been experiencing pain in her neck and upper extremities. Once again there were TrPs in the diaphragm and TrPs on the left side in the pectoralis major, psoas major, quadratus lumborum, pelvic floor, hip adductors, and biceps femoris, and movement restriction at the fibular head. After PIR of the diaphragm, all TrPs were eliminated, including the restriction at the fibula; only the first ribs with the cervicothoracic junction were treated. On 11 June 2002 the patient had only tingling in her fingertips, and this was treated with skin stretching; her scalenes were also relaxed. The patient was once more symptom free until 4 August 2004 when she was seen again because 328
tingling had reappeared in her upper extremities and fingertips and she was experiencing knee pain. Examination now revealed only skin changes at the fingertips and tingling on the soles of her feet; these were treated by exteroceptive stimulation. The thoracic outlet syndrome itself was no longer present.
Case summary Typical thoracic outlet syndrome with increased tension in the scalenes (although without characteristic clavicular breathing), and with the repeated finding of TrPs in the diaphragm and pelvic floor (coccygeus). The ‘glossy skin’ changes at the fingertips (erasure of skin creases and slight reddening) are not unusual in this context. Skin stretchability at the fingertips is invariably limited, and skin stretching eliminates tingling. The combination of increased tension in the scalenes and TrPs in the diaphragm often produces feelings of tightness, interpreted by this patient as shortness of breath.
7.5.3 Ulnar nerve weakness Ulnar nerve weakness will be mentioned here only in passing. The cause is generally to be found in the ulnar nerve canal and only very rarely in Guyon’s canal in the wrist region. This condition is not an object for manipulative therapy, but it does need to be distinguished from the two entrapment syn dromes described above. In terms of carpal tunnel syndrome it is necessary to differentiate between median nerve and ulnar nerve involvement. In terms of differentiation from the thoracic out let syndrome, it is important to identify patterns of weakness and atrophy that are characteristic of the ulnar nerve, as well as a true hypesthesia, since these hardly ever occur in thoracic outlet syn drome.
7.5.4 Nocturnal meralgia paresthetica This condition is the commonest entrapment syn drome affecting the lower extremity.
Symptoms Patients complain of excruciating tingling and hypes thesia in the territory innervated by the lateral cutaneous femoral nerve along the lateral surface of the
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
thigh, involving an area about the size of the palm of the hand. This nerve traverses the lateral end of the inguinal ligament. Due to increased tension in the iliopsoas and tensor fasciae latae, the inguinal liga ment itself becomes tense, producing compression of the nerve.
Therapy Therapy consists of relaxation of the iliopsoas and tensor fasciae latae muscles.
Case study
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that in the cervicocranial syndrome the cause is more frequently a lesion at the craniocervical junc tion, just as the lower cervical spine is more likely to produce pain in the upper extremity, there are frequent exceptions. This is understandable if we consider the musculature: long muscles such as the sternocleidomastoid, scalenes, trapezius, and levator scapulae react to all dysfunctions in the cervical region by developing TrPs and referring pain to the head and arms. The intensity of the nociceptive stimulus and the individual’s response are crucial in determining whether pain is felt only locally in the neck or whether pain will be referred elsewhere.
V V; male; born 1950.
Medical history The patient had complained of numbness and pain on the lateral surface of the left thigh since February 1988. Otherwise he had never been ill.
Headache is yet another example illustrating that the locomotor system is involved in the pain process.
Clinical findings Examination on 13 April 1988 revealed TrPs in the psoas major and iliacus on the left side. Trunk rotation was restricted to the right (40° to the right and 60° to the left) and extension was restricted at L5/ S1. Hypesthesia in the territory characteristic for the lateral cutaneous femoral nerve was detected on the lateral aspect of his left thigh.
Therapy Treatment consisted of mobilization of trunk rotation to the left and mobilization of L5/S1. For exercising at home the patient was recommended to self-treat using gravity-induced PIR of the iliopsoas and tensor fasciae latae. When seen again on 5 December 1988 the patient complained of pain between the shoulder blades. Asked about the pain in his thigh, he reported that this had cleared up within a few days.
7.6 The cervicocranial syndrome This syndrome covers headache of cervical origin as well as other clinical symptoms, such as dis turbances of equilibrium, and even neurological symptoms, such as nystagmus. The underlying dysfunction of the cervical spine here can be the same as in simple neck pain. While it may be true
7.6.1 Headache Headache with a cervical component This is an extremely frequent type of headache. In our view it also includes ‘tension headache’ which is sometimes thought to be mainly psychological. Increased muscle tension is due to many fac tors, and in the classic description by Wolff (1948) increased tension of the neck muscles is part of the clinical picture of tension headache. Increased muscle tension is the consequence of practically all disturbances of the locomotor system, regardless of whether it emanates from excessive strain due to external factors, faulty head posture, muscle imbal ance, or psychogenic tension or whether it stems from TrPs due to movement restrictions. There can be no doubt that psychological problems have a role to play in headache (see Section 4.1), but this does not alter the fact that increased muscle tension is a muscular phenomenon that can be treated appropri ately and effectively using physiological methods. Neither is ‘vasomotor’ headache incompatible with headache of cervical origin: the mere fact that the cervical spine plays a role militates in favor of its reflex origin. If we assume that disturbed func tion plays the role of a nociceptive stimulus, then a vasomotor reaction to that stimulus is bound to occur. 329
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As this type of headache is very frequent, it should not be diagnosed simply on the basis of exclusion, that is after every other possible ori gin has been ruled out, as the neurology textbooks often teach. Admittedly, serious pathology must be excluded; but it should be remembered that head ache due to locomotor system dysfunction has its own characteristic features (see also Section 4.1). Examination will usually reveal chain reaction pat terns that involve the entire locomotor system. For example, in a series of 38 patients with nonmigraine-type headache, we detected an average of 6.3 TrPs, of which 34 were in the sternocleidomas toid, 31 in the short extensors of the craniocervi cal junction, 23 in the diaphragm, 17 in the erector spinae, 13 in the quadratus lumborum, 11 in the masticatory muscles, 11 in the biceps femoris, and 6 in the soles of the feet. TrPs in the biceps femoris and the soles of the feet are linked to a forwarddrawn posture, which is associated with tension in the neck muscles on standing (see Section 4.20).
Symptoms Everything that is characteristic for vertebrogenic pain is also true for cervicocranial headache (see Section 4.1). In particular, this applies to the posi tion of the head, for example working for long peri ods with the head bent forward (seamstresses), sitting at the computer, headache on waking due to an adverse position of the head during sleep, and a forward-drawn posture on standing due to inad equate fixation of the pelvis. The pain is generally asymmetrical, often uni lateral, and usually paroxysmal, that is the patient enjoys pain-free intervals or days with only mini mal pain interspersed with hours or days of intense pain. Summing up all of this, together with the material presented in Section 4.1 concerning the role of autonomic, endocrine, and psychological factors, we come to the surprising conclusion that the more features a headache has in common with migraine, the more likely it is that a vertebrogenic factor is implicated in its causation. The localization of the pain is also important. The diagnosis of cervicocranial syndrome is rendered likely if the patient complains of pain radiating from the neck into the temples and eyes. However, this in itself is insufficient for a diagnosis. In adoles cents and in children particularly, headache is fre quently the first sign of disturbed cervical function long before neck pain has been felt. Children often 330
complain only of pain in the forehead or the tempo ral region. Even pain radiating into the face can be referred pain of cervical origin, as has been shown by Travell (1981). Very often, however, facial pain is also the result of TrPs in the masticatory muscles (orofacial origin).
Clinical signs The clinical picture is dominated by dysfunctions in the cervical region, which form chain reactions with dysfunctions in other parts of the locomotor system. However, these are no different from dys functions encountered in pain states that are lim ited only to the cervical region. Common findings include muscle imbalance, TrPs with movement restrictions (especially affecting the craniocervical junction), faulty posture, and clavicular breathing. The most important pain points are on the lateral surface of the spinous process of C2 (more fre quently on the right), at the posterior arch of the atlas (in the short extensors), at the posterior mar gin of the occipital foramen magnum, at the trans verse processes of the atlas, in the upper part of the trapezius, and in the sternocleidomastoid. The frequent pain points on the occiput in the region of the nuchal line are usually secondary; further pain points are found on the scalp (the restricted mobility of which is an important softtissue finding, as is that of the fascia in the cervical region). Although the exit points of the trigeminal nerve may suggest trigeminal neuralgia, isolated tenderness at the exit point of the first branch is more suggestive of headache of cervical origin. Typ ical HAZs are found behind the mastoid processes, in the vicinity of the eyebrows (Maigne 1996), and at the temples. The common TrPs in the diaphragm point to involvement of the deep stabilizer system, and a forward-drawn posture to involvement of the feet, in particular if increased tension in the dorsal neck muscles (typical in forward-drawn posture) ceases when the patient is seated.
Therapy This follows the same rules as for any other cer vical dysfunction. It may be worth stressing that special attention should be devoted to the crani ocervical junction, the mobility of which should be tested in all directions. The pain points should also not be overlooked. All chain reaction patterns should always be identified. If pain regularly begins on waking, we must enquire about the sleeping
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
position of the patient and correct this where nec essary. Muscle TrPs are best treated by PIR and RI. TrPs that remain unresponsive are treated with need ling; and pain points on the scalp are treated prima rily using the specific soft-tissue technique. The same also applies for HAZs at the forehead, temples, and nose. Stroking should also be considered.
The mandibulocranial syndrome Headaches due to a painful temporomandibular joint (TMJ) and to TrPs in the orofacial system also have their origin in the locomotor system but not in the cervical spine. They are far more common than was previously thought, and if correctly diagnosed, they can be treated effectively. Two causes should be distinguished: 1. Poor occlusion in which there is malpositioning of the teeth on biting together because teeth are missing or dentures do not fit properly. 2. TrPs in the masticatory muscles due to faulty muscle control (as in bruxism), faulty movement patterns on chewing, or increased psychological tension. Where TrPs are present in the masticatory muscles, the TMJ is also generally painful.
Symptoms There is great similarity with pain emanating from the transverse process of the atlas or from the attachment point of the sternocleidomastoid; how ever, the pain may also mimic neuralgic pain in the vicinity of the trigeminal nerve. Where there is increased tension in the digastricus, there is often dysphagia with the sensation of a lump in the throat. Patients commonly complain of dizziness (Costen’s syndrome).
Clinical signs Mouth opening may be restricted (it is normally possible to insert three knuckles between the upper and the lower incisors). During opening and clos ing of the mouth there may be deviation of the chin to one side, or the chin may retract prematurely while the TMJ moves forward, causing a popping sound at the joint. There may be tenderness at the TMJ and TrPs should be looked for at the tempo ralis, masseter, and internal and external pterygoid
Chapter 7
muscles. Interestingly, patients are usually aware of pain in the temples but not of pain in the other masticatory muscles, which may be far more pain ful on palpation. Palpation of TrPs in the digastricus (behind the angle of the mandible and at the floor of the mouth) is not straightforward. The simplest way to diagnose increased tension is to move the thyroid cartilage and/or the hyoid bone from side to side. Where the increase in tension is considerable, there may even be visible deviation of the thyroid carti lage, in which case the contours of the floor of the mouth are also distorted.
Therapy PIR of the relevant muscles is the treatment of choice, followed by self-treatment (see Section 6.6.2). If the joint is involved, isometric traction is a useful addition. However, where there is malocclu sion, prosthetics and/or orthodontics are essential. In most cases, disturbance of function in the oro facial system is bound up with changes elsewhere in the locomotor system, particularly in the cervical spine, and the primary task is to discover in a judi cious manner the most relevant link in the chain.
Case study T L; male; born 1947.
Medical history First seen on 26 November 1987, the patient complained of dizziness on waking on the morning of 17 August 1987, with a sensation of pulling to the right; he experienced vomiting for two days. Subsequently, brief attacks of dizziness occurred when bending the head forward and to the side; this lasted for about a month. Later there was headache and pain in the neck, mainly on head rotation. From 1985 there was a history of headache at the occiput, radiating to the eyes and associated with nausea. No other history of illness.
Clinical findings and therapy At examination, readings on two scales showed a weight difference of 5 kg (30 kg on the right, 35 kg on the left); deviation in Hautant’s test was to the left, disappearing on head anteflexion and rotation to the left. Examination showed TrPs in the masseter on both sides and in the digastricus. The digastricus was therefore treated on both sides. Immediately after treatment, Hautant’s test was negative. 331
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Self-treatment of the digastricus was prescribed as a home exercise. At the follow-up examination on 10 December 1988 there were no symptoms at all. However, there was still a difference in the two-scale test. The clinical course confirmed that the symptoms were due merely to dysfunction.
Anteflexion headache In the modern-day workplace the commonest working position is sitting, with the head bent forward. The resultant excessive strain produces anteflexion headache. Hypermobile subjects are particularly prone to this type of headache. Other groups of common sufferers include accident vic tims and school children. We therefore share Gut mann’s (1968) opinion that headaches in children are far less often due to psychogenic factors than to an adverse head posture.
Symptoms The children are pain free on waking. Not long after the start of the school day, especially after long periods of reading or writing, they start to fidget because they find it hard to keep still. The headaches as such start only later. During weekends and holidays the children are usually pain-free. As the condition worsens, the headaches start ever earlier in the day and the children find it increas ingly difficult to concentrate, with the result that performance at school deteriorates, and they are repeatedly reprimanded or even punished. Small wonder then that they are not keen on school; and this is why their condition is often explained away as ‘school headache’ of psychogenic origin. These same patients also experience pain on jolting, espe cially when travelling by road or rail and when turn ing somersaults.
Clinical signs The anteflexion test is positive, that is if the patient’s head is held for a short time without force in maximum anteflexion, merely by taking up the slack, pain sets in after 10–15 seconds. Immediate pain may be indicative of a movement restriction at the craniocervical junction or, in exceptional cases, of meningism. Pain points are found particularly around the posterior arch of the atlas, and signs of hypermobility are often visualized on X-ray 332
(see Figures 3.51 and 3.52). Restricted mobility at the craniocervical junction is a common additional finding.
Therapy If there is movement restriction – especially involv ing the craniocervical junction – this should be treated, as it aggravates the symptoms. The main therapeutic measure is to advise the patient to avoid head anteflexion – for instance, by using a sloping desk especially when reading and writing. In fact, the incidence of these headaches increased with the introduction of horizontal classroom tables to replace the old-fashioned sloping desks. These children should also avoid forceful anteflexion of the head, as when turning somersaults. However, carrying loads on the head is beneficial.
Migraine I have already pointed out that many of the charac teristic symptoms of headache of cervical origin fit the clinical picture of migraine, and also that vaso motor disturbance is compatible with headache of cervical origin. Nevertheless it would be wrong to suggest that migraine as such is just another verte brogenic disease, simply because involvement of the spinal column or of the locomotor system var ies very widely from case to case. In practice, however, in the large majority of migraine patients (including children) we find numerous dysfunctions in the locomotor system, including clavicular breathing where the thorax is lifted during inha lation. For example, Sachse et al (1982) found restricted mobility of the cervical spine in 19 out of 22 patients with classic migraine, and normal respiration patterns in only three patients. Bakke et al (1982) and Clifford et al (1982) have reported greatly increased electromyographic activity of head and neck muscles during provoked attacks of migraine. In our own case series of 40 migraine patients studied between 1998 and 2003, we dis covered an average of 7.7 TrPs, in 32 cases in the diaphragm, in 31 cases in the sternocleidomas toid, in 26 cases in the erector spinae, in 24 cases in the pelvic floor (coccygeus), in 23 cases in the short extensors of the craniocervical junction, and in 18 cases on the soles of the feet. In a ran domized controlled study, Tuchin et al (2000) have demonstrated the beneficial effect of manipulative therapy.
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
It therefore appears that, as with many internal diseases, the pain of migraine is associated with dys functions and especially with TrPs in the locomotor system, and that these changes are contributory causal factors and potentiators of the pain. Inter estingly, the deep stabilizers, that is the diaphragm, pelvic floor, and feet, play a major role here.
Differential diagnosis I must again stress the importance of differential diagnosis. Understandably, patients in the early stages of serious pathomorphological disease will be treated with analgesics for their pain and it is gen erally the failure of symptomatic treatment that prompts further investigation. The same also applies to manual therapy. With the gentle manipulation techniques currently at our disposal, however, the risk of unwanted side effects is less than with phar macotherapy. The surest way to avoid diagnostic error (or to correct it) is for patient follow-up to be as long as possible: headache patients do not usually lose their headaches within a short period, and as soon as something out of the ordinary occurs in the clinical course, fresh diagnosis and examination are necessary. A short and progressive clinical course is always a warning sign.
7.6.2 Disturbances of equilibrium The importance of the craniocervical junction for maintaining equilibrium was explained in Section 2.5.1. The most significant symptom of disturbed equilibrium is dizziness or vertigo. If patients are routinely examined using the two-scales test and Hautant’s test (see Figure 4.45), it will be found that many patients without dizziness at all show a weight difference of 5 kg or more when standing with each foot on separate scales. Hautant’s test in these patients is then generally positive, at least in one head position – usually retroflexion and rotation of the head in the direction opposite to the devia tion. In contrast, anteflexion and rotation of the head in the direction of deviation cancels out any deviation that is already present in a neutral posi tion. It is therefore legitimate to speak of a ‘cervi cal pattern.’ In the two-scale test the patient must be instructed to place weight on both legs equally otherwise there will be an automatic tendency to
Chapter 7
load the standing leg more. The direction of the movement restriction in the cervical spine, in con trast, plays only a subordinate role for the very rea son that more than one restriction is often present and these are not always in the same direction. In a consecutive series of 106 patients without dizziness (Lewit 1986) we detected a disturbance pattern in 55 cases. A locomotor system dysfunction was consistently present, but not always involving the cervical spine; sometimes the mastica tory muscles and even the feet were involved. After treatment of the relevant dysfunction, the distur bance pattern also reverted to normal in every case. These were the same type of patients in whom Norré et al (1976) reported nystagmus and move ment restrictions at the craniocervical junction but without dizziness. Finally, it should be noted that the maintenance of equilibrium (and of disturbances to equilibrium) depends on proprioception with sensory input from the locomotor system, labyrinth, and eyes, all of which is integrated in the brainstem. Dizziness or vertigo are experienced if there is a disturbance to any one of these systems.
The maintenance of equilibrium is a function of the locomotor system that permits upright body posture.
Forms of dizziness/vertigo Ménière’s disease Ménière’s disease is characterized by attacks of rotational vertigo, lasting for hours or even days, in which the patient is able to indicate the direction of rotation (clockwise or anticlockwise) and there is usually nystagmus toward the affected ear. Vertigo is accompanied by nausea and vomiting, typically coupled with tinnitus and disturbance of hearing. Attacks need not always be that severe, in which case they are shorter, without tinnitus and audi tory disturbance, and instead of the characteristic rotational vertigo the patient experiences a swaying sensation (rather like sea-sickness).
Positional vertigo These patients suffer short attacks (lasting just a few seconds) of true rotational vertigo on changing 333
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the position of the head in space, that is together with the rest of the trunk, and not necessarily on changing the position of the head relative to the trunk. Patients close their eyes tightly while the attacks are in progress. If it proves possible to open the patient’s eyes, then nystagmus will be observed.
Cervical dizziness This polymorphous group consists of short attacks of dizziness provoked by certain head positions and/or movements of the head in relation to the trunk: the patient has the sensation of being pushed or pulled to one side, forward or backward, and is apprehensive of falling. Nausea or vomiting and tin nitus are absent, but headache is usually present concurrently.
Cervical syncope attacks These are extremely violent attacks that are pro voked by a pathogenic head position, most typically retroflexion and rotation to one side. The patient is briefly aware of intense dizziness, falls to the ground and loses consciousness for a short time. These attacks are described as ‘cervical syncope’ or ’drop attacks’ and loss of consciousness need not necessarily occur.
Mixed and transitional forms Not infrequently, we are called upon to treat patients who experience different types of dizziness at once or in whom the type of attack changes dur ing the course of their illness.
Case study K I; male; born 1908; surgeon.
Medical history The patient suffered from concussion after an automobile accident in 1948. Two days later, there was slight dizziness when he bent his head to the right. Three years later, he developed tinnitus and acute paroxysms of Ménière’s disease, usually lasting for two to three days. Three years later these attacks ceased but the patient had a feeling of instability and a fear of falling. He actually fell three times, with the feeling that the ground had ‘come up and hit him in the face’. In 1959, lying under an automobile with his head turned to the right, he felt sharp pain and dizziness which disappeared instantly when he turned 334
his head to the left. He repeated this ‘experiment’ until he provoked a genuine Ménière’s attack. From that time onward he had constantly suffered from dizziness and a feeling of unsteadiness. He therefore came to see us on 15 January 1960.
Clinical findings In Hautant’s test with his head rotated to the left there was deviation to the right. On turning from the supine to the side-lying position, dizziness with second-degree rotational nystagmus counterclockwise was provoked.
Case summary Over the course of his illness this patient exhibited a wide variety of forms of dizziness, ranging from simple feelings of unsteadiness and positional vertigo through to classic Ménière’s attacks with tinnitus and cervical syncope, which caused him to fall down. He was further able to provoke a true Ménière’s attack by head rotation against the trunk, as in ‘cervical’ dizziness. This abundantly illustrates the importance of obtaining from the patient the most precise details possible regarding the nature of the dizziness experienced. The first step therefore is to establish exactly what the patient means by the words ‘I felt dizzy’. In very general terms, patients use the word ‘dizzy’ to describe their fear of falling, for example when looking over the edge of a precipice. Sometimes these are circulation-related attacks of weakness, a feeling of ‘drunkenness’ that is of cerebellar origin, or even ataxia and other situations in which the patient’s legs give way. It is therefore our professional duty to closely question patients who use the word dizzy. And as soon as we hear the phrase ‘My head was spinning’, the (obligatory) question then is whether spinning was clockwise or counterclockwise. Patients may also feel that they are being pulled or pushed to one side, forward or backward, or experience a swaying sensation. Findings may also be negative in the interval between attacks.
Clinical signs Only if it is possible to examine the patient during a classic Ménière’s attack can we observe the typical signs of labyrinthine disorder, character ized by nystagmus to one side with deviation (of the arms or trunk) to the opposite side, that is toward the side of the labyrinthine lesion; this is best detected using Romberg’s test. For this, the patient stands with heels close together and eyes
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
closed, with the head at first in a neutral position; the trunk will deviate to the side of the labyrin thine lesion. When the head is rotated to the side of the labyrinthine lesion the trunk then deviates (sways) backward; when the head is rotated to the opposite side, the trunk deviates forward. In the interval between attacks these findings may be negative; however, Hautant’s test (as outlined below) may nevertheless be positive in different head positions in cases where there are lesions in the locomotor system. Routine examination using Hautant’s test in patients with locomotor system dysfunction gen erally reveals a characteristic pattern, regardless of the type of disturbance of equilibrium, and indeed often even in patients not experiencing any dizzi ness. In 72 examinations in 69 patients the position that provoked deviation of the forward-stretched arms was head retroflexion and rotation of the head in the opposite direction to that of deviation. In contrast, deviation of the forward-stretched arms disappeared on head anteflexion and rotation in the direction of deviation. Commonly there is no devia tion in a neutral position, this phenomenon only occurring on head retroflexion. It then becomes more pronounced when the head is additionally rotated in the opposite direction to that of devia tion. (In purely labyrinthine disorders, deviation with the patient seated leaning against the back of a chair is not dependent on head position.) In what might be called ‘typical’ cases, deviation was also dependent on the direction of movement restric tion, but only in 70% of cases. However, movement restrictions were often present toward both sides and in more than one segment. After treatment for movement restriction, deviation is generally no longer seen. It is important to stress here that a cervical fac tor may be present in all forms of vertigo and diz ziness; this is apparent from testing (as described above) and from the results of treatment. Comparable treatment results were obtained predominantly with manipulative therapy in 70 patients with cervical dizziness and in 33 patients with mixed forms (Lewit 1963). Positional ver tigo responds least well to manual therapy. Where auditory impairment is also present, this may also be improved, although far less often than diz ziness itself. The vast majority of our cases had dysfunctions in the vicinity of the craniocervical junction and masticatory muscles (TMJ). Similar results were obtained by Travell & Simons (1999)
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following ‘spray and stretch’ and anesthesia of the sternocleidomastoid, and have also been reported following PIR of the masticatory muscles.
Importance of the vertebral artery The cervical spine acts to maintain equilibrium by means of receptors in muscles, tendons, and joint capsules, but also indirectly through the supply of blood to the labyrinth and brainstem via the verte bral artery. The role of the brainstem is to inte grate proprioceptive, labyrinthine, and visual input. Hence the tendency to explain most equilibrium disturbances, not as the consequence of faulty affer ent stimuli due to dysfunction, but rather as the consequence of a mechanical circulatory disorder of cervicogenic origin in the territory of the verte bral artery. It is therefore vitally important to know when a vertebral artery lesion should be suspected as a potential cause of a disturbance of equilibrium: • In patients of advanced age, particularly if there are other signs of arteriosclerosis. • If there are drop attacks (cervical syncope). • If retroflexion of the head coupled with rotation produces dizziness, particularly in the absence of movement restriction, or if retroflexion of the head coupled with rotation continues to produce dizziness after movement restriction has been released. A positive de Kleyn test is further confirmation. This test should be performed gently. It may also trigger positional vertigo, and this needs to be distinguished on clinical grounds: positional vertigo is characterized by a sudden onset with a short latency period and also ceases abruptly. It is even more important that when provocation is repeated, positional vertigo can no longer be triggered. Vertebral artery insufficiency increases when the test is repeated. Due to rotation of the head, arterial blood flow is suppressed on the side from which the head is turned away. In a positive de Kleyn test, the insufficient artery is the one on the side to which the head is turned. • Certain X-ray findings: retrolisthesis, in particular if oblique pictures of the cervical spine in head retroflexion show a narrowed intervertebral foramen (see Figure 3.26). A difference in the obliquity of the joint space in the same segment is also particularly important (see Figure 3.58), because it enforces rotation on retroflexion. Marked uncovertebral 335
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neoarthrosis may also have an adverse effect on the vertebral artery. All of these clinical criteria are merely suggestive of possible vertebral artery insufficiency, the only defi nite proof being provided by Doppler sonography and arteriography. The more recent literature has in many cases called into question the results of the de Kleyn test in light of ultrasound findings; however, Nefye dov & Sitel (2005) have also provided ultrasound confirmation of the usefulness of this test. Clini cal experience speaks clearly in favor of the de Kleyn test; many patients become dizzy and many fall down when they retroflex the head and rotate in the standing position, as when hanging out the washing, cleaning windows, or painting a ceiling. These patients should therefore be warned against such activities.
Differential diagnosis In the large majority of cases with involvement of the vertebral artery there is also involvement of the cervical spine. This is no mere coincidence if we consider the close anatomical inter-relationships and the fact that elderly patients often have simultane ous degenerative changes affecting both the blood vessels and spinal column. Compared with a normal vessel, a sclerotic artery reacts much more sensitively to mechanical irritation from the cervical spine. A high proportion of patients with disturbances of equilibrium also suffer from disturbances of the cervical spine, as is borne out by the litera ture, which refers to the ‘posterior cervical sym pathetic syndrome’ (Barré 1926) and ‘cervical migraine’ (Bärtschi-Rochaix 1949). Both authors describe a combination of cervicogenic headache with disturbances of equilibrium and involvement of the vertebral artery and nerve, sometimes even with symptoms of mild neurological deficit. Vítek (1970) makes the point that headache in patients with arteriosclerosis is generally caused by distur bances of the cervical spine. If there is vertebral artery involvement, then mild focal neurological symptoms must be expected and other pathological processes must also be excluded. From our own experience, we would stress here that an improvement in the patient’s condition following manual therapy by no means excludes the presence of an intracranial space-occu pying lesion. 336
Therapy Therapy essentially follows the same principles as already outlined for other locomotor system dys functions, provided that the practitioner is satis fied that these play an important role in the case in question. Once examination of the locomotor sys tem has been completed, the practitioner should analyze the findings, identify any chain reaction pat terns, and then look for the key link in the chain.
Positional vertigo It is assumed that the free mobility of otoliths plays a role in positional vertigo and that these can there fore be ‘mobilized’ by changing position rapidly. For example, the patient might sit up and lie down in quick succession, rotate head and trunk from one side to the other while lying down, or sit up and lie down again with head rotated. The maneuver that produces vertigo will cease to do so after a few repeats. Therapy then also follows the same lines: ideally in the early morning while still in bed, the patient practices the maneuver that provokes posi tional vertigo until this ceases to happen. This can also be repeated several times; the patient is then less likely to suffer an attack while out and about. The results are incomparably superior to those of pharmacotherapy, which produces undesirable side effects in these cases, such as drowsiness and stupor.
Vertebral artery insufficiency The intimate pathogenetic inter-relationships between the cervical spine and the vertebral artery are of major consequence for therapy. We know from experience with angiography that a sclerotic artery when punctured reacts in a far more spas modic way than a normal healthy artery. The same is true following mechanical irritation produced by the cervical spine. Hence the need for appropriate therapy. This also forms the background to the con troversy as to whether manual therapy should be considered in this setting or whether it might dam age the vertebral artery. From what has already been stated in Section 5.1.2, it is clear that serious complications arise principally as a result of major technical errors in the application of manual therapy. On the other hand there can be no justification for leaving a dys function untreated if it is known to be a source of mechanical irritation to the vertebral artery.
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
Most severe dysfunctions occur in the vicinity of the craniocervical junction, and it is there that the most favorable effects of manual therapy in the vertebral artery syndrome are seen. This is because in normal functioning of the craniocervical junc tion the loops of the vertebral artery in this region allow for head rotation without increasing tension in the artery. If head rotation is impaired at the craniocervical junction, head rotation has to take place below C2, which means that it occurs at the level of the vertebral artery canal, that is between the transverse processes of the cervical vertebrae, thus exposing the artery to shearing forces if rota tion takes place. This is further borne out by our own clinical experience. In a group of 70 patients with dizzi ness, vertigo, or both, 21 showed signs indicative of vertebral artery involvement. Whereas in those patients without vertebral artery involvement man ual therapy failed in only 10%, in the group with vertebral artery involvement manual therapy was unsuccessful in 28.5% of cases, but yielded excel lent results in 38% and positive results in a further 33.5%. In most instances, therapy took the form of mobilization at the craniocervical junction, exclu sively using gentle neuromuscular techniques that do not produce any more strain than the spontane ous head movements performed by the patient on a daily basis. These results are also significant for diagnosis. If no improvement of the patient’s condition fol lows on from treatment of the cervical spine, the inescapable conclusion is that the symptoms are attributable exclusively to an arterial disturbance. Adequate manipulative treatment thus not only gives satisfactory results in cases where other con servative modalities have failed, but also permits identification of those patients in whom arterio graphy is indicated with a view to possible surgical treatment.
It should be remembered that skillful mobilization is the most effective form of conservative therapy for vertebral artery insufficiency where there is a simultaneous dysfunction in the (upper) cervical spine.
Finally, we would emphasize that the above con siderations should not deter anyone from treating
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patients with dizziness or vertigo: provided that the indication and technique are correct, there are very few conditions for which there is a more effective conservative therapy.
Case study P E; female; born 1934.
Medical history The patient was first seen 21 August 1986, complaining of vertigo which was worse when she lay down, giving a sensation of pull to the left and forward rotation. During an attack in June she had actually fallen. Such attacks had occurred repeatedly over the past 11 years; on one occasion while exercising, for example, she had fallen on to her right side, after head retroflexion. Since then her condition had deteriorated, with nausea and buzzing in her ears. She had suffered with headaches since 1973, and low-back pain since 1984. The patient had suffered from tonsillitis repeatedly, and from low-back pain during menstruation and in the course of two pregnancies.
Clinical findings and therapy On examination there was deviation to the right in Hautant’s test, which disappeared on head anteflexion and rotation to the right. The readings in the two-scales tests were 30 kg on the right and 37 kg on the left. There was a movement restriction at C0/ C1, and a painful coccyx. After mobilization and a traction thrust, Hautant’s test was negative, while the scales showed 33 kg and 34 kg with both legs fully load-bearing. At follow-up examination on 11 September 1986 vertigo was less frequent, but there was no change in its intensity. This had given her particular problems on one occasion while watching storks flying overhead. Hautant’s test showed deviation to the left, but only on retroflexion of the head and rotation to the right. Anteflexion and retroflexion of the head provoked dizziness, which soon ceased in a neutral position. There was again restriction at C0/C1 and at C7/T1. The de Kleyn test was strongly positive. At a further follow-up examination on 29 September 1986 the vertigo remained unchanged; the de Kleyn test was positive on mere retroflexion of the head and became worse on left rotation. We recommended angiography, which was performed on 6 January 1987 and revealed wear and tear of the left vertebral artery. The patient underwent surgery on her left vertebral artery at the end of January 1987. 337
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The patient was seen again on 6 April 1988, when she complained of pain in her left arm, stating that it had started after femoral artery catheterization for angiography. She was found to have a movement restriction of the first rib and increased tension in her scalenes. She was no longer suffering from dizziness.
Case summary This case study illustrates in particularly impressive fashion the diagnostic value of manual techniques.
To reiterate: the differential diagnosis of dizziness and vertigo touches on many clinical specialties, and in many cases interdisciplinary diagnostic clari fication is needed.
7.7 Active scars In a publication dating from 1947, Huneke described how symptoms of pain in the locomotor system, often at remote locations, subsided imme diately following local anesthesia of scars, a finding that he termed the ‘instant relief phenomenon’. He attributed this effect to the use of novocaine. While at the time his observations attracted widespread attention and ushered in the era of neural ther apy, that is administration of local anesthetics into pathogenic foci (Dosch 1964, Gross 1979), general interest in its use for the treatment of scars slipped back into oblivion. Despite this, the efficacy of treating scars con tinued to be investigated and over the years it was found that it was not the local anesthetic but rather the act of needling that was responsible for the effect (Lewit 1979). However, the crucial devel opment here was that the clinical characteristics, diagnosis, and therapy of soft tissue came to be rec ognized. Today, scars have become a model for the study of soft-tissue pathology. This is because a scar may involve all layers, from the epidermis, subcuta neous tissue, muscles, and fascia, right through to the abdominal cavity, for example, and each layer has to be diagnosed and treated separately. All these layers share a common feature: if they do not behave normally, then their ability to stretch and move relative to each other is impaired. As with all other mobile structures, it is also necessary here to differentiate between a normal (physiological) barrier and a pathological one. Where a pathological barrier is diagnosed, we speak of ‘active scars’. And it is only when the surface of the skin is stroked that 338
we may also diagnose increased skin drag, which enables us to recognize active scars very quickly. The importance of active scars in pathogenic terms is also easy to understand: when our body moves, this movement is not limited to our muscles, joints, and bones, that is the locomotor system proper, but all other tissues have to contribute harmoniously to this movement, that is they have to stretch and shift relative to each other. If this associated movement is disturbed (and this is a largely neglected field of research), then the function of the locomotor system will also be impaired by reflex mechanisms. And this also applies to the visceral organs.
7.7.1 Diagnosis At first sight the diagnosis of an active scar appears to be extremely straightforward: in each layer we look for a pathological barrier, that is we test for skin stretch, subcutaneous folding and stretching of the fold, the typical resistance pattern of TrPs, the degree to which fascia and areas of resistance can be shifted, and pathological barriers in the abdominal cavity. However, the following difficulties should be highlighted, on the basis of extensive clinical experi ence: in the case of surgical scars, the skin incision is often selected so as not to produce a cosmetic blem ish. However, the actual surgical procedure involving the deeper-lying structures may take place some dis tance away from the incision, and this fact needs to be realized if pathological barriers are to be detected there. The diagnosis of resistance in the abdominal cavity demands special skill. Surgery today makes widespread use of laparoscopic procedures, and for this reason nothing will be palpated in the superficial layers. We therefore have to rely on our palpatory skill if we are to identify the location and direction of resistance in the abdominal cavity. And it is no less important to be able to recognize the release phe nomenon reliably; for if there is no release phenom enon, then we are dealing not with a scar but with a pathological process in the abdominal cavity. The requisite diagnostic steps then have to be initiated. Clinically, it is important that palpation for resist ance should not be limited to areas above the pubic symphysis. Resistance is commonly found below the symphysis in toward the pelvis, especially after gyne cological operations, and complicated deliveries are a frequent cause. As abdominal scars are stretched by backward bending they restrict extension of the lum bar spine, and the patient interprets this as low-back
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
pain. In the absence of segmental restriction in the lumbar spine, backward bending is then restored by treatment of scars in the abdominal region. However, diagnosis alone is not enough; it is also important to determine relevance. An active scar need not necessarily be a factor in the symp toms for which the patient is being treated. In order to determine relevance, a complete exami nation should be followed initially by treatment of the scar so that we can determine whether or not the dysfunctions and their chain reaction pattern can be influenced by our intervention there. This is important because if the effect is positive, then we continue to target the scar with our treatment. Conversely, if a relevant active scar is not treated, then all other therapy will remain unsuccessful.
7.7.2 Therapy In every case therapy consists of taking release through to the very end. In the case of areas of resistance in the abdominal cavity it is often neces sary to change direction, depending on where fur ther resistances can be palpated. The patient will often indicate where the referred pain is felt in the locomotor system (usually in the back). It is impor tant to understand that a single treatment will not usually suffice and that it is generally helpful also to stroke the skin surface and to prepare the deeper layers for treatment by using hot packs. The number and frequency of treatments will be deter mined by the clinical course. The pathogenic effect of resistance in the abdominal cavity depends not on the organ or even on its position, or whether this or that structure in the abdominal cavity is palpated, as practitioners of visceral osteopathy insist. It is determined solely by the pathological barriers in the abdominal cavity that interfere with the harmonious cooperation of the viscera as the body moves.
Case study B W; female; born 1967.
Medical history First seen on 3 October 2000 complaining of pain in her arms and shoulders. She had given birth three years previously; the baby weighed 4 kg and the patient lost a great deal of blood, had a high fever, and received antibiotics. Her shoulder pain started soon after the baby was born.
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Clinical findings and therapy Examination of the patient revealed a chain of TrPs extending down to her left foot. The patient’s history evoked a suspicion of an active scar in her lower abdomen, and in fact resistance was palpated in her left hypogastric region. Once the release phenomenon was obtained, the patient’s symptoms (including TrPs) cleared up. At follow-up examination one month later the patient’s condition had largely improved, treatment in the lower abdomen was repeated and at the same time her cervicothoracic junction was treated by traction manipulation. After this the patient was symptom-free.
Case summary This case is instructive for the following reasons: the patient’s symptoms started shortly after she had given birth; palpation of her hypogastric region confirmed painful resistance; and a release phenomenon was obtained, simultaneously with the ‘instant relief phenomenon’ described by Huneke (1947).
7.8 Structural diseases associated with locomotor system dysfunction 7.8.1 Basilar impression and spinal canal narrowing These two anomalies have in common the ability to cause compression syndromes, the former of the medulla oblongata, the latter of the cervical part of the spinal cord. They are both congenital conditions that also share a tendency for symptoms to become apparent only in (very) advanced old age. From this it follows that we are dealing here with decompen sation due to degenerative and functional change. Provided that surgical intervention is not indicated immediately, it is therefore possible to embark on treatment aimed at the restoration of function. In basilar impression there are frequently no signs of neurological compression, and patients complain only of symptoms similar to those reported in the cervicocranial syndrome. In such cases the treat ment procedure is the same as for patients who do not present the anomaly. However, even patients 339
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with some signs of compression in the posterior cra nial fossa may improve after manipulation. The same is true for cervical myelopathy and for narrowing of the cervical spinal canal, not only with regard to pain symptoms but also for milder forms of weakness. The case studies below illustrate the importance of treating dysfunctions of the locomotor system caused by neurological diseases of organic origin.
Case study K M; female; born 1895.
Medical history First seen on 27 January 1957. The patient and her family had a history of pulmonary tuberculosis. Since 1948 she had suffered from headache, and from cervical and low-back pain. Her hearing and sight had been deteriorating since 1954. She complained of a feeling of vertigo (being pulled backward and sometimes to both sides). She also had pain radiating down her arms and numbness in her fingers.
Clinical findings Examination revealed second-degree vertical nystagmus downward and when looking to the side, diagonally. The corneal reflex was weak on the left, there was slight paresis of the VIIth cranial nerve on the left; when her tongue was extruded it deviated to the left. The patient had a very short neck with limited inclination and rotation to either side. In the upper extremities, the deep tendon reflexes were increased and more marked on the left; Hoffmann’s sign was positive on both sides. There were exaggerated tendon reflexes in the legs and pyramidal tract signs were present. The patient lacked stability when standing and had a spastic gait. X-rays of her skull and cervical spine showed marked basilar impression. C6 was shifted forward relative to C7, and there were spondylotic osteophytes at C6. Myelography with air insufflation revealed a protrusion dorsally below the foramen magnum extending as far as the level of the arch of the axis, while the anterior subarachnoid space was of normal width. The cerebrospinal fluid was normal. This was a case of basilar impression with the Chiari-Arnold malformation.
After conclusion of treatment the patient’s condition worsened in March 1958, prompting her renewed admission in April 1958. At a subsequent follow-up examination in March 1959 the patient complained of vertigo attacks. Her bilateral sway on standing was immediately improved following traction combined with head rotation. At her last follow-up visit on 13 May 1961 the patient had no further gait disturbance and had only occasional attacks of dizziness. She had first-degree nystagmus, and her neck was freely mobile. Gait spasticity was minimal. Hautant’s test indicated slight lateral deviation to the right side, which was abolished immediately after traction.
Case study H A; male; born 1893.
Medical history The patient felt pins and needles in the first, third, and little finger of his right hand in February 1950. His hand gradually became weaker and so clumsy that he could no longer shave.
Clinical findings Findings included atrophy of the interossei and adductor pollicis muscles on the right, restricted extension of the fingers, and exaggerated reflexes at C5–C7. The palmomental reflex was positive. There was no disturbance of tactile perception. X-ray of the cervical spine showed only minor signs of cervical spondylosis. Initially, the putative diagnosis was progressive spinal muscular atrophy (Aran-Duchenne). The patient was examined again between 1951 and 1954. Minor symptoms involving the left hand were also detected. There was little change in neuro logical findings. Myelography with air insufflation showed disk protrusion at C3/C4 and C5/C6. There was slight hyperalbuminosis. Because of the myelography findings the patient was invited for further follow-up in October 1955. On closer examination, the areas of muscle atrophy were found to correspond to segment C8 where there was also discrete hypesthesia.
Therapy
Therapy
Manual traction of the cervical spine was started experimentally at the beginning of March 1957. By the end of March the patient was able to walk without difficulty and nystagmus was noticeably improved. The patient was treated by manual traction on an outpatient basis until the summer of 1957.
A simple traction test improved sensation in the patient’s right hand and he was able to oppose his fingertips again. Manual therapy was therefore started, and this was followed by significant improvement to the extent that the patient was able to shave himself again after years of being unable to do so.
340
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
These case studies show that both in basilar impres sion as well as in cervical myelopathy it is possible to achieve clinical improvement by using therapy that is targeted at function. Similar findings have also been made in syringomyelia.
Case study S M; female; born 1905.
Medical history The patient had complained of pains in the neck, shoulders, and arms since 1949, and later of a burning sensation in her left cheek and watering of her left eye. Gradually her left hand also became weaker and clumsy; by 1953 her right hand was also affected, and her gait had been deteriorating since 1952.
Clinical findings At the initial examination in early 1953 the patient had Horner’s syndrome on the left and first-degree nystagmus; the left corneal reflex was weak; muscular atrophy (in both arms) was worse on the left and there were trophic changes in the skin. The C5 reflexes were abolished on both sides, the C6 and C7 reflexes were weak, while the C8 reflex was normal on the left and exaggerated on the right. There were also pyramidal tract signs on the right. The abdominal reflexes were abolished, while the deep tendon reflexes in both legs were exaggerated.
Therapy The patient was X-rayed in October 1953 during her first stay in hospital. At that time traction of the cervical spine was tried experimentally. Prior to traction the patient was able to abduct her shoulders only to 150° on both sides; after traction this increased to 170° on the left and 160° on the right. Traction therapy was therefore prescribed and shoulder mobility was restored to normal within three weeks. During a further hospital stay in 1954 the patient complained once more of shoulder pain that again cleared up after traction. Nevertheless, the neurological examination showed progressive deterioration of her underlying condition. By this time there was a complete absence of reflexes in her left arm, while on the right side only the C8 reflex was preserved. Despite this deterioration in objective findings, the patient felt better and more able to move her arms at the shoulders. This was attributable to pain relief following the improvement in vertebrogenic dysfunction.
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7.8.2 Radicular syndromes The radicular syndromes are also generally caused by a pathomorphological lesion (most commonly a herniated disk), primarily affecting the lower extremities where dysfunctions play a major role. In the upper extremities the process is more complex, leading to narrowing or compression of the intervertebral canal, with disk herniation being a rather rarer cause. Other morphological changes include narrowing of the spinal canal in both the cervical and lumbar regions. Although less common, space-occupying lesions should also be considered as possible causes of radicular compression. With the exception of space-occupying lesions, the pathomorphological changes listed here do not constitute absolute indications for surgery. Even without surgery the great majority of radicular syn dromes heal as a result of functional compensation and resorption of the intervertebral disk. This is also why conservative treatment is so often success ful, that is traction, manipulation, various types of reflex therapy, remedial exercise, and stabilization methods. Indeed, surgery in isolation fails more often than not if it is not followed by appropriate rehabilitation, that is if we do not help to restore normal function. This is why the problem of disk herniation is dealt with in this book. The interplay of changes in structure and function constitutes a complex problem in terms of diagnosis and patho genesis. The clinical differences between radicular syndromes in the upper and lower extremities are considerable and so the two will be dealt with sepa rately. The reader is also referred back to Section 2.12.
Radicular syndromes in the lower extremities History taking Although radicular syndromes share many com mon features with other vertebrogenic disorders, they possess certain special characteristics. The first is that, in most cases, pain radiating into the lower extremity is preceded by low-back pain. This is why disk herniation is thought to be the main cause not only of radicular pain, but also of lowback pain. However, because low-back pain occurs 341
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much more frequently than radicular syndromes, this merely indicates that only low-back pain that is caused by disk herniation is likely to be a precur sor of radicular syndromes. This is why the char acteristic symptoms of discogenic low-back pain were described in Section 7.1.5. There are, how ever, radicular syndromes in which the pain starts in the legs and is never preceded by low-back pain. In such cases, low-back pain usually appears only later, if at all. Pain felt in the buttocks occurs com monly, hence the old term ‘sciatica.’ Radicular pain may have a sudden onset after a lifting injury or when getting out of bed in the morning. It may also begin so insidiously that the patient cannot remem ber precisely when it started. For best advice to be given in individual cases, it is important to elicit from the patient details of those circumstances that aggravate symptoms and that bring relief. Radicular pain differs from simple referred pain in that pain and numbness radiate down as far as the toes; the pain is accompanied by paresthesia with pins and needles or numbness; and patients have the feeling that they cannot reliably con trol the affected leg. Sometimes patients are also aware of weakness. Pain is typically felt on cough ing, sneezing, defecation, and, sometimes, laughing. Except in acute cases, walking tends to alleviate the pain. However, if patients complain of pain when walking, it is essential to ask whether they have to stop after a certain distance and what position they then adopt. This is the only way to identify inter mittent claudication.
Clinical signs The patient is often able to describe the pattern of pain and paresthesia on the affected extremity. The typical antalgic posture is frequently encoun tered when the patient is examined in the standing position (see Figure 7.1). Here, too, however, there are exceptions: for example, patients who adopt an extremely erect posture and are entirely unable to bend forward. The more common antalgic posture, that of anteflexion with the pelvis deviating toward the painful side, is easily explained because it is the position that keeps the intervertebral foramen as wide as possible. The lordotic posture has been explained in terms of the position of the herniated disk relative to the dural sac and the nerve root (de Sèze & Welfling 1957). If the straight-leg raising test is positive, then anteflexion in the standing position with straight 342
legs will also be restricted. In patients with an exag geratedly erect posture, trunk anteflexion will often be impaired, even when the patient is seated with knees bent. In less acute cases, posture when stand ing at ease may be more or less normal but ante flexion with straight legs will be reduced as long as straight-leg raising is impaired. Anteflexion in the seated position should then also be tested. Not infrequently, shortly after anteflexion has started, a painful barrier is encountered (the ‘painful arc’ described by Cyriax (1977, 1978)); once this has been overcome, anteflexion then proceeds normally. This pattern suggests a herniated disk. It is important to point out that antalgic posture and movement limitation in radicular syndromes are not due to motion segment restriction, and that indeed such restriction may be absent. In the L5 and S1 radicular syndromes, the straight-leg raising test is generally clearly positive. However, when the pain occurs, it should also be established whether or not it is possible to flex the straight leg still further at the hip. More rarely there may be a ‘painful arc,’ as described by Cyriax, in which the patient experi ences pain when the leg is raised a little, followed by no pain when the straight leg is flexed further at the hip. The femoral nerve stretch test is a reli able indicator of a lesion in segment L4. When the straight non-lesioned leg is raised and the patient experiences pain on the lesioned side, this is indica tive of disk herniation. The femoral nerve stretch test should never be omitted, thus ensuring that we do not overlook the L4 radicular syndrome in which the straight-leg raising test can be negative. Of major significance are the neurological signs of root involvement, such as motor weakness and hypesthesia, without which the diagnosis of true radicular syndrome is inconclusive because of the often highly deceptive nature of referred pain. For this reason, even minimal weakness of a mus cle, hypotonus, or hypesthesia consistent with the segment in question may be highly significant and should be carefully looked for. The following sections will now discuss the symptoms of the individual radicular syndromes of the lower extremities. Radicular syndromes L4, L5, and S1 are the only conditions here of any clinical relevance.
L4 radicular syndrome
Pain radiates over the ventral aspect of the thigh to the knee and can radiate further on the anteromedial aspect of the leg down to the medial malleolus. In
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
this syndrome, the straight-leg raising test is often only mildly positive, whereas the femoral nerve stretch test is always strongly positive. There is weakness of the quadriceps femoris and of the hip flexors (rectus femoris) when the patient is seated and the patellar reflex is weakened or absent. Where major weakness is present, walking down stairs is troublesome, as is straightening up from the kneesbent position while loading the lesioned leg. The patient’s gait may be unsteady. Hypesthesia may be present on the anterior aspect of the thigh.
L5 radicular syndrome
Pain and paresthesia radiate laterally over the but tocks and down the thigh and lower leg as far as the lateral malleolus and then over the instep to the big toe where hypesthesia is also found. None of the routinely tested tendon reflexes is altered. The muscles most commonly affected by weak ness are the extensor hallucis longus and the exten sor digitorum brevis. Aside from weakness of these muscles, their reduced tonus can be very easily pal pated close to the tibial margin and above the lat eral malleolus. In severe cases the tibialis anterior is also weakened and hence also dorsiflexion at the talocrural joint and dorsiflexion of the toes. This is clearly apparent during heel-walking owing to the dorsiflexion weakness of the foot (‘signe du talon’). Severe weakness may be seen in the very acute stage, so that the patient’s foot hangs flaccidly, pro ducing a steppage gait. This should not be confused with the far rarer condition of peroneal nerve weak ness. Internal rotation of the hip is also weakened (Horácek 2000). A valuable neurological sign is increased resist ance when stretching the skin of the interdig ital fold between the first (big) and second toes, and between the second and third toes, as well as increased resistance on dorsoplantar movement of the first metatarsal bone against the second, and the second against the third, especially in patients in whom pain radiates as far as the toes. The pain ful key muscle (TrP) is the piriformis, and hence the patient will report pain in the hip.
S1 radicular syndrome
Pain and paresthesia radiate dorsally over the but tock and thigh as far as the lateral malleolus and then laterally along the foot to the little toe. Hypesthesia is consistent with this pattern. The weakened mus cles are the fibularis, the triceps surae (especially the lateral part), and the gluteal muscles, causing lower
Chapter 7
ing of the gluteal fold in the standing position (hypo tonus). According to Véle (personal communication), an early sign is the weakened reaction of the toe flexors when the patient leans forward (but without standing on tiptoe). Characteristically there is no toe flexion on the side of the radicular syndrome. The weakness is also clearly evident when the patient tries to walk on tiptoe. The Achilles tendon reflex is weakened or abolished. This syndrome is also often characterized by a definite disturbance of proprio ception. A comparison of both sides reveals that the patient notices passive movement of the lateral toes later on the lesioned side than on the healthy side. In this syndrome, too, we find increased resistance to stretching of the interdigital fold of skin between the third and fourth, and fourth and fifth toes, and increased resistance on dorsoplantar movement of the third metatarsal bone against the fourth, and the fourth against the fifth.
Problems of diagnosis In clinical terms, a radicular syndrome can be reli ably distinguished from referred pain; however, establishing when a radicular syndrome is caused by disk herniation is far more difficult. A herniated disk may be clinically ‘silent’ and radicular com pression may be caused by a narrow spinal canal, a narrow lateral recess, or a space-occupying lesion. Localization can also be more problematic than would appear at first sight. Anomalies are encoun tered along the course of nerve roots, and computed tomography (or magnetic resonance imaging) often discloses more than one herniated disk. Only one of these will probably be relevant clinically. Patients who have been immobilized for long periods often develop thrombophlebitis, the pain of which must not be confused with radicular pain and must be treated specifically. If surgery is indicated, the diagnosis must first be confirmed by imaging techniques. However, even these are not infallible. Although imaging may reveal more than one herniated disk, it can provide little information regarding their clinical relevance.
Neurogenic intermittent claudication (radicular claudication) Some remarks on the problem of neurogenic inter mittent claudication (radicular claudication) will be apposite at this point. In this syndrome, which is intimately linked with a narrow spinal canal, the patient at rest often has no clinical signs. The 343
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symptoms, usually pain shooting down into the leg, only become apparent when the patient starts to walk; after a certain distance, the pain is sufficient to compel the patient to stop walking, crouch, and – if possible – sit down. After a few moments the patient is able to walk on, but after about the same distance has been covered the episode is repeated. As a rule, very little is found at examination. The patient usually also experiences pain after long peri ods of standing. Neurogenic intermittent claudication always has a serious prognosis and therapy is difficult. Often the diagnosis is not even made at all because findings at examination are minimal. A detailed case history is therefore crucial. If these patients are asked when they feel pain, the response is invariably ‘On walk ing’. Except in the acute stage, however, that is nor mally not the case. Therefore, as soon as a patient who is symptom-free at rest reports pain on walk ing, we must ask whether this makes the patient stop and adopt a particular position. Many patients suffering from neurogenic intermittent claudica tion escape diagnosis and this creates the mistaken impression that it is a rare condition. Some patients also present only with low-back pain.
Case study H M; female; born 1926.
Medical history The patient complained of low-back pain and pain in her left leg. Pain did not increase on coughing or sneezing. Low-back pain began in 1965, mainly when walking; since 1986 the patient has needed to sit down after walking about 200 meters; after two minutes’ rest she can continue walking. Since March 1989 she has had severe pain in her left leg, especially when standing.
Clinical findings and therapy At examination on 28 August 1989 she had a marked forward-drawn posture, and retroflexion was restricted. There was deviation to the left in Hautant’s test, cervical spine examination showed movement restriction of C0/C1 in all directions, and there was marked hypertonus of the abdominal and gluteal muscles. After sustained pressure was applied to the gluteals, tension was normalized, not only in the gluteals but also in the rectus abdominis, and the patient’s forward-drawn posture disappeared. Also the movement restriction at C0/C1 was now hardly noticeable. Slight movement restriction remained at 344
C4/C5, which was also treated. Afterward there was no deviation in Hautant’s test. X-ray of the lumbar spine showed typical signs of a narrow spinal canal and a pseudospondylolisthesis of L4 relative to L5. At follow-up examination on 18 October 1989 the patient’s condition had improved, but she had experienced a severe attack of pain during September and still needed to rest after walking 200 meters. On examination there was restricted anteflexion in the L5/S1 segment with lumbosacral hyperlordosis and shortening of the lumbar erector spinae. On this occasion, L3–S1 was stretched into flexion and the patient was told to use the ‘cradle’ exercise at home (see Figure 6.144) and to practice self-mobilization into retroflexion while standing. In November and December the patient was much improved; there had been just one painful attack, and pain during walking was clearly less intense, enabling her to engage in systematic walking training. At a further follow-up visit on 24 January 1990, the patient volunteered that she no longer had to interrupt her walks and sit down; it was enough if she bent forward slightly. Examination again revealed a forward-drawn posture, with increased tension in the straight abdominal muscles, tenderness on both sides at the pubic symphysis, and hypertonus in the gluteals. After sustained pressure in the vicinity of the ischial tuberosity, tonus in the gluteal and abdominal muscles was normalized and the forward-drawn posture was corrected. The patient’s further home exercise was then to strengthen her abdominal muscles.
Case summary This case illustrates that compensation for radicular intermittent claudication due to a narrow spinal canal can be achieved by treating dysfunctions, namely by utilizing exercises that train flexion of the lumbar spine, such as the ‘cradle’ or the McKenzie technique of flexion self-mobilization (Haig AJ, et al 2006, Witmann JM 2006). It also demonstrates the chain reaction pattern linking the gluteal muscles with the abdominal muscles and the craniocervical junction. (If this case had been seen today, the feet would also be included in that chain.)
General therapy Acute stage
Radicular syndromes also pose major problems in terms of therapy. In the acute stage, rest in the antalgic position is indicated. The increased muscle tension in the antalgic position encourages rest, and pillows can be improvised to support this position.
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
Analgesics, administered intravenously if need be, are also indicated. If traction in the antalgic posi tion brings relief, then traction (see Section 6.1.3) and counterstrain (see Section 6.2.2) may be tried as first aid if there is a direction of ease. If some improvement sets in after these measures, then the attempt can be made to mobilize into flexion, and even to deliver an HVLA thrust. For further therapy, emphasis nowadays is placed on the detailed analysis of findings and on tailoring the therapeutic approach to the chain reaction pat terns of dysfunctions found. Often there are uni lateral chain reaction patterns extending from the cervical region down to the feet: these are char acterized by ‘fascial binding’ and by insufficiency of the deep stabilizer system in the lumbar spine and feet. If relief cannot be obtained by traction, coun terstrain, or mobilization, then root infiltration or epidural anesthesia is the most effective method. Another option is needling of the most painful TrPs or of an extremely hyperalgesic interdigital fold (the insertion point for the needle should then be between the metatarsal bones). Active scars, where present, must be addressed wherever possi ble at the start of therapy. When needling or local anesthesia are performed, needle insertion must always reproduce intensive pain. However, where manual soft-tissue techniques or PIR and RI are effective, preference should be given to these noninvasive methods. Where necessary, the above measures can be supported with analgesics. Rest in the antalgic posi tion should be permitted only for as short a time as is necessary. In cases of acute pain where even standing upright is distressingly uncomfortable, it is a mistake to refer patients to a practice some dis tance away for an injection or physical therapy.
Chronic stage
During the subchronic and chronic stage, the chief objective of treatment is to restore normal func tion. In this endeavor, treatment should be guided by familiar principles governing the restoration of joint function using manipulative techniques. Treat ment on the painful side is always given into flexion so as to ease the strain on the nerve root. And even before starting to mobilize the joints, we should also always treat the fascia if these are not freely mobile against the underlying structures. The exercises advocated by McKenzie are help ful in the long term for intervertebral disk lesions
Chapter 7
(see Figure 6.73). Where there is insufficiency of the deep stabilization system in the lumbar spine and feet, priority should be given to activating this system. Active scars must also not be overlooked, and their treatment should even be undertaken so that we can satisfy ourselves as to their relevance. Resistant TrPs should be needled if they are not abolished when chain reaction patterns are treated or following PIR and RI. Faulty movement patterns should be treated by remedial exercise incorporating sensorimotor training. Quite specifi cally, patients who report pain on anteflexion and lifting should be instructed how to lift correctly (see Section 6.8.6) and how to stabilize their stance at the wash basin. It is important to remember that during the chronic stage other lesions in the lower extrem ity may complicate recovery: these may be due to cramp or to movement restrictions particularly involving the fibula and the feet. Important findings such as outflare and inflare must not be overlooked. Complications arising from the hips, whether in the form of coxalgia or incipient osteoarthritis of the hip, are also by no means rare. The same is true with regard to a painful coccyx. Possible complica tions arising from thrombophlebitis must not be forgotten in patients who have been immobilized for long periods.
The indications for surgery Although the conservative therapy described here is generally effective, there remain cases of radicu lar syndrome in which all efforts fail and surgery is indicated. Indeed, it is no exaggeration to claim that it is the very effectiveness of our conservative ther apy that enables cases requiring surgery to be identi fied earlier. The problem is to decide at what point we consider our conservative therapy to have failed. Naturally, opinions on this vary, partly because the course of the disease varies greatly from one case to the next. For example, if there is absolutely no improvement in intense pain in an acute disease course, surgery should not be deferred for long so as to spare the patient unnecessary suffering. How ever, in most cases some improvement is achieved, although this may turn out to be merely temporary. Where the disease course fluctuates, our decision is much more difficult. It is necessary also to decide whether we are dealing ‘merely’ with a herniated disk or with a narrow spinal canal, since the latter is always associated with a worse prognosis. 345
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Another conundrum is whether muscle weakness is a factor in determining the indication for surgery. The answer to this common question is as follows: evidence of a peripheral nerve lesion is one of the characteristic signs of a radicular syndrome. Expe rience has shown that even patients with marked radicular weakness usually recover well after pain has improved. However, there is one exception, namely where there is sudden onset of weakness. In typical cases the patient describes excruciating pain that disappears suddenly (overnight) so that sleep is possible. On waking the patient can no longer lift the foot or toes. Examination confirms exten sor paralysis. If in such cases no improvement takes place within 24 hours, emergency surgery is indi cated to avoid permanent nerve root paralysis. Another indication for emergency surgery is the cauda equina syndrome, a disturbance of sphincter function leading to bladder and bowel disorders. There is a danger that the manual therapy practi tioner may not recognize this condition. This is either because patients are unwilling to mention it (especially if the sphincter lesion is incomplete); or because they may not be aware of its importance and may even be over-preoccupied with the pain. It is therefore essential to know when to ask patients about their control of micturition and bowel action. This question is particularly relevant if the Achilles tendon reflex is absent on both sides in a patient with acute bilateral radicular pain, or more rarely with simple low-back pain. Surgery is indicated far more rarely for patho logical hypermobility or instability. It is indicated in spondylolisthesis that is not (yet) fixed, particularly in adolescents. Radiological imaging has a key role to play here. It is worth emphasizing that nowa days, by activating the deep stabilization system, we are in a far better position to restore stability using conservative methods. Finally, surgery cannot ever do more than remove a local mechanical lesion that constitutes an obsta cle to therapy and rehabilitation. It does not and cannot eliminate the locomotor system dysfunc tion or restore normal function. Surgery should be viewed as just one element in the treatment of a disturbance that affects the whole locomotor sys tem but requires a complex approach that is deter mined by the needs of the individual case. Gentle mobilization can be started a few weeks after sur gery (at sites further away from the operated seg ment it can be applied even earlier) before moving on to active rehabilitation. 346
Radicular syndromes in the upper extremities Radicular syndromes C6, C7, and C8 are the main conditions here of any clinical relevance.
Symptoms Patients complain of pain radiating down the arm to the fingers, coming either from the neck, or usually from the shoulder blade. Pain is frequently worst when the patient is in bed, and is exacerbated on head retroflexion, and less often on head anteflex ion. A high pillow is therefore helpful in most cases and many patients sleep sitting up. Pain is typi cally accompanied by paresthesia and a feeling of weakness.
Clinical signs The characteristic pain points are at Erb’s point (located above the clavicle, at the side of the neck in the mass of the scalenes) and a point medial to the superior medial angle of the shoulder blade. The latter is a TrP in the interscapular part of the trapezius which tenses like a cord on maximal hori zontal adduction of the arm. Pain is usually trig gered by head retroflexion and rotation to the side of the lesion, that is by a movement that causes nar rowing of the intervertebral foramina, even if there is no movement restriction at all. There are also patients in whom pain is aggravated on anteflexion (Frykholm 1969). The nerve root stretches tight (and causes pain) if it follows a descending course from the cervical cord (Adams & Logue 1971a,b,c). Otherwise anteflexion tends rather to afford relief, as it widens the intervertebral foramina.
C5 radicular syndrome
This is a rare condition that is characterized merely by shoulder pain. The biceps tendon reflex is weak and there is weakness of the deltoid and possibly of the biceps brachii.
C6 radicular syndrome
Pain radiates over the radial (lateral) aspect of the upper arm and forearm to the thumb and forefin ger, and here hypesthesia may be found. There is weakness of pronation and of the radial prona tion reflex. This can be elicited with the patient’s arm flexed so that the forearm is supported, for
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
example, on the patient’s knees; the practitioner then taps on the styloid process from the palmar aspect to obtain a pronatory jerk. (This is in con trast to the styloradial reflex which produces flex ion at the elbow, corresponding more to segment C5.) Some patients with this syndrome also have winging of the scapula. This is best tested by the patient stretching both arms forward and maintain ing this position for a while.
Case study T L; male; born 1941; professional wrestler.
Medical history Treated by us since 1971 for recurrent neck pain (connected to his sporting activity) that responded well to manual therapy. The patient had a recurrence of neck pain in the spring of 1973, but he did not attend for treatment and the pain persisted. Toward the end of 1973 surgery was considered. After a temporary improvement, the patient’s condition again deteriorated. It was not until 5 February 1974 that he was referred to us again for treatment with the diagnosis ‘cervicobrachial syndrome.’
Clinical findings and therapy Examination revealed pronounced winging of the shoulder blade, and the pronation reflex on the left side was abolished. There was movement restriction at C2/C3 to the left and at C5/C6 to the right; these were released without difficulty. An intensive program of remedial exercise was prescribed because of the muscle findings. Marked improvement, including the winged shoulder blade, was obtained over a fourmonth period.
Case summary A serious C6 radicular syndrome was misdiagnosed because the patient’s winged scapula was overlooked (probably because the patient was not examined from behind).
C7 radicular syndrome
In this by far the most common of the radicular syndromes involving the upper extremities, pain radiates over the middle of the dorsal aspect of the arm toward the second to fourth fingers, being maximally pronounced in the middle finger; hypes thesia may also be found in this area. There is typi cal weakness of the triceps brachii, and the triceps tendon reflex is weak.
Chapter 7
C8 radicular syndrome
Pain radiates over the ulnar (medial) aspect of the upper arm and forearm to the fourth and fifth fin gers. Hypesthesia may be found in this area. There is weakness of the long digital flexors and grip strength is reduced. This is consistent with a weak ened digital flexor reflex. Typically, there is weak ness of the abductor muscle of the little finger. Sometimes there is also atrophy of the small mus cles of the hand, including the adductor pollicis. The C8 radicular syndrome is rare and needs to be differentiated from the thoracic outlet syndrome, ulnar nerve weakness, and cervical myelopathy.
General therapy By contrast with radicular syndromes of the lower extremities, their counterparts in the upper extremities pose a less difficult problem because disk herniation is a less prominent feature here. As a result, conventional conservative therapy is gener ally effective and failures are less common. Never theless, a radicular syndrome should be classified as a more serious condition than a cervicobrachial reflex syndrome because it involves not merely dys function but radicular compression in the interver tebral canal, although dysfunctions may also play some role in the pathogenesis. In the acute stage, treatment begins with admin istration of analgesics and post-isometric traction in the antalgic position, and with soft-tissue tech niques for the neck and extremities, especially if a painful interdigital fold is present and there is increased resistance on dorsopalmar movement of the metacarpals against each other. Mobilization is then performed, depending on the existing chain reaction pattern, often starting at the craniocervical junction and the cervical spine provided that there are no major dysfunctions in the deep stabilization system, including faulty respiration. If increased tension disappears after these measures, then they may be followed by extremely gentle traction manipulation of the lower cervical spine with the patient seated (see Figure 6.52b). If typical TrPs then still persist, for example in the scalenes (Erb’s point), the upper and lower parts of the trapezius, or the diaphragm, then PIR and RI are brought into play. Needling in particular is indicated for TrPs that do not respond to those treatments. Surgery is indicated in those relatively rare cases where conservative therapy fails. Preoperative diag nosis is performed using medical imaging techniques. 347
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7.9 Vertebrovisceral inter-relationships 7.9.1 General principles The possibility that reflex inter-relationships between different structures may exist side by side with referred pain in the same body segment has already been discussed in Section 2.11. The practi cal clinical aspects of this phenomenon will now be considered. In very broad terms, the following five possibilities should be envisaged: 1. The spinal column (motion segment) is causing symptoms that are mistaken for visceral disease. 2. Visceral disease is causing symptoms that are interpreted as a lesion in some part of the locomotor system. 3. Visceral disease is producing changes in the locomotor system, such as TrPs, movement restrictions, etc. 4. Visceral disease that has caused changes in the locomotor system has subsided; however, the resultant dysfunctions have persisted and are simulating visceral symptoms. 5. A disturbance in the motion segment is triggering visceral disease or (more likely) is activating already latent visceral symptoms (hypothetical). The first two points highlight the necessity for pre cise differential diagnosis and the problems associ ated with this. The spinal column with its motion segments can in fact produce symptoms that may mimic symptoms arising in the viscera and that are frequently interpreted as such by both patients and practitioners. This explains why patients who have been successfully treated by lay manipulators believe they have been ‘cured’ of their visceral disease. No less important is the fact that these differen tial diagnoses are not always sufficiently recognized’. consequently, when no pathological changes are found in the visceral organs, the term ‘functional’ is used to describe these disturbances. And given the prevailing ignorance concerning dysfunctions, the word ‘functional’ tends to be used as a euphemism for ‘of psychogenic origin’ or even for ‘malingering’. 348
As already stated in Section 1.1, any practitioner who finds no pathological changes to corroborate a diagnosis should first look for a disturbance in the corresponding segment of the locomotor system before labeling a disorder as psychogenic. The pejo rative use of the word ‘functional’ in general and especially in connection with the locomotor system reflects a lack of awareness that tends to underesti mate the significance of locomotor system dysfunc tions. It is this underestimation, combined with ignorance, that gives unqualified lay manipulators the opportunity to claim ‘miracle’ cures. The other side of the coin (point 2) is the warn ing that pain perceived in the locomotor system may be a deceptive sign masking serious underlying visceral disease. This suspicion is strengthened if the symptoms of spinal segmental disturbance tend to relapse repeatedly without obvious cause. While the error in point 1 is more common, that in point 2 is all the more fraught with danger. Point 3 is of major theoretical significance and demonstrates that visceral disease is actually one of the possible causes of dysfunction in the motion segment (see Section 1.1). Clinical experience teaches that certain visceral diseases are associated with characteristic patterns in the locomotor sys tem. These patterns are of considerable diagnostic importance and are described below. They are so specific that their recurrence is in all probability predictive of a recurrence of the visceral disease. It is therefore literally ‘in our hands’ to make the diagnosis and influence the prognosis. Point 4 follows on from point 3. If the visceral disease has been cured and we manage to treat the reflex dysfunctions caused by it, we obtain most satisfactory results and can thus confirm the suc cess of visceral treatment. Here patients and prac titioners alike tend to draw the following incorrect conclusion: because of persistent symptoms due to secondary dysfunctions in the motion segment, the patient still feels affected by the visceral disease. If after treatment of the dysfunction the patient is symptom-free, all the credit for the success of ther apy is then given to the practitioner who treated the dysfunction, even though the underlying vis ceral condition had already been cured. However, if the dysfunction recurs in the same motion segment, this is generally an early sign of a recurrence of the visceral disease. Point 5 is the pipe-dream cherished by many (lay) practitioners in the past; even today, however, it remains conjectural. Nevertheless, it would seem
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
Chapter 7
justifiable to assume that lesions in a motion seg ment of the spinal column may impair function in the corresponding internal organs. This is borne out by the vasomotor response in the whole segment to which pain is referred. In such cases we can see the disorder clearing up as soon as we treat the motion segment. Reactions of this kind have been noted particularly in connection with the cervicocranial syndrome, especially at the craniocervical junc tion, including disturbances of equilibrium. Similar phenomena have been observed in connection with certain cardiac arrhythmias. According to Schwarz (1996), a motion segment dysfunction may activate latent disease in an internal organ. Multiple patho genic factors may also need to be considered in terms of their cumulative impact. As well as those that affect the locomotor system, other factors may be important in terms of their influence on the organism as a whole, for example infections, meta bolic disturbances, menstruation, diet, etc. None of these individual factors on its own would be suffi cient to provoke disease, but it is legitimate to refer to them as risk factors.
(Lewit & Abrahamovicˇ 1976). Thirty-seven of these patients were followed up again three years later. Eighteen patients remained without tonsillitis recur rence, but in 7 cases movement restriction did recur and had to be treated. Two patients had a few recur rences of tonsillitis without movement restriction, 3 suffered repeatedly from tonsillitis, and 9 under went tonsillectomy. In total, 13 patients remained without any recurrence of movement restriction. Interestingly, the tonsillitis patients had hardly any HAZs in the cervical region, but there was increased muscle tension (défense musculaire) laterally at the floor of the mouth below the tonsillar bed. It can be concluded from this study that chronic tonsillitis goes hand in hand with movement restric tions at the craniocervical junction, mainly in seg ment C0/C1, and that these have a tendency to become chronic. This means that there is a danger of permanently disturbed function in one of the key regions of the locomotor system. In addition, our experience suggests that movement restriction in this region is associated with an increased suscep tibility to recurrent tonsillitis.
7.9.2 Tonsillitis
7.9.3 The lungs and pleura
Systematic questioning when taking the case his tory in patients with vertebrogenic disturbances reveals a strikingly high incidence of tonsillitis. In a randomly selected sample of 100 cases from our files, 56 patients had a history of chronic relapsing tonsillitis and/or tonsillectomy. This finding was made particularly often in patients with movement restriction of the occiput against the atlas. It there fore seemed justifiable to investigate this problem further. In a study sample of 76 predominantly ado lescent patients with chronic tonsillitis, move ment restriction at the craniocervical junction was detected in 70 cases, in the great majority of them between the occiput and atlas. Following tonsillec tomy, movement restrictions were still present in the vast majority of these cases. However, where movement restrictions were previously not present or had been treated, they developed only in excep tional cases after tonsillectomy. They could there fore not be interpreted as a consequence of surgery. In 40 non-operated patients in long-term fol low-up who underwent just one manipulative pro cedure, 26 remained without tonsillitis recurrence and 15 without movement restriction recurrence
Recognition of the close interplay between respiration and the locomotor system has also improved our understanding of the relationship between the lungs and the function of the thorax. Pronounced clavicular breathing or paradoxical breathing may be the underlying cause of dyspnea in the absence of any disturbance of the organs of respiration. Of course, pain experienced in the context of pleurisy or pneumonia needs to be differentiated from pain due to rib movement restriction or a slipping rib. Palpation of rib mobility is useful here. In pleu ral disease the impairment of mobility involves the greater part of one side of the thorax whereas movement restrictions affect one or just a few motion segments. The respiratory disease in which involvement of the thorax has been studied most is obstructive respiratory disease (Bergsmann 1974, Köberle 1975, Sachse & Sacshe 1975, Steglich 1971). The follow ing factors play a key role here: rigidity of the chest wall further increases resistance during respiration, and the inspiratory position of the thorax in asthma patients is worsened by clavicular breathing, which is typical for that disease. Movement restrictions of the ribs are also associated with pulmonary rigidity, 349
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as detected by Köberle (1975) principally in seg ments T7–T10. In a group of 23 patients, Sachse & Sachse (1975) found a taut pectoralis major in 15 cases and a weakened lower trapezius in 15 cases. Increased tension in the scalenes is the most fre quent change associated with clavicular breathing. TrPs in the diaphragm are also common. Therapy comprises mobilization of movement restrictions in the thoracic spine and ribs, and remedial exercise for asthma patients who adopt a clavicular breathing pattern, so that respiratory resistance (which is increased in this disease) can be kept as low as possible. As a result of thoracic rigidity, extremely pro nounced clavicular breathing in combination with abdominal breathing, both with and without short ness of breath, is often encountered in ankylosing spondylitis. This is important because despite the presence of ankylosis, specific remedial exercises can achieve a correct thoracic breathing pattern thanks to the elasticity of the ribs.
7.9.4 The heart Of all the vertebrovisceral inter-relationships, that between the heart and the spinal column has received most attention. This is due not only to the importance of the problem, but also to the fact that in the largest group of patients, that is in those with angina, the role of pain is comparable to that in tho racic dysfunctions. Pain of cardiac origin is also felt in the thorax, while pain referred from the heart is localized mainly to the shoulder and left arm. Patients with angina show a characteristic pattern of disturbance that includes movement restrictions involving the thoracic spine, especially segments T3–T5 and most commonly T4/T5, the third to fifth ribs on the left side, the cervicothoracic junc tion, and often the craniocervical junction. Most commonly, TrPs are located paravertebrally at the level of T4, in the pectoralis major, subscapularis, serratus anterior, and upper part of the trapezius on the left side. TrPs in the scalenes go hand in hand with painful sternocostal joints in the vicinity of T3–T5 on the left side where the attachment points of the pectoralis minor are also located. Clavicular breathing is also often encountered in this setting, with the patient experiencing sensations of tightness not dissimilar to those felt in angina. It is obviously imperative to distinguish as clearly as possible between angina with its characteristic 350
pattern of disturbances and the pseudocardiac syndrome emanating primarily from the locomotor system. Rychlíková (1975) has shown that the more complete the described pattern of (reflex) changes in the locomotor system, the more likely it is to be secondary to primary heart disease. A number of important clinical criteria can aid the distinction between true angina and pseudoangina. Pain in true angina is dependent on physical effort, such as climbing stairs, and responds within sec onds to administration of nitroglycerine. Retros ternal pain also tends to be indicative of a cardiac origin. On the other hand, pain provoked by certain positions of the body or by specific movement(s) is more characteristic of pseudoangina. Attacks are shorter in true angina than in the pseudoangina syndrome. The course of the disease is also differ ent: if locomotor system dysfunctions recur or are aggravated despite specific treatment, this should be taken to indicate that the true cause is primary heart disease. The role of the locomotor system in pain of cardiac origin is borne out by the fact that Rychlíková (1975) did not find any signs of loco motor system dysfunction in a group of patients who suffered a myocardial infarction without pain. Regardless of whether the locomotor system dysfunction pattern is primary or secondary, its treatment is always justified, as is rehabilitation for locomotor system dysfunction. If increased resist ance is detected when shifting fascia around the thorax, the gentlest approach is to begin by releas ing the fascia before using neuromuscular treatment techniques that address movement restrictions and TrPs simultaneously. This is followed by rehabilita tion with training to correct breathing and posture. In view of the difficulties of diagnosis, cardiological monitoring is always indispensable. In cases where cardiological treatment is successful and locomotor system dysfunctions recur during the course of rehabilitation, it should be emphasized that these are often the first sign of a recurrence of heart dis ease, even before any evidence appears on the elec trocardiograph (ECG). While the role of angina in the development of locomotor system dysfunctions appears to be estab lished, the same cannot be claimed for the role of the locomotor system in the pathogenesis of heart disease. There is one cardiological condition, how ever, where reflex locomotor system involvement seems well founded: paroxysmal tachycardia with no organic heart lesion. There are some cases where
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
tachycardia occurs regularly if a certain movement restriction is present but where cardiac rhythm reverts to normal when the restriction is released (Vecan & Lewit 1980). Although hard evidence for a role of the locomotor system in the causation of organic heart disease is lacking, it would seem rea sonable to concede that it could be a possible risk factor. The prime significance of the treatment of loco motor system dysfunction in heart disease lies in the relief of pain, which greatly enhances the reha bilitation of these patients, as illustrated by the fol lowing case study.
Case study K H; female; born 1937.
Medical history The patient reported pain between the shoulder blades and radiating into her neck and thorax, mainly on the left side. The pain had an acute onset on the morning of 5 February 1980. The patient reported retrosternal ‘burning,’ and an ECG was taken, revealing normal findings. The patient first became aware of pain in her neck and thorax in 1976. In her youth she had repeatedly suffered from angina. She had also received psychiatric treatment for depression. The patient played basketball as an adolescent.
Clinical findings and therapy Examination on 9 December 1980 revealed a bilateral movement restriction at C0/C1, and limited retroflexion at T4/T5 and T6/T7. TrPs were present in the pectoralis major and there was a pain point at the sternocostal joint at T4 on the left side. The patient also presented with pronounced clavicular breathing but without any increase in scalene muscle tension. The movement restrictions at C0/C1, T4/T5, and T4/T7 were treated, as well as the painful attachment point of the pectoralis major at the fourth sternocostal joint. The patient experienced relief immediately after treatment and a start was made on correcting her faulty breathing pattern. On 6 January 1981 the patient developed acute cervical myalgia with a typical movement restriction to the right at C2/C3 and C5/C6. Isometric traction and mobilization of C5/C6 was followed by traction manipulation of C5/C6 with the patient seated, and a residual TrP in the upper part of the trapezius was treated by PIR. On 13 January 1981 the patient was symptom-free. This was evidently a case of a vertebrocardiac syndrome.
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7.9.5 The stomach and duodenum As in heart disease, painful conditions in these organs may well produce reflex changes in the loco motor system. We had the opportunity to study the characteristic pattern in a group of young ulcer patients aged between 15 and 22 years (Rychlíková & Lewit 1976). The characteristic pattern of dis turbance was noted primarily in segment T5/T6. Compared with a control group of similar age, there was an increased incidence of movement restric tions at the craniocervical junction. However, the most striking finding was pelvic distortion (87% as compared with 44.4% in the controls). There was also increased muscle tension in the thoracic erec tor spinae in segments T5–T9 on both sides, with a maximum at T6, and a HAZ in the same region on both sides – also significantly more common than in the control group. It is interesting that these changes were almost symmetrical, with a very slight preponderance on the right side. However, there was no difference between the cases of gastric and of duodenal ulcer. In this group, the intensity of reflex changes correlated with the intensity of pain; where there was no pain, as in some cases after surgery, there were also no locomotor system dysfunctions. It must be added that this was the pattern found in young patients; in older patients suffering from ulcers the incidence of pelvic distortion is very much lower.
Case study V S; male; born 1922; X-ray technician.
Medical history Since 1960 the patient had suffered from low-back pain that radiated into his thighs. He had been treated for a gastric ulcer since 1948.
Clinical findings and disease course At examination on 28 February 1969 the patient was found to have movement restrictions at C1/ C2 on both sides, and of T5/T6 and L5/S1 into extension. One year later, on 27 February 1970, he reported pain in his thorax and right hypogastric region. Examination again revealed a slight movement restriction at C1/C2, and palpation elicited pain in the right upper abdomen and at the psoas major, but nothing conclusive was discovered in the 351
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thoracic spine. This set of findings was insufficient to explain the patient’s symptoms and prompted a full clinical examination, with ulcer pathology being confirmed on X-ray.
7.9.6 The liver and gall bladder Because pain is a prominent feature in disorders of the liver and gall bladder, reflex changes must be anticipated here too. According to Rychlíková (1974), the motion segments most frequently affected by dysfunction are T6–T8. There is also fre quently pain that is referred to the right shoulder, as borne out by a HAZ in the C4 dermatome and TrPs in the upper part of the trapezius on the right. Noninflammatory gall bladder dysfunction can sometimes be halted successfully using reflex techniques.
Case study Professor L O; male; born 1906; theater manager.
Medical history The patient was referred to us for treatment because of chronic low-back pain radiating into both legs. Despite many treatments, his symptoms had been constant since 1956. He also complained of pain between the shoulder blades that troubled him particularly when he moved his head.
pain radiates into the groin. A thorough analysis of reflex changes in the locomotor system in kid ney disease has been made by Metz (1986). In 208 cases of chronic kidney disease (glomerulonephritis, pyelonephritis) he found the following pattern: movement restriction at the thoracolumbar junction (T11–L1), and increased tension at the lowest ribs and in the psoas major, quadratus lumborum, and the thoracolumbar erector spinae. Metz emphasized that pain only became manifest in these patients with ‘genuine’ renal disease when the above loco motor system findings were apparent. Pelvic distortion and a markedly increased inci dence of faulty statics in the lumbar spine and pel vis were present (according to Metz) especially in nephroptosis (downward displacement of the kid ney), where the symptoms were also determined decisively by locomotor system dysfunctions. Symp toms and locomotor system disturbance patterns were identical in a group of 40 patients with neph roptosis and another 40 patients after nephropexy: they primarily involved the thoracolumbar junction with unilateral hardening of the psoas major. The patients were mainly asthenic, hypermobile women with faulty statics, recurrent movement restrictions at L5/S1, and ligament pain. (Nowadays we would seek to identify insufficiency of the deep stabiliza tion system.) In these cases, however, locomotor system dysfunction proved to be the decisive cause of the renal symptoms.
Clinical findings and therapy When he was examined on 18 January 1961 the patient omitted to mention his gall bladder condition. Pelvic distortion was detected, together with faulty movement patterns that necessitated remedial exercise therapy. On 11 July 1961 the patient complained of gall bladder pain. His low-back pain worsened. On 26 October 1961 he suffered an episode of biliary colic that made remedial exercise impossible. Extensive HAZs were found in the thoracic region and there was a painful spinous process at T9, which was treated by rotation manipulation. The pain disappeared almost at once. The patient returned regularly for follow-up until 1965 and there were no further recurrences of biliary colic.
7.9.7 The kidneys Reflex changes are most clearly apparent in patients with renal colic. They always occur on the painful side in segments T10–T12 in the lower back and 352
7.9.8 Importance of the psoas major and rectus abdominis Because the psoas major is located deep in the abdominal cavity, it may provoke symptoms similar to those associated with other internal abdominal structures. This is extremely important for differ ential diagnosis. As we have noted, there is a reflex increase in tension in the psoas major secondary to kidney disease. Most frequently this is associated with TrPs in the psoas major and limitation of trunk rotation. Where there are faulty movement pat terns, this muscle has a tendency to shorten (due to increased tension) and can cause flexion at the hip simultaneously with (paradoxical) lumbar lordosis. The psoas major should be examined for shorten ing (see Figure 4.55). Palpation of the typical TrPs is performed from the side with the patient supine
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
and legs extended: the practitioner presses and snaps the muscle against the patient’s spine, which is in lordosis because the legs are extended. TrPs in the psoas major are linked in a chain with those in the quadratus lumborum and the thoracolumbar erector spinae, and are responsible for the functional limitation of trunk rotation to the opposite side. TrPs in the psoas major may also be the cause of pain in the ‘post-cholecystectomy syndrome.’ Like other painful structures in the abdominal cavity, TrPs in the psoas major may also give rise to ten sion and rigidity (défense musculaire) in the rectus abdominis. Because of the location and size of the psoas major, TrPs in this muscle can simulate symp toms associated with most of the abdominal viscera: duodenum, gall bladder, kidneys, pancreas, and ver miform appendix. Not only is the pain intense, but there may also be autonomic reactions such as loss of appetite and a feeling of indigestion, etc. Ther apy involving PIR and RI is simple and effective. Increased tension in the abdominal muscles, especially the rectus abdominis, is often a sign of painful visceral disease. However, it is also encoun tered in locomotor system dysfunction, particularly in patients with a forward-drawn posture on stand ing, where it is caused by a chain reaction pattern extending from the feet via the fibula and associ ated with TrPs in the biceps femoris. As a result the anatomical fixation of the pelvis is disturbed from below, leading to TrPs in the rectus abdominis with painful attachment points at the pubic symphysis, xiphoid process, and neighboring ribs, with for ward-drawn posture, restricted retroflexion while standing, and (referred) low-back pain (see Figure 6.121). Needless to say, TrPs in the abdominal mus cles are also capable of simulating visceral pain.
7.9.9 Gynecological disorders and low-back pain Gynecological disorders have always been tradi tionally associated with low-back pain. From our modern-day perspective the role of gynecologi cal disorders as a leading cause of low-back pain in women has been overestimated. It was the gynecol ogist Martius (1953) who placed critical emphasis on the importance of the locomotor system. Novotný & Dvorák (1984) conducted a study in 600 women attending a gynecology clinic at the University of Prague. They subdivided these patients as follows: the first group comprised 113
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women with dysmenorrhea and normal gyneco logical findings who had low-back pain with typical onset at the menarche. This condition rarely dete riorates and very often improves after childbirth. A second large group developed symptoms during pregnancy and after delivery, that is dysfunctions occurred at a period when there is increased strain on and vulnerability of the spine and pelvis. A third group consisted of 59 patients with gynecologi cal conditions giving rise to low-back pain. These were apparently viscerogenic disorders. The fourth and largest group of patients were women suffering from minor dysfunctions of the spine and pelvis, in whom gynecological examination was carried out as a routine diagnostic procedure, but with negative findings. In a group of 150 pregnant women, 48 had a his tory of dysmenorrhea (Lewit et al 1970). Of these 48 patients, 38 had lumbosacral movement restric tion or pelvic distortion. Findings in the lumbosacral spine and pelvis were ‘normal’ in only 10 women. ‘Normal findings’ meant that pain was generally felt only in the hypogastric region but not in the lumbar region. Moreover, low-back labor pains during an otherwise normal delivery were closely correlated with dysfunctions of the spinal column and pelvis. In another group of 70 women with menstrual pain and normal gynecological findings, treatment of the spine, mainly by manipulation, brought con siderable improvement in 43 cases, improvement in 13 cases, and no improvement in 14 cases. In summary, it appears that low-back pain may have its origin in the female pelvic organs and may become manifest during childbirth and menstrua tion as well as following gynecological disease or surgery. In a very large number of patients, lowback pain is of locomotor system origin and is mistakenly attributed to primary gynecological dis turbances. One reason for this may be a TrP in the iliacus which is palpated as a site of tender resist ance in the hypogastric region. Menstrual pain with otherwise normal gynecological findings, especially when localized in the low back, is usually of verte brogenic origin and is often the first clinical mani festation of locomotor system dysfunction Labor pains felt in the low back in an otherwise normal delivery should also be interpreted as being of vertebrogenic origin. Current knowledge also points to the importance of the pelvic floor. Screen ing for a TrP there should also be conducted as rou tine (see Figure 4.12) and, if found, its treatment is a major preventive factor. 353
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Research conducted by Mojžísová (1988) and Volejníková (1992) suggests that manual therapy may offer some prospect of success in women with sterility of cryptogenic origin (i.e. with negative organic findings).
In women with locomotor system dysfunction, history taking should include questions to elicit information about dysmenorrhea, especially in adolescence, and low-back labor pains during childbirth.
Case study B B; female; born 1933.
Medical history The patient had suffered from headaches since the age of 12, and subsequently from metrorrhagia and pain on menstruation. She was first referred to us by her gynecologist on 16 October 1958.
Clinical findings and therapy Examination revealed pelvic distortion with deviation to the left, and her left PSIS was painful as was retroflexion in the lumbosacral region. Segments C1/ C2 and L5/S1 were treated. On 15 January 1959 the patient reported that menstruation was much improved but her headaches were unchanged. Manipulation of L5/S1 and of the cervicothoracic junction was repeated. The patient subsequently reported that menstruation now lasted for one week instead of two weeks as in the past, and her headaches were more bearable. She remained under our treatment but her headaches never disappeared completely. Low-back pain was now present only from time to time. On 20 February 1962 menstruation had again increased to eight or nine days. Pelvic distortion to the left had returned and temperature measurement revealed a difference of 0.5° at the PSIS. Treatment of the lumbosacral junction was repeated. The patient was last seen by us on 9 July 1967 because her menstrual pain had worsened. On this occasion we detected pelvic distortion to the right.
Case summary The case of this patient repeatedly illustrates the dependence of menstrual symptoms on lumbosacral segment dysfunction. 354
7.10 Post-traumatic states The important role of trauma in the causation of vertebrogenic disorders was pointed out in Sec tion 2.4.7, and it was emphasized in Section 4.1 that a record of trauma in the patient’s history is a characteristic feature of vertebrogenic disorders. Right from childhood people are exposed to the risk of injury, and when spinal dysfunction is detected in children, trauma is often one of the key causes. These dysfunctions may remain latent and unnoticed due to compensatory adjustments (by other motion segments, for example), and these in turn may lead on to secondary changes. In this way, the ground is prepared that allows the effects of subsequent trauma to be even more devastating. Trauma impacting an already com promised spinal column readily produces further decompensation, and even apparently trivial trauma may set this in motion. The words ‘apparently trivial trauma’ deserve emphasis here because the forces acting on the spinal column are so great that even an uncoordinated movement may expose it to a sudden load amounting to several hundred kilo grams. Once the acute consequences of trauma have subsided, it is often noted that there is a latency period after which the post-traumatic syndrome develops gradually – a pattern that is typical in cranial trauma, for example. It is often forgotten that the spinal column also suffers following most injuries to the extremities, the trunk and, in par ticular, the head. In the initial phase, however, the local injury takes center stage, and because the spi nal effects are still in the latency period referred to above, they are commonly neglected.
7.10.1 Cranial trauma To illustrate this point, let us take concussion as an example. It stands to reason that any force act ing on the head must also affect the cervical spine. Similarly, from the size and weight of the human skull compared with the cervical spine, it will be obvious which of these two structures represents the site of lessened resistance, in relative terms. It is also therefore no coincidence that the majority of injuries to the cervical spine, including vertebral fractures, are concomitant effects of craniocere bral trauma. This fact is also borne out by autopsy
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
findings: without exception, in all 20 cases of death after head injury, Leichsenring (1964) also found serious damage to the cervical spine. We can only concur with Junghanns (1952) who wrote that symptoms usually attributed to concussion were in reality caused by trauma to the cervical spine. And this opinion is also shared by Gutmann and others. In fact, a striking simi larity exists between the post-concussion syn drome and the cervicocranial syndrome. In both conditions, patients experience headache that is frequently paroxysmal and is associated with diz ziness or vertigo. This was first described by Barré & Liéou (1926) as ‘posterior cervical sympathetic syndrome’ and later by Bärtschi-Rochaix (1949) as ‘cervical migraine’ occurring in the wake of cranial trauma. The close relationship between concussion (closed head injury) and whiplash injury is also evident from a study conducted by Torres & Sha piro (1961) in which they compared the clinical and electroencephalogram (EEG) findings after concussion or whiplash injury. The neurologi cal findings were virtually identical, with the dif ference that pain was more common in the neck and arms after whiplash injury. EEG abnormali ties were present in 44% of patients after con cussion and in 46% of patients after whiplash injury. In both cases temporal lobe foci were seen predominantly. With ever-increasing numbers of vehicles on the roads, the incidence of whiplash injury is rising all the time. Whiplash injury often causes dispropor tionately severe symptoms and poses a problem in terms of therapy. Such incidents usually involve an unexpected rear-end impact that causes the trunk of the individual(s) leaning back against the auto mobile seat to suddenly jerk forward at high speed; in this process the head and neck engage in a whip lash movement relative to the trunk. This can be particularly harmful if the head is also rotated rela tive to the trunk. Immediately after the accident it is common for the whiplash injury victim to feel that little of note has occurred, with any symp toms being minimal. It is not until hours or a few days later that the often considerable symptoms of a severe post-traumatic cervicocranial syndrome develop, and these commonly take a chronic course. In very recent whiplash injury, gentle examination often reveals hypermobility, whereas movement restrictions develop later due to muscle TrPs.
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Case study T M; female; born 1949.
Medical history The patient was first seen by us on 25 May 1959 complaining of headache. In November 1958 she had received a blow in the neck from a school bag and had experienced intense local pain to begin with. She then vomited before lunchtime. Ever since that first day she had had headaches every day and had to stay at home for three weeks. At the time of her initial presentation she was suffering from headaches several times a week, localized to her occiput, frontal region, and sometimes involving her entire head.
Clinical findings and therapy The clinical findings were unexceptional, although X-rays revealed dextrorotation of the axis. A repositioning effect was achieved by manipulation and at the follow-up examination on 22 October 1959 the patient stated that she had been symptomfree up until the middle of October when the pain had returned, prompting the repeat of manipulation (after five months).
Case summary In this young girl’s case the blow to her cervical spine simulated a post-concussion syndrome with headache and vomiting.
As this case illustrates, forceful rear-end impact is not the only mechanism capable of causing whip lash injury. For example, it may also be produced by a fall on to the shoulder and we even know of one case where the condition was brought about by the impact of a wave against the head while the patient was in the sea. Although the underlying mecha nism bears some similarity to distortion, the clinical course is far more severe. In computed tomogra phy scans obtained in such patients, Dvorák (1989) detected tears in the alar ligament with hypermo bility of the craniocervical junction, a finding that explains the often unfavorable response to HVLA thrust techniques. One complication of whiplash trauma has been described by Berger (personal communi cation) under the designation ‘stiff or frozen neck syndrome’. He has reported the following characteristic pattern based on an analysis of 20 cases: movement is restricted, slow and jerky on 355
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cervicomotography (which involves registration of head movements in three planes simultaneously: fast movement; slow movement, eyes and head following a pendulum; passive movement). Passive movement is less restricted than active, and slow movement has a greater range than fast movement. Rotation with the patient supine (fixation at T1) is less restricted than rotation in the sitting posi tion. There is marked hypertonus in muscles and soft tissues and there are extensive HAZs. Patients report intense pain radiating into the head and arms, often accompanied by dizziness and blurred vision. In this stage, patients cannot tolerate any type of physical therapy, whether mobilization, manipulation, or massage. They require immobili zation, a supportive cervical collar, and sometimes cryotherapy. By 1965 we had followed up more than 65 postconcussion patients who had lost consciousness after an accident. Abnormal neurological findings (signs of disturbed equilibrium) were present in one case. By contrast, clinical findings in the cervi cal spine were normal in only six cases. The results of manipulation and reflex therapy were excellent in 37 cases, good in 8 cases, and unsatisfactory in 10 cases. In a further group of 95 cranial trauma patients without concussion, seen during the period from 1964 to 1970, movement restrictions involv ing the cervical spine were absent in only 4 cases. Interestingly, the predominant finding was move ment restriction at C1/C2. A painful anteflexion test, indicative of ligament pain, was present in 10 patients who were treated without success. From the perspective of prevention, the acute stage following trauma is most important of all. In this respect, post-concussion patients offer a model for acute spinal trauma because they are routinely admitted to hospital and there fore are not lost to medical examination. With a view to preventing later complications, a series of 32 patients in the acute post-trauma stage was referred to us for examination and treatment. All the patients were fully conscious, with no suspi cion of intracranial hemorrhage, and with negative X-ray findings in the skull and cervical spine. A chronic disease course evolved in only one patient, who also developed arterial hypertension. Treat ment was further unsuccessful in one patient with dizziness and a calcaneal fracture. Twenty-four patients (75%) became symptom-free immediately after treatment. 356
Case study K E; female; born 1941.
Medical history The patient had slipped and fallen over on 5 April 1958. Although she did not lose consciousness after the fall, she vomited and complained of headache.
Clinical findings and therapy Neurological findings were normal. The transverse process of the atlas was tender to the touch and its movement was slightly restricted. The pain ceased instantaneously following manipulation on the left side. At follow-up examination on 12 August 1958 the patient reported that she had experienced no further symptoms at all since manipulation.
Case study K J; male; born 1910; bricklayer.
Medical history The patient fell from a height of 2 meters on 6 August 1958 and was unconscious for a short time. When first seen by us on 7 August 1958 he complained of pain in the temples.
Clinical findings and therapy His nasopalpebral and labial reflexes were exaggerated, and head rotation to the right was restricted. After treatment of C1/C2, head rotation was normal. At follow-up examination on 23 April 1959 the patient notified us that he had been entirely symptomfree since manipulation.
Case study V B; male; born 1910.
Medical history While riding his motorbike, the patient collided with an automobile and was unconscious briefly, later complaining of headache with dizziness.
Clinical findings and therapy At examination, Hautant’s test showed deviation to the right with first-degree nystagmus to the left. However, manipulation was not successful. On the next day, the patient was hospitalized for vertigo. As on the previous day, the findings were
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
unchanged, with marked limitation of cervical spine rotation to the left. The attempt to treat this with manipulation again proved unsuccessful. On 9 June 1958 the patient returned, with a diminished corneal reflex on the left, first-degree nystagmus to the right, and mild hypermetria of the left arm. X-ray showed asymmetry at C3. Manipulation of the C2/C3 segment abolished the nystagmus and hypermetria, and the patient reported immediate relief. The patient was symptom-free at follow-up examinations on 18 June 1958 and 12 July 1958, and all findings were normal.
Bartel (1980a, b) has published almost identical results: in 50 cases examined immediately after head injury he detected movement restriction in all patients but 2, the lesion being most frequently located at C1/C2. In 40 cases, a single treatment was sufficient, usually involving neuromuscu lar techniques. Treatment had to be repeated in 6 cases, in 2 of these without success. (As a historical footnote to the three case studies presented above, it should be pointed out that neuromuscular tech niques were still unknown in 1958.) These experiences suggest a preventive role for manipulative therapy in acute head injury while movement restrictions are still in the early stage. Lack of awareness and understanding concerning manual diagnosis and therapy means not only that this opportunity is frequently missed but also that the patient complaining of pain quite literally has insult added to injury, being told that there are no organic findings and hence the pain must be ‘all in the mind.’
7.10.2 Trauma to the extremities What is true for head injury is equally valid for other parts of the locomotor system: a patient who falls on a hand may also suffer from indirect injury to the cervical spine, while one who falls on a foot may also sustain injury to the pelvis and lumbar spine. A fall on to the shoulder may have the same effect as whiplash injury. A number of typical lesions are encountered in the extremities after injury. A fall on to the hand, whether the radius is fractured or not, gener ates a force on the radius that pushes it upward at the elbow, causing dysfunction at the elbow joint. Clinically, this is often manifest as pain at the
Chapter 7
styloid process; and this may not start until after the plaster cast has been removed following a Colles’ fracture. Examination then regularly reveals impaired radial abduction at the wrist with move ment restriction between the radius and ulna; how ever, the cause is located at the elbow where there are signs of a lateral epicondylopathy. Any treat ment administered at the site of the pain is futile, but pain is immediately relieved by treatment for movement restriction at the elbow. A fall on to the shoulder is likely to affect not only the cervical spine but also the structure that bore the direct brunt of the impact, namely the acromioclavicular joint and/or a first rib. After foot injury, with or without fracture, we usually find movement restrictions in the tarsometa tarsal and intertarsal joints, as well as in the ankle joint. After knee injury there is often movement restriction at the fibular head. Functional coxalgia is not uncommonly the sequel to a sprain of or fall on to the hip. Appro priate mobilization or manipulation is the proper procedure immediately after injury, and the effect is often seen promptly. However, this depends on diagnostic precision in excluding fracture and hematoma. Early treatment will avoid later compli cations and prevent the condition from becoming chronic. As described in Section 7.1.8, major lesions such as outflare and inflare dysfunction result mainly from trauma following a fall on to the buttocks (coccyx).
7.11 The clinical picture of dysfunctions in individual motion segments The most frequent symptom of locomotor system dysfunction (especially involving the spinal column) is pain and the structure which most frequently expresses pain is the muscle with its TrPs and painful attachments. It is the great achievement of Travell & Simons (1999) to have systematically described the muscles that harbor TrPs. Closely related to muscle TrPs are the articulations of the spinal column and their dysfunctions – movement restrictions in particular – and it seems most impor tant now to give a concise overview of the clinical symptoms of dysfunctions in the individual motion 357
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segments. However, it should be emphasized that muscle TrPs also determine the clinical picture as soon as dysfunctions occur in the spinal articula tion (motion segment). Examination techniques for these dysfunctions are described in detail in Chapter 4.
7.11.1 The temporomandibular joint (TMJ) The main symptom is headache on the side of the affected joint, with pain radiating strongly into the ear and face. When taking the patient’s history, questions should always be asked about missing teeth, badly fitting false teeth, or trauma. However, pain may also be caused by increased tension in the masticatory muscles, and psychological tension (teeth grinding, bruxism) may also be a factor. The masticatory muscles are in a chain with the muscles at the craniocervical junction and consequently the clinical picture may be difficult to distinguish from dysfunction at the craniocervical junction. Dizziness or vertigo or possibly tinnitus may also be present. Dysphagia and dysphonia may be noted where there is increased tension at the floor of the mouth, also involving the digastricus.
7.11.2 Atlanto-occipital segment Patients commonly complain of headache felt at the occiput, mainly on one side. History taking often reveals evidence of recurrent tonsillitis or oti tis media. Pain typically occurs in the morning and may waken the patient during the night. TrPs are located primarily in the short exten sors of the craniocervical junction and in the upper part of the sternocleidomastoid. Other pain points are found at the posterior arch of the atlas, at the transverse processes of the atlas, at the nuchal line, and at the posterior margin of the foramen mag num. Mobility testing reveals restriction of ante flexion and retroflexion most commonly, followed by restriction of side-bending to the left, and then of side-bending to the right. Joint play is reflected in dorsal shifting of the occipital condyles relative to the atlas. As with all motion segments in the cervical spine, there is frequently an important TrP in the diaphragm. The mobility of the scalp is restricted relative to the underlying tissues. 358
7.11.3 Atlantoaxial segment Dysfunction in this segment is most commonly the result of trauma, but otherwise it is encountered less frequently. Although headache predominates, neck pain is usually also present. There is a typical pain point at the lateral surface of the spinous process of the axis, more commonly on the right side. There are characteristic TrPs in the sternocleidomastoid and levator scapulae. Head rota tion is restricted, usually to the right, whereas sidebending (‘nodding’) is more often restricted to the left. This is the only cervical segment in which rota tion restriction is not necessarily in the same direc tion as restriction of side-bending. In this segment, rotation takes place precisely around a vertical axis.
7.11.4 Segment C2/C3 This is the segment where acute wry neck occurs. However, this does not mean that it is the only segment in acute wry neck where movement is restricted. The most prominent TrPs are found in the sterno cleidomastoid, levator scapulae, and the upper part of the trapezius. Pain may therefore be felt not only in the head but also in the shoulder. A pain point is routinely found at the lateral edge of the spinous process of the axis (usually on the right side), and rotation and side-bending are usually restricted to the right.
7.11.5 Segments C3/C4–C5/C6 Although headache may be present, pain referred to the arms is the characteristic finding here, in partic ular epicondylar pain at the elbow, more frequently on the lateral aspect. This may occur in combina tion with pain at the styloid process and with teno vaginitis that is common on the forearm. Most TrPs are found in the deep layers of the paravertebral muscles, in the upper part of the tra pezius, in the middle part of the sternocleidomas toid, and in the muscles with increased tension in epicondylar pain – the supinator, the finger and hand extensors, and the biceps and triceps brachii. Movement restriction at C3/C4 is sometimes also accompanied by symptoms of restriction at the
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
craniocervical junction. There may be ‘binding’ of the cervical fascia.
7.11.6 The cervicothoracic junction (C6/C7–T2/T3) Even here headache is no exception, but cervico brachial and shoulder pain in particular is typical, in association with paresthesia. All the joints of the shoulder may thus be involved, as well as the first ribs. Muscle tension is increased (with TrPs) primarily in the upper and middle parts of the trapezius, and in the sternocleidomastoid, scalenes, diaphragm, subscapularis, and infraspinatus as well as in the corresponding fascia. Together with the movement restrictions at the cervicothoracic junction, the sca lenes and the pectoralis minor are responsible for the thoracic outlet syndrome, which is frequently in a chain with the carpal tunnel syndrome.
7.11.7 Thoracic segments T3/T4–T9/T10 Because pseudovisceral pain is particularly com mon in these segments, differential diagnosis is of prime importance. Symptoms on the left side may simulate pain from the heart, lung, stomach, and pancreas; on the right side they may simulate pain from the gall bladder, liver, duodenum, and lung. If thoracic pain is not of visceral origin, it is usually secondary to dysfunction either of the cervical or of the lumbar spine (assuming that the patient is not suffering from a severe form of juvenile osteochon drosis). The exception to this rule is pain in the region where thoracic kyphosis peaks and the erec tor spinae is weakest, approximately at the level of T5. In rib dysfunctions there may also be pain at the sternocostal joints, which provide the main attachment points for the pectoralis major and minor. If the rib lesion is acute, breathing in and out is painful. Painfulness in the vicinity of the inferior costal arches is a characteristic sign of a slipping rib. The most important TrPs are in the pectoralis major and minor subscapularis, serratus anterior, erector spinae, the diaphragm and pelvic floor, and only rarely in the latissimus dorsi. The mobility of the deep fascia is disturbed on the back (in a cranial direction) and especially around the thorax.
Chapter 7
7.11.8 Restricted trunk rotation (segments T10/T11–L1/L2) Pain is characteristically felt in the low back or between the shoulder blades. If the condition is acute, the patient will often volunteer the informa tion that it has been provoked by straightening up suddenly from anteflexion with rotation. Because limited trunk rotation is not due to restricted joint movement but to TrPs in the thoracolumbar erector spinae, psoas major, and quadratus lum borum, the pain is felt principally at the attach ment points for these muscles – at the iliac crest (low back) and at the lower ribs (below the shoul der blades), but hardly ever at the thoracolumbar junction. Kyphotic posture is the consequence of psoas spasm, which may also provoke pseudovis ceral symptoms. If TrPs are simultaneously present in the abdominal muscles, then the pubic symphy sis and xiphoid process may be tender. There is a viscerovertebral inter-relationship between these motion segments and the kidneys. Trunk rota tion here is generally restricted in the direction opposite to the side where the muscle TrPs are located.
7.11.9 Segment L2/L3 It is rare for this segment to suffer from dysfunc tion; when it does, it causes low-back pain. TrPs are found in the gluteus medius, below the iliac crest.
7.11.10 Segment L3/L4 Like the other more caudal lumbar segments, dysfunction here is characterized by pain that is referred to the lower extremities. It is largely iden tical to pain originating in the hip joint, and is felt in the hip and the groin, radiating ventrally down the thigh to the knee and sometimes beyond as far as the tibia. Muscle spasm with TrPs in the rectus femoris is characteristic, and therefore the femoral nerve stretch test is positive; the straight-leg raising test is usually negative. Further TrPs are found in the hip adductors, and for this reason Patrick’s sign is mildly positive. 359
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7.11.11 Segment L4/L5
7.11.14 The coccyx
Pain in this segment is felt in dermatome L5 that travels down the lateral aspect of the leg, from the thigh to the lateral malleolus. The characteristic TrP is in the piriformis, and therefore pain is felt mainly in the hip. There is usually also increased tension in the hamstring mus cle group, especially the biceps femoris, and the straight-leg raising test is therefore positive. There may be pain and movement restriction at the fibu lar head. Increased tension in the rectus femoris and hence also in the ischiocrural ligament and piri formis muscle often results in secondary movement restriction at the sacroiliac joint.
Only about one-fifth of patients in whom the coc cyx is tender at palpation feel their pain as coccygo dynia. Instead they tend to complain of low-back pain. Conversely, if patients report pain arising from the coccyx, it may in fact originate from the lower part of the sacroiliac joint, the pelvic floor, or even from a painful ischial tuberosity. This is especially the case when the coccyx is tender not in the mid line but to one side. Pain is felt mostly when the patient is seated. The part played by trauma tends to be overestimated: psychological tension is a key factor. TrPs are present in the levator ani, gluteus max imus, hip adductors, ischiocrural muscle group, and sometimes also in the piriformis and iliacus, which explains why Patrick’s sign and the straight-leg rais ing test may be positive.
7.11.12 Segment L5/S1 The pattern of pain here is consistent with derma tome S1, and radiates down the back of the leg as far as the heel and lateral malleolus. There is increased tension in the hamstring mus cle group and the straight-leg raising test is posi tive. As in dermatome L5, there is therefore often movement restriction of the fibula, with second ary sacroiliac restriction. A TrP in the iliacus is very characteristic, with pseudovisceral symptoms in the lower abdomen. In hypermobile patients there is often a pain point at the spinous process of L5.
7.11.13 The sacroiliac joint Because the pattern of pain distribution here too is consistent with dermatome S1, it is virtually indis tinguishable from that experienced in lumbosacral movement restriction. Owing to the wide variations in anatomical topography in this region, the pain point (indicated by many patients as lying above and medial to the PSIS) cannot be differentiated from the neighboring lumbosacral joint. The TrP in the iliacus muscle is characteristic of the lumbosacral joint and differential diagnosis is possible only on the basis of mobility testing. In cases where the lower part of the sacroiliac joint is painful, the pain may be felt to one side in the sacrococcygeal region. Current knowledge with regard to chain reaction patterns of dysfunctions indicates that most sacroiliac restrictions are second ary in nature, apart from those in osteoarthritis of the hip. 360
7.11.15 The diaphragm and pelvic floor The most easily palpated TrPs of the deep stabiliza tion system are found in the diaphragm and pelvic floor. From these starting points, innumerable chain reaction patterns extend upward to the craniocer vical junction and masticatory muscles, and down ward to the pelvis and lower extremities. Screening for these TrPs should therefore be performed as routine in all patients. TrP relaxation is exception ally straightforward and effective, particularly in the diaphragm, but activation is generally the pre ferred option in stabilization system dysfunction.
7.11.16 The hip joint When merely dysfunctional or in the early stages of osteoarthritis of the hip, the hip joint most fre quently causes (asymmetrical) low-back pain radiat ing into segment L4. Knee pain is therefore often an early indicator of osteoarthritis of the hip. By con trast with the situation in vertebrogenic low-back pain, it is walking for longer periods that is painful, especially over a hard terrain; and by contrast with knee dysfunction, stair climbing is also painful. The key TrPs are located in the hip adductors, flexors, and abductors. A positive Patrick’s sign and the characteristic capsular pattern are typical.
Clinical aspects of locomotor system dysfunction (vertebrogenic disorders)
7.11.17 The foot and fibular head The foot is a key region of fundamental importance. However, the main chain reaction patterns extend via the fibular head and may even start from there if findings at the feet are negative. In the foot itself there are often movement restrictions between the individual bones, as well as TrPs in the deep plantar muscles with attach ment point pain at a calcaneal spur. TrPs are also located dorsally between the metatarsal bones. TrPs in the soleus muscle are associated with pain in the Achilles tendon and its attachment
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point. The most important faulty movement pat terns relate to functional flat foot and automatic flexion of the toes during the toe-off phase of the gait cycle and when the body’s center of gravity is shifted forward. Afferent pathway disorders are especially important here, characterized by increased or diminished tactile perception, along with simultaneous alterations in muscle tonus that are often asymmetrical. The typical chain reaction pattern is a forward-drawn posture that extends from the fibular head to the biceps femoris and onward via the abdominal, gluteal, and back mus cles to the craniocervical junction. The foot pos sesses all the key characteristics of the deep stabilization system.
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8
Chapte
Prevention of locomotor system dysfunctions
8.1 Importance and incidence of locomotor system dysfunctions . . . . . . . . . . . 363 8.2 Principles and goals of prevention . . . . 364 8.3 Lifestyle factors . . . . . . . . . . . . . . 365
8.3.1 Passive prevention . . . . . . . . 365 8.3.2 Active prevention . . . . . . . . . 367 8.4 Manipulation as a prophylactic measure . . . . . . . . . . . . . . . . . . 369
8.1 Importance and incidence of locomotor system dysfunctions The previous chapter in particular has highlighted the role of dysfunctions of the spinal column in the pathogenesis of pain involving the locomotor system. That discussion will enable us now to formulate a strategy for their prevention as we remind ourselves that it is possible to apply preventive principles not only to therapy itself, but also to rehabilitation, the main goal of which is to ward off relapses and complications. Before going into detail, we first need to consider the importance of locomotor system dysfunctions and the sheer scale of the problems they pose. The patients we see comprise the vast majority of all those who suffer from back pain and from pain associated in any way with the spinal column. The statistical data are unreliable because our patients are recorded under a range of different diagnostic labels, for example headache, chest pain, vertigo,
rheumatism, etc. Many patients who suffer constantly from these painful conditions do not even seek medical help, having learned from experience that conventional treatment is ineffective: and so they escape the record. Even so, the statistics are impressive. The category heading of ‘soft-tissue rheumatism’ clearly includes many patients suffering from locomotor system dysfunctions. As a cause of absenteeism from work, it is a sobering fact that locomotor system disorders rank second only behind common infections of the upper respiratory tract. However, if we consider only those locomotor system disorders that are of vertebrogenic origin, we find that they account for 15 million lost working days. Table 8.1 gives official data from the Czech Republic. These give a good overview and are significant economically; they cover only patients who missed work because of their symptoms. Impressive though this statistic may be, unfitness for work is only part of the problem. It is mainly low-back pain and/or pain in the lower extremities that renders people unfit for work, and ‘unfitness’ also depends on the nature of the work involved. It is therefore critical to cite data that relate more directly to the incidence of locomotor system dysfunctions. According to Säker (1957), in a survey population aged between 60 and 80 years, 440 out of 1 000 people questioned stated that they had experienced at least one episode of low-back pain or sciatica in their lives. In his 1951 study conducted in Stockholm among 1 200 workers from a variety of occupations, Hult (1954) found current symptoms or a history of cervical disk or lumbar disk lesions in 51% and 60% respectively. In a randomly selected
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Table 8.1 Numbers unfit for work per 100 000 inhabitants in the Czech Republic and average number of working days lost
Disease category
Year
Average number of working days lost
1968
1979
1989
2004
1989
2004
7898
9451
11 798
11 627
21.9
53.0
Vertebrogenic disease
3763
4895
7338
19.9
*
Circulatory disease
3114
3335
2254
35.7
69.4
Psychiatric disease
1430
1229
1075
32.0
68.9
Neurological disease
1037
940
732
29.0
64.0
Respiratory infection
36 538
40 203
37 896
9.4
17.6
Locomotor system disease
*Since 1989 ‘vertebrogenic disease’ has no longer been categorized separately in the statistics issued by the Ministry of Health of the Czech Republic.
rural district near Prague, Uttl (1966) found that 61 subjects from a representative sample of 100 had a history of vertebrogenic symptoms. When older and more recent data are compared, it is evident that the incidence of such dysfunctions is increasing year on year and that the number of lost working days has in fact doubled over the course of 20 years. Locomotor system dysfunctions primarily affect middle-aged individuals, that is those in the most productive years of their working lives. Treatment is frequently time-consuming and costly, and there is a marked tendency for these conditions to become chronic. The cardinal symptom is pain, and this is associated with a burden of suffering that is impossible to quantify. According to Frymoyer (1991, Frymoyer et al 1980), back pain affects 80% of the general population at some point in their lifetime.
8.2 Principles and goals of prevention As locomotor system dysfunctions play a key role in the pathogenesis of back pain, it is important to know the circumstances that most frequently produce them. Major factors here also include muscle imbalance, instability, and faulty patterns of muscle movement, among which incorrect breathing is probably the most common. No less important is the influence of the modern industrialized world in which we live: not only have 364
our dietary habits altered, but we are also exposed to air and water pollution and to risks from chemicals and radiation. And the change in our locomotor habits has been no less radical: although we have become increasingly sedentary, excessive static strain is on the increase. It is precisely this that produces the imbalances described by Janda: our predominantly postural, phylogenetically ‘older’ muscles become hyperactive and contract, whereas our predominantly phasic, phylogenetically ‘younger’ muscles grow flaccid. The same process is also at work in the deep stabilizers. This is one reason for the epidemic increase in disorders involving the locomotor system and spinal column. Instead of walking, or even riding, we sit or stand in automobiles and other vehicles in which we are jolted about. Most work nowadays is carried out in a more or less fixed position, frequently sitting or bending forward. Long hours of working at the computer are especially harmful. And the worst thing about this unfavorable trend is that it begins in early childhood: in front of the TV screen, sitting in school, or playing computer games. Children travel to school by automobile, bus, or tramcar, even though the distance may be short. Healthy children may resist this trend for a while, boisterously involving themselves in fun and games, but once they start to grow older they are seduced by the appeal of watching TV, riding motorbikes or sitting in a café or bar. These facts deserve to be emphasized because the public gaze is so narrowly focused on environmental pollution that the harm
Prevention of locomotor system dysfunctions
done as a result of changes to our patterns of locomotor behavior is easily overlooked. From this there emerge two logical approaches to prevention: one is to minimize excessive static strain as far as possible, and the other is to seek to compensate for it by exercise.
Our highly-developed technological society is suffering from the twin evils of sedentary lifestyle and excessive static strain.
8.3 Lifestyle factors 8.3.1 Passive prevention Sitting As most of our time is spent seated, a correct sitting position is of great importance. This, however, depends on the chair used: the height of the chair is correct if the subject’s thighs are horizontal, with feet resting flat on the floor. The back of the chair should provide support where the kyphosis peaks in a position of complete relaxation (see Figure 6.159). When the patient is sitting relaxed, the peak of kyphosis is more often in the lumbar than in the thoracic region of the back. Under these circumstances it may even be helpful if the sitting surface is tilted backward slightly. If leaning back is not possible, then the patient’s elbows and forearms should be able to rest on the desk or work surface. If the patient is not supported either by the chair back or the desk/work table, it is better if the seat slopes up at the back, rather like a saddle, because this tilts the pelvis forward and prevents excessive lumbar kyphosis. Special chairs are now manufactured with the seat tilted forward and a knee rest, thus ensuring that the patient sits up straight. However, it is helpful to advise the patient to change sitting position as soon as back pain is felt, and chairs should be recommended that allow patients to vary their position. Specially-designed wedged cushions are also recommended. Long periods of sitting can be particularly harmful if they are compounded by jolting, for example when riding on lorries or tractors (the shock absorption and suspension on such vehicles should therefore be as smooth and efficient as possible).
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It is important that the height of the desk or work table is on a level with the elbows when the patient is sitting upright with upper arms vertical. If the chair has forearm rests, these should be adjusted to the height of the freely hanging elbows. For work at the computer, it is also important that the monitor is positioned so that the patient’s gaze is not directed up or down or to one side. Like forward-bending of the trunk, head and neck anteflexion can also pose problems in the long term. Care must therefore be taken to ensure that this head position is avoided if at all possible. If the work surface is horizontal, the plane of the visual field forces the head into anteflexion. This can be overcome by using a desk with a tilted surface but not by raising the height of the desk. A potentially even more harmful situation arises when simple head and neck anteflexion is compounded by rotation of the head to one side. This is the position typically adopted by keyboard operators as they copy texts lying flat on the desk. The remedy is for the text to be positioned directly in front of the keyboard operator.
Standing If work is performed standing, the goal should be an erect posture, because a forward-bending position held for any length of time is always a strain. At this point it is helpful to note that bending forward slightly, for example over a wash basin while shaving, may constitute more of a strain than maximum forward-bending. This is because in the former position the erector spinae is maximally contracted, exerting greatest pressure on the spinal column (see Cyriax’s ‘painful arc’, Section 4.6.1). During forward-bending, it is therefore always recommended to advance one leg while bending the knee at the same time (see Figure 4.72). When standing at the wash basin, patients should turn to the side slightly and brace themselves with one thigh against the basin.
Lifting and carrying If lifting is the cause of symptoms (or relapses), the patient must be taught how to lift objects correctly. For light objects, the principle is the same as when bending forward: there must be harmonious synergism between the trunk and the advanced leg, and ‘uncurling’ of the trunk is accompanied by 365
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co-contraction of the abdominal muscles. Heavy objects should be lifted with a straight back while bending and straightening the knees and holding the load close to the trunk to eliminate any leverage effect. Here, too, it would be ideal if everyone obliged to work bending forward for long periods were encouraged to change this position occasionally, or given a short break in which to do so.
Sleeping position Just as important as the position held during the day is the way the body lies at night, in bed. It is no exaggeration to say that there are few lifestyle factors that affect the spinal column so powerfully – for good or ill – as the patient’s sleeping position in bed. This applies especially in cases where a patient reports that symptoms are felt mainly during the night or in the morning on waking up. Questioning about the type of bed slept on is usually followed by advice to use a hard mattress over a firm, unyielding frame. We believe that this is the wrong approach. The patient should first demonstrate the usual sleeping position and only then should we offer advice on how this might be corrected. For this we need to know, for example, whether the patient’s symptoms are mainly in the cervical or lumbosacral region. If symptoms are mainly in the low back we need to know whether the patient sleeps in the supine, side-lying, or prone position. If the answer is supine or prone, and symptoms occur during the night or on waking, the trouble is usually due to lordosis. We may then advise the patient either to adopt a sidelying position, or – if the patient lies supine – to put a thick pillow under the legs or a rolled towel or blanket under the waist. If the patient sleeps in the prone position, it is usually best to advise a different position. If that proves impossible, it can be helpful to raise the pelvis using a pillow. If sidelying produces symptoms, this may be due to scoli osis because the shoulders and pelvis are wider than the waist. In this case a rolled towel should be placed under the waist. More often though it is necessary to correct the patient’s sleeping position due to symptoms associated with the cervical spine. This is also borne out by the fact that acute wry neck and cervicogenic headache most frequently occur after a night in bed, and radicular pain has a tendency to be worse when lying down. All too frequently advice is given 366
to patients to lie flat. This counsel may be helpful for a young person who sleeps in the supine position. However, if the patient sleeps side-lying, it should be remembered that the shoulders are wider than the head. If such a patient sleeps with only a thin pillow (or no pillow at all), this means that the cervical spine slopes downward at an angle. The patient’s head should be supported so as to keep the cervical spine in a neutral position; this will depend not only on the width of the shoulders but also on the position that the patient adopts. Many patients demonstrate a side-lying position in which one arm is under their head. While they cannot sustain this position for long, they are nevertheless demonstrating their need for a sufficiently thick support. The pillow should be squarish, sufficiently big so that the patient’s head does not slip off it, and firm enough to give constant support. It must not be placed under the shoulders and therefore should not be wedge-shaped. If the patient has the unfortunate habit of lying prone, this should be discouraged, because it is a position that forces the cervical spine into maximum rotation. Again, a firm pillow giving the necessary support to allow comfortable side-lying will both encourage this and prove an obstacle if the patient tries to turn into a prone position. Specially-designed pillows with a hole for the face and nose can be purchased that enable the patient to lie prone with the head in a neutral position. However, this position may produce extreme cervical lordosis. The most suitable compromise for those who cannot drop this habit is to place a large pillow under the shoulder and chest on the side to which the head is turned, instructing them to clutch this to them, thus lessening neck rotation. The habit of lying prone usually dates from early childhood, when the position has much to recommend it; later in life, unfortunately, it can give rise to pathological changes. Even when lying supine, most older people with a rounded back need a fairly thick, firm head support to prevent their head falling into retroflexion. Head retroflexion is not only unfavorable for the cervical spine but may actually jeopardize the blood supply to the vertebrobasilar region, especially if there are already signs of arteriosclerosis.
Summary In each individual case it is most important to identify the circumstances that precipitate symptoms,
Prevention of locomotor system dysfunctions
so as to prevent further disturbances or relapses. In fact, there is probably no more effective way of helping these patients than by judicious advice concerning workplace organization, leisure activities, and sleeping position. Our best treatment efforts often go awry because we fail to discover that the patient adopts a faulty position when working at the computer, or sits incorrectly when driving, or stands without proper support. It is therefore a grave omission on our part if, after learning that symptoms occur in the morning, we do not ask for a demonstration of the patient’s usual sleeping position – or if we learn that symptoms are precipitated by lifting or carrying objects and fail to investigate the patient’s techniques for doing this. Indeed, one of the main purposes of taking the case history is to investigate these matters meticulously. We are of no help to the patient in the long term if we detect a lifestyle error on repeated visits and fail to offer advice as to how this might be corrected. It also follows that prevention of disease or relapse and advice on lifestyle-related issues apply equally to patients and to the healthy population.
8.3.2 Active prevention There are a number of activities – especially leisure pursuits – that can be used to compensate for the potentially harmful effects of the technological society in which we live.
Sports The amount of exercise taken can be easily increased by making minor changes to our habitual lifestyle: for example, people might walk to work or use the stairs instead of taking the elevator. Patients often ask which activities or sports they should take up for prophylactic reasons. The question seems straightforward, but we are instantly aware that there is no simple answer. Not only do the various forms of sport and physical exercise affect our bodies in very different ways, but they may even be downright harmful. It is therefore essential to analyze each type of sport carefully, bearing in mind the patient’s constitution and their medical history. Then there is the question of competitive sports: in view of the extreme and everincreasing demands made by competitive sports on
Chapter 8
their devotees, their usefulness for prevention of disease is highly questionable. Indeed, competitive athletes are among the groups who are most at risk and most likely to become our future patients. It cannot fall within the scope of this book to give a comprehensive picture of the effect of various types of sport on the locomotor system. It may be useful, however, to give a few examples of how to approach the question. Take swimming, for example, considered by most people to be a particularly ‘healthy’ sport: all the muscles are brought into play, the body weight does not act on the spinal column and there is very little risk of injury. On further analysis, however, we find that the breast stroke and even the crawl make the pectoralis muscles overactive and taut, so that most swimmers become slightly round-shouldered. Moreover, most exponents of the breast stroke and the ‘butterfly’ tend to develop lumbar hyperlordosis and hypermobility. Elderly swimmers have a habit of holding their head out of the water while swimming, keeping the cervical spine in hyperlordosis. All of which is not intended to imply that swimming is harmful. Patients who are round-shouldered or who have lumbar hyperlordosis should be advised to swim on their back if they suffer from low-back pain. And because swimming in cold water sends a signal to the body to form a good layer of insulation, this particular type of swimming is not recommended for people wishing to lose weight. Volleyball is one of the most popular and at the same time one of the most dangerous types of sport. As they leap up and land again on the ground, players at the net must keep their lumbar spine in hyperlordosis so that no part of their body touches the net. This is most unphysiological and constitutes a great danger to the low lumbar disks (‘nutcracker mechanism’). High-board diving poses dangers for the same reason, with spondylolisthesis being significantly more frequent among divers than in the population at large (Groh 1972). As usually taught, gymnastic exercises have a tendency to aggravate muscle imbalance, particularly when the legs and trunk are held straight and at right angles to each other. In order to achieve this, the gymnast is required to suppress the normal function of the abdominal muscles, which is to approximate the xiphoid process of the sternum to the pubic symphysis and thus bring the lumbar spine into kyphosis. Instead, the iliopsoas and the erector spinae enable the gymnast to hold the legs straight at right angles to the trunk, the net result of 367
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such training being to provoke what Janda defined as the ‘lower crossed syndrome’ (see Section 4.16). An important protective mechanism is lost, namely that of curling and uncurling the lumbar spine, to be replaced by unphysiological leverage in the particularly vulnerable lumbosacral region. In terms of prevention, therefore, preference should always be given to exercises that have become familiar to us from yoga or Tai Chi. In these traditional exercise systems, movements are smooth, never abrupt, while at the same time being rounded and gradual. Muscle contraction and relaxation are alternated and there is a focus on correct breathing; all these aspects tend to be absent from European-style gymnastics. Apparatus-based gymnastic exercises routinely make the upper fixators of the shoulder girdle overactive, leading to the ‘upper crossed syndrome’ (see Section 4.16). The emphasis on very rapid, forceful movement here makes safe control of the body difficult, and it is not easy to avoid (micro-)trauma. One leisure activity that can always be recommended is regular walking, preferably on soft paths and wearing suitable trainers that support and cushion the feet; this is the most physiological form of locomotor movement. Similarly, cross-country skiing has much to commend it because it also exercises the arms, as does Nordic walking. We should also not forget that dancing is among the oldest forms of exercise that people have enjoyed throughout history. Because it can be carried on for hours at a time, its beneficial effects are considerable while harmful effects are a rare exception. Dancing can also be highly recommended as a weapon in the war against obesity. However, with the high noise levels generated by modern amplification systems, a warning against auditory damage may not be out of place.
Clothing Although posture and movement, and their correction, naturally play the principal part in preventing disturbed locomotor function and its sequelae, the influence of other important factors such as food and clothing should not be underestimated. It has long been known that regions that are highly susceptible to pain, such as the neck and low back, should be protected from cold and draughts, especially in situations where the individual is perspiring. (In this regard, many aspects of modern-day 368
women’s fashion are particularly harmful.) At the same time it is also necessary to develop a certain degree of resistance or hardening. Thus although it is sensible to protect regions that we know are apt to be vulnerable to symptoms, we should aim to harden the body as a whole. Nor should it be forgotten that the susceptibility to cold of certain body regions is often due to a clinically latent lesion that is localized there, and that after successful treatment cautious hardening may be undertaken. Nevertheless, the main purpose of wearing clothes is to protect the body from the cold, but this should be judicious so as to maintain thermoregulation and the ability to cope with fluctuations in temperature. Besides clothing, this also applies to the question of when and to what extent we should expose our bodies to the air, water, and the sun. There is yet another side to the question, something that might be termed the mechanical effect of clothing; and the most telling example here is the sometimes devastating effect of brassieres that are too tight. Tight brassieres with thin straps cut deeply into the skin and muscles of the shoulders, resulting in permanent excessive strain in which the shoulder girdle and cervical spine are drawn forward. Overlooking this problem in our female patients may be the root cause of treatment failure. Use of shopping bags instead of rucksacks can also be harmful. For men, wearing belts that are too tight can be a problem, particularly in cases where there are hyperalgesic zones in the abdominal or dorsal regions. Braces are recommended for obese patients. Wearing pantyhose is not helpful for women with weak abdominal muscles; elasticated stocking suspenders are far better if an abdominal support belt around the waist is not necessary. Without doubt, shoes are the biggest problem area. High heels do not merely change the position of the feet but also tilt the pelvis forward, thus altering the body’s center of gravity, as well as accentuating lumbar lordosis, which in turn adversely affects the abdominal muscles and breathing. What is more, the toes are forced into dorsiflexion and the great toe is angled away from the midline of the body, which encourages the development of splay foot and hallux valgus. From the purely physiological standpoint, only walking barefoot can be termed ‘normal’; footwear should therefore be constructed from yielding material that allows the foot to adapt well to the walking surface. Hard soles and heels should therefore be avoided, and they are especially harmful where
Prevention of locomotor system dysfunctions
osteoarthritis is already present in the joints of the lower extremities.
Obesity It is only too obvious that the campaign against obesity common to many fields of medicine is very relevant for the correct functioning of the locomotor system. A vicious circle easily develops in which pain (due to overstrain and faulty statics) makes the patient reluctant to move and lack of movement encourages obesity. It is beyond the scope of this book to deal in detail with the problem of obesity. However, it is important to decide whether obesity is a relevant factor in any given case. We should remember that obesity seriously affects the joints of the lower extremities in particular, less so the lumbosacral spine, and at most has only indirect relevance for the cervical spine. We frequently encounter subjects who have very little fat on their trunk but whose buttocks and thighs are hugely obese; this may be completely irrelevant for the spinal column. The patient’s somatic type is also important: individuals with a stocky, compact (‘pyknic’) build tolerate obesity much better than those with a graceful (‘asthenic’) build. A stockily-built subject who weighed about 80 kg at 20 years, increasing to 90 or even 100 kg at 50 years, may handle the additional weight very well, whereas someone who weighed 50 or 60 kg at 20 years, increasing to 80 or 90 kg at 50 years, will be decompensated. When advising weight reduction we must have good reason to think that obesity is a potential cause of the symptoms.
8.4 Manipulation as a prophylactic measure Having discussed some of the basic principles of prevention, we will now turn to the question of preventive correction of specific disturbances. Treatment should not be directed only at the site where pain is manifest. Instead we should attempt to target treatment at those structures that appear to be key regions for the dysfunction in question, even though the patient may be experiencing no pain there whatsoever, because we are convinced that abnormal findings in these structures are a source of potential trouble. We do this because the
Chapter 8
pain for which the patient is seeking help would shortly recur if we were not to take such action. From this it is evident that the aspect of prevention must also be taken into account when we are establishing the indications for treatment. We should therefore ask ourselves whether, and under what circumstances, it is justifiable to treat clinically latent lesions in persons without (perceived) symptoms, purely for reasons of prevention. This needs to be considered particularly in cases of non-painful restriction in a motion segment or of latent trigger points (TrPs) that can be easily abolished. So what are the options for treating patients with non-painful dysfunctions, purely as a prophylactic measure? Given the astronomical incidence of latent dysfunctions, prophylactic manipulative treatment for the population as a whole is probably an illusory goal. However, it may be entirely reasonable in future to envisage such preventive measures for pre-school and school children. Our own experience suggests that a locomotor system check-up once a year would be sufficient, to be carried out exclusively by qualified physicians and/or physiotherapists. This would ensure prevention during the decisive growth phase. There are also a number of at-risk groups for whom preventive manipulation is indeed desirable. The first category comprises patients recovering from injury, and this group may be further extended to include those recovering from painful visceral diseases where spinal column involvement is to be anticipated. Surgical patients are another candidate group here because the position of the head for intubation is likely to result in dysfunctions involving the cervical spine. Similar considerations are appropriate following tonsillectomy. There may also be some value in advocating preventive manipulation for certain occupational groups that appear to be at particular risk, although, as we have noted, this might be seen as including most occupations in our modern technological society. However, there is one group in which manipulative treatment for preventive purposes is justified, namely competitive athletes, a fact which throws light on the effects of competitive sport. One other aspect should be mentioned while we are on the subject of prevention: it is imperative that choice of employment should take into account the individual’s physical constitution. And here we are most concerned with hypermobility; it is the hypermobile subject who is least able to tolerate static overstrain and jolting. 369
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It would of course be misleading to give the impression that manipulation is the only therapeutic measure with a potential role in prevention. It forms the subject of this book, and serves to illustrate the fact that a therapeutic method can also be useful for prevention. The classic method used in a preventive setting is, of course, remedial exercise, and this has been accorded due importance in Chapters 4 and 6. Remedial exercise, too, is effective only if it is applied specifically on the basis of a precise diagnosis. However, it must be emphasized that remedial exercise is far more demanding in terms of time and effort than are manipulation or TrP treatment. Herein perhaps lies the chief reason for its limited practicability in a preventive context. Remedial exercise has always been used for children with bad posture, but it has only ever been implemented consistently in a tiny proportion of those who need it. A more effective approach would be to introduce the principles of remedial exercise into normal physical education in schools: teaching correct techniques for respiration, bending down, picking up objects from the floor,
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carrying bags/satchels, and sitting. I have already made reference to the potentially harmful effects of traditional European-style exercise systems, but it would certainly also be possible to introduce many elements from yoga into school gymnastics lessons. However, the greatest obstacle to achieving this is the attitude of many, if not most, physical training instructors. Like sports trainers, they are primarily interested in those children who shine in sports and gymnastics – those who (perhaps to their own detriment) seem promising as future competitive athletes. Instead it is the ‘awkward’ children who really need more of the teacher’s attention. In sports and athletics clubs, the above attitude is even more accentuated: in the public interest, youngsters deemed not to have what it takes to make the grade at the very highest level are ruthlessly dropped from the program. Finally, there are two groups for whom the prescription of remedial exercise is obligatory: these are women after childbirth and, for the same reason, patients with weak abdominal muscles after abdominal surgery. Failure to prescribe remedial exercise in such cases constitutes gross negligence.
Chapter Nine
9
Expert assessment of locomotor system dysfunctions
Chapter contents 9.1 Assessment of (un)fitness for work . . . 371 9.2 Assessment of trauma and its consequences . . . . . . . . . . . . . . 373
9.2.1 Did an accident happen? . . . . . 373 9.2.2 Did the accident cause the symptoms? . . . . . . . . . . . . 374 The words ‘expert assessment’ here refer to any medical evaluation of a patient in terms of fitness for work and potential employment and in terms of any insurance-related issues in the particular case in question.
9.1 Assessment of (un)fitness for work The most numerous category of patients suffering from pain originating in the locomotor system comprises those with back pain. While their lives are not 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 threatened with invalidity. In addition, there is the question of harm traceable to the type of work they do, or to occupational injury, sometimes involving litigation with claims for compensation. All these aspects have to be assessed by an expert. If the assessment is to be scientifically based, it must take account of the pathogenesis, evolution, and prognosis of the condition. Our experience with reflex therapy and with manual therapy in particular has modified our views concerning
pathogenesis, leading us to conclude that function is the decisive factor here. Since it is precisely this aspect that must be reflected in any expert assessment, the considerable difficulties are obvious. One problem is that patients have often not received either adequate therapy or rehabilitation. This scenario will continue for as long as there are only relatively few physicians who understand how to diagnose and treat locomotor system dysfunctions adequately. In this highly regrettable situation significant lesions may pass unnoticed, and this is a particularly serious consequence in view of the principal symptom, that is pain. A physician who is unfamiliar with the diagnosis of painful trigger points (TrPs), tension, and resistance in the tissues has to rely on the patient’s own description of the symptoms. The physician then has the choice of either believing the patient or not. When called upon to provide an expert opinion, the physician tends to search for objective criteria, in the misguided belief that these are supplied by X-ray examination findings. However, any changes detected in that way are primarily morphological. Because this approach is consistent with conventional, received wisdom it is psychologically advantageous. The patient is informed, more often than not, of the changes found on X-ray and these are presented as the true cause of the pain, thus confirming the patient’s own ideas about the significance and potential duration of the underlying condition. It then becomes very difficult to motivate the patient concerning the benefits of an arduous rehabilitation program. On the other hand, young patients with serious pain that is often of a radicular nature are
Manipulative Therapy
considered to be malingerers because their X-rays show ‘no degenerative changes’. In recent years, despite significant advances made in the fields of computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound, not much has altered; indeed, if anything, the situation has become even more complicated. It is beyond the capability of any imaging technique to demonstrate the relevance of morphological changes, that is to show whether the patient has a herniated disk or ‘merely’ narrowing of the spinal canal. If no radicular syndrome is present, even a herniated disk may be irrelevant. These findings, obtained using the most up-to-date and most expensive techniques, divert attention away from gross yet highly relevant dysfunctions. It is therefore important to give some indication here of how an expert assessment can and should be performed with regard to disturbed function. While we cannot deal with all types of pain caused by locomotor disturbance, we will focus primarily on back pain and radicular syndromes, because these are the commonest causes of unfitness for work that necessitate expert assessment. Because expert assessment is chiefly called for in conditions with a chronic or chronic relapsing course, we will deliberately not be considering acute cases. It is also important to exclude pathological conditions such as ankylosing spondylitis, tuberculosis, osteoporosis, etc. Chronic disease courses without pathomorphological findings are characterized by decompensation due to dysfunctions of muscles, joints, or soft tissues, by faulty statics, or by muscle imbalance. The chief concern must be to correct these, so as to reverse the pattern of dysfunction, while at the same time assessing to what extent the work the patient is expected to perform contributes to this decompensated state. This assessment of the locomotor system has to be performed specifically in each individual case. For instance, if a patient consistently develops back pain after sitting for extended periods, there should be a (temporary) ban on sedentary work but walking should be encouraged if the patient feels comfortable with this. First, however, a check must be made to ensure that the bad effects of sitting are not due to an unsuitable chair or to a table at the wrong height. Similarly, if the symptoms are produced by bending down, lifting, or carrying loads, it must be established whether the patient’s corresponding movement patterns are at fault – in which case these must be corrected. Steps should also be taken to ensure that the patient returns to work as 372
soon as possible after learning how to perform these activities correctly. If the symptoms are due to lack of exercise, we should be reluctant to forbid movement, even if it is perceived to be unpleasant. It should not cause a sensation if a patient who is signed off sick from work is spotted walking in the countryside or even moving about on skis so as to get fit. Sometimes unfitness for work is caused not by the patient’s work itself, but by how the patient travels to and from work, particularly if the journey involves being jolted about. Here again it is important to distinguish between (low-)back pain, with or without pain referred to the lower extremities, and true radicular pain. In the former case, movement (especially walking) is usually very well tolerated and should be encouraged, while in the acute stage of a radicular syndrome it may be harmful. Patients with degenerative joint disease involving the lower extremities do not tolerate walking (or standing) for long periods, especially on hard paved surfaces or concrete. There is a specific problem in the case of patients who have been unfit for work for a long period due to a radicular syndrome, particularly where an operation has been necessary. These people are out of training. If a young athlete, for example, were confined to bed for several weeks or months, nobody would expect them to be ready to compete again straight away. However, people with physically demanding jobs do not enjoy the same consideration, although it should be obvious that a period of adaptation is necessary if they are to train themselves up to the same level of efficiency as before. If we do not want to run the risk of relapse, it is helpful if the patient works for a time under somewhat easier conditions, that is either part-time or omitting some of the more demanding operations involved, until full work fitness is regained. Even though they are equally intense, pain in the low back and the lower extremities is a more frequent cause of work incapacity than pain involving the neck, head, or upper extremities; this is because intense low-back or lower extremity pain may prevent the patient from standing or walking. Pain of cervical origin may result in unfitness for work if the job demands full use of the hands or if the nature of the work considerably aggravates the pain. (As an aside, pain is often more bearable if the patient is not alone and resting or ‘taking things easy’.) From all that we have noted so far, it is evident that in terms of function it is possible for the expert
Expert assessment of locomotor system dysfunctions
to make a concrete assessment of the demands imposed on the patient by a particular type of work and to relate these demands to the patient’s symptoms and capabilities. In this way the patient can be helped far more efficiently to overcome those symptoms produced by locomotor system dysfunctions or by adverse circumstances in the workplace. Before turning to the much-discussed question of trauma, it will be appropriate to say a few words about the harmful effects of certain types of work per se. In the preceding chapter we noted the unfavorable repercussions on the locomotor system of most forms of work in our technologically developed world. Having said that, there are certain occupations that appear to be particularly vulnerable from this point of view: drivers, particularly those exposed to severe jolting, as in a tractor; people whose jobs involve extreme static overstrain, for example long hours of computer work in an ergonomically unsound position; and production line workers who have to perform rapid hand movements for hours at a time (repetitive strain injuries). Even so, it seems premature to regard back pain as an occupational disease. Frequently, symptoms develop if patients are engaged in work for which they are clearly unsuited physically. This should be prevented by screening employees in the workplace when they are first taken on. Worst affected are older employees who find it hard to adapt and have to move to another job. They then rightly claim that symptoms appeared or got much worse because of their new job. However, the real fault lies in lack of prevention.
9.2 Assessment of trauma and its consequences Because an accident, and particularly an accident in the workplace, may give the patient the right to claim compensation, this is a frequent area for litigation and one that requires expert assessment. The expert needs to consider two main questions: (1) Did an accident really happen? and (2) Was the alleged accident responsible for the patient’s condition, and to what extent? Both these questions may be contentious and therefore both will be explored here.
9.2.1 Did an accident happen? If a heavy object falls on someone’s toe and causes fracture, nobody would question that the fracture
Chapter 9
was due to injury. When someone bends forward to lift a heavy object, the force generated in the trunk on straightening up may amount to several hundred kilograms. If in such a situation a sudden, uncoordinated, jerky movement occurs, for example if the person slips or unexpectedly lets go of the load, the dynamic forces brought to bear on the lumbosacral junction may be even greater. It would be illogical not to regard the sudden, unexpected effect of such a force as an injury. We know from experience that sometimes it will not be easy to determine with certainty precisely which mechanism actually caused the alleged injury because most injuries affect the spinal column indirectly. If, therefore, symptoms pointing to spinal involvement occur after a fall on to the buttocks, shoulders, or head, they should be considered as a consequence of the trauma, even if the patient is unaware of the connection. The greater the damage to the structure directly injured, the easier it will be for indirect spinal involvement to be overlooked. Immediately after fracture of the humerus or pelvis, local pain is such that it draws all attention to the major trauma, while the insidious concomitant injury to the spinal column is barely noticed. In the cervical spine, this same phenomenon is often seen in whiplash-type injury. After the fracture has healed, the vertebrogenic symptoms deteriorate and often assume a chronic course. It is also not sufficiently recognized that a fall on to the shoulder or a blow on the head (e.g. in boxing) can have an effect similar to that of whiplash injury after a classic rear-end automobile impact. It should be recalled that although a patient’s symptoms after trauma are frequently due to disturbed function, only relatively few physicians have the skills needed to accurately diagnose locomotor system dysfunctions. And it can be particularly difficult to recognize hypermobility resulting from trauma. It may easily happen therefore that patients who have suffered injury end up ‘merely’ with disturbance of function. If they then complain of symptoms, they are dismissed as having ‘no objective signs of illness’, their pain is labeled as ‘psychological’ and in the worst-case scenario they may even be accused of malingering. Inevitably, patients register this and feel a deep sense of injustice. A typical conflict then ensues, in which patients tend to come off worse, eventually reacting in a neurotic and usually inappropriate way, and sealing their own fate. The diagnosis is then one of ‘pain behavior’, although this is often the result of 373
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physician ignorance regarding dysfunctions that are eminently treatable.
9.2.2 Did the accident cause the symptoms? Where trauma as such has been admitted, the question then to be answered is whether the patient’s symptoms are indeed the result of the accident. This is a difficult question in some circumstances, for example if symptoms do not follow immediately after the accident and if there is a symptomfree interval of days, weeks, or even months. We know that the immediate result of an accident may be ‘merely’ disturbance of function and that this may not become clinically manifest for some time, being triggered, for example, by a sudden movement or by additional strain. Another contentious issue is whether the trauma affects a structure that was completely intact, or whether the structure now affected has previ ously been injured. This question is frequently put in cases of elderly patients in whom degenerative changes are usually already present. It is reasonable to argue that trauma impacting an intact structure should cause less harm than if there was previous damage to the structure. In the first case there is ‘merely’ a (reversible) dysfunction that, if treated adequately, should recover in time without sequelae. In the second case (with the previously damaged structure), even if the patient was symptom-free prior to injury, there were probably compensatory mechanisms at work that were already functioning well; the subsequent trauma therefore brings about decompensation, which may be (and frequently is) a much more serious condition. In actual fact, however, most expert assessors arrive at the opposite conclusion. They reason that in view of the demonstrable morphological (i.e. degenerative) changes, the patient would sooner or later have developed the same symptoms, and therefore the trauma did not produce the symptoms but merely caused a clinically latent disorder to become manifest. The same thinking is also used to explain the clinical manifestation of intervertebral disk herniation. Again the argument runs like this: trauma affecting an intact spinal column is more likely to result in fracture of the vertebra than in disk herniation. If, however, signs of disk degeneration are already present, prolapse with its clinical consequences would have occurred anyway, so that
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again the trauma would have been no more than a precipitating factor. The above reasoning can be criticized point by point, as follows: 1. There are conditions under which a disk may prolapse even if intact. This occurs when a force impacts the disk in lordosis or hyperlordosis, as is known from those tragic accidents when an adolescent diver’s head strikes the bottom of a pool. Acute herniation of the disk then compresses the spinal cord, resulting in quadriplegia. In this process the vertebrae remain intact and the radiological appearance is normal. 2. Disk degeneration is a very common condition, as confirmed by radiological evidence of such in the majority of persons studied over 50 years of age. Yet relatively few suffer from any clinical manifestations at all, let alone from radicular pain. 3. Even if a disk has prolapsed, it may be asymptomatic: disk herniation is often an opportunistic finding at autopsy in subjects who never suffered radicular pain (McRae 1956). Currently, thanks to CT or MRI, we are detecting increasing numbers of herniated disks that are clinically irrelevant, that is the patient’s symptoms have cleared up. This serves to confirm the commonly opportunistic nature of this finding, as pointed out by McRae more than half a century ago. It is therefore untenable to argue that particular morphological, mainly degenerative changes are necessarily predictive of certain clinical conditions. This applies not only to the ‘degenerative’ changes themselves but also to the disk lesions associated with them. In principle, it is wrong to assess the consequences of trauma as ‘less serious’ simply because pre-existing degenerative changes have been demonstrated. To follow that line of reasoning may give rise to a number of potential anomalies, as illustrated in the following example. A young injury victim with an intact locomotor system would receive extremely generous compensation, even though recovery from the consequences of trauma is normally quite straightforward. By contrast, an older injury victim with no symptoms up to the time of the accident (i.e. because of good adaptation to any pre-existing degenerative changes) is likely to show
Expert assessment of locomotor system dysfunctions
functional deterioration following trauma. This individual would receive relatively little financial compensation despite the fact that recovery from injury will be far more difficult than in the case of the younger colleague. The crucial question then is: what are the criteria for providing an expert assessment in the field of locomotor system dysfunctions? The basis here should be the clinical examination because this offers insight into the significance of any dysfunctions present and provides a measure of the intensity of the reflex changes that are the direct expression of the pain or nociceptive stimulus. However, the true role played by trauma is determined primarily on the basis of the case history: according to the criteria set out in this chapter, did the trauma really occur and was the patient in fact symptom-free up to the time of the accident? If the answer is yes on both counts, then the trauma must be recognized as having caused the patient’s symptoms. The pain-free interval between the occurrence of trauma and the onset of symptoms should be relatively brief and not longer than a few weeks. On the other hand, if the patient
Chapter 9
already had symptoms before the accident and the clinical course alternated between typical episodes and remissions, then the trauma was at most a precipitating cause, and even then only if the pain occurred shortly afterward. And this is irrespective of the presence or absence of degenerative changes on X-ray. As most employed persons are registered with a physician, it is not usually difficult to establish how often the patient sought medical help for pain even before the accident and whether the symptoms had previously necessitated the patient being signed off sick.
Trauma impacting a previously damaged but compensated spinal column will have more serious repercussions than trauma impacting an intact spinal column. The fact that a patient shows evidence of pre-existing degenerative changes in no way justifies the assumption that symptoms and/or disk herniation would eventually have occurred anyway. A useful criterion here is the presence of similar symptoms prior to the accident.
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Chapter Ten
10
The place of manipulative therapy and its future
There are two aspects to manipulation. First, it is an extremely effective form of reflex therapy in many types of pain, a feature that it shares in common with many other methods of physical therapy such as massage, electrical stimulation, and local anesthesia. Second, it is a specific form of treatment for important locomotor system dysfunctions, namely for functionally reversible movement restrictions involving joints and motion segments of the spinal column. And these movement restrictions can be regarded as a model for locomotor system dysfunctions in general. It soon became clear that treatment of restricted joint movement had its limits and that passive movement restriction in itself involves not only joints but also muscles. It was this recognition of the importance of trigger points (TrPs) and their role in restricted joint movement and in the pathogenesis of locomotor system pain that signaled the next decisive step forward. Indeed, the close interrelationships between joints and muscles became the starting point for further advances, leading to an improved understanding of active movement and its dysfunctions, and enabling us to identify muscle imbalance and faulty motor patterns. No less important than movement are posture and statics, as demonstrated by the ever-increasing practical significance of excessive static strain in contemporary technological society. In recent years we have benefited immensely from progress in the field of developmental kinesiology made by Vojta & Peters (1992) and Kolárˇ (1996, 2001) and this now forms the basis of our understanding of upright posture in humans. These insights relate to the co-activation pattern of flexors and extensors in the trunk
and of adductors and abductors and of external and internal rotation in the extremities. In addition, we know that the deep stabilizer system operates to maintain the otherwise labile equilibrium of the human body in the sagittal plane. The harmonious associated movement of all soft tissue, including the viscera, is a further important element that should not be forgotten, as demonstrated by the role of active scars in pathogenesis. Familiarity with all the above aspects is indispensable if we wish to negotiate the uncharted ‘no man’s land’ of dysfunctions devoid of gross pathological changes that occupies the indeterminate borderlands between the traditional specialist disciplines of neurology, orthopedics, rheumatology, and physical medicine. We have coined the phrase ‘functional pathology of the locomotor system’ to describe this no man’s land. The most frequent clinical manifestation of this pathology is pain, the symptoms of which include TrPs, hyperalgesic zones, restricted joint movement, and changes in tissue tension. Manipulative or manual medicine played a major role in these developments not only as the initial step toward ‘functional pathology’, but also because as a form of ‘bloodless surgery’ it called for precise palpatory diagnostic skills. While it is relevant in restricted joint movement, this palpatory diagnostic aspect also serves to enhance understanding of muscle TrPs, of soft-tissue mobility and relative displacement, and ultimately of pathological resistance in the abdominal cavity where active scars are present. In all these changes, the barrier phenomenon is utilized to impart a degree of objectivity to palpatory findings. Only a diagnostic approach
Manipulative Therapy
that includes all tissues will permit comprehensive therapy that is consistent with the pathogenesis of locomotor system dysfunctions. For all the importance that has come to be attached to the manipulative treatment of joints, it is only one method among many. Anyone who uses it should never limit themselves to just one method, no matter how effective it may be. The object of treatment is not any single method but the locomotor system and, primarily, its function, and historically this has had no specialist discipline of its own. Today there is a growing tendency to designate this emerging specialty as ‘musculoskeletal medicine’. We should remind ourselves that locomotor system function is the most complex of all functions in the human body, and this is reflected in the fact that the largest part of the brain is associated with locomotor system function and control. This control is reflected in motor system programs that are designed to implement function: these relate to the locomotor apparatus as a whole, and this explains why dysfunctions only rarely affect a limited part of the locomotor system but usually involve the system as a whole. The clinical expression of this fact is the chain reaction pattern: this phenomenon was initially understood solely in empirical terms although we are now beginning to unravel something of the theoretical background too. One major difficulty is that although we are familiar from experimental research with the basic neurophysiology of reflex mechanisms at a spinal level up to and including the brainstem, the same cannot be said for those that encourage the co-activation patterns responsible for human upright posture and stability. These are reflex processes that we observe daily when we treat the lower extremities or the trunk and provoke reactions in the cervical region, or conversely when we treat the craniocervical junction and influence function in the pelvic region. Vojta’s developmental kinesiology has provided some insight into these situations: his stimulation techniques demonstrate these reflex patterns in humans in an ‘experimental setting’ as it were. Advances made in the theoretical field are the prerequisite for understanding the modern-day development of musculoskeletal medicine. The practical point to emerge from the concept of chain reaction patterns is that once the relevant link in the chain has been identified, it is then possible not only to administer treatment with the utmost economy, but also to determine the direction for further therapy and rehabilitation. In this context 378
it has been found that most chain reaction patterns originate in the deep stabilizers of the trunk (which are intimately associated with respiration) and in the feet. The key role in stability is played by mono articular muscles which are largely under involuntary control. Dysfunctions of these muscles very often result in intensive chain reaction patterns that manifest themselves as pain due to TrPs and movement restrictions. These lead in turn to faulty movement patterns that create a kind of compensatory stability in which the true stabilization system is no longer operative. After successful activation of the deep stabilizers, it is routinely observed that TrPs and movement restrictions disappear throughout the system as a whole. Summarized in the proverbial nutshell, the development has been from joint to muscle, and from an accent on mobilization to stabilization, which leads automatically to the release of pathological movement restrictions, provided that these are not caused by viscerovertebral reflex mechanisms or active scars, for example. Recognition of the importance of muscles and TrPs has not been without consequences for the development of manipulative techniques, and of mobilization in particular. In recent years we have learned to apply neuromuscular techniques that make use of the patient’s own muscles to achieve mobilization. TrP relaxation and mobilization go hand in hand, serving simultaneously also to abolish pain at the attachment point of the tensed muscle. And from these techniques that depend on the active cooperation of the patient it is just a small step to self-treatment: every patient should be assigned a daily program of home exercises tailored specifically to the most recent examination findings. In this way, therapy transitions seamlessly into rehabilitation, with the practitioner functioning merely to monitor progress and suggest corrections. This trend has also had the effect of bringing a radical change to the relationship between practi tioner and patient. In most fields of medicine the unquestioning patient expects to be cured of suffering, whether by drugs, surgery, or miracle. In such situations where the practitioner is the authority figure, the patient is the object and is not required to do anything, and certainly must not ask (annoying) questions. In manual medicine, however, the patient is the subject and, as such, cooperates intelligently at every opportunity even while treatment is in progress, increasingly taking responsibility for
The place of manipulative therapy and its future
self-treatment and responding to advice designed to correct lifestyle errors. If the patient is moved out of the ‘comfort zone,’ so too is the practitioner who has to face up to the difficult problem of psychological motivation. It is illusory to imagine that the function of the locomotor system, the organ of voluntary movement, can be treated successfully without the active involvement of the patient. From the very outset the human factor plays a major role here, as reflected in the intimate hands-on contact established with the patient. At a time when apparatus-based techniques have come increasingly to the fore, we must continue to rely on our hands and eyes as we strive to acquire those skills that modern medicine has largely neglected in favor of sophisticated (and costly) technology. Only the skilled human hand is capable of sensing the patient’s reactions and of adapting to the patient’s needs. The function of the locomotor system is an expression of personality and therefore a personal relationship between patient and practitioner is vital. The logical conclusion to be drawn is that manipulation has its place within the framework of physical medicine and rehabilitation, the goal of which is to restore function using physiological methods. Attainment of this goal is possible only in a team, the members of which are the physician, the physio therapist and the patient. The role of the physician is to form the diagnosis and, most importantly, to analyze the locomotor system dysfunction. This necessitates close familiarity with the functional approach, and this is as difficult to acquire as a polished manual technique. Because the university education of physicians in mainstream medical schools leaves much to be desired in this respect, intensive efforts are needed to introduce appropriate training for physicians who wish to specialize in musculoskeletal medicine. The treatment itself should then be implemented in consultation with the physiotherapist. The problem for physiotherapists today is due in no small measure to the fact that their training lacks uniformity. However, one certainty is that the future belongs to physiotherapists who, as a minimum requirement, have completed a full university degree course. This is already largely the case in the Czech Republic; on completion of university studies, the graduate physiotherapist has a greater knowledge of the locomotor system than a physician newly qualified from medical school. By that stage the physiotherapist has also learned how to inspect
Chapter 10
patients and how to approach them in a hands-on manner, while already possessing a broad understanding of the principles of manipulative therapy. Because it is indispensable for rehabilitation, the functional approach is also more intuitive for the physiotherapist. The division of labor between physician and physiotherapist will vary considerably, depending on the manual skills of the physician and physiotherapist working together in the same team. The physician may initiate therapy in order to be satisfied about the correctness of the diagnosis and case analysis, but the physician may also delegate therapy to the physiotherapist; however, as physiotherapy proceeds, the physician will need to assess the results so far and then determine any subsequent treatment steps in consultation with the physiotherapist and patient. It is to be expected that, because of their training, physiotherapists will on average be better prepared than physicians for the practice of manual medicine. Because manipulative therapy moves naturally and seamlessly into rehabilitation where the activity of the patient is crucial, the physiotherapist has an important role to play here. In consultation with the physician, the physiotherapist is also responsible for the application of other physical therapy modalities. As in the past, so too in the future, the training of physicians and physiotherapists is a decisive factor, with the functional approach being more important than mere cramming of facts, which often simply involves regurgitating what was taught during student days and then forgetting it again. In this respect, too, the physiotherapist has things easier because, as far as the physician is concerned, the functional approach invariably entails a degree of re-learning, and that is always difficult. For practical training purposes, a sufficient number of instructors is essential in order to guarantee highquality courses. And if participants are to acquire the necessary skills, the trainee-to-instructor ratio should be such that one-to-one tuition is possible. The foundation stone of good technical training is a hands-on approach. For the reasons enumerated above, it would be highly desirable if the basic principles of musculo skeletal medicine and rehabilitation were introduced into the medical school curriculum, with the objective of awakening interest in this specialist field. Given the enormously high incidence of patients with painful dysfunctions of the locomotor 379
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system, every family physician will inevitably come up against these conditions on a daily basis but at present can do little more than prescribe analgesics. They should themselves at least be capable of adequately treating the more straightforward cases. With the easily learned and safe mobilization and soft-tissue techniques in current use, it is also unlikely that the patient will be harmed in any way. And this brings us to the ultimate goal of our work. The vast majority of painful disorders designated as ‘functional’ and perceived by the patient as organic disease have their origin in the loco motor system and its dysfunctions, which simultaneously give rise to innumerable minor painful ailments. The techniques described in this book are suitable for treating these conditions using physio logical methods. It would indeed be a significant contribution to modern medicine as a whole if these methods, which are free from side effects, were to be judiciously brought into play in such patients. Pharmacotherapy, injections, and anesthesia, etc. (with all their side effects) could then be held in reserve, ready to be deployed at the right moment
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for the more demanding cases where structural changes are generally also present. The locomotor system, the subject of this book, is the largest and most intricate system in the human body. We need to learn not only to understand its function better but also to take better care of this precious and perfect instrument that we have at our disposal. In an age when we are learning to use ever-more sophisticated mechanical systems, we are losing an intelligent understanding of our own bodies. And this applies particularly to those of us who treat other people: we have learned to utilize increasingly complicated equipment while at the same time neglecting the evidence of our eyes and in particular of our hands, as well as forgetting how to communicate with our patients. However, by comparison with communicating with the patient, observing with our eyes and sensing with our hands, no piece of high-tech equipment is able to yield such a wealth of varied information. And all this is heightened by the capacity for feedback – indeed empathy – between practitioner and patient.
Glossary Agonist A muscle that causes a specific movement to occur Antagonist A muscle that acts in opposition to or slows down the specific movement generated by the agonist muscle Autonomic reaction A reaction of the autonomic nervous system, particularly involving the internal organs (viscera) and blood vessels Barrier The limit of the range of motion; may also refer to soft tissue. Under normal circumstances, resistance is felt at the physiological barrier, whereas limitation of movement is felt at the pathological or restrictive barrier Basion A craniometric landmark located at the mid point of the anterior border of the foramen magnum Capsular pattern Movement restriction pattern due to an intraarticular lesion of the joint capsule Cervicomotography A technique for the graphic analysis of head and neck movements, developed by Berger (1990) Co-activation, co-contraction The simultaneous contraction of antagonist muscles producing a stabilizing effect Concentric movement against resistance A movement by the patient against resistance that the patient overcomes Costen’s syndrome A symptom complex involving the temporomandibular joint (TMJ) and associated with headache and dizziness de Kleyn test With the patient supine, the head in retroflexion is rotated in both directions to detect vertebral artery insufficiency Deceleration Slowing down; due to the inertia of the head, sudden braking, or acceleration (speeding up) may produce whiplash injury to the cervical spine Distraction Separation or drawing apart; produces ‘gapping’ of the joint surfaces
Eccentric movement against resistance A movement against resistance in which the examining practitioner overcomes the patient’s resistance Facilitation The promotion of muscle activity Gamma system The efferent motor system consisting of fine myelinated motor fibers that chiefly innervate muscle spindles and thus primarily regulate muscle tonus Inhibition (neuromuscular) Reflex inhibition of muscle activity Isokinetic resistance A movement at constant rate or velocity against resistance that is set by a machine or piece of apparatus Isometric Maintaining uniform length, that is without positional change or movement Isometric muscle contraction Muscle contraction against resistance that permits no movement Isometric phase The time period during which no movement occurs because the forces involved are in equilibrium Isometric resistance Resistance that permits no movement because the forces involved are in equilibrium Isotonic resistance Resistance employing a constant force Joint play Movement that can be produced only passively in the joint, for example distraction, translation, and occasionally rotation Kinematics The science that deals with the possible motions of a material body Kinesiology The study of the motion of the human body Locus minoris resistentiae A site of lessened resistance Manipulation with thrusting Manipulation employing a high-velocity, low-amplitude (HVLA) thrust Mobilization A gentle form of manipulation in which release or relaxation is obtained by waiting or by repetition
Motor program The sum total of movements that permit complex activities; a motor program comprises memory, triggering, and combinatory skills and usually involves the whole locomotor system Motor stereotype The sum total of unconditioned and conditioned reflexes that determine a movement pattern or habit Movement pattern A persistent repetitive sequence of motor actions (posture, movement) Neoarthrosis New joint formation, a ‘false’ joint Nictitating membrane A thin fold of skin lying deep to the eyelids; the ‘third eyelid’ Nociception Perception of injurious, usually pain-provoking stimuli Nutation A slight nodding movement, usually in the sense of anteflexion and retroflexion Occlusion Locking, a position in which no further joint movement is possible Offset Minor mutual displacement of the surfaces of a joint Opisthion A craniometric landmark located at the mid point of the posterior border of the foramen magnum Osteopenia A decrease in bone mass below the normal; the term includes both osteoporosis and osteomalacia Panjabi’s neutral zone A region of laxity around the neutral resting position of a spinal motion segment that is maintained only by muscles and not by passive structures Phasic muscle A muscle, usually an extensor, that has a tendency to weaken; in terms of developmental kinesiology, these are phylogenetically ‘younger’ muscles Proprioception Perception of position and movements of the body Reciprocal inhibition Inhibition by stimulating the antagonist muscle(s)
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Reflex therapy Therapy involving stimulation of receptors that automatically provoke an efferent response Relational diagnosis Assessment of mutual position, especially of vertebrae in a spinal motion segment Restriction A functionally reversible impairment of movement produced by a pathological barrier Rhythmic stabilization A method in which the patient performs a rhythmic movement in the direction opposite to alternating resistance, thus causing rhythmic contraction of the antagonist muscle(s)
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Segment An area or region of the body Taking up the slack Reaching the point in the range of that is innervated by a nerve root or movement where initial resistance a (hypothetical) spinal cord segment is met; engaging the physiological Somatic dysfunction The sum total barrier of reflex changes that take place in Tonic muscle A muscle, usually a dysfunctional motion segment a flexor, that has a tendency to Somatic reaction A reflex reaction hyperactivity and shortening; in the locomotor system, primarily in terms of developmental in muscle kinesiology, these are Stabilization system, deep A phylogenetically ‘older’ muscles system of monoarticular muscles Trigger point (TrP) A small hardened that maintain the stability of the or contracted nodule in muscle motion segments of the spinal that is a source of referred pain, column, shoulder blades, and especially when irritated bones of the feet Static posturography A method for recording body sway in a standing subject
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Butler D S 1995 Mobilisation des Nervensystems. Springer, Berlin Caillet R 1993 Pain mechanisms and management. F A Davies, Philadelphia Caillet R 1994 Low back pain syndrome, 5th edn. F A Davies, Philadelphia Cairns M C, Foster N E, Wright C 2006 Randomized controlled trial of specific spinal stabilization exercises and conventional physiotherapy for recurrent low back pain. Spine 31:E670–E681 Carmichael J P 1987 Inter- and intraexaminer reliability of palpation for sacroiliac joint dysfunction. Journal of Manipulative and Physiological Therapeutics 10(4):164–171 Cassidy J D, Lopes A A, Yong-Hing K 1992 The immediate effect of manipulation versus mobilization on pain and range of motion in the cervical spine. Journal of Manipulative and Physiological Therapeutics 15(9):570–575 Cassidy J D, Thiel H W, KirkaldyWillis W H 1993 Side posture manipulation for lumbar intervertebral disk herniation. Journal of Manipulative and Physiological Therapeutics 16(2): 96–103 Caviezel H 1977 Torticollis acutus. Manuelle Medizin 15:67–73 Chaitow L 1991 Palpatory literacy. Thorsons, Bath. Chandnani V, Ho C, Gerharter J et al 1992 MR findings in asymptomatic shoulders, a blind analysis using symptomatic shoulders as controls. Clinical Imaging 16:25–30 Chang H-T 1979 Acupuncture analgesia today. Chinese Medical Journal 92:7–16 Cherkin D C, Deyo R A, Wheeler K et al 1995 Physician views about treating low back pain. The results of a national survey. Spine 20:1–9 Chaouat H 1979 Les myelopathies cervicothoraciques. Revue de Médecine 34:1816–1820 Cholewicki J 1993 The mechanical role of lumbar ligaments in lifting. A review article. Journal of Orthopaedic Medicine 15:39–48 Cholewicki J, Panjabi M M, Khachatryan A 1997 Stabilizing function of trunk flexor–extensor muscles around a neutral spine posture. Spine 22(19):2207–2212
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Manipulative Therapy Chrást B, Korbicka J 1962 Die Beeinflussung der Strömungsverhältnisse in der Arteria vertebralis durch verschiedene Kopf- und Halshaltungen. Deutsche Zeitschrift für Nervenheilkunde 183:426–448 Chrastek J 1968 The harmful effect of competitive volleyball on the musculoskeletal system [in Czech]. Acta Chir Orthop Traumatol Cechoslov 35:39–48 Christiansen H W, Nielsen N 1998 Natural variation of cervical range of motion, a one-way repeated measuring design. Journal of Manipulative and Physiological Therapeutics 21:383–387 Christiansen H W, Vach W, Manniche C et al 2002 Palpation of the upper thoracic spine, an observer reliability study. Journal of Manipulative and Physiological Therapeutics 25:285–292 Christiansen H W, Vach W, Gichangi A et al 2005 Manual therapy for patients with stable angina pectoris, a non randomised open prospective trial. Journal of Manipulative and Physiological Therapeutics 28: 654–661 Chung S H, Dickenson A 1980 Pain, encephalin and acupuncture. Nature 283:243–244 Ciancaglini R, Testa M, Radaelli G 1999 Association of neck pain with symptoms of temporomandibular dysfunction in the general population. Scandinavian Journal of Rehabilitation Medicine 31:17–22 Cihák R 1970 Variations of lumbosacral joints and their morphogenesis. Acta Universitatis Carolinae Medicinae 16:145 Clarke J, van Tulder M, Blomberg S et al 2006 Traction for low back pain with or without sciatica, an updated systematic review within the framework of the Cochrane collaboration. Spine 31:1591–1599 Coenen W 1996 Manualmedizinische Diagnostik und Therapie bei Säuglingen. Manuelle Medizin 34:108–113 Coenen W 2002 Koordinationsund Konzentrationsstörungen im Kindesalter. Manuelle Medizin 40:352–358 Collard M, Conraux C, Thiébaut M S et al 1967 Le nystagmus d’origine cervical. Revue Neurologique 117(6):677–688
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Conradi F (ed) 1990 Schmerz und Physiotherapie. Volk und Gesundheit, Berlin Coulter I 1996 Manipulation and mobilization of the cervical spine, the results of a literature survey and consensus panel. Journal of Musculoskeletal Pain 4:113–124 Coupé C, Mittun A, Hilden J et al 2001 Spontaneous needle electromyographic activity in myofascial trigger points in the infraspinatus muscle, a blinded assessment. Journal of Musculoskeletal Pain 9:7–16 Cramer A 1955 Lehrbuch der Chiropraktik. Haug, Ulm. Cramer A, Döring J, Gutmann G 1990 Geschichte der Manuellen Medizin. Springer, Berlin Cramer G D, Tuck N R, Knudsen J T 2000 Effects of sideposture positioning and sideposture adjusting on the lumbar zygapophysial joints as evaluated by magnetic resonance imaging, a before and after study with randomization. Journal of Manipulative and Physiological Therapeutics 23: 380–394 Crisco J J, Panjabi M M 1991 The intersegmental and multisegmental muscles of the lumbar spine. A biomechanical model comparing lateral stabilizing potential. Spine 16:793–799 Croft A C 1993 Cervical acceleration/ deceleration trauma. A reappraisal of physical and biomechnical events. Journal of the NeuroMusculoskeletal System 1:45–51 Croft P R, Macsfarale G J, Papagorgiu A C et al 1996 Outcome of low back pain in general practice, a prospective study. British Medical Journal 316:1356–1359 Dabbs V, Lauretti W J 1995 Risk assessment of cervical manipulation vs. NSAIDs for treatment of neck pain. Journal of Manipulative and Physiological Therapeutics 18:530–536 Dalseth L 1974 Anatomic studies of osseous craniovertebral joints. Manuelle Medizin 12:19–24 D’Ambroglio K J, Roth G B 1997 Positional release therapy. Mosby, St. Louis Dan N G, Sacassan P A 1983 Serious complications of lumbar spine manipulation. Medical Journal of Australia 10:672–673
Danek V 1989 Haemodynamic disorders within the vertebrobasilar arterial system following extreme positions of the head. Journal of Manual Medicine 4:127 Danenberg H J 1992 Subtle gait malfunction and chronic musculoskeletal pain. Journal of Orthopaedic Medicine 14:18–26 Danz J 1982 Gelenkspielbefunde an der Hand bei Patienten mit rheumatoider Arthritis. Manuelle Medizin 20:70 Davidoff F A 1998 Trigger points and myofascial pain. Cephalalgia 18:436–438 Davies C G, Fernando C A, Motta A 1993 Manipulation of the low back under general anaesthesia, case studies and discussion. Journal of the Neuro-Musculoskeletal System 1:126–132 Davis C 1985 Osteopathic manipulation resulting in damage to the spinal cord. British Medical Journal 291:1540–1541 Davis C G 1998 Rear-end impacts, vehicle and occupant response. Journal of Manipulative and Physiological Therapeutics 21: 629–639 Davis P T, Hulbert J R, Kassak K M et al 1998 Comparative efficacy of conservative medical and chiropractic treatments for carpal tunnel syndrome, a randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 21:317–326 Decher H 1969 Die zervikalen Syndrome in der Hals-Nasen-OhrenHeilkunde. Thieme, Stuttgart DeFranca R G 1996 Pelvic locomotor dysfunction. Aspen, Gaithersburg. Dejung B 1985 Iliosakralblockierungen – eine Verlaufsstudie. Manuelle Medizin 23:109–115 Dejung B 1999 Die Behandlung unspezifischer chronischer Rückenschmerzen mit manueller Trigger-Punkt-Therapie. Manuelle Medizin 37:124–131 Delitto A, Erhard R E, Bowling R W 1995 A treatment-based classification approach to low back syndrome, identifying and staging patients for conservative treatment. Physical Therapy 75:470–485 Descarreaux M, Normand M C, Laurencelle L et al 2000 Evaluation of a specific home exercise program
Further reading for low back pain. Journal of Manipulative and Physiological Therapeutics 25:497–503 de Sèze S 1960, 1961 Étude sur l’épaule douloureuse (parts I, II and III). Revue du Rhumatisme 27,323–327, 443–453, 28,85–94 de Sèze S, Thiérry-Mieg J 1955 Les manipulations vertébrales. Revue du Rhumatisme 22:633–650 Deyo R A 1998 Low-back pain. Scientific American 279(2):48–53 Diakow P R, Gadsby T A, Gadsby J B et al 1991 Back pain during pregnancy and labor. Journal of Manipulative and Physiological Therapeutics 14:116–118 DiFabio R P 1995 Efficacy of comprehensive rehabilitation program and back school for patients with low-back pain. Physical Therapy 75:865–878 DiFabio R P 1999 Manipulation of the cervical spine, risks and benefits. Physical Therapy 79:50–65 Dishman J D, Ball K A, Burke J 2002 Central motor excitability changes after spinal manipulation, a transcranial magnetic stimulation study. Journal of Manipulative and Physiological Therapeutics 25:1–9 Dolan P, Adams M 2000 Biomechanical factors affecting the disc. Journal of Orthopaedic Medicine 22:3–9 Dölken M 2000 Biomechanische und pathomechanische Aspekte des Humeroskapulargelenks und Auswirkungen auf die Rehabilitation der Schulter. Manuelle Medizin 38:242–247 Doran D M L, Newell D L 1975 Manipulation in treatment of lowback pain. British Medical Journal 2:61 Dorman T A 1994 Pelvic mechanisms and dysfunction. Journal of Orthopaedic Medicine 16:45–48 Dorman T A, Buchmiller J D, Cohen R E et al 1994 Energy efficiency during walking. Journal of Orthopaedic Medicine 16:13–19 Downey B J, Taylor N F, Niere K L 1999 Manipulative physiotherapists can reliably palpate nominated lumbar spinal levels. Manual Therapy 4(3):151–156 Downing C H 1935 Osteopathic principles in disease. Orozko, San Francisco Dreyfuss P, Michaelsen M, Horne M 1995 MUJA, manipulation under
joint anesthesia/analgesia, a treatment approach for recalcitrant low back pain of synovial joint origin. Journal of Manipulative and Physiological Therapeutics 18:537–546 Dul J C, Snijders J, Timmermann J 1982 Bewegungen und Kräfte im oberen Kopfgelenk beim Vorbeugen der Halswirbelsäule. Manuelle Medizin 20,51. DuPriest C M 1993 Nonoperative management of lumbar spinal stenosis. Journal of Manipulative and Physiological Therapeutics 16:411–414 Durianova J 1985 Objektivzácia úcinku manipulacie a postizometrickej relaxacie kvantitativnou termografiou [in Czech] (Objectifying the effect of manipulation and post-isometric relaxation by means of quantitative thermography). Bratisl Lek listy 83:87–93 Duus P, Kahlau G, Krücke W 1951 Allgemeinbetrachtungen der Foramina intervertebralia. Langenbecks Archiv für Chirurgie 268:431 Dvorák J 1988 Rotationsinstabilität der oberen Halswirbelsäule. In: Hohmann D, Kügelgen B, Liebig K (eds) Neuroorthopädie 4. Springer, Berlin, p. 37 Dvorák J 1991 Inappropriate indication and contraindication for manual therapy. Journal of Manual Medicine 6:85–88 Dvorák J, Dvorák V 1983 Manuelle Medizin. Springer, Berlin Dvorák J, Orelli F 1982 Wie gefährlich ist die Manipulation der Halswirbelsäule? Manuelle Medizin 20:44–48 Dvorák J, Aebi M, Baumgartner H et al 1991 Functional CT scans for diagnosis of atlanto-axial rotatory fixation. Journal of Manual Medicine 6:203–204 Ebbets J 1979 Manipulation of the foot. Physiotherapy 194:202 Eddie G 1995 A series of 43 patients complaining of shoulder pain who responded to treatment of the first rib. Journal of Orthopaedic Medicine 17:62–64 Eder M, Tilscher H 1988 Chirotherapie. Hippokrates, Stuttgart Editorial 1960 Children’s headache. British Medical Journal 1154. Ellis R, Swain I 1990 Frozen wrist, the contribution of thermography. In:
Paterson J K, Burn L (eds) Back pain, an international review. Kluwer Academic, Dordrecht, p. 214 Epstein J, Lavine L S 1964 Herniated lumbar intervertebral discs in teenage children. Journal of Neurosurgery 21:1070–1075 Erdmann H 1967/1968 Grundzüge einer funktionellen Wirbelsäulenbetrachtung. Manuelle Medizin 5,55–63, 6,32–37, 78–90. Eschler J 1967 Das Costen-Syndrom aus der Sicht mandibulomotorischer Inkoordination. Deutsche medizinische Wochenschrift 92: 711–714 Evers W T 1985 Muskeldehnung, Warum, wann und wie? In: Frisch H (ed) Manuelle Medizin heute. Springer, Berlin, p. 157–169 Evers E 2004 Zervikogener Kopfschmerz. Manuelle Medizin 42:99–102 Evjenth O, Hamberg J 1981 Muskeldehnung. Remed, Zug/ Switzerland Falkenau H A 1977 Pathogenese und Chirotherapie des pharyngoösophagealen zervikalen Syndroms. Laryngologie, Rhinologie, Otologie 56:467–469. Falla D L, Jull G A, Hodges P W 2004 Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test. Spine 29:2108–2114 Farfan H F 1980 The scientific basis of manipulative procedures. In: Grahame R (ed) Low back pain. Clinics in rheumatic diseases. Saunders, Philadephia, p. 159–177 Farrell J P, Twomey L T 1982 Acute low back pain. Comparison of two conservative treatment approaches. Medical Journal of Australia 1: 160–164 Fassmeyer W B 2001 Was man vom Kiefergelenk des Menschen wissen sollte. Manuelle Medizin 39:126–132 Fast A, Zinicola D F, Marin E L 1987 Vertebral artery damage complicating cervical manipulation. Spine 12: 840–842 Feinstein B, Langton J N, Jameson R M et al 1954 Experiments on pain referred from deep somatic structures. Journal of Bone and Joint Surgery 36A:981–997
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Manipulative Therapy Feld M 1954 Subluxation et entorse sousoccipitales. Leur syndrôme fonctionel consecutif aux traumatismes crâniens. Semaine des Hôpitaux 30:1952 Feldenkreis M 1999 Body awareness as healing therapy. The case of Nora. North Atlantic Books, Berkeley/ California Fick R 1911 Handbuch der Anatomie und Mechanik der Gelenke. Teil III. Spezielle Gelenk- und Muskelmechanik. Bardeleben, Handbuch der Anatomie des Menschen. Fischer, Jena. Figar Š, Krausová L, Lewit K 1970 Plethysmographische Untersuchungen bei manueller Behandlung vertebragener Störungen. Acta Neurovegetativa 29:618–623 Fischer A A 1986 Pressure tolerance over muscles and bones in normal subjects. Archives of Physical Medicine and Rehabilitation 67: 406–409 Fischer A A 1990 Application of pressure algometry in manual medicine. Journal of Manual Medicine 5:145 Fischer A A 1998 Algometry in diagnosis of musculoskeletal pain. An evaluation of treatment outcome, an update. Journal of Musculoskeletal Pain 6:5–32 Fisk J W 1986 The low back problem. The 1982 Menell-Travell Lecture. Journal of Manual Medicine 2: 32–132 Fitz-Ritson D 1991 Assessment of cervicogenic vertigo. Journal of Manipulative and Physiological Therapeutics 14:193–198 Fjellner A, Bexander C, Faleij R et al 1999 Interexaminer reliability in physical examination of the cervical spine. Journal of Manipulative and Physiological Therapeutics 22: 511–516 Foreman S M, Croft A C 1988 Whiplash injuries, the cervical acceleration/ deceleration syndrome. Williams & Wilkins, Baltimore Forestier J, Lagier R 1971 Hyperostoses vertébrales ankylosantes. Médecine et Hygiene 29:668–670 Fortin J D, Aprill C N, Ponthieux B et al 1994 Sacroiliac joint, pain referral maps upon applying a new injection/ arthrographic technique. Spine 19:1483–1489
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Fossgreen J 1991 Editorial, Complications in manual medicine. Journal of Manual Medicine 6: 83–84 Franca G G 1992 Proximal tibiofibular joint dysfunction and chronic knee and low back pain. Journal of Manipulative and Physiological Therapeutics 15:382–387 Franca G G, Levine L J 1991 The quadratus lumborum and low back pain. Journal of Manipulative and Physiological Therapeutics 14: 142–149 Fredrickson J M, Schwarz D, Kornhuber H H 1976 Convergence and interaction of vestibular and deep somatic afferents upon neurons in the vestibular nuclei of the cat. Acta Otolaryngologica 61: 168–188 French S D, Green S, Forbes A 2000 Reliability of chiropractic methods commonly used to detect manipulable lesions in patients with chronic low back pain. Journal of Manipulative and Physiological Therapeutics 23:231–238 Friberg O 1987 Lumbar instability, a dynamic approach by tractioncompression radiography. Spine 12:119–129 Fricton J R 1993 Myofascial pain. Clinical characteristics and diagnostic criteria. Journal of Musculoskeletal Pain 1:37–39 Fricton J R 2002 Masticatory myofascial pain, an explanatory model of regional muscle pain syndromes. Journal of Musculoskeletal Pain 10:131–150 Fried K 1966 Die zervikale juvenile Osteochondrose. Fortschritte auf dem Gebiete der Röntgenstrahlen und der Nuklearmedizin 105:69 Friedrich M, Tilscher H, Liertzer H 1985 Segmentale Wirbelfunktionsstörungen bei stationär aufgenommenen Patienten mit spondylogenen Schmerzen. Manuelle Medizin 23:38–42 Frisch H 1985 Manuelle Medizin heute. Springer, Berlin Frisch H 1996 Programmierte Therapie am Bewegungsapparat. Springer, Berlin Fritsch C, Jeangros P 1994 Die Dehnung der neuromeningealen Strukturen bei Adhäsionen nach lumbalen Diskusoperationen. Manuelle Medizin 32:159–172
Fritz J M, Delitto A, Welch W C et al 1998 Lumbar spinal stenosis, a review of current concepts in evaluation, management and outcome measurements. Archives of Physical Medicine and Rehabilitation 79:700–708 Frühwirth J, Lackner R, Höllerl G 1992 Postoperative manuelle Medizin. Manuelle Medizin 30:35–37 Fryette H H 1954 Principles of osteopathic technique. Academy of Applied Osteopathy, Carmel/ California Fullenlove T M, Justin Williams A 1957 Comparative roentgen findings in symptomatic and asymptomatic back. Radiology 68:572 Fusek L 1970 Príznaky a operacní nálezy pri výhrezech bederních meziobratlových plotének u mladistvých [in Czech] (Symptoms and surgical findings in herniated disk lesions in adolescents). Ceskoslovenská Neurologie 33: 199–202 Gaizler G 1973 Die Beurteilung der Ruhehaltung der Halswirbelsäule – eine erledigte Frage? Fortschritte auf dem Gebiete der Röntgenstrahlen und der Nuklearmedizin 103:566 Gaizler G, Madarász J 1979 Funktionelle Röntgendiagnostik der Halswirbelsäule. Manuelle Medizin 17:82–84 Gallinaro P, Cartesegna M 1983 Three cases of lumbar disc rupture and one of cauda equina associated with spinal manipulation (chiropraxis). Lancet 8321:41 Galm R, Rittmeister, Schmitt M 1998 Vertigo in patients with cervical spine dysfunction. European Spine Journal 7:5–8 Gambardino M A, Affaitati G, Lezzi S et al 1999 Referred muscle pain and hyperalgesia from viscera. Journal of Musculoskeletal Pain 7:436–438 Garzillo M J, Garzillo T A 1994 Does obesity cause low back pain? Journal of Manipulative and Physiological Therapeutics 17:601–604 Gassin R 1999 Low back pain during pregnancy. Australian Musculoskeletal Medicine 4:16–23 Gassin R, Masters S 2001 Spinal manual therapy – the evidence. Australian Musculoskeletal Medicine 6:26–31 Gatcheva J, Boykikev N, Damyanova J et al 1986 Der vertebrale Faktor in der Pathogenese eines erhöhten
Further reading Augeninnendruckes und dessen Beeinflussung durch physikalische und manuelle Therapie. Manuelle Medizin 24:105–108 Gatterman M I 1995 Foundations of chiropractic subluxation. Mosby, St Louis Gay J R, Abbott K H 1953 Common whiplash injuries of the neck. Journal of the American Medical Association 152(18):1698–1704 Gaymans F, Lewit K 1975 Mobilisation techniques using pressure (pull) and muscular facilitation and inhibition. In: Functional pathology of the motor system. Rehabilitácia Supplement 10–11,47–51. Geerinckx P 1979 Vorlaufphänomen der Rippen. Manuelle Medizin 17:41–44 Geiger T, Gross D 1967 Therapie über das Nervensystem Volume 7 Hippokrates, Stuttgart Geiser M 1972 Rückenuntersuchungen in einer Infanterie-Rekrutenschule. Schweizer medizinische Wochenschrift 102:1301–1309 Gelb H (ed) 1977 Clinical management of head, neck and TMJ pain and dysfunction. Saunders, Philadelphia Gelb H, Bernstein I 1983 Clinical evaluation of 2000 patients with temporo-mandibular joint syndromes. The Journal of Prosthetic Dentistry 49:234 Gemell H A, Jacobson B H 1990 Incidence of sacroiliac joint dysfunction and low back pain in fit college students. Journal of Manipulative and Physiological Therapeutics 13:63–67 Gerstenbrand F, Tilscher H, Berger M 1980 Radikuläre und pseudoradikuläre Symptome der mittleren und unteren Halswirbelsäule. In: Kocher R, Gross D (eds) Schmerzstudien 3. Fischer, Stuttgart, p. 82–90 Gerwin R D 2002 Myofascial and visceral pain syndromes, visceralsomatic pain representation. Journal of Musculoskeletal Pain 10: 165–175 Gerwin R D, Shannon S, Hong Z 1997 Interrater reliability in myofascial trigger point examination. Pain 69(1–2):65–73 Getzendanner S, Johnson K B 1988 1. Permanent injunction order against AMA. 2. Statement from AMA’s General Counsel. Journal of the
American Medical Association 259:81–83 Geyer K H, Bücheler E 1967 Zur vaskulären Genese des synkopalen zervikalen Vertebralissyndroms. Nervenarzt 38:270–275 Ghia J N, Mao T, Twomey T C et al 1976 Acupuncture and chronic pain mechanisms. Pain 2:285–299 Gibbons P 1997 Coupled motion, relationship to joint assessment. Journal of Orthopaedic Medicine 19:66–71 Giles L G 1986 Lumbosacral and cervical zygapophyseal joint inclusions. Journal of Manual Medicine 2:89–92 Giles L G F 1989 Anatomical basis of low back pain. Williams & Wilkins, Baltimore Giles L G 1992 Paraspinal autonomic ganglia distortion due to vertebral body osteophytosis, a cause of vertebrogenic syndromes? Journal of Manipulative and Physiological Therapeutics 14:551–555 Giles L G 1994 A histological investigation of human lower lumbar intervertebral canal (foramen) dimensions. Journal of Manipulative and Physiological Therapeutics 17:4–14 Giles L G, Kaveri M J 1991 Lumbosacral intervertebral disc degeneration revisited, a radiological and histological correlation. Journal of Manual Medicine 6:62–66 Gill K P, Callaghan M J 1998 The measurement of lumbar proprioception in individuals with and without low back pain. Spine 23:371–377 Gläser O, Dalicho A W 1962 Segmentmassage. Thieme, Leipzig Glover J R, Morris J G, Khosla T 1974 Back pain, a randomized clinical trial of rotational manipulation of the trunk. British Journal of Industrial Medicine 31:59–64 Goddard N J, Stabler J, Albert J S 1990 Atlanto-axial rotatory fixation and fracture of the clavicle. Journal of Bone and Joint Surgery 72(B):72–75 Good A B 1985 Spinal joint blocking. Journal of Manipulative and Physiological Therapeutics 8:1–8 Goodridge J P 1981 Muscle energy technique, definition, explanation, methods of procedure. Journal of the American Osteopathic Association 81:249–254
Gorman R F 1978 Cardiac arrest after cervical spine mobilization. Medical Journal of Australia 2:100–103 Gottfrýd O 1973 Príspevek k patogenezi syndromu canalis intervertebralis [in Czech] (A contribution on the pathogenesis of the intervertebral canal syndrome). Rozhl Chir 52: 100–103 Govind J, Bogduk N, Lau P 2005 Headache and the cervical zygapophyseal joints. Australian Musculoskeletal Medicine 10: 108–110 Graber-Duvernay J 1972 Coxarthroses mineurs et réactions ostéophytiques. Rhumatologie 24:123–133 Gracovetsky S, Farfan H 1986 The optimum spine. Spine 11: 543–573 Gracovetsky S, Kary M, Pitchen I 1989 The importance of pelvic tilt in reducing compression stress in the spine during flexion–extension exercises. Spine 14:412–441 Granata G I, Agarwal G G 1995 The influence of trunk muscle coactivity on dynamic spine loads. Spine 20:913–919 Granges G, Littlejohn G 1993 Prevalence of myofascial pain syndrome in fibromyalgia syndrome and regional pain syndrome, a comparative study. Journal of Musculoskeletal Pain 1:19–35 Grant R (ed.) 1988 Physical therapy of the cervical and thoracic spine. In: Clinics in physical therapy, volume 17. Churchill Livingstone, New York Grave-Nielsen T, Arend-Nielsen L, Svensson P et al 1997 Experimental pain, a quantitative study of local and referred pain in humans following injection of hypertonic saline. Journal of Musculoskeletal Pain 5:49–71 Green D 1959 Vascular accidents to the brain stem associated with neck manipulation. Journal of the American Medical Association 170:522–524 Greenman P E 1979 Verkürzungsausgleich – Nutzen und Unsinn. In: Neumann H D, Wolff H D (eds) Theoretische Fortschritte und praktische Erfahrungen der Manuellen Medizin. Konkordia, Bühl, p. 333–341 Greenman P E 1984 Eingeschränkte Wirbelbewegung. Manuelle Medizin 22:15–18
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Manipulative Therapy Greenman P E 1984 Schichtweise Palpation. Manuelle Medizin 22:46–48 Greenman P E (ed) 1984 Concepts and mechanisms of neuromuscular functions. Springer, Berlin Greenman P E 1985 Die osteopathische Untersuchung des Haltungs- und Bewegungsapparates in 10 Schritten. In: Frisch H (ed) Manuelle Medizin heute. Springer, Berlin, p. 43–50 Greenman P E 1986 Innominate shear dysfunction. Journal of Manual Medicine 2:114–121 Greenman P E 1990 Clinical aspects of sacroiliac function in walking. Journal of Manual Medicine 5:125 Greenman P E 1991 Grundlagen der myofaszialen Entspannungstechnik. Manuelle Medizin 29:67–71 Greenman P E 1991 Principles of manipulation of the cervical spine. Journal of Manual Medicine 6: 106–113 Greenman P E 2003 Principles of manual medicine, 3rd edn. Lippincott Williams & Wilkins, Philadelphia Greenman P E 2006 Non-operative management of spinal stenosis. American Academy of Osteopathy Journal 16(4):18–20 Gregg G 1974 The commonest lumbar disc – L3! British Journal of Sports Medicine 8:69–73 Grieve G P 1981 Common vertebral joint problems. Churchill Livingstone, Edinburgh Grim M, Rerábková L, Carlson B M 1988 A test for muscle lesions and their regeneration following intramuscular drug application. Toxicologic Pathology 16: 432–442 Groh H 1972 Wirbelsäule und Leistungssport. Selecta 14:324 Gross A R, Hoving G L, Haines T A et al 2004 A Cochrane review of manipulation and mobilization for mechanical neck disorders. Spine 29:2108–2114 Gross A R, Goldsmith C, Hoving J L et al 2007 Conservative management of mechanical neck disorders. Journal of Rheumatology 34:1083–1102 Gross D (ed) 1974 Funktionelle Störungen des Bewegungsapparates. Therapie über das Nervensystem Volume12. Hippokrates, Stuttgart Gross D 1982 Contralateral local anaesthesia in the treatment of
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phantom limb and stump pain. Pain 13:313–320 Gross D, Kobsa K 1984 Polymyographische Untersuchungen und Rückenschmerzen. Manuelle Medizin 22:74 Guechev G, Guechev A 1994 Clinical and electrophysiological changes in neurological deficit of patients with lumbosacral radiculopathy undergoing traction therapy. Journal of Orthopaedic Medicine 16: 80–83 Gunn C C, Milbrandt W E 1976 Tennis elbow and the cervical spine. Canadian Medical Association Journal 114:803–809 Gunn C C, Chir B, Milbrandt W E 1978 Tenderness at motor points. A diagnostic and prognostic aid for low back injury. Journal of Bone and Joint Surgery 58A:815–825 Gurfinkel V S 1973 Muscle afferentation and postural control in man. Agressologie 14C:1–8 Gutmann G 1953 Die obere Halswirbelsäule im Krankheitsgesehen. Neuralmedizin 1 Gutmann G 1955 Schädeltrauma und Kopfgelenke. Deutsche medizinische Wochenschrift 41:1503–1505 Gutmann G 1956 Einführung in die statisch-funktionelle Röntgendiagnostik der Wirbelsäule unter besonderer Berücksichtigung der Kopfgelenke und der Halswirbelsäule. In: Wirbelsäule in Forschung und Praxis, Volume 1. Hippokrates, Stuttgart, p. 70–72 Gutmann G 1962 Halswirbelsäule und Durchblutungsstörung in der Vertebralis-Basilaris-Strombahn. In: Wirbelsäule in Forschung und Praxis, Volume 25. Hippokrates, Stuttgart, 138–155 Gutmann G 1963 Das cervicodiencephale Syndrom mit synkopaler Tendenz und seiner Behandlung. In: Wirbelsäule in Forschung und Praxis, Volume 26. Hippokrates, Stuttgart, p. 112–132 Gutmann G 1968 Das cervicaldienzephal-statische Syndrom des Kleinkindes. Manuelle Medizin 6:112–119 Gutmann G 1983 Verletzungen der Arteria vertebralis durch manuelle Therapie. Manuelle Medizin 21:2 Gutmann G 1985 Die funktionsanalytische Röntgenuntersuchung der
Wirbelsäule und ihre tatsächliche klinische Bedeutung. In: Manuelle Medizin heute. Springer, Berlin, p. 61–89 Gutmann G (ed) 1985 Arteria vertebralis, Traumatologie und funktionelle Pathologie. Springer, Berlin Gutmann G, Biedermann H 1984 Allgemeine funktionelle Pathologie und klinische Syndrome. In: Gutmann G (ed) Funktionelle Pathologie und Klinik der Wirbelsäule. Vol. 1, Die Halswirbelsäule (part II). Gustav Fischer, Stuttgart Gutmann G, Biedermann H 1992 Funktionelle Pathologie und Klinik der Wirbelsäule, Volume 3, Die Lenden-Becken-Hüftregion, Part 1. Fischer, Stuttgart Gutmann G, Roesner J 1979 The subforaminal stenosis headache. Acta Neurochirurgica 50: 201–215 Gutzeit K 1956 Anamnese und Klinik der vertebragenen Erkrankungen. In: Wirbelsäule in Forschung und Praxis, Volume 1. Hippokrates, Stuttgart, p 22–28. Haas M, Nyiendo J 1992 Lumbar motion trends and correlation with low back pain. Part II. A roentgenological evaluation of quantitative segmental motion in lateral bending. Journal of Manipulative and Physiological Therapeutics 15:224–234 Haas M, Peterson D 1992 A roentgenological evaluation of the relationship between segmental motion and malalignment in lateral bending. Journal of Manipulative and Physiological Therapeutics 15:350–360 Haas M, Nyiendo J, Peterson C et al 1992 Lumbar motion trends and correlation with low back pain. Part I. A roentgenological evaluation of coupled lumbar motion in lateral bending. Journal of Manipulative and Physiological Therapeutics 15:145–158 Haas M, Taylor J A, Gillette R G 1999 The routine use of radiographic spinal displacement analysis, a dissent. Journal of Manipulative and Physiological Therapeutics 22:254–259 Hack A 2002 Therapeutische Ergebnisse mit der muscle
Further reading energy technique nach Mitchell beim Bandscheibenvorfall der Lendenwirbelsäule. Manuelle Medizin 40:141–145 Hack A 2002 Wirbelsäulenschonendes Heben (parts 1–5). Manuelle Medizin 40,276–278, 279–281, 282–285, 286–288, 289–290. Hack A 2003 Die Klavikula – der Schlüssel zum Schultergelenk. Manuelle Medizin 41:199–204 Hack G D, Koritzer R, Robinson W L et al 1995 Anatomic relation between the rectus capitis posterior minor muscle and the dura mater. Spine 20:2484–2486 Hadler N M, Curtis P, Gillings D B et al 1990 Der Nutzen von Manipulationen als zusätzliche Therapie bei akuten Lumbalgien, eine gruppenkontrollierte Studie. Manuelle Medizin 28:2 Hadley L A 1957 The covertebral articulations and cervical foramen encroachment. Journal of Bone and Joint Surgery 39A:910–920 Hagbarth K E, Hägglund J V, Nordin M et al 1980 Thixotropic behaviour of human finger flexor muscles with accompanying changes in spindle and reflex responses to stretch. Journal of Physiology 368:323–342 Haig A J, Tong H C, Yamakawa K S et al 2006 Predictors of pain and function in persons with spinal stenosis, low back pain and no back pain. Spine 31:2950–2957 Haldeman S 1977 Why one cause of back pain? In: Buerger A A (ed) Approaches to the validation of manipulative therapy. Charles C Thomas, Springfield, p. 87–197 Haldeman S 1984 Manipulation and massage for the relief of pain. In: Wall P D, Melzack R (eds) Textbook of pain. Churchill Livingstone, London, p. 942–951 Haldeman S 1990 Presidential address. North American Spine Society, Failure of the pathology model to predict back pain. Spine 15: 718–724 Haldeman S (ed) 1992 Principles and practice of chiropractic. Appleton & Lange, East Norwalk Haldeman S, Dagenais S 2008 Supermarket or science for chronic back pain. The Spine Journal 8:1–278 Haldeman S, Rubinstein S M 1993 The precipitation or aggravation of
musculoskeletal pain in patients receiving spinal manipulative therapy. Journal of Manipulative and Physiological Therapeutics 16:47–50 Haldeman S, Kohlbeck F G, McGregor M 1999 Risk factors and precipitating neck movements causing vertebrobasilar artery dissection after cervical trauma and spinal manipulation. Spine 24:785–794 Hamann A 1974 Massage in Wort und Bild. Volk und Gesundheit, Berlin Hammer W I 1999 Functional soft tissue examination and treatment by manual methods, 2nd edn Aspen, Gaithersburg Hanten W P, Dawson D D, Iwata M et al 1998 Craniosacral rhythm, reliability and relationships with cardiac and respiratory rates. Journal of Orthopaedic and Sports Physical Therapy 27:213–218 Hargrave-Wilson W A, Sherry J H 1966 Cervical spondylosis and vertigo. Lancet 7449:1262–1263 Harrison D E, Harrison D D, Troyanovich S J 1997 The sacroiliac joint. A review of anatomy and biomechanics with clinical implications. Journal of Manipulative and Physiological Therapeutics 20:607–617 Hartman L S 1983 Handbook of osteopathic technique. N M K, Hadley Wood Hasner E, Schalimtzek M, Snorrason E 1952 Roentgenological examination of the function of the lumbar spine. Acta Radiologica 37:141–149 Hausamann E 1971 Hüftschmerz und Sakroiliakalgelenk. Manuelle Medizin 9:73–75 Hautant H 1927 L’étude clinique de l’examen fonctionel de l’appareil vestibulaire. Revue Neurologique 34:909–997 Hawk C, Long C, Azad A 1997 Chiropractic care for women with chronic pelvic pain, a prospective study. Journal of Manipulative and Physiological Therapeutics 20: 73–79 Head H 1893 On disturbances of sensation, with especial reference to the pain of visceral diseases. Brain 16:1–133 Heidsieck C H 1990 Der Kreuzschmerz und das Sakroiliakalgelenk in der Schwangerschaft. Manuelle Medizin 28:59
Heilig D 1981 The thrust technique. Journal of the American Osteopathic Association 81:244 Hellsten W 1969 Epikondyläre Schmerzen. Manulle Medizin 7:59–61 Hemborg B, Moritz U, Hohnström E 1985 Lumbar spinal support and weightlifters belt. Effect on intra-abdominal and intra-thoracic pressure during lifting. Journal of Manual Medicine 2:86–92 Hensell V 1976 Neurologische Schäden nach Repositionsmaßnahmen an der Wirbelsäule. Medizinische Welt 27:656–658 Henssge R 1984 Intermittierende vertebrobasiläre Insuffizienz. Fahrradergometrie als Provokationstest. in, Buchmann J, Badtke B, Sachse J (eds) Manuelle Therapie. Report [in German] of the 2nd Joint Conference of the Manual Therapy Section of the DDR Society for Physiotherapy and the Department of Sports Medicine of the Karl Liebknecht University, Potsdam, p. 196–199. Hermachová H 1995 Dysfunkce svalu pánevního dna [in Czech] (Dysfunction of the muscles of the pelvic floor). Rehabilitace a Fyzikální Lékarstvi 2:32–34 Hermachová H 1998 Jaké boty? [in Czech] (Which shoes?). Rehabilitace a Fyzikální Lékarstvi 5:29–31 Hermachová H 1999 O svalovém napetí a jeho ovlivneení ve fyzioterapii [in Czech] (Muscle tonus and how it is influenced by physiotherapy). Rehabilitace a Fyzikální Lékarstvi 6:108–110 Hermachová H 2001 O kožním vnímámí, jeho zmenách a ovlivnení [in Czech] (Tactile perception through the skin and how to modify it). Rehabilitace a Fyzikální Lékarstvi 8:182–184 Herrschmann H 1975 Ein Beitrag zur Behandlung des Sudeck-Syndroms. Zeitschrift für Physiotherapie 28:143–144 Hertel R, Ballmer F T, Gerber C 1999 Lag sign in the diagnosis of rotator cuff rupture. Journal of Orthopaedic Medicine 19:73–76 Herzog W, Read L J, Conway P J et al 1989 Reliability of motion palpation procedures to detect sacroiliac joint fixations. Journal of Manipulative and Physiological Therapeutics 12:86–92
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Manipulative Therapy Herzog W, Zhang Y T, Conway P J et al 1993 Cavitation sounds during spinal manipulative treatments. Journal of Manipulative and Physiological Therapeutics 16:523–526 Hestbaek L, Leboeuf-Yde C 2000 Are chiropractic tests for the lumbo-pelvic spine reliable and valid? Journal of Manipulative and Physiological Therapeutics 23: 258–275 Hestbaek L, Leboeuf-Yde C, Engberg M et al 2003 The course of low back pain in a general population. Results from a 5-year prospective study. Journal of Manipulative and Physiological Therapeutics 26: 213–219 Hettinger T 1983 Isometrisches Muskeltraining, 5th edn Thieme, Stuttgart Hides J A, Richardson C A, Jull G A et al 1995 Ultrasound imaging in rehabilitation. Australian Journal of Physiotherapy 41:187–193 Hildebrandt J, Argyrakis A 1986 Percutaneous nerve block of the cervical facets – a relatively new method in the treatment of chronic headache and neck pain. Pathological-anatomical studies and clinical practice, Journal of Manual Medicine 2:48–52 Hinck V C, Hopkins C E 1960 Measurement of the atlanto-dental interval in the adult. American Journal of Roentgenology 84: 945–951 Hinz P, Erdmann H 1978 Die Verletzungen der Halswirbelsäule durch Schleuderung und Abknickung. Wirbelsäule in Forschung und Praxis Volume47 Hippokrates, Stuttgart Hinzmann P, Sachse J 1988 Funktionelle Asymmetrie in der Beweglichkeit der oberen Extremität. Zeitschrift für Physiotherapie 40:77–85 Hirschberg G G, Fatt I, Brown E D 1986 Measurement of skin mobility in the upper back. Scandinavian Journal of Rehabilitation Medicine 18:173–175 Hirschberg G G, Williams K A, Byrd J 1992 Diagnosis and treatment of iliocostal friction syndrome. Journal of Orthopaedic Medicine 14:35–39 Hirscher G G 1998 An effective treatment of Morton’s neuralgia. Journal of Orthopaedic Medicine 20:13–14
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Hirschkoff S 1966 La palpation dynamique. Rheumatologie 18:47–51 Hodges P W, Richardson C A 1996 Inefficient muscular stabilization of the lumbar spine associated with low back pain. A motor control evaluation of transversus abdominis. Spine 21(22):2640–2650 Hoehler F K, Tobis J S, Buerger A A 1981 Spinal manipulation for low back pain. Journal of the American Medical Association 245:1835–1838 Hohl M 1964 Normal motion of the upper portion of the cervical spine. Journal of Bone and Joint Surgery 46A:1777–1779 Hohl M, Baker H R 1964 The atlantoaxial joint. Roentgenographic and anatomical study of normal and abnormal motion. Journal of Bone and Joint Surgery 46A:1739–1752 Hohmann D 1968 Die degenerativen Veränderungen an den Costotransversal-gelenken. Enke, Stuttgart Hong C-Z 1994 Considerations and recommendations regarding myofascial trigger point injection. Journal of Musculoskeletal Pain 2:29–59 Hong C-Z 1998 Algometry in evaluation of trigger points and referred pain. Journal of Musculoskeletal Pain 6:47–59 Hong C-Z 1999 Current research on myofascial pain. Journal of Musculoskeletal Pain 7:121–129 Hong C-Z, Chen Y C, Pon C H et al 1993 Immediate effect of various physical medicine modalities on pain threshold of an active myofascial trigger point. Journal of Musculoskeletal Pain 1:37–53 Hong C-Z, Chen Y C, Pon C H et al 1996 Histological findings of responsive loci in a myofascial trigger spot of rabbit skeletal muscle from where localized twich responses could be elicited. Archives of Physical Medicine and Rehabilitation 78:962 Horácek O 2002 Weakened muscles and instability in radicular syndromes [in Czech]. Rehabilitace a Fyzikální Lékarstvi 9:52–55 Howald H 1984 Morphologische und funktionelle Veränderungen der Muskelfasern durch Training. Manuelle Medizin 22:86–96 Howe J F, Loeser J D, Calvin W H 1977 Mechanosensitivity of dorsal root
ganglia and chronically injured axons, a physiological basis for the radicular pain of nerve root compression. Pain 3:25–41 Hsieh C J, Phillips R D, Adams A H et al 1992 Functional outcomes of low back pain, comparison of four treatment groups in a randomized controlled trial. Journal of Manipulative and Physiological Therapeutics 15:4–9 Hsieh C Y, Hong C-Z, Adams A H et al 2000 Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles. Archives of Physical Medicine and Rehabilitation 81(3):258–264 Huber E H, Ginzel H, Tilscher H 1977 Die Belastung des Skeletts von Kindern und Jugendlichen durch Ausübung verschiedener Sportarten. Pädiatrie und Pädologie 12:272–282 Hufschmidt H J 1959 Die Innervation der Rückenmuskulatur des Menschen. Pflügers Archiv für die gesamte Phyiologie 269:1–9 Hufschmidt H J 1970 Propriozeptivität und Steuerung der Rückenmuskulatur. In: Wolff H D (ed) Manuelle Medizin und ihre wissenschaftlichen Grundlagen. Physikal Med, Heidelberg, p. 75–78 Hughes B L 1993 Management of cervical disk syndrome utilizing manipulation under anesthesia. Journal of Manipulative and Physiological Therapeutics 16: 174–181 Huguenin F 1984 Der intrakanalikuläre Bandapparat des zerviko-okzipitalen Überganges. Eine klinische und diagnostische Studie seiner Funktion und Verletzungen. Manuelle Medizin 22:25–29 Huguenin F, Hopf A 1993 Die dynamische Untersuchung der Subokzipitalregion (Kopfgelenke) mit der Methode der Magnetresonanz. Manuelle Medizin 31:82–84 Hülse M 1992 Die zervikale Dysphonie. Manuelle Medizin 30:61–66 Hülse M 1994 Die zervikale Hörstörung. HNO 42:604–613 Hult L 1972 Frequency of symptoms for different age groups and professions. In: Hirsch C, Zotterman Y (eds) Cervical pain. Oxford, Pergamon Press Huneke W 1953 Impletholtherapie und andere neuraltherapeutische Verfahren. Hippokrates, Stuttgart
Further reading Hurwitz E L, Aker P D, Adams A H et al 1996 Manipulation and mobilization of the cervical spine, a systematic review of the literature. Spine 21:1746–1760 Hurwitz E L, Morgenstern H, Harber F et al 2002 The effectiveness of physical modalities among patients with low back pain randomized to chiropractic care, findings from the UCLA low back pain study. Journal of Manipulative and Physiological Therapeutics 25:10–20 Hutson M 2005 The challenge for science in manual/musculoskeletal medicine, in support of pragmatism. Australasian Musculoskeletal Medicine 10:108–110 Hutson M, Ellis R 2006 Textbook of musculoskeletal medicine. Oxford University Press, Oxford Hvidim H 1971 The influence of chiropractic treatment on rotatory mobility of the cervical spine – a kinesiometric and statistical study. Annals of the Swiss Chiropractic Association 5:31–44 Hvidim M A 1997 Work-related upper limb disorders. ButterworthHeinemann, Oxford Ibatulin I A, Zaiceva R L, Chudnovskij N A 1987 Strojenie i gistografia meniskoidnych struktur atlantozatylocnovo i atlantoosevych sustavov [in Russian] (Structure and histotopography of the meniscoids of the atlanto-axial joints). Archiv anatomii, gistologii i embriologii 92:30 Iljajeva S M 1994 Radonbäder und manuelle Therapie in der Behandlung von Patienten nach kraniozervikalen Verletzungen. Manuelle Medizin 32:189–195 Iselin M 1977 Influence de la colonne vertébrale sur l’épicondylite. Therapeutische Umschau (Revue Thérapeutique) 34:88–91 Ivanichev G A 1983 Functional status of the cervical spinal cord segments in patients with localized muscle hypertonus [in Russian]. Nevropatol i psichiat 83:646–650 Ivanichev G A 1986 Manual therapy for secondary contracture of the muscles of facial expression [in Russian]. Nevropatol i psichiat 86:357–359 Ivanichev G A 1992 The electromyographic characteristics of muscle trigger points [in Russian]. Vertebronevrologia 2:33–37
Ivanichev G A, Lewit K 1994 Pathogenesis of contracture of the muscles of facial expression [in Czech]. Rehabilitace a Fyzikální Lékarstvi 1:11–15 Ivanichev G A, Ivanicheva N A, Jesin R G et al 1985 Changeable discrete tonometry in the assessment of the efficacy of post isometric relaxation of local muscle tension [in Russian]. Nevropatol i psichiat 85:519–523 Jacob H A, Kissling R O 1995 The mobility of the sacroiliac joints in healthy volunteers between 20 and 50 years of age. Clinical Biomechanics 10:352–361 Jacobson G, Adler D C 1953 An evaluation of lateral atlanto-axial displacement in injuries of the cervical spine. Radiology 61:355–362 Jacobson G, Adler D C, Bleecher A A 1959 Pseudosubluxation of the axis in children. American Journal of Roentgenology 82:472 Jakoubek B, Rohlícek V 1982 Changes of electrodermal properties in acupuncture points in men and rats. Physiologia bohemicoslovaca 31:143–149 Janda V 1967 Die Motorik als reflektorisches Geschehen und ihre Bedeutung in der Pathogenese vertebragener Störungen. Manuelle Medizin 5:1–5 Janda V 1968 The dynamic motor patterns and their importance in the rehabilitation of motor system dysfunctions [in Czech]. In: Pokroky v rehabilitaci. SZdN, Prague, p. 119–137 Janda V 1968 Die Bedeutung der muskulären Fehlhaltung als pathogenetischer Faktor vertebragener Störungen. Archiv für Physikalische Therapie 20:113–116 Janda V 1972 What is the typical standing position in humans? [in Czech] Cas Lék ces 111:748–750 Janda V 1975 Muscle and joint correlations. In: Functional pathology of the motor system. Rehabilitácia Supplement 10–11, 154–158 Janda V 1975 Die muskulären Hauptsyndrome bei vertebragenen Beschwerden. In: Neumann H D, Wolff H D (eds) Theoretische Fortschritte und praktische Erfahrungen der Manuellen Medizin. Konkordia, Bühl, p. 61–65 Janda V 1982 Introduction to the functional pathology of the motor
system. Physiotherapy in Sport 3:39–42 Janda V 1983 Prevention of injuries and their late sequelae. Australasian Journal of Physiotherapy 29:83–84 Janda V 1983 Muscle function testing. Butterworth, London Janda V 1984 Gestörte Bewegungsverläufe und Rückenschmerzen. Manuelle Medizin 22:74–79 Janda V 1991 Muscle spasm – a proposed procedure for differential diagnosis. Journal of Manual Medicine 6:136–139 Janda V 1993 Die Muskelabschwächung in der Rückenschule. In: Rieder H, Eichler J, Kalinke H (eds) Rückenschule interdisziplinär. Medizinische, pädagogische und psychologische Beiträge. Thieme, Stuttgart, p. 203–206 Janda V 1999 The relationship between structural and functional changes in the locomotor system [in Czech]. Rehabilitace a Fyzikální Lékarstvi 6:6–8 Janda V 2002 The cervicocervical junction. Journal of Orthopaedic Medicine 24:77–78 Janda V, Gilbertová S 1988 Excessive strain on the upper extremities due to repeated movements (RSI syndrome) [in Czech]. Pracov Lék 40:180–183 Janda V, Lewit K 1980 Trends und Perspektiven der Manuellen Medizin. Manuelle Medizin 18:1–6 Jandová J 2002 Contribution to a clinical understanding of the scalene muscles [in Czech]. Rehabilitace a Fyzikální Lékarstvi 9:12–13 Jani L 1972 Der Kreuzschmerz bei Kindern und Jugendlichen. Orthopädische Praxis 1:156–164 Jarvis G 1997 The relationship between upper and lower limb disorders and lower limb neurodynamics. Journal of Orthopaedic Medicine 19:35–42 Jayson M I V 1970 The problem of backache. The Practitioner 205: 615–621 Jayson M I V 1981 The lumbar spine and back pain, 2nd edn. Pitman Medical, London Jenker F L, Dossi A 1977 Zusammenhänge und Diskrepanzen zwischen klinischer Symptomatologie und röntgenologischen Veränderungen an der Halswirbelsäule beim
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Manipulative Therapy Zervikalsyndrom und Arm-SchulterSyndrom. Manuelle Medizin 15:115–123 Jensen M C, Brant-Zawadzki M N, Obuchowski N et al 1994 Magnetic resonance imaging of the lumbar spine in people without back pain. New England Journal of Medicine 331:69–73 Jensen R, Bendtsen L, Olesen J 1998 Muscular factors are of importance in tension-type headache. Headache 38(1):10–17 Jirout J 1964 Korelace dynamických poruch krcní pátere v sagitální a frontální rovine [in Czech] (Correlation of dynamic dysfunctions of the cervical spine in the frontal plane). Ceskoslovenská Neurologie 27:196 Jirout J 1967 Dynamics of the spinal dural sac under normal conditions. British Journal of Radiology 40: 209–213 Jirout J 1970 The response of the cervical spine to stress on the upper extremities in healthy subjects [in Czech]. Ceskoslovenská Neurologie 33:7–61 Jirout J 1971 Patterns of changes in the cervical spine on lateroflexion. Neuroradiology 2(3):164–166 Jirout J 1971 Vertebral tilting in the sagital plane on lateral flexion [in Czech]. Ceskoslovenská Neurologie 34:225–229 Jirout J 1972 Motility of the cervical vertebrae in lateral flexion of the head and neck. Acta Radiologica, Diagnosis (Stockholm) 13:919–927 Jirout J 1972 Úcinek zevních vlivu na lateroflexi krcní pátere [in Czech] (The influence of exogenous factors on lateral flexion of the cervical spine). Ceskoslovenská Neurologie 35:119–123 Jirout J 1973 Changes in the atlas-axis relations on lateral flexion of the head and neck. Neuroradiology 6(4):215–218 Jirout J 1976 Bedeutung der Synkinesien für die Entstehung der Wirbelblockierung. Manuelle Medisin 16:1–2 Jirout J 1978 Veränderungen der Beweglichkeit der Halswirbel in der frontalen und der horizontalen Ebene nach manueller Beseitigung der Segmentblockierung. Manuelle Medizin 16:2–5
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Jirout J 1980 Rotational synkinesis of occiput and atlas on lateral inclination. Neuroradiology 21:1–4 Jirout J 1980 Einfluss der einseitigen Grosshirndominanz auf das Röntgenbild der Halswirbelsäule. Radiologe 20:466–469 Jirout J 1986 Significance of the time factor in the dynamics of the cervical spine. Journal of Manual Medicine 5:277–293 Jirout J 1987 Die segmentale synkinetische sagittale Hypermobilität bei Seitneigung. Manuelle Medizin 25:71 Jirout J 1990 Radiographic signs of the function of the intrinsic muscles of the spine. In: Paterson J K, Burn L (eds) Back pain. An international review. Kluwer Academic, Dordrecht, p. 391 Jirout J 1990 Das Gelenkspiel der Halswirbelsäule. In: Biedermann H, Gutmann G (eds) Funktionelle Pathologie und Klinik der Wirbelsäule. Vol. 1. Die Halswirbelsäule, Part 3. Fischer, Stuttgart Jirout J 1991 A new approach to testing of long-term resistance of the spine to mechanical stress. Journal of Manipulative and Physiological Therapeutics 14:509–511 Jirout J 1991 Effect of variations in mobility in the frontal plane at the occiput-atlas level on the dynamics of the atlas-axis segment during side-bending of the head and neck. Journal of Manual Medicine 6:182–184 Jirout J 1997 The role of the deep intersegmental muscles in the dynamic synkinesis of the cervical spine [in Czech]. Rehabilitace a Fyzikální Lékarstvi 4:131–132 Jirout J, Lewit K, Kvícala V et al 1973 Neuroradiology of the spine [in Czech]. Avicenum, Prague Johansson H P, Sjolander P, Sojka O 1991 Receptors in the knee joint ligaments and their role in biomechanics of the joint. Critical Reviews in Biomechanic Engineering 18:341–368 Johnston W L 1993 Functional technique. In: Basmajian J V, Nyberg R (eds) Rational manual therapies. Williams & Wilkins, Baltimore, p. 335–346 Jones L H 1981 Strain and counterstrain. The Academy of Osteopathy, Newark
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pseudoanginal root syndrome and angina pectoris. American Heart Journal 59:191–207 Maitland G D 1983 Vertebral manipulation, 4th edn. Butterworth, London Maitland G D 1985 The importance of adding compression when examining and treating synovial joints. In: Glasgow E F, Twomey L T, Scull E R et al (eds) Aspects of manipulative therapy, 2nd edn. Churchill Livingstone, Melbourne, p. 100 Malinský J 1959 The innervation of the intervertebral disks in humans in the course of ontogenesis [in Czech]. Acta Univ Palac Olomouc 19:69–84 Mallinson A I, Longdridge N S, Peacock C 1996 Dizziness, imbalance and whiplash. Journal of Musculoskeletal Pain 4:105–112 Malmivaara A, Pohjola R 1982 Cauda equina syndrome caused by chiropraxis on a patient previously free of lumbar spine symptoms. Lancet II:986–987 Manca Š, Niepel G, Dinka I 1977 Anteil der Kokzygodynie an den Kreuzschmerzen. Manuelle Medizin 15:32–35 Manga P, Angus D, Papadopoulos C et al 1993 A study to examine the effectiveness and cost-effectiveness of chiropractic management of low-back pain. Pran Manga and Associates, University of Ottawa Mannello D M 1992 Leg length inequality (review of the literature). Journal of Manipulative and Physiological Therapeutics 15: 576–590 Marcus D A, Scharff L, Marcer S et al 1999 Musculoskeletal abnormalities in chronic headache. A controlled comparison of headache diagnosis groups. Headache 39:21–27 Marshall K, Walsh D M, Baxter G D 2002 The effect of vaginal delivery on the integrity of the pelvic floor. Clinical Rehabilitation 16:195–199 Martin P 1985 Classification of headache, the need for radical revision. Editorial. Cephalalgia 5:1–4 Masters S, McConachie A 1999 Musculoskeletal outcomes in primary care, six months outcome. Australasian Journal of Musculoskeletal Medicine 4:24–31 Maxwell J, Walsh B A, Polus I 1999 A randomized placebo-controlled clinical trial on the efficacy of
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Manipulative Therapy chiropractic therapy on the premenstrual syndrome. Journal of Manipulative and Physiological Therapeutics 22:282–285 Meade T W, Dyer S, Brwne W et al 1990 Low back pain of mechanical origin, randomised comparison of chiropractic and hospital outpatient treatment. British Medical Journal 300:1431–1437 Med M 1972 Articulations of the thoracic vertebrae and their variability. Folia Morphologica 20:217–218 Med M 1973 Articulations of the cervical vertebrae and their variability. Folia Morphologica 21:324–327 Med M 1975 Variability of intervertebral articulations with regard to movement of the spine. In: Lewit K, Gutmann G (eds) Functional pathology of the motor system. Rehabilitácia Supplement 10–11. Obzor, Bratislava, p. 36–40 Med M 1980 Prenatal development of intervertebral articulations in man and its association with ventrodorsal curvature of the spine. Folia morphologica 28:264–277 Med M 1982 Prenatal development of lumbar intervertebral articulations. Folia morphologica 30:285–390 Meeker W C, Haldeman S 2002 Chiropractic, a profession at the crossroads of mainstream and alternative medicine. Annals of Internal Medicine 136:216–227 Meier B 1975 Der Schmerz im Bewegungsapparat – Manuelle Therapie in einer Betriebspoliklinik. Zeitschrift für Ärztliche Fortbildung 6:599–621 Meijne W, van Neerbos K, Aufdemkampe G et al 1999 Intraexaminer and interexaminer reliability of the Gillet test. Journal of Manipulative and Physiological Therapeutics 22:4–9 Melzack R 1973 The puzzle of pain. Penguin Books, Harmondsworth Melzack R 1975 Prolonged relief of pain by brief intense transcutaneous somatic stimulation. Pain 1:357–373 Menegaz A A, Fasoli M 1970 Die Innervation der vertebralen interapophysären Gelenke in verschiedenen Abschnitten der Wirbelsäule. In: Manuelle Medizin und ihre wissenschaftlichen
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Grundlagen. Physikalische Medizin, Heidelberg, p. 69–75 Mennell J McM 1972 Treatment of myofascial pain secondary to facet joint dysfunction. Manuelle Medizin 10:84–88 Mennell J McM 1979 Manipulation therapy for low back pain. In: Bonica J (ed) Advances in pain research and therapy, Vol 1. Raven Press, New York Mense S 1991 Physiology of nociception in muscles. Journal of Manual Medicine 6:24–33 Mense S 1991 Considerations concerning the neurobiological basis of muscle pain. Canadian Journal of Physiology and Pharmacology 69:610–616 Mense S 1999 Neue Entwicklungen im Verständnis von Triggerpunkten. Manuelle Medizin 37:115–120 Mense S 2005 Muskeltonus und Muskelschmerz. Manuelle Medizin 40:156–161 Mense S, Simons D G 2001 Muscle pain. Lippincott, Williams & Wilkins, Baltimore Mensendieck B 1954 Look better, feel better. New York Harpers Metz E G 1976 Manuelle Therapie in der Inneren Medizin. Zeitschrift für Physiotherapie 28:83–94 Metz E G 2003 Manuelle Therapie bei zervikogenem Kopfschmerzen. In: Schilgen M, Evers S (eds) Zervikogener Kopfschmerz. Bertelsmann Stiftung, Gütersloh Metz E G, Badtke G 1980 Manuelle Therapie. Conference report. Wissenschaftlich-Technisches Zentrum der Pädagogischen Hochschule ‘Karl Liebknecht’, Potsdam Metz E G, Knäblich C, Fröhling P et al 1980 Die Bedeutung vertebragener Funktionsstörungen für den Beschwerdenkomplex bei Nephroptose. Zeitschrift für Physiotherapie 32:405–411 Meyr T G, Mooney V, Gtatchel R J 1991 Conservative care for painful spinal disorders. Lea & Febiger, Philadelphia Mierau D, Cassidy J D, Hamin T et al 1984 Sacroiliac joint dysfunction and low back pain in school aged children. Journal of Manipulative and Physiological Therapeutics 7:81–84 Mildenberger R 1979 Indikationen zur Röntgenuntersuchung der
Wirbelsäule. Manuelle Medizin 17:99–100 Miratský Z, Süssová J, Figar Š et al 1964 Electroencephalographic studies of the formation and fixation of pain reflexes in lumbar disk lesions [in Czech]. Ceskoslovenská Neurologie 27:260 Mitchell B S, Humphries D C, Sullivan E 1998 Attachment of the ligamentum nuchae to the cervical posterior dura and the lateral part of the occipital bone. Ceskoslovenská Neurologie 21:145–148 Mohr U 1977 Kopfgelenksblockierung beim Kleinkind. Manuelle Medizin 15:45–47 Montgomery C 1976 Preemployment back X-rays. Journal of Occupational Medicine 18:495–498 Moran R W, Gibbons P 2001 Interexaminer and intraexaminer reliability of the cranial rhythmic impulse at the head and sacrum. Journal of Manipulative and Physiological Therapeutics 24: 183–190 Moravec I 1962 Vertigo cervicalis. Cas Lék ces 101:20–25 Morris C E 1993 Spinal manipulation under anesthesia. An overview. California Workers’ Compensation Enquirer, August, p. 9 Morris C E (ed) 2006 Low back syndromes. Integrated clinical management. McGraw-Hill, New York Moser M, Simon H 1977 Der Cervikalnystagmus als objektiver Befund beim HWS-Syndrom und seine Beeinflussbarkeit durch Manualtherapie. HNO 25:265–268. Mottram S, Comerford M 1998 Stability dysfunction and low back pain. Journal of Orthopaedic Medicine 20:13–18 Mühlemann D, Zahnd F 1993 Die lumbale segmentale Hypermobilität. Eine häufige Ursache chronischer Rückenschmerzen. Manuelle Medizin 31:47–54 Müller E 1966 Das Schleudertrauma der Halswirbelsäule und seine verschiedenen Folgen. Deutsche medizinische Wochenschrift 91: 588–593 Müller W 1985 Das femoropatelläre Gelenk. Orthopäde 14:204–214 Mumenthaler M 1980 Der SchulterArm-Schmerz. Huber, Bern
Further reading Mumenthaler M, Schliack H 1965 Läsionen peripherer Nerven. Thieme, Stuttgart Murphy D R (ed) 2000 Conservative management of cervical spine syndromes. McGraw-Hill, New York Nachemson A 1963 The influence of spinal movements on the lumbar intradiscal pressure and on the tensile stresses of the anulus fibrosus. Acta Orthopaedica Scandinavica 33:183–207 Nachemson A 1981 A critical look at conservative treatment of low back pain. In: Jayson M I V (ed) The lumbar spine and back pain, 2nd edn. Pitman Medical, London, p 341–358 Naegeli O 1954 Nervenleiden und Nervenschmerzen. Ihre Behandlung und Heilung durch Handgriffe. Haug, Ulm. Nansel D, Cremata E, Carlson J et al 1989 Effect of unilateral spinal adjustment on goniometricallyassessed cervical lateral-flexion end-range asymmetries in otherwise asymptomatic subjects. Journal of Manipulative and Physiological Therapeutics 12:419–427 Nansel D, Peneff A L, Jansen R D et al 1989 Interexaminer concordance in detecting joint-play asymmetries in the cervical spine of otherwise asymptomatic subjects. Journal of Manipulative and Physiological Therapeutics 12:428–433 Nansel D, Peneff A, Quitoriano J 1992 Effectiveness of upper versus lower cervical adjustments with respect to the amelioration of passive rotational versus lateral-flexion end-range asymmetries in otherwise asymptomatic subjects. Journal of Manipulative and Physiological Therapeutics 15:99–102 Nansel D, Waldorf T, Cooperstein R 1993 Effect of cervical spinal adjustment on lumbar paraspinal muscle tone, evidence for facilitation of intersegmental tonic neck reflexes. Journal of Manipulative and Physiological Therapeutics 16:91–95 Natchev E A 1994 Manual of autotraction treatment for low back pain. Folksam Scientific Council, Stockholm Nause E 1987 Rationelle Epikondylitidenbehandlung. Manuelle Medizin 25:82
Nesit V, Horinová M 1975 Funktionsstörungen der Wirbelsäule in der ambulanten gynäkologischen Praxis. Manuelle Medizin 13: 31–34 Neumann H D 1981 Die manualmedizinische Behandlung des akuten Schiefhalses. Zeitschrift für Orthopädie 119:693 Neumann H D 1989 Manuelle Medizin. Eine Einführung in Theorie, Diagnostik und Therapie, 3rd edn. Springer, Berlin Neumann H D 1985 Manuelle Diagnostik und Therapie von Blockierungen der Kreuzdarmbeingelenke nach F Mitchell (Muskelenergietechnik). Manuelle Medizin 23:116–126 Neumann H D, Wolf H D 1979 Theoretische Fortschritte und praktische Erfahrungen der Manuellen Medizin. Sixth International FIMM Congress, Baden-Baden. Konkordia, Bühl. Niboyet J E H 1968 Pratique de la médecine manuelle. Maisonneuve, Paris Niethart F U, Rompe G 1982 Das lumbale Facettensyndrom. Manuelle Medizin 19:49–53 Nilsson N 1995 The prevalence of cervicogenic headache in a random population sample of 20–50 year olds. Spine 20:1886–1888 Nilsson N 1996 Randomized controlled trial of the effect of spinal manipulative treatment of cervical headache. Journal of Manipulative and Physiological Therapeutics 19:435–440 Nilsson N, Hartvigsen J, Christensen H W 1996 Normal ranges of passive cervical motion for women and men 20–60 years old. Journal of Manipulative and Physiological Therapeutics 19:306–330 Nilsson N, Christensen H W, Hartvigsen J 1997 The effect of spinal manipulation of cervicogenic headache. Journal of Manipulative and Physiological Therapeutics 20:326–330 Nordemar R, Thörner C 1981 Treatment of acute cervical pain – a comparative group study. Pain 10:93 Norden N, Skovron M L, Hiebert R et al 1997 Early predictor of delayed return to work in patients with low back pain. Journal of Musculoskeletal Pain 5:5–27
Novotný A, Dvorák V 1972 Dysfunctions of the spinal column in gynecology [in Czech]. Cas Lék ces 111:107–115 Nwuga V B C 1982 Relative therapeutic efficacy of vertebral manipulation and conventional treartment for back pain management. American Journal of Physical Medicine 61:273–278 Oesch R 1995 Die Rolle der Zygapophysealgelenke in der Ätiologie lumbaler Rückenschmerzen mit und ohne Ausstrahlung. Eine Literaturumschau. Manuelle Medizin 32:107–114 Olsen T L, Anderson R L, Dearwater S R et al 1992 The epidemiology of low-back pain in an adolescent population. American Journal of Public Health 82:606–608 Onderka W, Müller-Stephan H 1973 Die manuelle Extension der Halswirbelsäule. Zeitschrift für Physiotherapie 25:461–465 Osterbauer P J, Derickson K L, Peles J D et al 1992 Three-dimensional head kinematics and clinical outcome of patients with neck injury treated with spinal manipulative therapy, a pilot study. Journal of Manipulative and Physiological Therapeutics 15:501–511 Osterbauer P J, Long K, Ribaudo T A et al 1996 Three-dimensional head kinematics and cervical range of motion in the diagnosis of patients with neck trauma. Journal of Manipulative and Physiological Therapeutics 19 :231–237 O’Sullivan P, Twomey L T, Allison G et al 1997 Altered patterns of abdominal muscle activation in patients with chronic low back pain. Australasian Journal of Physiotherapy 43:91–97 Otte P 1965 Über das Wachstum der Gelenkknorpel. Hüttig, Heidelberg Palmer B J 1933 The subluxation specific, the adjustment specific. Palmer College of Chiropractic, Davenport/Iowa Parade G W 1955 Halswirbelsäule und Herz. Die zervikalen Vertebralsyndrome. Thieme, Stuttgart Parker G P, Tupling H, Pryor D S 1978 A controlled trial of cervical manipulation for migraine. Aust N Z J Med 8:589–593
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Manipulative Therapy Patijn J 1991 Complications in manual medicine, a review of the literature. Journal of Manual Medicine 6:89–92 Patijn J 2002 Studien zur Reproduzierbarkeit und Validität diagnostischer Verfahren in der manuellen Medizin. Manuelle Medizin 40:339–351 Patijn J, Durinck J R 1991 Effects of manual medicine on absenteeism. Journal of Manual Medicine 6:49–53 Patijn J, Ellis R 2001 Low back pain, reproducibility of diagnostic procedures in manual/ musculoskeletal medicine. Journal of Orthopaedic Medicine 23:36–42 Patijn J, Kingma H 1994 Der Zervikalnystagmus und die Manuelle Medizin. Manuelle Medizin 32: 81–90 Patijn J, Jonquiere M, Brouwer R et al 1998 The whiplash-associated acromio-clavicular syndrome. Journal of Orthopaedic Medicine 20:10–12 Patterson M N, Steinmetz J F 1986 Long-lasting alterations of spinal reflexes. A potential basis for somatic dysfunction. Journal of Manual Medicine 2:38–42 Pavlu D, Novosadová K 2001 Objective demonstration of the efficacy of sensomotor stimulation after Janda and Vávrová as a contribution to evidence-based practice [in Czech]. Rehabilitace a Fyzikální Lékarstvi 8:178–181 Pellow J E, Brantingham W 2001 The efficacy of adjusting the ankle in the treatment of subacute and chronic grade I and grade II ankle inversion sprain. Journal of Manipulative and Physiological Therapeutics 24:17–24 Penning L 1978 Normal movements of the cervical spine. American Journal of Roentgenology 130:317–326 Penning L, Töndury G 1963 Entstehung, Bau und Funktion der meniskoiden Strukturen in den Halswirbelgelenken. Zeitschrift für Orthopaedie 98:1–14 Peper W 1978 Der chiropraktische Report. Haug Heidelberg Perfetti C 1997 Der hemiplegische Patient, cognitiv-therapeutisches Üben. Pflaum, Munich Piganiol G 1987 Les manipulations vertébrales. Bases théoriques, cliniques et bioméchaniques. GEMABFC, Dijon Piganiol G, Trouilloud P, Binnert D et al 1994 Zur dreidimensionalen
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Rekonstruktion des FunktionsCT der subokzipitalen Region bei segmentaler Funktionsstörung. Manuelle Medizin 32:162–164 Pikula J R 1999 The effect of spinal manipulative therapy (SMT) on pain reduction and range of motion in patients with acute unilateral pain, a pilot study. Journal of the Canadian Chiropractic Association 43:111–119 Pioch E, Niemeier K, Seidel W 2006 Manual medicine in the treatment of chronic musculoskeletal pain syndromes, evaluation of an inpatient treatment programme. Journal of Orthopaedic Medicine 28:4–12 Plato G, Kopp S 1999 Kiefergelenk und Schmerzsyndrome. Manuelle Medizin 37:143–151 Plaugher G, Hendricks A H, Doble R W Jr. et al 1993 The reliability of patient positioning for evaluating static radiologic parameters of the human pelvis. Journal of Manipulative and Physiological Therapeutics 16:517–522 Pollard H, Ward G 1998 The effect of upper cervical or sacroiliac manipulation on hip flexion range of motion. Journal of Manipulative and Physiological Therapeutics 21:611–616 Ponge T, Cottin S, Ponge A et al 1989 Accident vasculaire vertébrobasilaire après manipulation du rachis cervical. Revue du Rhumatisme 56:545–548 Pope M H, Phillips R B, Haugh L D et al 1994 A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain. Spine 19:2571–2577 Popelyanski Y U 1992 Neuroses and osteochondroses are the most widespread diseases affecting humankind [in Russian]. Veretebronevorolgia 2:22–26 Popelyanski Y U, Popelyanski A Y 1984 Therapy of neurodystrophic disorders of the musculoskeletal apparatus [in Russian]. Revmatologija 84:66–70 Popelyanski Y U, Podolskaya M A 1990 Über zerebrale Faktoren vertebragener Erkrankungen. Die Rolle der Propriozeption und der Wahrscheinlichkeitsprognose. Manuelle Medizin 28:48
Porter R W, Hibbert C, Wellman P 1980 Backache and the lumbar spinal canal. Spine 5:99–105 Prang L, Ludolf E 1984 Die posttraumatische Instabilität im Bereich der Lendenwirbelsäule – ein diagnostisches Problem. Manuelle Medizin 22:133–135 Prantl K 1985 X-ray examination and functional analysis of the cervical spine. Journal of Manual Medicine 2:5–15 Pros J R 1961 Exercise and sport as prevention for dysmenorrhea [in Czech]. Cs Gynek 26:48–49 Putto E, Tallroth K 1990 Extension– flexion radiographs for motion studies of the lumbar spine. Spine 15:107–110 Putz R 1986 Biomechanik des Schultergürtels. Manuelle Medizin 24:1–7 Quon J A, Cassidy J D, O’Connor S M et al 1989 Lumbar intervertebral disc herniation, treatment by rotational manipulation. Journal of Manipulative and Physiological Therapeutics 12:220–227 Radanov B P, Davorák J, Valach L 1990 Folgezustände der Schleuderverletzung der Halswirbelsäule. Manuelle Medizin 28:28 Radebold A, Cholewicki J, Panjabi M M et al 2000 Muscle response pattern to sudden trunk loading in healthy individuals and patients with chronic low back pain. Spine 25(8):947–954 Rahlmann J F 1987 Mechanisms of intervertebral joint fixation, a literature review. Journal of Manipulative and Physiological Therapeutics 10:177–187 Rasmussen G G 1979 Manipulation in treatment of low back pain (a randomised clinical trial). Manuelle Medizin 17:8–10 Refior H, Zenker H 1970 Wirbelsäule und Leistungsturnen. Münchener medizinische Wochenschrift 112:463–467 Refisch A, Bischoff P 2004 Manipulation und Läsionen der Zervikalarterie. Manuelle Medizin 42:109–118 Reich C, Dvorák J 1986 The functional evaluation of craniocervical ligaments in side-bending, using X-rays. Journal of Manual Medicine 2:108 Reitinger A, Radner H, Tilscher H et al 1995 Morphologische
Further reading Untersuchungen an Triggerpunkten. Manuelle Medizin 34:156–262 Retzlaff E W, Mitchell F L Jr. (eds) 1987 The cranium and its sutures. Springer, Berlin Reynolds M D 1981 Myofascial trigger point syndromes in the practice of rheumatology. Archives of Physical Medicine and Rehabilitation 62: 111–114 Reynolds M D 1983 The development of the concept of fibrositis. Journal of the History of Medicine and Allied Sciences 38:5–35 Ribbe E B, Lindgren S S, Norgren L E 1982 Clinical diagnosis of thoracic outlet syndrome – evaluation of patients with cervicobrachial symptoms. Journal of Manual Medicine 2:82–85 Richardson C A, Snijders C J, Hides J A et al 2002 The relation between the transversus abdominis muscles, sacroiliac joint mechanics and low back pain. Spine 27:399–405 Richter R 1971 Die Bedeutung der ‘entrapment neuropathy’ für die Differentialdiagnose vertebragener Schmerzzustände. Manuelle Medizin 9:101–111 Richter T, Lawall J 1993 Zur Zuverlässlichkeit der manualdiagnostischen Befunde. Manuelle Medizin 31:1–11 Ridder P S 1996 Kieferfunktionsstörungen und Zahnfehlstellungen mit ihren Auswirkungen auf die Körperhaltung. Manuelle Medizin 35:100–105 Rinsky L A, Reynolds G G, Jameson R M et al 1976 A cervical spinal cord injury following chiropractic manipulation. Paraplegia 13:223–227 Robertson J T 1981 Neck manipulation as a cause of stroke. Stroke 12:54–59 Rogers J T, Rogers J G 1976 The role of osteopathic manipulative therapy in treatment of coronary artery disease. Journal of the American Osteopathic Association 76:71–78 Rogers R G 1997 The effect of spinal manipulation on cervical kinesthesia in patients with chronic neck pain, a pilot study. Journal of Manipulative and Physiological Therapeutics 20:80–85 Rohde J 1975 Die Automobilisation der Extremitätengelenke. Zeitschrift für Physiotherapie 27:57–65 Rohde J 1976 Die Automobilisation der Extremitätengelenke. Teil II, Hand
und Fußgelenke. Zeitschrift für Physiotherapie 28:51–61 Rohde J 1976 Die Automobilisation der Extremitätengelenke. Teil III, Therapieverfahren. Zeitschrift für Physiotherapie 28:121–134 Rohde J 1997 Zervikales und lumbales Radikulärsyndrom, Untersuchung der Klopfschmerzhaftigkeit des Periosts der Extremitäten. Manuelle Medizin 35:313–318 Rohde J 2003 Die Gelenkschule. Manuelle Medizin 41:189–198 Rohde J, Jaschke B 2004 Die Gelenkschule. Teil 2, Untersuchung zum Einfluss des Fahrradergometertrainings auf Gelenkschmerzen bei Gonarthrose. Manuelle Medizin 42:279–286 Rosber A L 2003 Zerebrovaskuläre Ereignisse. Manuelle Medizin 41:215–223 Rossi F 1978 Spondylosis, spondylolisthesis and sports. Journal of Sports Medicine 18:317–340 Rubin D 1981 Myofascial trigger point syndromes, an approach to management. Archives of Physical Medicine and Rehabilitation 62: 107–111 Ruddy T J 1961 Osteopathic rhythmic resistive duction therapy. Academy of Applied Osteopathy Yearbook, Colorado Springs, p. 58–65 Rude J 1981 Zur Morphologie der Okzipitalkondylen und Gelenksmechanik der oberen Kopfgelenke. Manuelle Medizin 22:101–106 Ryan G M S 1955 Cervical vertigo. Lancet 2:1355–1358 Rychlíková E 1973 Reflex changes in ischemic heart disease and their amenability to therapeutic influence [in Czech]. Prakt Lék 53:378–381 Rychlíková E, Véle F 1973 Acute myocardial infarction in the setting of acute movement restriction of the cervical spine [in Czech]. Prakt Lék 53:428–492 Saal J A, Saal J S 1989 Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy. An outcome study. Spine 14:431–437 Sabo L A Jr. 1988 Possible clinical significance of intraarticular synovial protrusions, a review of the literature. Journal of Manual Medicine 3:148
Sachse J 1984 Konstitutionelle Hypermobilität als Zeichen einer zentralen motorischen Koordinationsstörung. Manuelle Medizin 22:116–121 Sachse J 1988 Diagnostische Erfassung von Störungen des M. tensor fasciae latae bei Schmerzsyndromen der Hüftregion. Zeitschrift für Physiotherapie 40:87–92 Sachse J 1995 Zum Kapselmuster des Schultergelenkes. Manuelle Medizin 33:84–87 Sachse J 2001 Extremitätengelenke. Manuelle Untersuchung und Mobilisationsbehandlung für Ärzte und Physiotherapeuten. Urban und Fischer, Munich Sachse J, Berger M 1986 Mobilisationswirkung von Blickrichtungen im Zervikomotogramm. Zeitschrift für Physiotherapie 38:61–68 Sachse J, Kunz B 1974 Funktionelle Befunde an der Halswirbelsäule bei Atlasberstungsfraktur nach Jefferson. Beiträge zur Orthopädie und Traumatologie 21:200–204 Sachse J, Schildt K 1992 Manuelle Untersuchung und Mobilisationsbehandlung der Wirbelsäule. Methodischer Leitfaden. Ullstein Mosby, Berlin Sachse J, Wiechmann J, Gomolka U 1976 Vorschlag für einen gestuften Test zur Beurteilung des Bewegungstypes (Steifheit – Hypermobilität). Zeitschrift für Physiotherapie 28:95–112 Sachse J, Biedermann H, Kanig F et al 1993 Malum subooccipitale (Rusti) als unspezifische Arthritis. Manuelle Medizin 31:85–88 Säker G 1955 Schädeltrauma und Halswirbelsäule. Deutsche medizinische Wochenschrift 79: 547–550 Säker G 1957 Die Morbidität an Lumbago-Ischias. Münchener medizinische Wochenschrift 104:1151 Salter R B, Simmonds D F, Malcolm B W et al 1980 The biological effect of continuous passive motion on the healing of full-thickness defects in articular cartilage. Journal of Bone and Joint Surgery 62A:1232–1251 Salit I E 1995 The chronic fatigue syndrome. An overview of the literature. Journal of Musculoskeletal Pain 3:17–24
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Manipulative Therapy Sato H, Kikuchi S 1993 The natural history of radiographic instability of the lumbar spine. Spine 18: 2075–2079 Saxler G, Schophoff E, Quirmann H et al 2004 Können durch Chirotherapie neurologische Schäden hervorgerufen werden? Manuelle Medizin 42: 287–292 Scaggs C D 2000 Diagnosis and treatment of temporomandibular disorders. In: Murphy G R (ed) Conservative management of cervical spine syndromes. McGraw-Hill, New York, p. 579–592 Schildt K 1975 Untersuchungen zum Entwicklungsstand der Motorik bei Kindergartenkindern. In: Lewit K, Gutmann G (eds.) Funktionelle Pathologie des Bewegungssystems. Rehabilitácia Supplement 10–11, 166–170. Schildt K 1982 Funktionelle Therapie von Sprunggelenksfrakturen unter manualtherapeutischen Gesichtspunkten. Manuelle Medizin 20:137 Schildt K 1986 Funktionsstörungen der Muskulatur und der Wirbelsäule in Verlaufsuntersuchungen von Kindern im 1 und 2. Gestaltwandel. Zeitschrift für Physiotherapie 38:79–83 Schildt K (ed) 1994 Thoraxschmerz. Ullstein Mosby, Berlin Schilgen M, Evers S 2003 Zervikogener Kopfschmerz. Bertelsmann Stiftung, Gütersloh Schilgen M, Refisch A, Reingelsein E B 2004 Chirotherapie und Vertebralisläsion. Manuelle Medizin 42:103–107 Schiller L 2001 Effectiveness of spinal manipulation in the treatment of mechanical thoracic spine pain. A pilot randomized clinical trial. Journal of Manipulative and Physiological Therapeutics 24: 394–401 Schimek J J 1988 Untersuchungen zum Spannungskopfschmerz. Manuelle Medizin 26:107 Schimek J J 1988 Gesichtsschmerz und Triggerpunktsyndrome der Kaumuskulatur. Manuelle Medizin 26:38 Schmitt H P 1991 Zur Morphologie und Pathomechanik der Komplikationen der Manualtherapie unter besonderer Berücksichtigung der anatomischen Strukturen der
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Further reading Koxarthrosebehandlung. Beiträge zur Orthopädie 21:351–355 Weber H 1983 Lumbar disc herniation, a controlled prospective study with 10 years of observation. Spine 8:131–140 Weber J 1986 Die Bedeutung der manuellen Therapie für die sportmedizinische Betreuung. Medizin und Sport 25:82–87 Weh L, Hörmann K, Fröhlke O 1989 Hörsturz und Beweglichkeit der Halswirbelsäule. Manuelle Medizin 27:29 Weh L, Torklus D 1984 Das Gleitrippensyndrom. Manuelle Medizin 22:130–132 Weingart J R, Bischoff H P 1992 Doppler-sonographische Untersuchung der A. vertebralis unter Berücksichtigung chirotherapeutisch relevanter Kopfpositionen. Manuelle Medizin 30:62–65 Weiss J H 2001 Pelvic floor myofascial trigger points, manual therapy for interstitial cystitis and urgencyfrequency syndrome. Journal of Urology 166:226–231 Werne S 1957 Studies in spontaneous atlas dislocation. Acta Radiologica Supplement 23 West D T, Mathews R S, Miller M R et al 1999 Effective management of spinal pain in 177 patients evaluated for manipulation under anesthesia. Journal of Manipulative and Physiological Therapeutics 22:299–308 White A M, Panjabi M 1978 Clinical biomechanics of the spine. Lippincott, Philadelphia Whittingham W, Nilsson N 2001 Active range of motion in the cervical spine after manipulation (toggle recoil). Journal of Manipulative and Physiological Therapeutics 24:552–555 Whitty C W, Willison R G 1958 Some aspects of referred pain. Lancet 1:226–231 Wiberg J M, Nordsteen J, Nilsson N 1999 The short-term effect of spinal manipulation in the treatment of infantile colic, a randomized controlled clinical trial with a blinded observer. Journal of Manipulative and Physiological Therapeutics 22:517–522 Wickström G 1974 Effect of work on degenerative back disease. Scandinavian Journal of Work
Environment and Health 4(Suppl 1):1–12 Wiesner H, Mummenthaler M 1975 Schleuderverletzungen und Halswirbelsäule. Eine katamnestische Studie. Archiv für Orthopädie und Unfallchirurgie 81:13–36 Wilk V, Vivian D 2000 The interobserver reliability and validity of craniosacral palpation. Australasian Musculoskeletal Medicine 5:6–8 Wilkinson H A, Le May M L, Ferris E J 1969 Clinical and radiographic correlations in cervical spondylosis. Journal of Neurosurgery 30:213–218 Williams N, Wilkinson C, Russel I 1999 Clinics in musculoskeletal medicine, what outcomes should be measured? Journal of Orthopaedic Medicine 21:87–91 Winer C E 1979 Ergebnisse von Manipulationsbehandlungen bei Migräne. In: Neumann H D, Wolff H D (eds) Theoretische Fortschritte und praktische Erfahrungen der Manuellen Medizin. Konkordia, Bühl, p. 301–307 Wingfield B R, Gorman R F 2000 Treatment of severe glaucomatous visual field deficit by chiropractic spinal manipulative therapy. A prospective case study and discussion. Journal of Manipulative and Physiological Therapeutics 23:428–434 Wislowska M 1989 Study of the contribution of pain to rotation of vertebrae in the etiology and pathogenesis of lateral spinal curvature. Journal of Manual Medicine 4:229 Wolf J 1946 The chondrosynovial membrane and its importance in reducing friction and protecting joint surfaces [in Czech]. Sborník lék 48:274–289 Wolf J 1975 The reversible deformation of the joint cartilage surface and its possible role in joint blockage. In: Lewit K, Gutmann G (eds) Funktionelle Pathologie des Bewegungssystems. Rehabilitácia Supplement 10–11,30–35, Obzor, Bratislava Wolf J, Havelka S 1973 Comparison of articular surface replicas in osteoarthrosis deformans and rheumatoid arthritis. ‘R’ III 4: 389–395 Wolfe F 1994 When to diagnose fibromyalgia, USA Fibromyositis
Association. Education and research in Fibromyalgia, TMG. Chronic Pain Syndrome 29:1–8 Wolfe F 1995 The future of fibromyalgia. Journal of Musculoskeletal Pain 3:3–15 Wolff H D 1980 Abstand und Haftung. Manuelle Medizin 17:89–92 Wolff H D 1983 Neurophysiologische Aspekte der manuellen Medizin, 2nd edn. Springer, Heidelberg Wolff H D 1987 Anmerkungen zu den Begriffen ‘degenerativ’ und ‘funktionell’. Manuelle Medizin 25:52 Wolff H D 1990 Comments on the evolution of the sacroiliac joints. In: Paterson J K, Burn L, 1 (eds) Back pain, an international review. Kluwer Academic, Dordrecht, p. 175 Wolff H D 1991 Kopfgelenke und Evolution. Manuelle Medizin 29:41–46 Wolff H D, Lonquich C 2000 Einfache Messmethode der HWS-Funktion nach der Neutral-Null Methode. Manuelle Medizin 38:284–288 Wong A, Nansel D D 1992 Comparison between active vs. passive endrange assessment in subjects exhibiting cervical range of motion asymmetries. Journal of Manipulative and Physiological Therapeutics 15:159–163 Wood P H, Badley E M 1980 Epidemiology of back pain. In: Jayson M I V (ed) The lumbar spine and back pain, 2nd edn. Pitman Medical, London, p. 29–55 Wortzman G, Dewar F P 1968 Rotatory fixation of the atlantoaxial joint. Rotational atlantoaxial subluxation. Radiology 90:479–487 Wyke B D 1967 The neurology of joints. Annals of the Royal College of Surgeons of England 41:25–50 Wyke B D 1976 Morphological and functional features of the innervation of the costovertebral joints. Folia Morphologica 23:296 Wyke B D 1979 Neurology of the cervical spine joint. Physiotherapy 65:72 Wyke B D, Polácek P 1976 Articular neurology – its present position. Journal of Bone and Joint Surgery 57B:401 Yaksi A, Ozgönenel L, Ozgönenel B 2007 The efficiency of gabapentin therapy in patients with lumbar spinal stenosis. Spine 32:939–942
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Manipulative Therapy Zicha K, Zabel M 1979 Yates C A 1981 Spinal stenosis. Journal Zeller H J, Klawunde G 1974 Zur Proliferationstherapie bei Objektivierung der Manualtherapie of the Royal Society of Medicine Enthesopathien. Manuelle Medizin als Reflextherapie und ihre Beziehung 74:334–342 17:101–113 zu vegetativen und zentral nervösen Zbojan L 1985 Vertebrogenic syndromes Regulationsvorgängen. Zeischrift für Zicha K, Ruhrmann W 1985 and visceral disease [in Slovakian]. Physiotherapie 26:333–339 Die Druckwellen-Mobilisation Cs Gastroenterologie 39:277–278 im Rahmen der Zetterberg C, Andersson G B, Schultz Zeitler E, Markuske P 1962 physikalischen Therapie A B 1987 The activity of individual Röntgenologische Bewegungsanalysen und Rehabilitation. Manuelle trunk muscles during heavy physical der Halswirbelsäule bei Medizin 23:68–71 loading. Spine 12:1035–1040 gesunden Kindern und Zicha K 1970, 1971 Manuelle Therapie Zuckschwerdt L, Emminger E, Jugendlichen. Fortschritte Biedermann F et al 1960 bei der Spondylitis ankylopoetica. auf dem Gebiete der Wirbelgelenk und Bandscheibe, 2nd Manuelle Medizin 8:97–104, Röntgenstrahlen und der edn. Hippokrates, Stuttgart 9:117–120 Nuklearmedizin 96:87
416
Index A Abdominal muscles low-back pain due to overload, 303 postural function, 29, 30–31 respiration effects, 30–31 active exhalation, 31 active inhalation, 32 Abdominal surgery, remedial exercise following, 370 Abdominal wall, diaphragm contraction coordination, 160–161 Abductor hallucis, 129 Abductor pollicis brevis, 296 carpal tunnel syndrome, 326 Achilles tendon, 160 Achilles tendon pain, 321, 361 post-isometric relaxation, 277 soft tissue manipulation, 235 Achilles tendon reflex, 346 S1 radicular syndrome, 343 Acromioclavicular joint, 16 dysfunction, 126 examination, 126 shoulder pain, 324 springing movements, 184 Active mobility testing, 100 Active movement limb joints, 124 lumbar spine, 108–109 shoulder, 124–125 thoracic spine, 112 Active scars, 7, 161, 338–339, 377 case study, 339 diagnosis, 172, 338–339 ‘instant relief phenomenon’, 172, 338 local anesthesia, 338 needling, 338 palpation, 94 radicular syndrome treatment, 345 stretching connective tissue fold, 231 sustained pressure application, 231 tactile perception alteration, 227–228 therapy, 172, 339 Acupuncture, indications, 174 Acupuncture points, 174 Acute lesions, strain and counterstrain technique, 225 Adductor pollicis, 255 Adson’s maneuver, 327 Age-related disorders degenerative changes, 10 patient history, 90 Algodynia, normalizing tactile perception, 226 Allergy, 90 Analgesic medication, 178 disk herniation, 310 frozen shoulder, 323 radicular syndromes, 345, 347 Ancient classical times, 1–2 Angina, 350
case study, 351 Ankle examination, 129 Ankylosing spondylitis, 12, 90 clavicular breathing, 350 differential diagnosis, 165 indications for manipulative treatment, 168 Antagonists, motor patterns (stereotypes), 29 Antalgic posture, 21 acute lumbago, 15 radicular syndromes, 342 rest in acute stage, 344, 345 Anteflexion, 58, 59 atlantoaxial joint, 66, 67, 69 atlanto-occipital joint, 65–66, 67, 69, 122–123 self-mobilization, 244 cervical spine, 65, 67–70, 79 examination, 117 locomotor system dysfunction prevention, 365 mobility between occiput and atlas, 122–123 with rotation, 117–118 craniocervical junction mobilization, 222 head, 67, 69 lumbar spine hypermobility examination, 141–142 individual motion segments, 111 radiography, 58 screening examination, 108 self-mobilization, 238–239 mobility testing, 101 spinal column, 140 thoracic spine examination, 113 hypermobility examination, 142–143 self-mobilization, 241 trunk lower extremity radicular syndromes, 342 motor stereotypes examination (stooping and straightening), 145–147 retraining, 289–290 Anteflexion headache, 332 Anteroposterior (AP) projection, 41 cervical spine, 62, 63–64, 71–72 lumbar spine, 54–55 and pelvis, 41 thoracic spine, 59–60 Antidepressants, 178 Arch of foot, 129 Arm abduction, shoulder pain, 323 Arm pain, C3/C4–C5/C6 segments dysfunction, 358 Arm raising motor pattern (stereotype) disturbance, 30
examination, 148–149 retraining, 290–292 Arnold–Chiari malformation, 83 Asymmetry spinal column radiology, 40 tactile perception, 229 Athletes, prophylactic manipulative treatment, 369 Atlantoaxial joint, 63 hyperlordosis/forward-drawn posture, 74 movement, 66, 67, 79 restriction, 20, 117 in infants, 25 side-bending examination, 119 X-ray anatomy, 72 Atlantoaxial segment, symptoms of dysfunction, 358 Atlanto-occipital joint, 63 hyperlordosis/forward-drawn posture, 74 mobility exmination, 122–123 movement, 65–66, 67, 79 restriction, 20, 117 in infants, 25 self-mobilization, 255 anteflexion/retroflexion, 244 X-ray anatomy, 71, 72 Atlanto-occipital segment, symptoms of dysfunction, 358 Atlas, 64, 71 functional anatomy, 65, 66 isolated rotation, 75 mobility at occiput examination, 122–123 plane, 73 positional irregularities, 75 tipping, 69, 75 Atlas assimilation, 79, 83 Australia, 4 Autodermography, disk herniation, 37 Automobile transport, 177 Axis, 64, 71, 72 dens anomalies, 84 functional anatomy, 66 plane, 73 rotation, 67, 78, 79 in neutral position, 75, 77 Axis of motion, 19
B Baastrup’s phenomenon, 303 Back pain, 302, 363 fitness for work assessment, 371, 372 lumbar spine/pelvic region, 302–317 morphological changes, clinical significance, 9–10 nonspecific (Jayson)/idiopathic, 10 thoracic spine, 317–318 see also Low-back pain Back support, lumbar spine hypermobility, 177
417
Manipulative Therapy Balance, 19, 20 disturbance see Equilibrium disturbance role of feet, 229, 294 Barrier, 13–14, 171, 172, 175, 377 anatomical, 13 engagement technique (taking up the slack), 183, 230 passive mobility testing, 100 pathological, 13 active scars, 338 painful periosteal points, 236 physiological, 13, 14, 183 protective function, 14 soft-tissue examination, 93–94 Basilar impression, 74, 83–84, 339–340, 341 case study, 340 indications for manipulative treatment, 168 Bed rest, disk herniation, 310 Belts, 368 Biceps brachii C5 radicular syndrome, 346 lateral epicondylar pain, 324 post-isometric relaxation, 257 trigger points, 256, 257 unilateral chains of dysfunction, 161 Biceps femoris, 129 forward-drawn posture, 160 post-isometric relaxation, 275–277 self-treatment, 276–277 trigger points, 311 fibular head restriction, 321 headache, 330 Biceps tendon pain, 125 Biedermann, F, 3 Block vertebrae, cervical spine, 82 Body statics see Statics Body temperature elevation, 90 Bones, relative mobility examination, 94 Braces, 368 Brachial plexus compression, thoracic outlet syndrome, 327 Brassieres, 368 Breath hold, diaphragm postural function, 31 Breathing retraining, 293–294 see also Respiration; Respiratory synkinesis Britain, 3 British Institute of Musculoskeletal Medicine (BIMM), 3 Brushing technique, 226 Bruxism, 130, 331, 358 Buttocks, rotational shifting of deep fascia, 233
C C3/C4–C5/C6, symptoms of dysfunction, 358–359 C5 radicular syndrome, 346 C6 radicular syndrome
418
case study, 347 symptoms, 346–347 C7 radicular syndrome, 347 C8 radicular syndrome, 347 Calcaneal spur, 321 post-isometric relaxation, 277–279 self-treatment, 279 soft tissue manipulation, 235 Capitate, manipulation techniques, 188 Capsular pattern elbow, 126 knee joint, 321 limb joints, 124 shoulder, 125 frozen, 323 Cardiac arrhythmias, 349 Cardiac disease, 350–351 case study, 351 Carpal bones distraction, 326 manipulation techniques, 190 self-applied traction, 245 Carpal tunnel syndrome, 26–27, 190, 326, 359 case study, 326–327 clinical signs, 326 high-velovity, low amplitude technique indications, 168 pathogenesis, 326 symptoms, 326 therapy, 326 Carpometacarpal joint of thumb manipulation techniques, 188–189 self-applied traction, 245 wrist pain, 325 Carpometacarpal joints, 127 manipulation techniques, 189–191 Carrying locomotor system dysfunction prevention, 365–366 motor pattern disturbance, 30 examination, 149 retraining, 292 work-related back pain assessment, 372 Cauda equina syndrome, 178, 346 Central paresis, motor pattern disturbances, 28 Cervical collar, 297 Cervical dizziness, 334, 335 Cervical migraine, 355 Cervical myalgia, acute, 225 Cervical region, stretching exercises, 237 Cervical rib, 59, 82 Cervical spine, 62–85 anomalies, 82–84 anteflexion/retroflexion, 65, 67–70, 79, 117, 122–123 basilar impression, 83–84 block vertebrae, 82 C3/C4–C5/C6, symptoms of dysfunction, 358–359 childhood movement restriction, 25 degenerative changes, 85
examination, 116–124 individual motion segments, 118–119 mobility between occiput and atlas, 122–123 passive mobility, 117–118 patient in side-lying position, 119–120 patient sitting, 119 patient supine, 119 screening, 116–117 shifting techniques, 121–122 functional anatomy, 65–70 C3-C7, 65 craniocervical junction, 65–66 functional evaluation, 74–77 axis rotation in neutral position, 75, 77 forward-drawn posture, 74 isolated rotation of atlas, 75 localized irregularities, 74–75 natural posture evaluation, 74 rotation of vertebrae, 75, 77 statics, 74, 77 functional techniques, 224–225 inspection, 116 intervertebral disk thickness, 65 intervertebral joints, 65 joint play, 67, 121 kinematics, 66–67 manipulation techniques, 218–223 Jirout’s maneuver, 218–219 mobilization, 219–220 rotation high-velocity, lowamplitude thrust, 222 traction, 218 traction high-velocity, lowamplitude thrust, 220 traction low-velocity thrust, 220–222 mobility testing, 101, 143 morphological changes, 82–85 movement studies, 77–81 muscle imbalance, 318–319 symptoms, 318 therapy, 318–319 osteochondrosis, 26 pain, 318–319 see also Wry neck, acute palpation, 116–117 pain points, 117 respiratory synkinesis, 32 retraining, movement pattern correction, 296 rotation, 78–79, 117–118, 120–121, 123–124 hypermobility assessment, 143 self-mobilization, 243–244 anteflexion/retroflexion between occipus and atlas, 244 side-bending, 243 side-bending, 117, 118–120, 123, 243 trauma with cranial trauma, 354, 356 whiplash injury, 355–356 X-ray anatomy, 71–74 anteroposterior view, 71–72
Index lateral view, 72–74 X-ray film assessment, 63–64 X-ray technique, 62–63 Sandberg–Gutmann procedure, 62 Cervical syncope (drop attacks), 334, 335 Cervical syndrome, 318, 319 Cervicobrachial pain, cervicothoracic junction dysfunction, 359 Cervicobrachial syndrome, epicondylar pain, 324 Cervicocranial syndrome, 329–338, 349 equilibrium disturbance, 333–338 headache, 329–333 post-traumatic states, 355 Cervicothoracic junction, 21, 59, 67 dysfunction, 21 symptoms, 359 manipulation techniques high-velocity, low-amplitude thrust, 219–220 traction low-velocity thrust, 220–222 mobilization techniques rotation, 220 side-bending, 219–220 respiratory synkinesis, 32 restriction, thoracic outlet syndrome, 327 rotation examination, 121 self-mobilization, 242–243 forward and backward movement, 242 rotation (Gaymans method), 243 side-bending examination, 119 Cervicothoracic region, 96 soft tissue (fascia) rotation, 234 Cervicothoracic transitional vertebrae, 82 Chain reaction patterns, 20, 155–162, 167, 174, 378 analysis, 161–162 basic function patterns, 155 causes, 160–161 course of manipulative treatment, 179 developmental kinesiology, 157–158 diaphragm, importance of, 160–161 feet, importance of, 294, 321 forward-drawn posture, 311 lower extremity radicular syndromes, 345 multiple patterns, 180 pathomechanisms, 159–160 reaction chains of dysfunction, 155–157 trunk rotation, 161, 269 restriction, 315, 316 unilateral, 161 Chairs, 365, 372 Childbirth, 353, 354 remedial exercise following, 370 Children anteflexion headache, 332 programming of movement patterns, 157–159 prophylactic manipulative
treatment, 369 remedial exercise, 370 school headache, 332 spinal column dysfunction, 24–26 cervical region, 25 tactile perception development, 225–226, 228 see also Developmental kinesiology; Newborn infants ‘Chinese stance’, 286 Chiropractic, 2 barrier, definition, 14 training, 2 Chopart’s joint see Tarsal transverse joint Clavicular breathing, 31, 150, 151, 179, 253, 318, 349, 350 angina, 350 breathing pattern retraining, 293 migraine, 332 reaction chains of dysfunction, 156 syndrome of superior thoracic aperture, 161 thoracic outlet syndrome, 327 Clivus, 71, 72 Clothing, locomotor system dysfunction prevention, 368–369 Clothing sensitivity, 228 Clumsiness, 22, 33 Co-activation patterns, 377, 378 developmental kinesiology, 23, 159 Coccygeal pain, 107, 303–304, 320, 360 clinical signs, 304 symptoms, 304 therapy, 304 gluteus maximus/levator ani postisometric relaxation, 272 Coccygeus examination, 106–107 facilitation, 283–284 trigger points, 107 clinical findings, 315 low-back pain, 314–315 migraine, 332 therapy, 315 Coccyx manipulation techniques, 208–209 per rectum, 209 palpation, 107 symptoms of dysfunction, 360 Cold avoidance, 368 Colles’ fracture, 325, 357 Compensation of dysfunction, 26 Computer monitor position, 365 Computerized tomography (CT), spinal canal, 56 Concussion, 354 associated cervical spine trauma, 354–355 Connective tissue fold stretching, 171, 230–231 Connective tissue massage, 171 Contraindications of manipulation, 169–170 Coordinated movements, 145–146 see also Motor patterns (stereotypes)
Coracoid process, pain points, 263 Cortisone preparations, 178 acromioclavicular joint treatment, 324 carpal tunnel syndrome, 326 frozen shoulder, 323 lateral epicondylar pain, 325 Costen’s syndrome, 331 Costotransverse joint, 59, 60 gapping, 217 Costovertebral joint, 59–60 Counterstrain technique see Strain and counterstrain technique Course of disease, patient history, 88–89 Coxalgia see Hip joint pain ‘Cradle’, 284 Cramer, A, 3 Cranial base, 64, 72 Cranial trauma, post-traumatic states, 354–355 Craniocervical junction, 20 balance maintenance, 20 dysfunctions, 20–21 functional anatomy, 65–66 hypermobility, 79, 81 manipulation techniques, 222–223 mobilization techniques anteflexion, 222 retroflexion, 223 side-bending, 222 side-bending between atlas and axis, 223 restriction children, 25 thoracic outlet syndrome, 327 tonsillitis, 349 stabilizer retraining, 296 Craniocervical junction short extensors post-isometric relaxation, 250–251 self-treatment, 251 trigger points, 319, 358 migraine, 332 unilateral chains of dysfunction, 161 Cross-country skiing, 368 Crossed extension reflex, 22 Curvatures of spine effects of pelvis type, 50 inspection, 91–92 spinal column radiology, 40, 45, 47, 48 thoracic, 60–61 Cyriax, J, 3, 11 Czechoslovakia, 3
D Dancing, 368 de Kleyn test, 132, 335, 336 Deep neck flexors facilitation, 279–280 muscle test, 136 upper crossed syndrome, 152 Deep stabilizers of spinal column, 157, 377, 378 dysfunctional chain reactions, 160
419
Manipulative Therapy facilitation, 282–285 posture, 23 Deep tissue mobility restoration, 171–172 Degenerative changes, 10, 26 cervical spine, 65, 85 clinical relevance, 10 compensation of dysfunction, 26 disk herniation, 10 sequelae, 26 Deltoid C5 radicular syndrome, 346 frozen shoulder, 323 Dens, 71, 72, 74 hypoplasia, 84 reclination, 84 Depression, 6, 7, 8, 90 masked differential diagnosis, 164 pharmacotherapy, 178 Dermatomes, 99 radicular syndromes, 96, 99, 100 Desk height, 365 Deutsche Gesellschaft für Manuelle Medizin, 3 Developmental kinesiology, 22–23, 377, 378 chain reactions, 157–158 co-activation patterns, 23, 157, 159 motor pattern disturbances, 28, 29 Diagnostic error, 162–163 Diaphragm, 157, 160 abdominal wall contraction coordination, 160–161 breathing retraining, 293 chain reactions, 160–161 facilitation, 282 post-isometric relaxation, 264 postural function, 23, 30–31, 160 respiration movements, 160 symptoms of dysfunction, 360 trigger points, 359, 360 clavicular breathing, 350 headache, 330 migraine, 332, 333 radicular syndromes, 347 shoulder pain, 322 thoracic outlet syndrome, 327 Differential diagnosis, 162–165 case studies, 163 problems, 162–163 Digastricus, 32, 160 post-isometric relaxation, 249–250 self-treatment, 250 trigger points, 130, 331 Disk herniation, 10, 12, 26, 90, 374 acute stage, 310 antalgic posture, 309, 310 autodermography, 37 chronic stage, 310 clinical signs, 309–310 degenerative changes, 10 differential diagnosis, 164 fitness for work assessment, 372 low-back pain, 309–311, 341, 342 case study, 310–311
420
lumbar spine self-mobilization (McKenzie technique), 239 manipulative treatment indications, 168 mechanism of effect, 11 painful arc, 109, 309, 342 radicular syndromes, 341, 342 diagnostic problems, 343 root compression, 36–37 symptoms, 309 therapy, 310 traction indications, 170 Disk hypoplasia, 57 Disk lesions, lumbar spine radiography, 58 Disk thickness cervical spine, 65 lumbar spine, 54, 56 thoracic spine, 58 Distraction acromioclavicular joint, 194 carpometacarpal joint of thumb, 188, 189 elbow joint, 191 interphalangeal joints, 187–188 intervertebral joints (gapping), 202 knee joint, 199 metacarpophalangeal joints, 188 metatarsophalangeal joints, 195 shoulder, 192 sternoclavicular joint, 194 with leverage, 194 subtalar joint, 197 tarsal transverse (Chopart’s) joint, 196 tarsometatarsal (Lisfranc’s) joints, 196 temporomandibular joint, 201 wrist joint, 190–191 Dizziness, 333–334, 335 see also Equilibrium disturbance Dorsal deep fascia, shifting cranially, 232 Dorsopalmar shift, interphalangeal joints, 187–188 Draughts avoidance, 368 Duodenum, vertebrovisceral interrelationships, 351 Dysmenorrhea, 353, 354 pelvic distortion, 311 young girls, 24
E Eastern Europe, 3 Eating, motor programs, 155 Elbow capsular pattern, 126 examination, 126–127 hypermobility, 143 joint play, 126 manipulation techniques, 191–192 pain, 324–325 self-mobilization in radial direction, 245 Electrical stimulation, indications, 174 Electromyography, trigger points, 96
Ellis, Richard, 3 End of range positions, spinal column radiology, 40 Endesopathy, 96 Entrapment syndromes, 325–329 high-velovity, low amplitude technique indications, 168 Epicondylar pain, 126, 127, 324 C3/C4–C5/C6 segments dysfunction, 358 lateral, 324–325 medial, 325 Epicondylopathy manipulation techniques, 191 post-isometric relaxation radial, 256 ulnar, 258 Epidural anesthesia disk herniation, 310 lower extremity radicular syndromes, 345 Equilibrium disturbance case studies, 334, 337–338 ‘cervical pattern’, 131 clinical signs, 334 craniocervical syndrome, 333–338 differential diagnosis, 336 examination, 130–132 lateral deviation assessment, 131 test using two scales, 131 therapy, 336 vertebral artery disease, 335–336 Erb’s point, 253, 346, 347 Erector spinae, 21, 160 active exhalation, 31–32 deep stabilizer function, 23 forward-drawn posture, 159 hypertonus, 311 hip extension, 27, 28 hip retroflexion, 133, 134 low-back pain due to overload, 303 lower crossed syndrome, 151, 152 lumbar, muscle test, 139 middle thoracic spine, 59 motor pattern (stereotype) disturbance, 29 palpatory illusion/palpatory examination, 223–224 post-isometric relaxation, 264–265 lumbar region, 206, 266–267 self-treatment, 267 thoracic region, 265–266 thoracolumbar region, 266 trunk rotation restriction, 315 spasm, 5, 19 stratification syndrome, 152 thoracic, mobilization techniques, 210 thoracolumbar, stretching mobilization, 206 trigger points, 161, 303, 307, 315, 353, 359 headache, 330 migraine, 332 trunk rotation chain reaction pattern, 269
Index unilateral chains of dysfunction, 161 Evidence-based medicine, 153 treatment strategy, 167 Examination, 87 balance disturbance, 130–132 cervical spine, 116–124 coordinated movements (motor stereotypes), 145–146 course in patients with dysfunctions, 153–154 foot, 129–130 functional approach, 154–155 hip, 127–128 hypermobility, 140–145 knee, 128–129 limb joints, 124–130 lumbar spine, 108–112 mobility testing, 100–101 muscle function, 132–140 palpation (soft-tissue examination), 93–100 pelvis, 101–108 retesting, 153 ribs, 115–116 temporomandibular joint, 130 thoracic spine, 112–115 Exhalation, 151 active, 31–32 mouth opening, 32 muscle relaxation facilitation, 32 passive, 31 respiratory synkinesis, 184, 185 Expert assessment, locomotor system dysfunction, 371–375 fitness for work, 371–373 trauma, 373–375 Extensor digitorum brevis, L5 radicular syndrome, 343 Extensor hallucis longus, L5 radicular syndrome, 343 Exteroceptive stimulation, 225–229 abdomen, 229 facilitation, 279 feet, 228–229, 294, 321 hands, 228 indications, 173 mouth, 228 self-treatment, 229 tongue, 228 see also Tactile perception Extremities post-traumatic states, 357 self-mobilization of joints, 245–246 shifting (stretching) deep fascia, 234–235 soft tissue (fascia) rotation, 234–235 see also Lower extremities; Upper extremities Eye movement, 185 combining techniques, 185 inhalation/exhalation facilitation (respiratory synkinesis), 29, 32, 185 motor pattern training, 29 with post-isometric relaxation, 247
F
Flabby posture, 49, 92 Flat foot, 129 Facilitation (training weak muscles), functional, 295, 361 279–285 unilateral, pelvic obliquity, 176 coccygeus, 283–284 Flexion, lumbar spine mobilization, ‘cradle’, 284 205–206 gluteus maximus, 285 self-mobilization, 239 gluteus medius, 285 Flexion posture, newborn infants, 22 hip muscles, 285 Flexor retinaculum, 27 lumbar spine deep stabilizers, Follow-up 282–283 examination, 8, 179 neck deep flexors, 279–280 therapy/aftercare, 186–187 pelvic floor, 283–285 Foot, 21 ‘pelvic see-saw’, 284–285 arch, 129 rectus abdominis, 281–282 balance maintenance, 294 serratus anterior, 280–281 chain reaction patterns, 294, 321 transversus abdominis, 282, 283 unilateral, 161 trapezius (lower part), 280 dysfunctions, 21 trunk muscles, 279–285 symptoms, 361 Fascia examination, 129–130 mobility restoration, 171–172, 231, exteroceptive stimulation, 173, 359 294–295, 321 dorsal, 232 functional diagnosis, 129 extremities, 234–235 joint play, 130 lower extremity radicular joints, 130 syndromes, 345 pain, 321 lumbar, 231–232 instep, strain and counterstrain neck, 234–235 technique, 225 scalp, 233–234 post-traumatic states, 357 thorax, 233 retraining of movement patterns, trunk, 232 294–295 palpation, 94 abductor pollicis brevis/hallux self-mobilization, 237 valgus, 296 shifting (stretching), 231–232 dorsiflexion, 296 Fatigue, motor pattern (stereotype) functional flat foot, 295 disturbances, 28 splay foot, 295–296 Femoral nerve stretch test, 274 standing posture, 286 L4 pseudoradicular (reflex) syndrome, walking, 286 320 rocking technique, 295 lower extremity radicular syndromes, rotation, 129 342, 343 stratification syndrome, 153 rectus femoris spasm, 306–307 tactile sensitivity, 294 segment L3/L4 dysfunction, 359 assessment, 228–229 Fibromyalgia syndrome, 96 asymmetry, 228, 229 differential diagnosis, 164–165 trigger points on sole Fibular head headache, 330 pain, biceps femoris post-isometric migraine, 332, 333 relaxation, 275 Foot deep flexors restriction, 129, 198, 320–321, 360 post-isometric relaxation, 321 forward-drawn posture, 311 splay foot, 295 symptoms of dysfunction, 361 trigger points, 321 Fibularis, S1 radicular syndrome, 343 Foot extensors, post-isometric Field of disturbance, 7 relaxation, 277 Finger extensors Footwear, 368 lateral epicondylar pain, 324 corrective post-isometric relaxation, 256–257 pelvic obliquity, 176–177 self-treatment, 256–257 splay foot, 295 stimulation, 23, 29 Foramen magnum, 71, 72 trigger points, 358 basion, 72 unilateral chains of dysfunction, 161 opisthion, 72 Fingers, self-applied traction, 245 plane, 73 Fitness for work Foramen transversarium, 64, 72 exercise training, 372 Forearm extensors, trigger points, 256 expert assessment, 371–373 Forward-drawn posture, 49, 92, 93, Fixation, spinal column manipulation, 159–160, 177, 321, 330, 201, 202 361
421
Manipulative Therapy abdominal muscle tension, 353 cervical spine pain, 318 cervicocranial headache, 330 chain reaction patterns, 311 clinical findings, 311 low-back pain, 311–313 case study, 312–313 therapy, 311–312 palpatory illusion, 311 symptoms, 311 France, 3 Frozen neck syndrome, 355–356 Frozen shoulder, 126, 192, 322–323 capsular pattern, 323 clinical signs, 323 stages, 322 symptoms, 322 therapy, 323 trigger points in subscapularis, 260 Functional approach, 154–155 Functional diagnosis, 40–41 body statics, 40 spinal column mobility (kinematics), 40 Functional techniques, 223–224 cervical spine treatment, 224–225 lumbar spine treatment, 224 palpatory examination/palpatory illusion, 223–224 thoracic spine treatment, 224
G Gait, 155 motor stereotypes examination, 150 reaction chains of dysfunction, 156 see also Walking Galen, 1–2 Gall bladder disease case study, 352 vertebrovisceral inter-relationships, 352 Gastrocnemius, muscle test, 137 Germany, 3 Glenohumeral joint joint play, 124 mobility examination, 143–144 Glomerulonephritis, 352 Gluteal muscles coccygeal pain, 303, 304 low-back pain due to overload, 303 S1 radicular syndrome, 343 Gluteus maximus coccygeal pain, 107, 303, 304 facilitation, 285 forward-drawn posture, 160 hip extension, 27 hip retroflexion, 133 lower crossed syndrome, 151, 152 motor pattern disturbance, 29 muscle test, 133–134 post-isometric relaxation, 208, 272, 304 self-treatment, 272 trigger points, 360
422
unilateral chains of dysfunction, 161 Gluteus medius facilitation, 285 lower crossed syndrome, 152 muscle test, 134–135 post-isometric relaxation, 273 trigger points, 359 ‘Gothic’ shoulders, 139 Gravity-induced post-isometric relaxation, 247 biceps brachii, 257 erector spinae, lumbar region, 266 gluteus maximus, 272 gluteus medius, 273 hip adductors, 274 iliopsoas, 270 infraspinatus, 260 ischiocrural muscles, 274 latissimus dorsi, 261 levator ani, 272 levator scapulae, 253 pectoralis major, 261, 262 pectoralis minor, 263 quadratus lumborum, 269 rectus abdominis, 270 rectus femoris, 274 scalenes, 253 serratus anterior, 264 soleus, 277 sternocleidomastoid, 254 subscapularis, 260 tensor fasciae latae, 273 teres major, 261 toe deep short flexors, 279 trapezius horizontal part, 268–269 upper part, 253 triceps brachii, 258 Gravity-induced relaxation, 184, 185, 247 combining techniques, 185 see also Gravity-induced postisometric relaxation Greater trochanter tenderness, 272 Gutmann device, 41 Gutmann, G, 3 Gymnastics, 367, 370 Gynecological disorders, low-back pain, 353–354
Head position, 20 locomotor system dysfunction prevention, 365 weight carrying, 30 reaction chains of eating/speaking dysfunction, 157 rotation, 26, 79 arm lifting retraining, 292 Head injury patient history, 89 post-traumatic states, 354–355 prevention, 357 Head and neck muscles, post-isometric relaxation, 248–255 Headache, 363 anteflexion, 332 atlantoaxial segment dysfunction, 358 atlanto-occipital segment dysfunction, 358 C3/C4–C5/C6 segments dysfunction, 358 with cervical component, 329–330, 336 clinical signs, 330 sleeping position, 366 symptoms, 330 therapy, 330–331 cervicocranial syndrome, 329–333 cervicothoracic junction dysfunction, 359 children, 24, 332 differential diagnosis, 333 forward-drawn posture, 312 mandibulocranial syndrome, 331 patient history, 89, 90 post-concussion syndrome, 355 temporomandibular joint dysfunction, 358 tension, 329 thoracic outlet syndrome, 327 vasomotor, 329, 332 Heart, vertebrovisceral interrelationships, 350–351 Heel insert, 47, 102 pelvic obliquity, 177 Heel pain, 321 soft tissue manipulation, 235 Heel, self-mobilization, 237 Hemihypertrophy, 92 High-velocity, low-amplitude thrust H techniques, 2, 17 carpometacarpal joint of thumb, Hallux valgus, 129 188–189 abductor pollicis brevis retraining, 296 cervical spine Hand rotation, 222 hypersensitivity, 228, 229 traction at upper vertebra, 220 hypertonus/cramping, 296 cervicothoracic junction, 219–220 post-traumatic states, 357 contraindications, 169–170 retraining movement patterns, 296 case report, 170 tactile sensitivity assessment, 228 errors, 169, 186 Hand extensors hip joint, 199–200 post-isometric relaxation, 256 pain (coxalgia), 304 self-treatment, 256–257 indications, 168 trigger points, 358 lower extremity radicular syndromes, Hard palate, 64 acute stage, 345 Hautant’s test, 130–131, 333, 335
Index lumbar spine, 202, 206 metacarpophalangeal joints, 188 ribs, 215–217 first, 218 sacroiliac joint, 206, 208 safety, 186 talocrural joint, 198 technical aspects, 186 thoracic spine, 212–214 wrist joint, 190–191 Hip examination, 127–128 extension, motor pattern disturbance, 27, 29 flexion testing, 141 hypermobility examination, 145 joint pattern in dysfunction, 128 manipulation techniques, 199–200 muscle facilitation, 285 osteoarthritis, 304, 360 sacroiliac joint restriction, 308 pain points, 128 post-traumatic states, 357 retroflexion, 133–134 rotation, walking re-training, 287 symptoms of dysfunction, 360 Hip abductors, post-isometric relaxation, 272–273 Hip adductors, 160 post-isometric relaxation, 274 trigger points, 360 unilateral chains of dysfunction, 161 Hip flexors L4 radicular syndrome, 343 low-back pain due to overload, 303 lower crossed syndrome, 151, 152 muscle test, 138–139 Hip joint pain (coxalgia), 304, 359, 360 case study, 306 following hip injury, 357 lifestyle advice, 304 motor pattern disturbances, 28 symptoms, 304 therapy, 304 Hippocrates, 1, 11 History of manipulation therapy, 1–4 Hot pack therapy, active scars, 339 Housemaid’s knee, 129 Humeroradial joint, 191 Humeroscapular periarthropathy, 322 Humeroulnar joint, 191 Hyperalgesic zone, 4, 5, 35, 36, 377 coccygeal pain, 107, 304 headache with cervical component, 330 palpation, 93–94 stretching techniques connective tissue fold, 231 skin, 171, 230 Hyperkyphosis, 140 Hyperlordosis cervical spine, forward-drawn posture, 74 craniocervical region, 92 lumbar spine, 140 lower crossed syndrome, 152
Hypermobility cervical spine, 77, 79, 81 compensation of restriction, 26 constitutional, 33–34 diagnostic guidelines, 140 examination, 140–145 lower limb joints, 144–145 spinal column, 140–143 upper limb joints, 143–144 generalized pathological, 33 high promontory (assimilation) pelvis, 50 high-velocity, low-amplitude thrust techniques induction, 186 localized pathological, 33 low-back pain due to muscle/ligament overload, 303 lumbar spine, 58, 177 manipulation contraindications, 170 passive mobility testing, 100 seated patient inspection, 93 Hypersensitivity, 226, 227 abdomen, 229 hands, 228 normalizing tactile perception, 226 surgical scars, 227 clothing sensitivity, 228 paradoxical hypersensitivity, 227 tongue, 228 Hypesthesia carpal tunnel syndrome, 326 nocturnal meralgia paresthetica, 328 radicular syndromes, 342, 343, 346, 347 surgical scars, 227 Hyposensitivity feet, 228–229 normalizing tactile perception, 226 tongue, 228
I Idiopathic back pain, 10 Iliacus, 311 trigger points, 270, 304, 307, 353, 360 S1 pseudoradicular syndrome, 320 unilateral chains of dysfunction, 161 Iliolumbar ligament pain, 108 post-isometric relaxation, 272 Iliolumbar ligaments, 56 Iliopsoas muscle test, 138 nocturnal meralgia paresthetica, 329 post-isometric relaxation, 270 trunk rotation restriction, 315 Immobilization disk herniation, 310 indications, 177 radicular syndromes, acute stage, 344, 345 Impingement syndrome, shoulder, 193, 323 Indications, 167–180 acupuncture, 174
electrical stimulation, 174 exteroceptive stimulation, 173 high-velovity, low amplitude thrust techniques, 168 immobilization, 177 local anesthesia, 173–174 manipulation, 168 massage, 172–173 needling, 173–174 pharmacotherapy, 178 reflex therapy, 172–173 remedial exercise, 175–176 soft-tissue manipulation, 171–172 supports, 177 surgery, 178 traction, 170–171 Indirect techniques, 223–225 Inflammatory disorders, 9–10, 162 differential diagnosis, 165 manipulation contraindications, 170 Inflatable cushion, 297 Infraspinatus, 125 frozen shoulder, 323 post-isometric relaxation, 259–260 self-treatment, 260 trigger points, 359 shoulder pain, 322 Inguinal region pain, rotational shifting of deep fascia, 233 Inhalation, 151 mouth opening, 32 respiratory synkinesis, 32, 184, 185 Inspection, 90–93 cervical spine, 116 limb joints, 124 pelvis, 101 posture, 90–92 seated patient, 93 ‘Instant relief phenomenon’, 172, 338 Intermittent claudication, 342 neurogenic (radicular), 343–344 case study, 344 International Federation for Manual (Musculoskeletal) Medicine (FIMM), 4 Interphalangeal joints, 127 dorsopalmar shift/distraction/ laterolateral shift, 187–188 manipulation techniques, 187–188 toes, 195 Interscapular muscles, upper crossed syndrome, 152 Intra-articular cortisone injection frozen shoulder, 323 see also Cortisone preparations Intradermal blebs, 173 Ischiocrural muscles, 29, 160 forward-drawn posture, 160 hip extension, 27, 28 hip retroflexion, 133–134 lower crossed syndrome, 151, 152 muscle test, 137–138, 141 post-isometric relaxation, 274 stratification syndrome, 152 trigger points, 360
423
Manipulative Therapy L5 pseudoradicular syndrome, 320 S1 pseudoradicular syndrome, 320 Isometric traction, respiratory synkinesis, 185
J Jirout’s maneuver, 218–219 acute wry neck, 319 Johnston’s functional techniques see Functional techniques Joint mobility passive testing, 100 remedial exercise, 175 Stoddard’s classification, 169 Joint movements functional, 14 passive joint play, 14–15 restriction demonstration, 14 Joint play, 14–15, 16 ankle, 129 carpal tunnel syndrome, 326 cervical spine, 67, 121 elbow, 126 foot joints, 130 glenohumeral joint, 124 knee, 128 limb joints, 124 passive mobility testing, 100 restriction demonstration, 14 sacroiliac joints, 50–51 shoulder, 124, 126 temporomandibular joint, 130 tibiofibular joint, 129 Juvenile osteochondrosis (Scheuermann’s disease), 90 indications for manipulative treatment, 168 kyphotic deformity, 62 thoracic spine pain, 317
K Kidney disease, vertebrovisceral interrelationships, 352 KISS syndrome, 25 Knee examination, 128–129 hypermobility, 144 joint dysfunction, 321 capsular pattern, 321 joint pattern, 129 joint play, 128 manipulation techniques, 198–199 osteoarthritis, 321 pain with hip joint pain, 304 motor pattern disturbances, 28 points, 129 post-traumatic states, 357 self-mobilization, 246 Kolárˇ’s tests, 282 Krauss, H, 3 Kubis, E, 3
424
Kyphosis, 21 juvenile osteochondrosis, 317 lumbar spine hypermobility, 177 radiographic evaluation, 57 respiratory synkinesis, 32 sitting posture, 317 thoracic spine, 61–62, 92 mobilization into extension, 209–210 upper crossed syndrome, 152
L L4 pseudoradicular (reflex) syndrome, 320 L4 radicular syndrome, 342 symptoms, 342–343 L5 pseudoradicular syndrome, 320 L5 radicular syndrome, 342 post-isometric relaxation of piriformis, 275 symptoms, 343 foot dorsiflexion weakness, 296 Labor pain, low-back, 353–354 Lasègue’s sign, 37 Lateral cutaneous femoral nerve entrapment case study, 329 nocturnal meralgia paresthetica, 328 Lateral epicondylar pain, 324–325 clinical signs, 324 symptoms, 324 therapy, 325 unilateral chains of dysfunction, 161 Lateral projection, 41, 55–56 cervical spine, 63, 64, 72–74 lumbar spine and pelvis, 41 thoracic spine, 60 Laterolateral shift, interphalangeal joints, 187–188 Laterolateral springing, knee joint, 199 Latissimus dorsi post-isometric relaxation, 260–261 trigger points, 359 Leg flexion/extension, walking movement pattern re-training, 287 Leg length difference, 102 body statics, 45 pelvic obliquity, 102 Levator ani coccygeal pain, 303, 304 post-isometric relaxation, 209, 272, 304 self-treatment, 272 trigger points, 107, 209, 304, 360 Levator scapulae arm raising, 30 muscle test, 139 post-isometric relaxation, 251–252 self-treatment, 253 trigger points, 319, 358 shoulder pain, 322 weight carrying, 30
Lewit, K, 3 Lifestyle factors, 178–179, 364–365 hip joint pain, 304 locomotor system dysfunction prevention, 365–367 active, 367–369 passive, 365–367 Lifting locomotor system dysfunction prevention, 365–366 straightening from forward-flexed position, 30 technique correction, 345 work-related back pain assessment, 372 Limb joints capsular pattern, 124 examination, 124–130 inspection, 124 joint play, 124 restriction, 124 Lisfranc’s joint see Tarsometatarsal joints Liver disease, vertebrovisceral interrelationships, 352 Load carrying see Carrying Local anesthesia, 298–299 acromioclavicular joint, 324 active scars, 338 carpal tunnel syndrome, 326 epicondylar pain, 325 frozen shoulder, 323 indications, 173–174 radicular syndromes, lower extremity, 345 slipping rib, 318 Locking techniques, spinal column manipulation, 201–202 coupled movements, 201 Locomotor system dysfunction, 301– 361 analysis of pathogenesis, 8 associated structural disease, 339–347 case studies, 340, 341 clinical features, individual motion segments, 357–361 diagnosis, 12–13, 87–165 equilibrium disturbance, 333 expert assessment, 371–375 functional disturbances, 7, 12–13, 36, 348, 377 importance, 363–364 incidence, 363–364 nervous control faults/psychological lability, 21–22 pain, 5–6, 34, 35 prevention see Prevention vertebrovisceral inter-relationships, 348 London College of Osteopathic Medicine, 3 Longissimus, 160 Lordosis, 40 cervical spine, 92 lumbar spine radiographic evaluation, 57 respiratory synkinesis, 32
Index spinal column reaction to obliquity, 45, 47, 48 Low-back pain, 302–317, 359, 360, 363 acute, strain and counterstrain technique, 225 case studies, 304, 306, 308–309, 310–311, 312–313, 316–317 coccygeal pain, 107, 303–304 coccygeus, 314–315 combined lesions, 316 disk herniation, 309–311, 341, 342 forward-drawn posture, 311–313 gynecological disorders, 353–354 hip joint pain, 304, 306 inflare and outflare, 313–314 labor pain, 353 lumbar spine/sacroiliac joint restriction, 308–309 overload, muscle/ligament, 303 pelvic distortion, 311 pelvic floor, 314–315 radicular syndromes, 341, 342 sleeping position, 366 traction indications, 170 trunk rotation restriction, 315–316 Lower crossed syndrome, 151–152, 368 Lower extremities manipulation techniques, 195–200 post-isometric relaxation, 272–279 reaction chains of gait dysfunction, 156 Lower extremity pain, 359, 360 fitness for work assessment, 372 referred, 320 Lower extremity radicular syndromes, 341–346 diagnostic problems, 343 history taking, 341–342 symptoms, 342–343 therapy acute stage, 344–345 chronic stage, 345 indications for surgery, 345–346 Lumbago, 20 acute, 12, 49 antalgic position, 15 children, 24 patient history, 89 Lumbar belt, 177 Lumbar deep fascia, shifting caudally, 231–232 Lumbar rib, 59 Lumbar spine, 54–58, 302 examination, 108–112 active movement screening examination, 108–109 anteflexion, 111, 141–142 hypermobility, 140–142 individual motion segments, 109–110 mobility, 101, 110 palpation, 109, 110 retroflexion, 110–111, 140–141 rotation, 142 side-bending, 111–112, 142 springing tests, 109–110
mobility restoration, 17 functional techniques, 224 safety (complications), 169–170 intervertebral disk thickness, 54, 56 case study, 170 joints of vertebral arches, 54 technical aspects, 182–223 low-back pain, 302–317 direction of treatment, 183 due to muscle/ligament overload, fixation, 182 303 follow-up treatment/aftercare, manipulation/mobilization techniques, 186–187 203–205 high-velocity, low-amplitude thrust, mobilization into flexion, 205–206 186 rotation mobilization, 203–205 neuromuscular mobilization, traction, 202–203 184–186 physiological reaction to obliquity, 45 position of practitioner, 182 radiography, 41–43 positioning of patient, 182 anatomy, 54–57 record keeping, 186 evaluation of function, 57 retesting, 186 fifth (last) lumbar vertebra, 56 simple mobilization, 183–184 movement studies, 58 starting position of joint, 183 statics evaluation, 43–45 taking up the slack (engaging the statics in frontal plane, 43, 45–47 barrier), 183 statics in sagittal plane, 43, 48–49 see also Manipulation techniques restriction, 306–309 theoretical aspects, 10–12 case study, 308–309 treatment course, 179–180 clinical signs, 306, 307 Manipulation table height, 182 symptoms, 306 Manipulation techniques therapy, 306 acromioclavicular joint, 193–194 self-mobilization, 238–240 carpometacarpal joints, 189–191 extension, 239 thumb, 188–189 flexion, 239–240 cervical spine, 218–223 lower lumbar spine into elbow, 191–192 anteflexion/retroflexion, 238– extremity joints, 187–201 239 lower, 195–200 McKenzie technique, 239–240 upper, 187–195 retroflexion and side-bending, 239 hip joint, 199–200 symptoms of dysfunction interphalangeal joints, 187–188, 195 L2/L3, 359 knee joint, 198–199 L3/L4, 359 metacarpophalangeal joints, 188 L4/L5, 360 metatarsophalangeal joints, 195–196 Lumbodorsal fascia, 30 pelvis, 206–209 Lumbosacral hiatus, 96 coccyx, 208–209 Lumbosacral junction, 56 sacroiliac joint, 206–208 dysfunction, 21 radicular syndromes, lower extremity, symptoms, 360 345 X-ray imaging, 41, 43 radioulnar joint, distal, 191 Lumbosacral reflexes, role in balance, 20 ribs, 214–217 Lumbosacroiliac joint region, 21 shoulder, 192–193 Lung disease, 349–350 shoulder blade, 194–195 spinal column, 201–223 cervical, 218–222 M lumbar, 203–206 thoracic, 209–214 Maigne, R, 3, 11 sternoclavicular joint, 194–195 Malocclusion, 331 subtalar joint, 196–197 Mandibulocranial syndrome, 130, 331 talocalcaneonavicular joint, 196–197 case study, 331–332 talocrural joint, 197–198 clinical signs, 331 tarsal transverse (Chopart’s) joint, symptoms, 331 195–196 therapy, 331 tarsometatarsal (Lisfranc’s) joints, Manipulation, 377–380 195–196 cardinal errors, 169 temporomandibular joint, 201 contraindications, 169–170 tibiofibular joint, 198 future role, 377–380 wrist joints, 189–191 historical aspects, 2–3 Massage, 226 indications, 168 indications, 172–173 locomotor system dysfunction soft tissue manipulation comparison, prevention, 369–370 175 mechanism of effect, 11–12, 16–17
425
Manipulative Therapy Masseter, trigger points, 130, 248 Masticatory muscles, 32, 160 post-isometric relaxation, 248–249 self-treatment, 249 respiratory synkinesis, 201 trigger points headache, 330, 331 mandibulocranial syndrome, 331 Medial epicondylar pain, 325 Median nerve compression, 326 see also Carpal tunnel syndrome Ménière’s disease, 333, 334 Meningeal bleeding, 319 Meniscoids entrapment, 16 mechanism of manipulation therapy, 16–17 Mennell, JA, 2–3 Menstrual symptoms, 353, 354 case study, 354 Menstruation, 90 Metabolic disease, 162 Metacarpals, mutual shifting technique, 235–236 Metacarpophalangeal joints, 127 hypermobility examination, 143 manipulation techniques, 188 self-applied traction, 245 Metatarsals, 130 mobiliztion technique, 196 mutual shifting technique, 235–236 trigger points between, 321 Metatarsophalangeal joints fan-wize spreading of metatarsal heads, 195 manipulation techniques, 195–196 restriction, 321 Microspasticity, 28, 33 Microtrauma, 19 Midcarpal joint, 127 Migraine, 38, 180, 332–333 children, 24 differential diagnosis, 333 Minimal brain damage, 22, 33, 132 Mobility level scale, 140 Mobility normalization, 12 Mobility testing, 100–101 active mobility, 100 movement against resistance, 100 passive mobility, 100 spinal column, 101, 110 Mobilization acromioclavicular joint, 193, 324 carpal tunnel syndrome, 326 cervical spine, 219–220 rotation, 219 side-bending, 219 cervicothoracic junction side-bending, 219–220 epicondylar pain lateral, 325 medial, 325 lumbar spine, 203–204 flexion, 205–206 rotation, 203–205 radicular syndromes
426
lower extremity, 345 upper extremities, 347 ribs, 214–215 with one rib resticted during exhalation, 215 overtake phenomenon, 215 pressure mobilization, 215 with restricted inhalation, 215 sacroiliac joint, 206 in horizontal plane, 206 lower end, 207–208 in sagittal plane, 206 upper part, 207 shoulder, 193 shoulder blade, 194–195 sternoclavicular joint, 324 talocrural joint, 197 tarsal transverse (Chopart’s) joint, 195 tarsometatarsal (Lisfranc’s) joints, 195 techniques, 183–184, 378 neuromuscular, 184–185 temporomandibular joint, 201 thoracic spine, 209–212 vertebral artery insufficiency, 337 Mobilization massage, thoracic spine, 214 Morning stiffness, muscle/ligament overload low-back pain, 303 Morphological changes, 9–10 cervical spine, 82–85 Motion segments, vertebral dysfunction, 13–19 barrier phenomenon, 13–14 diagnosis, 13 effects of manipulation, 11, 17 facilitation, 15 restriction, 13, 15–16 sources of pain, 4, 5 Motor pattern (stereotype) disturbance, 5, 12, 27–29, 377 central nervous system disturbances in infants, 22 muscle test, 27–28 patterns of imbalance (clinical syndromes), 28 remedial exercise, 27, 175 lower extremity radicular syndromes, 345 respiration, 30–32 active exhalation, 31–32 clavicular breathing, 31 paradoxical breathing, 31 sequelae, 29–33 arm raising, 30 standing, 29 straightening from forward-flexed position, 29–30 walking, 29 weight carrying, 30 treatment methods, 6 Motor patterns (stereotypes), 21 basic functions, 155 chain reactions see Chain reaction patterns disorders in subjects with
psychological lability, 21–22 examination, 145–146 anteflexion (stooping and straightening), 145–147 gait, 150 head and neck rotation, 148 patient sitting, 145–149 patient standing erect, 149–150 raising arms, 148–149 respiratory movements, 150–151 standing on one leg, 149–150 trunk rotation, 148 training, 29 Mouth closure, 184 opening, 130, 184 respiratory synkinesis, 32 tactile sensitivity assessment, 228 Movement studies, spinal column radiology, 40 Multifidi, 16, 157, 160 facilitation, 282 Multiple chain reaction patterns, 180 Multiple sclerosis, 22 Muscle function examination, 132–140 clinical kinesiology, 132 muscle test, 27–28, 132–133 muscles with a tendency to shortening, 136–140 muscles with a tendency to weakness, 133–136 neurological screening, 132 Muscle hardness (myogelosis), 4, 5, 95 treatment methods, 6 Muscle imbalance, 28, 377 cervical spine, 318–319 remedial exercise, 175 Muscle relaxants, 178 Muscle spasm, 35, 237 post-isometric relaxation and reciprocal inhibition, 246 Muscle test, 27–28, 132–133 Muscle weakness radicular syndromes, 342, 343 training see Facilitation (training weak muscles) Muscle-energy techniques (MET), 2 Musculoskeletal medicine, 378 Mylohyoid post-isometric relaxation, 250 trigger points, 130 Myofascial pain, 36 Myogelosis see Muscle hardness Myotendinosis, 36
N Neck reaction chains of eating/speaking dysfunction, 157 shifting (stretching) deep fascia, 234–235 soft tissue (fascia) rotation, 234 Neck pain, 318 atlantoaxial segment dysfunction, 358
Index fitness for work assessment, 372 sleeping position, 366 Neck reflexes, role in balance, 20 Needling, 298 active scars, 338 dry, 298 effects in acupuncture, 174 epicondylar pain, 325 foot deep flexor trigger points, 321 frozen shoulder, 323 headache with cervical component, 331 indications, 173–174 local anesthesia, 298–299 radicular syndromes lower extremity, 345 upper extremity, 347 shoulder pain, 322 triceps brachii, 324 trigger points, 248 Neoplastic disease, 90, 162 manipulation contraindications, 170 Nephroptosis, 352 Nervous control, 21–22 motor pattern (stereotype) disturbance, 27 subjects with labile regulation, 21, 22 Neurogenic intermittent claudication, 343–344 case study, 344 Neurological deficit, radicular syndromes, 37, 96 Neuromuscular techniques, 184–186, 378 combining techniques, 185–186 effects of respiration, 32 Neutral position, 11, 12 Neutral posture, infants, 22 New Zealand, 4 Newborn infants flexion posture, 22 neutral posture, 22 reflexes, 22 Nociceptive stimulation, 4–5 autonomic response, 5 locomotor system dysfunction, 35, 36 somatic response, 5 Nocturnal meralgia paresthetica, 328–329 Nodding, 67, 69 Nonspecific (Jayson) back pain, 10 Non-steroidal anti-inflammatory drugs (NSAIDs), 178 Nordic walking, 368 Nuchal region muscles forward-drawn posture, 159–160 muscle test, 139–140 Nystagmus, 132
O Obesity, 369 palpation of pelvis, 102, 103 Oblique projection, cervical spine, 64 Obliquus internus abdominis, 282
Obstructive respiratory disease, 349–350 Occipital condyles, 71 Occupational health, 373 fitness for work, expert assessment, 371–372 prophylactic manipulative treatment, 369 Os odontoideum hypoplasia, 84 Osteoarthritis, 90 carpometacarpal joint of thumb, 325 hip, 304, 360 sacroiliac joint restriction, 308 knee, 321 Osteopathy, 2 barrier, definition, 14 training, 2, 3 Osteophytes cervical spine, 85 compensatory formation, 26 Osteoporosis, 12, 90 indications for manipulative treatment, 168 vertebral fracture T12/L1, 315 thoracic kyphotic deformity, 62 Overload cervical spine, forward-drawn posture, 74 compensatory osteophyte formation, 26 low-back pain, 303 lumbar spine, motor pattern disturbance, 29 restriction pathogenesis, 19 Overtake phenomenon pelvic distortion, 102–103 ribs examination, 115 sacroiliac joint restriction, 103
P Pain, 34, 37–38, 357, 377 acute, differential diagnosis, 164 biological function, 35 cardiac origin, 350 entrapment syndromes, 325 locomotor system, 5–6 functional pathology, 36 tension, 34–35 patient history, 89–90 localization, 89 paroxysmal character, 90 position of relief/pain provocation, 89–90 psychological factors, 35, 90, 164 radicular (root compression), 36–37, 96 referred, 35, 37 reflex effects, 4, 5 relief through normalization of function, 12 sources, 4, 5 see also Nociceptive stimulation Pain points
cervical spine, 117 hip, 128 knee, 129 ribs, 115 Pain threshold, 36 ‘Painful arc’ disk herniation, 309 lower extremity radicular syndromes, 342 lumbar spine screening examination, 109 shoulder, 124, 193 Palmer, DD, 2 Palpation, 28, 36, 93–100 cervical spine, 116–117 coccyx, 107 diagnostic skills, 377 fasciae, 94 first rib mobility, 116 functional techniques, 223 hyperalgesic zones, 93–94 lumbar spine, 109 patient feedback, 93 pelvic floor/coccygeus muscle, 106 pelvis, 101–102, 103, 106 periosteal pain points, 96–97 radicular syndromes, 96–97 subcutaneous tissue, 94 tender points, 96 thoracic spine mobility, 113 trigger points, 94–96 Palpatory illusion erector spinae examination, 223–224 forward-drawn posture, 311 pelvic shear dysfunction (Greenman), 106 Rosina test for sacroiliac joint restriction, 105 Pantyhose, 368 Paradoxical breathing, 31, 151, 349 Paresthesia carpal tunnel syndrome, 326 radicular syndromes, 96, 342, 343, 346 surgical scars, 228 thoracic outlet syndrome, 327 Parkinson’s disease, 22 Paroxysmal tachycardia, 350–351 Pars interarticularis, 56 Passive mobility cervical spine examination, 117–118 limb joints, 124 shoulder, 125 testing, 100–101 Patella gliding movements, 198 pain, 321 Patellar reflex, L4 radicular syndrome, 343 Patient cooperation in therapy, 236 Patient history, 88–90 age-related disorders, 90 course of disease, 88–89 localization of symptoms, 89 non-mechanical factors, 90 paroxysmal character of pain, 90
427
Manipulative Therapy position of relief/pain provocation, 89–90 posture, 89–90 psychological factors, 90 trauma, 89 Patient subjective statements following treatment, 153 Patient–practitioner relationship, 378– 379, 380 Patrick’s sign, 128, 274 coccygeal pain, 304, 320 coccyx dysfunction, 360 hip joint dysfunction, 360 hip joint pain, 304 L4 pseudoradicular syndrome, 320 lumbar spine/sacroiliac joint restriction, 307 segment L3/L4 dysfunction, 359 Pectorales, 160 muscle test, 139, 140 unilateral chains of dysfunction, 161 upper crossed syndrome, 152 Pectoralis major obstructive respiratory disease, 350 post-isometric relaxation, 261–262 self-treatment, 262 thoracic region pain, 317 trigger points, 359 angina, 350 shoulder pain, 322 weight carrying, 30 Pectoralis minor post-isometric relaxation, 263 syndrome of superior thoracic aperture, 161 thoracic outlet syndrome, 327, 359 trigger points, 327, 359 shoulder pain, 322 Pelvic belt, 177 Biedermann and Cyriax, 297–298 Pelvic distortion, 51–54, 102–103 body statics disturbance, 53 children, 24 kidney disease, 352 low-back pain, 311 overtake phenomenon, 102–103 palpation, 102 ulcer patients, 351 Pelvic dysfunction, 106 Pelvic floor, 157, 160 deep stabilizers of posture, 23 examination, 106–107 facilitation, 283–285 low-back pain, 314–315 symptoms of dysfunction, 360 trigger points, 107, 308, 359, 360 migraine, 332, 333 Pelvic inflare and outflare, 106 clinical findings, 313 low-back pain, 313–314 case study, 314 symptoms, 313 therapy, 314 Pelvic obliquity, 102, 128, 129 secondary compensation, 176 treatment, 176–177
428
walking movement pattern re-training, 286 Pelvic region ligament pain, 107–108 post-isometric relaxation, 271–272 self-treatment, 272 low-back pain, 302–317 due to muscle/ligament overload, 303 ‘Pelvic see-saw’, 284–285 Pelvic shear dysfunction (Greenman), 106 Pelvic tilt, 45, 49, 103, 285 correction, sitting movement pattern re-training, 289 motor pattern disturbance, 29 Pelvis, 49–50 anatomical variability, 50 examination, 101–108 inspection, 101 palpation, 101–102 pelvic floor/coccygeus muscle, 106–107 manipulation techniques, 206–209 coccyx, 208–209 sacroiliac joint, 206–208 palpation, 106 types, 50 high promontory, 50, 52, 54 low promontory (overload), 50, 52 normal, 50, 52 X-ray imaging, 41–43 statics in frontal plane, 43 statics in sagittal plane, 43 Per rectum manipulation techniques, 209 Periosteal painful points, 4 diagnostic importance, 98 palpation, 94, 96–97 self-mobilization, 237 soft tissue manipulation, 236 treatment methods, 6 Perl apparatus, 203 Pes planus see Flat foot Pharmacotherapy, 7–8 indications, 178 Phasic muscles, motor pattern disturbances, 28, 29 Physicians, 379 training, 379–380 Physiotherapists, 379 training, 379 Piriformis post-isometric relaxation, 275 trigger points, 304, 307, 308, 360 L5 pseudoradicular syndrome, 320 L5 radicular syndrome, 343 unilateral chains of dysfunction, 161 Pisiform, manipulation techniques, 190 Pleural disease, 349–350 Pleurisy, 349 Pneumonia, 317, 349 Positional vertigo, 131–132, 333–334, 335 therapy, 336 Positioning of patient for manipulation, 182
Post-cholecystectomy syndrome, 353 Post-concussion syndrome, 355, 356 case study, 355 prevention, 356–357 Posterior cervical sympathetic syndrome, 355 Post-isometric relaxation, 6, 34, 95, 172, 186, 246–279 Achilles tendon pain, 277, 321 adductor pollicis, 255 basic principles, 246–247 biceps brachii, 257 biceps femoris, 275–277 calcaneal spur, 277–279 coccygeal pain, 304 combining techniques, 185 craniocervical junction short extensors, 250–251 diaphragm, 264 digastricus, 249–250 epicondylar pain lateral, 325 medial, 325 epicondylopathy radial, 256 ulnar, 258 erector spinae, 264–265 lumbar region, 266–267 thoracic region, 265–266 thoracolumbar region, 266 trunk rotation restriction, 315 external pterygoid, 250 eye movement direction, 247 finger and hand extensors, 256–257 foot deep flexors, 321 extensors, 277 frozen shoulder, 192–193, 323 gluteus maximus, 208, 272, 304 gluteus medius, 273 gravity-induced see Gravity-induced post-isometric relaxation head and neck muscles, 248–255 headache with cervical component, 331 hip abductors, 272–273 hip adductors, 274 hip joint pain, 304 hip region muscles, 270–272 iliopsoas, 315 indications, 172 infraspinatus, 259–260 with inhalation/exhalation, 247 ischiocrural muscles, 274 latissimus dorsi, 260–261 levator ani, 209, 272, 304 levator scapulae, 251–252 low-back pain due to muscle/ligament overload, 303 lower extremity muscles, 272–279 lumbar erector spinae, 206 lumbar spine, 203 masticatory muscles, 248–249 mylohyoid, 250 pectoralis major, 261–262 pectoralis minor, 263
Index pelvic inflare and outflare, 314 pelvic ligament pain, 108 piriformis, 275 quadratus lumborum, 269 trunk rotation restriction, 315 radicular syndromes lower extremity, 345 upper extremity, 347 reciprocal inhibition combination, 247 rectus abdominis, 269–270 rectus femoris, 274–275 rib attachment point pain, 263 scalenes, 253–254 serratus anterior, 263–264 shoulder pain, 322 soleus, 321 sternocleidomastoid, 244, 254–255 subscapularis, 260 supraspinatus, 258–259 technique, 184 tensor fasciae latae, 273 teres major, 260–261 theoretical basis, 247–248 toe extensors, 277 trapezius horizontal part, 267–268 upper part, 252–253 treatment effect assessment, 247 treatment specificity, 247 triceps brachii, 258, 324 trunk muscles, 261–270 upper extremity muscles, 255–261 Post-isometric traction acute wry neck, 319 carpometacarpal joint of thumb, 188 cervical spine, 218 hip joint, 199, 200 lumbar spine, 203 radicular syndromes, upper extremity, 347 Post-traumatic states, 354–357 case studies, 355, 356–357 latency period, 354 prevention, 356–357 trauma to extremities, 357 Posture, 377, 378 co-activation pattern, 23, 159 diaphragm/abdominal wall, 160 deep stabilizers, 23 developmental kinesiology, 22–23, 157 facilitation, 279 inspection, 90–92 dorsal aspects, 91 lateral aspects, 91–92 seated patient, 93 ventral aspects, 92–93 low-back pain due to muscle/ligament overload, 303 motor pattern disturbance, 28, 29 on one leg, motor stereotypes examination, 149–150 re-training, 285–286 respiratory movements relationship, 30, 31–32, 150, 151 rotation of trunk, 23
spinal column radiology (functional diagnosis), 40, 41 see also Sitting; Standing; Statics Practitioner–patient relationship, 378– 379, 380 Prehension, 155 reaction chains of dysfunction, 156–157 ‘Present relevance’ diagnosis, 6–7 Pressure application, 171, 231 clavicle, 194 hands, hypertonus treatment, 296 trigger points, 95 Prevention, locomotor system dysfunction, 363–370 lifestyle factors, 365–367 active measures, 367–369 passive measures, 365–367 manipulation, 369–370 principles, 364–365 Proprioception disturbances, 33 role in balance maintenance, 20 Pseudocardiac problems, patient history, 90 Pseudocardiac syndrome, 350 Pseudoradicular pain, 35 Pseudospondylolisthesis, 57 Pseudovisceral pain, 359 patient history, 89, 90 trunk rotation restriction, 315 Psoas major, 160 rhythmic repetitive contraction, 184 trigger points, 161, 270, 307, 315, 359 visceral symptoms, 352, 353 trunk rotation chain reaction pattern, 269 vertebrovisceral inter-relationships, 352–353 Psychological factors, 6, 21–22 pain, 35 differential diagnosis, 164 patient history, 90 subjects with labile nervous regulation, 21, 22 tactile perception, 226 individual characteristics, 229 Psychosomatic disorders, differential diagnosis, 164 Pterygoids post-isometric relaxation, 250 trigger points, 130, 248 Pubic symphysis, 50 Pyelonephritis, 352
Q Quadratus lumborum, 160 lower crossed syndrome, 152 muscle test, 139 post-isometric relaxation, 269 trunk rotation restriction, 315 trigger points, 161, 303, 307, 315, 353, 359
headache, 330 trunk rotation chain reaction pattern, 269 unilateral chains of dysfunction, 161 Quadriceps femoris, 29, 160 weakness, radicular syndromes, 343
R Radial adduction restriction, 189 Radial epicondylopathy, post-isometric relaxation, 256 Radial styloid process pain, 325 Radial and ulnar springing (lateral gapping), 191 Radicular compression high-velocity, low-amplitude thrust indications, 168 traction indications, 170 Radicular intermittent claudication, 343–344 case study, 344 Radicular pain, 36–37 lumbar spine self-mobilization (McKenzie technique), 239 muscle spasm, body statics deviations, 49 patient history, 89 strain and counterstrain technique, 225 Radicular syndromes, 10, 341–347 cervical spine, 64 clinical signs, 342 dermatomes, 96, 99, 100 diagnosis, 96 fitness for work assessment, 372 lower extremities see Lower extremity radicular syndromes neurological deficit, 96 palpation (soft-tissue examination), 96–97 radiation pain, 96 surgery, 178 traction techniques, 202 unilateral chains of dysfunction, 161 upper extremities, 346–347 Radiocarpal joint, 127 manipulation techniques, 189–190 Radiography, spinal column, 10, 11, 39–40 cervical spine anteroposterior view, 71–72 lateral view, 72–74 movement studies, 77–81 technique, 62–63 X-ray film assessment, 63–64 fitness for work assessment, 371, 372 functional diagnosis assessability of films, 41 body statics, 40 spinal column mobility, 40 technique, 40–41 lumbar spine, 54–57 evaluation of function, 57 statics evaluation, 43–45
429
Manipulative Therapy technique, 41–43, 57 pelvis, 41–43 sacrum, 50 structural diagnosis, 39–40 thoracic spine, 59–60 Radioulnar joint, 126, 127 manipulation techniques, 191 Reciprocal inhibition, 6, 95, 172, 186, 246 adductor pollicis, 255 basic principles, 246–247 biceps brachii, 257 craniocervical junction short extensors, 251 diaphragm, 264 epicondylar pain lateral, 325 medial, 325 erector spinae thoracic region, 266 thoracolumbar region, 266 trunk rotation restriction, 315 finger and hand extensors, 256 foot extensors, 277 frozen shoulder, 323 gluteus medius, 273 headache with cervical component, 331 hip abductors, 273 hip adductors, 274 iliopsoas, 271 indications, 172 infraspinatus, 260 ischiocrural muscles, 274 levator scapulae, 253 low-back pain due to muscle/ligament overload, 303 pectoralis major, 261, 262 pectoralis minor, 263 pelvic ligament pain, 108, 272 piriformis, 275 quadratus lumborum, 269, 315 radicular syndromes lower extremity, 345 upper extremity, 347 rectus abdominis, 270 rectus femoris, 275 scalenes, 254 serratus anterior, 264 soleus, 277 subscapularis, 260 supraspinatus, 259 technique, 184 tensor fasciae latae, 273 toe deep short flexors, 279 toe extensors, 277 trapezius horizontal part, 268, 269 upper part, 253 triceps brachii, 258, 324 Record keeping, 186 Rectus abdominis, 160 défense musculaire, 353 facilitation, 281–282 forward-drawn posture, 160, 311, 321
430
lower crossed syndrome, 151 muscle test, 135 post-isometric relaxation, 269–270 self-treatment, 270 trigger points, 303, 311, 321 patellar pain, 321 vertebrovisceral inter-relationships, 352–353 Rectus femoris L4 radicular syndrome, 343 muscle test, 138 post-isometric relaxation, 274–275 self-treatment, 274 trigger points, 307, 359 L4 pseudoradicular syndrome, 320 unilateral chains of dysfunction, 161 Referred pain, 35, 320–325 coccyx, 107 L4 pseudoradicular syndrome, 320 lower extremities, 320 patient history, 89 radicular pain, 37 rectus abdominis trigger points, 269 shoulder, 322–324 surgical scars, 228 thoracic region, 317 upper extremities, 320 Reflex massage, 173 Reflex responses, 4, 5–6, 20 co-activation patterns, 378 effect of manipulation, 17 locomotor system functional pathology, 7 newborn infants, 22 restriction pathogenesis, 15–16, 19 vertebrogenic disturbances, 34–35 Reflex therapy, 6–7 advantages, 7 applications, 7–8 fundamental principles, 4–6 indications, 6, 7, 172–173 soft tissue manipulation comparison, 174–175 methods, 6 treatment selection, 6–7 Relational diagnosis, 40 Relaxation, 35 Release phenomenon, 183, 184 soft-tissue manipulation techniques, 230 Remedial exercise effectiveness, 175 indications, 175–176 preventive, 176 limitations, 175–176 locomotor system dysfunction prevention, 370 motor pattern (stereotype) disturbance, 27 patient motivation, 175–176 setting goals, 175 work-related back pain treatment, 372 see also Facilitation (training weak muscles) Renal colic, 352
Respiration, 155 diaphragm/abdominal wall contraction coordination, 160–161 effect on locomotor system, 30–32 active exhalation, 31–32 motor pattern (stereotype) disturbance, 31 examination, 150–151 retraining, 293–294 neuromuscular mobilization techniques, 184–186 postural function, 150, 151 reaction chains of dysfunction, 156 rib excursion examination, 115 tonus of lateral abdominal wall, 151 Respiratory synkinesis, 32, 184 cervical spine traction techniques, 218 combining techniques, 185 craniocervical junction mobilization techniques, 222, 223 eye movements, 185 masticatory muscle effects, 201 post-isometric relaxation, 247 masticatory muscles, 248–249 quadratus lumborum, 269 sternocleidomastoid, 254–255 post-isometric traction, lumbar spine, 203 Restriction, 4, 13, 357, 377, 378 atlantoaxial joint, 117 atlantoaxial segment, 358 atlanto-occipital joint, 117 atlanto-occipital segment, 358 cervical spine, movement studies, 77, 78–79 cervicothoracic junction, 327, 359 chain reactions, 20 childhood spinal column dysfunction, 25–26 compensation, 26 craniocervical junction, 327 tonsillitis, 349 fibular head, 129, 198, 311, 320–321, 360 foot, 295, 321 joint mobility evaluation (Stoddard’s recording system), 168, 169 joint play effects, 14 limb joints, 124 locomotor system tension muscular, 15–16 relation to pain, 35 lumbar spine, 306–309 manipulative treatment indications, 168 mechanism, 16–17 motor pattern (stereotype) disturbances, 27 normalization of mobility, 12 passive mobility testing, 100 pathogenesis, 17–19 overload/abnormal load, 17–19 reflex processes, 15–16, 19 trauma, 19 plamarflexion, 189 radial adduction, 189
Index ribs, 327 first rib, 116, 126 sacroiliac joint, 103–105, 107, 306–309 sequelae, 26–27 spinal column mobility testing, 101 treatment methods, 6 thoracic outlet syndrome, 327 thoracic region pain, 317 trunk rotation low-back pain, 315–316 segments T10/T11–L1/L2, 359 thoracic region pain, 317 ulnar abduction, 189 wrist dorsiflexion, 189 Retesting, 153, 162, 186 Retraining, movement pattern correction, 285–296 anteflexion, 289–290 breathing, 293–294 carrying loads, 292 feet, 294–295 hands, 296 lifting arms, 290–292 shoulder blade, 296 sitting, 287–289 standing on one leg, 286 on two legs, 285–286 walking, 286–287 hip rotation, 287 leg flexion/extension, 287 pelvic obliquity, 286 Retroflexion, 58, 59 atlantoaxial joint, 66, 67 atlanto-occipital joint, 65–66, 67, 123 self-mobilization, 244 cervical spine, 65, 67–70, 79 examination, 117 mobility between occiput and atlas, 123 with rotation, 118 craniocervical junction mobilization, 223 hip, 133–134 lumbar spine hypermobility examination, 140–141 individual motion segments, 110–111 radiography, 58 screening examination, 108 self-mobilization, 238–239 mobility testing, 101 ribs examination, 115 spinal column, 140 thoracic spine examination, 113 hypermobility, 142–143 self-mobilization, 240–241 Rheumatoid arthritis differential diagnosis, 165 sternoclavicular joint pain, 324 wrist pain, 325 Rhomboids, 30
Rhythmic pressure, first rib treatment, 218 Rhythmic repetitive muscle contraction technique, 184 Rhythmic repetitive trunk rotation, 204 Rhythmic traction, lumbar spine, 202–203 Ribs anomalies, 59 attachment point pain, 263 dysfunction, 359 shoulder pain, 322 thoracic spine pain, 317 examination, 115–116 overtake phenomenon, 115 palpation of resistance during retroflexion, 115 respiratory excursion, 115 screening examination, 115 first rib, 116 manipulation, 217–218 restriction, 126, 253 self-mobilization, 243 functional anatomy, 59 manipulation techniques, 214–217 high-velocity, low-amplitude thrust, 215–217 mobilization, 214–215 mobility, 349 movement, 59 self-mobilization on inhalation (upper ribs), 241–242 slipping, 317–318 manipulaion, 217 thoracic outlet syndrome, 327 X-ray anatomy, 60 Rocking, forward-drawn posture, 312 Romberg’s test, 131, 334–335 Rosina test, 104–105, 311 Rotation atlas, 75 axis, 78, 79 cervical spine, 65, 66–67, 75, 77, 78–79 in anteflexion, 117–118 atlantoaxial joint, 66 atlanto-occipital joint, 66, 123 axis in neutral position, 75, 77 during side-bending, 67 examination, 117–118 high-velocity, low-amplitude thrust, 222 hypermobility, 143 individual motion segments, 120–121 isolated of atlas, 75 with maximum forward nutation of head, 118 mobility between occiput and atlas, 123–124 mobilization techniques, 219 in retroflexion, 118 cervicothoracic junction mobilization technique, 220 self-mobilization, 243 foot, 129
head, arm lifting retraining, 292 hip, walking pattern re-training, 287 lumbar spine hypermobility examination, 142 mobilization techniques, 203–205 radiographic evaluation, 57 motor stereotypes examination head and neck, 148 trunk, 148 spinal column, 40, 140 locking techniques, 201 reaction to obliquity, 45, 47, 48 thoracic spine, 61 examination, 114–115 hypermobility, 142 mobilization techniques, 211–212 trunk chain reaction pattern, 161, 269 developmental kinesiology, 23 restriction, 306–307, 359 low-back pain315–316 thoracic region pain317 sitting movement pattern re-training, 287 Rotator cuff disturbance, 124 shoulder pain, 323 Round-shouldered sitting posture, 159
S S1 pseudoradicular syndrome, 320 S1 radicular syndrome, 342 symptoms, 343 S-reflex, 160 Saccrococcygeal syndesmosis pressure, 209 Sachse, J, 3 Sacroiliac joint, 16, 50–51 functional motion, 50 joint play, 50–51 mobilization techniques, 206–208 in horizontal plane, 206 lower end, 207–208 outflare/inflare treatment, 208 in sagittal plane, 206 self-mobilization, 238 upper part, 207 restriction, 103–105, 306–309 case study, 308–309 clinical signs, 306, 307 ligament pain, 107 overtake phenomenon testing, 103 pain points, 105 Rosina test technique, 104–105 spine sign test, 103 springing tests, 104 symptoms, 306 therapy, 306 springing movements, 184 symptoms of dysfunction, 306, 360 Sacroiliac ligament pain, 107, 108 post-isometric relaxation, 272 Sacrum, 50, 302 mobility, 50 Scalenes, 160
431
Manipulative Therapy breathing retraining, 293 clavicular breathing, 31 obstructive respiratory disease, 350 post-isometric relaxation, 253–254 self-treatment, 254 rhythmic repetitive contraction, 184 syndrome of superior thoracic aperture, 161 thoracic outlet syndrome, 327, 359 trigger points, 327, 359 angina, 350 radicular syndromes, 346, 347 Scalp self-mobilization, 237 shifting (stretching) technique, 233–234 Scapular instability, 325 Scars see Active scars Scheuermann’s disease see Juvenile osteochondrosis Schildt-Rutlow, K, 3 School headache, 24, 332 Sciatica, 342, 363 Scoliosis children, 25 indications for manipulative treatment, 168 pelvic deviation, 102 radiographic evaluation, 40, 57 spinal column reaction to obliquity, 45, 47, 48 thoracic spine, 61 Segment facilitation, 35 Self-treatment, 179, 378, 379 mobilization, 236–246 atlanto-occipital joint, 255 cervical spine, 243–244 cervicothoracic junction, 242–243 extremity joints, 245–246 lumbar spine, 238–240 ribs, 241–242, 243 sacroiliac joints, 238 thoracic spine, 240–242 post-isometric relaxation, 246 adductor pollicis, 255 biceps femoris, 276–277 craniocervical junction short extensors, 251 digastricus, 249–250 erector spinae, 267 external pterygoid, 250 finger and hand extensors, 256–257 foot extensors, 277 gluteus maximus, 272 infraspinatus, 260 levator ani, 272 levator scapulae, 253 masticatory muscles, 249 mylohyoid, 250 pectoralis major, 262 pelvic region ligament pain, 272 radial epicondylopathy, 256 rectus abdominis, 270 rectus femoris, 274 scalenes, 254 serratus anterior, 264
432
soleus (Achilles tendon pain), 277 supraspinatus, 259 toe extensors, 277 toe short flexors (painful calcaneal spur), 279 trapezius, 253, 268–269 skin sensitivity restoration, 229 stretching, 237–238 Sell, K, 3 Sella turcica, 64, 72 Serratus anterior arm raising, 30 facilitation, 280–281 muscle test, 136 post-isometric relaxation, 263–264 self-treatment, 264 retraining, 296 trigger points, 359 angina, 350 weight carrying, 30 Shaking distraction acromioclavicular joint, 194 sternoclavicular joint, 194 tarsal transverse (Chopart’s) joint, 196 tarsometatarsal (Lisfranc’s) joints, 196 Shaking mobilization carpometacarpal joint of thumb, 189, 325 elbow, 192 epicondylar pain, 325 extremity joints, 184 first rib, 218 hip joint, 199, 200, 304 knee joint, 199 self-mobilization, 246 metacarpophalangeal joints, 188 wrist joints, 191 Shaking, springing traction, lumbar spine, 202 Shifting, lumbar spine dorsal/ventral, radiographic evaluation, 57, 58 Shifting (stretching) deep fascia, 231–235 dorsal, shifting cranially, 232 extremities, 234–235 lumbar, shifting caudally, 231–232 neck, 234–235 scalp, 233–234 thorax, rotational shifting, 233 trunk, 232 Shoe insert splay foot, 295 see also Heel insert Shoes see Footwear Shoulder abduction, 126 impairment, 124 capsular pattern, 125, 192 examination, 124–126 active movement, 124–125 external rotation, 125 hypermobility, 143–144 passive movement, 125 impingement syndrome, 124, 193 internal rotation, 126
joint play, 124, 126 manipulation techniques, 192–193 pain, 322–324 acromioclavicular joint, 324 cervicothoracic junction dysfunction, 359 due to muscle dysfunction, 322 motor pattern disturbances, 28 provoked by arm abduction, 323 referred from spinal column, 322–323 sternoclavicular joint, 324 triceps brachii painful long head, 323–324 see also Frozen shoulder ‘painful arc’, 124, 193 post-traumatic states, 357 self-applied traction, 245–246 Shoulder blade manipulation techniques, 194–195 retraining movement patterns, 296 Shoulder girdle fixators, 160 stratification syndrome, 152 syndrome of superior thoracic aperture, 161 thoracic outlet syndrome, 327 upper crossed syndrome, 152 Side-bending, 54, 58, 59 cervical spine, 65, 67 atlantoaxial joint, 79, 119 atlanto-occipital joint, 66, 67, 79, 123 axis rotation, 67 C3-C7, 119 examination, 117, 118–120 mobilization techniques, 219 movement studies, 78, 79 self-mobilization, 243 cervicothoracic junction mobilization, 219–220 craniocervical junction mobilization, 222, 223 head, 67 lumbar spine hypermobility examination, 142 individual motion segments, 111–112 radiography, 58 screening examination, 108 self-mobilization, 239 mobility testing, 101 respiratory synkinesis, 32, 184, 185 spinal column, 140 locking techniques, 201 thoracic spine examination, 114 hypermobility examination, 142–143 mobilization techniques, 210–211 trunk rotation, 58 visual synkinesis, 185 Side-lying mobilization technique, lumbar spine, 203–204 ‘Signe du talon’, L5 radicular syndrome, 343 Sitting
Index lifestyle factors, 364 locomotor system dysfunction prevention, 365 posture, 33 motor stereotypes examination, 145 thoracic region pain, 317 work-related back pain assessment, 372 re-training, 287–288 erect with trunk rotation, 287–288 lateral movement of thorax, 288–289 pelvic tilt correction, 289 spinal column radiology (functional diagnosis), 40, 41 Skin effects of manipulation, 17 tactile perception, 226 assessment of alteration, 226–227 normalization, 227 Skin stretching, 171 self-mobilization, 237 technique, 230 Skin-fold rolling test, 171 Sleeping position, 319, 366 Slipping rib, 317–318, 349, 359 case study, 318 clinical findings, 317–318 symptoms, 317 therapy, 318 Soft tissues, 4, 5, 36 effects of manipulation, 17 examination see Palpation Soft-tissue fold stretching, 171, 230– 231 Soft-tissue manipulation, 230–236 indications, 171–172 reflex therapy comparison, 174– 175 mutual shifting of metacarpal/ metatarsal bones, 235–236 painful periosteal points, 236 stretching connective tissue fold, 171, 230–231 shifting deep fascia, 231–232 skin, 230 sustained pressure application, 231 Soft-tissue techniques, 2 epicondylar pain, 325 radicular syndromes lower extremity, 345 upper extremity, 347 Soleus, 160 Achilles tendon pain, 277, 321 muscle test, 137 post-isometric relaxation, 277 trigger points, 321, 361 unilateral chains of dysfunction, 161 Space-occupying lesions, radicular syndromes, 341 Spasmodic torticollis, 319 Speaking, motor programs, 155 Spina bifida atlantis, 74 Spinal canal, cervical, changes with
anteflexion/retroflexion, 65 Spinal canal narrowing, 56, 178, 339–340 case studies, 340, 341 cervical spine, 82 fitness for work assessment, 372 radicular intermittent claudication, 343 radicular syndromes, 341 Spinal column, 39–85 balance maintenance, 19, 20 deep stabilizers see Deep stabilizers of spinal column dysfunction in childhood, 24–26 key regions (transition zones), 20–21 functions, 19–20 hypermobility examination, 140–143 instability, surgical treatment, 178 manipulation techniques, 201–223 cervical spine, 218–223 coccyx, 208–209 contact holds, 202 craniocervical junction, 222–223 fixation, 201, 202 general principles, 201–202 locking, 183, 201–202 lumbar spine, 202–206 sacroiliac joint, 206–208 thoracic spine, 209–214 mobility testing, 101 reflex responses, 20 respiratory synkinesis, 184–185 cervical/thoracic segment, 32 screening examination, 20 vertebrovisceral inter-relationships, 348 Spine sign test, sacroiliac joint restriction, 103 Splay foot, 129, 130, 295–296 Velé’s test, 295 Spondylolisthesis, 56, 346 compensatory osteophyte formation, 26 indications for manipulative treatment, 168 radiographic evaluation, 57 Spondylosis, indications for manipulative treatment, 168 Sports, locomotor system dysfunction prevention, 367–368 children, 370 prophylactic manipulative treatment, 369 Spray and stretch method, 95, 248 Springing techniques, 183 acromioclavicular joint, 193–194 knee joint, 199 lumbar spine traction, 202 radius and ulnar (lateral gapping), 191–192 rhythmic repetitive movements, 184 talocrural joint, 197 tarsometatarsal (Lisfranc’s) joints, 196 thoracic spine, 213
Springing tests lumbar spine, 109–110 sacroiliac joint restriction, 104 thoracic spine, 112–113 Standing fitness for work assessment, 372 motor pattern disturbance, 29 posture, locomotor system dysfunction prevention, 365 re-training on one leg, 286 on two legs, 285–286 spinal column radiology (functional diagnosis), 40, 41 Static loading, spinal column radiology, 40 Static overload, 33, 35, 177 cervical spine pain, 318 restriction pathogenesis, 19 Statics, 12, 155, 377 cervical spine, 74 forward-drawn posture, 74 functional evaluation, 74, 77 curvatures of spine, 40, 45, 47, 48 disturbance low-back pain due to muscle/ ligament overload, 303 pelvic distortion, 53 treatment, 176–177 lumbar spine X-ray evaluation, 43 frontal plane, 45–48 sagittal plane, 47–48 pelvis influences, 50 reaction chains of dysfunction, 156 see also Posture Steppage gait, L5 radicular syndrome, 343 Stepping reflex, 22 Sternoclavicular joint dysfunction, 126 examination, 126 manipulation techniques, 194–195 shoulder pain, 324 springing movements, 184 Sternocleidomastoid, 160 clavicular breathing, 31 muscle test, 136 myotendinosis, 126 post-isometric relaxation, 244, 254–255 trigger points, 319, 358, 359 headache, 330 migraine, 332 shoulder pain, 322 unilateral chains of dysfunction, 161 Stiff neck syndrome, 355–356 Still, Andrew Taylor, 2, 11, 12 Stoddard, A, 3, 11 Stoddard’s classification of joint mobility, 169 Stomach, vertebrovisceral interrelationships, 351 Straight-leg raising test, 15, 23, 29, 159 coccygeal pain, 304, 320 coccyx dysfunction, 360 disk herniation, 310
433
Manipulative Therapy ischiocrural muscle spasm, 306 L5 pseudoradicular syndrome, 320 radicular syndromes, 96, 342, 343 S1 pseudoradicular syndrome, 320 segment L3/L4 dysfunction, 359 segment L4/L5 dysfunction, 360 segment L5/S1 dysfunction, 360 Straightening up motor pattern disturbance, 29–30 respiratory synkinesis, 32 Strain and counterstrain technique, 225 lower extremity radicular syndromes, 345 position of relief, 225 Stratification syndrome, 152–153 Stretching, 17, 19 connective tissue fold, 171, 230–231 self-mobilization, 237–238 shifting deep fascia, 231–232 skin, 171, 230, 237 Stretching exercises, 237 cervical region, 237 lateral fascia of trunk, 237 Stroking, 226 active scars, 228, 339 epicondylar pain, 325 exteroceptive stimulation, 173 asymmetric tactile sensitivity, 229 facilitation, 279 feet, 294 hands hypersensitivity, 228 hypertonus/cramping treatment, 296 headache with cervical component, 331 mouth hyposensitivity, 228 self-treatment, 229 Structural diagnosis, spinal column radiology, 39–40 Styloid process pain, 325 Subcutaneous tissue palpation, 94 stretching, 171, 230–231 self-mobilization, 237 Subdeltoid bursa disturbance, 124 Subluxation theory, 11, 40 Subscapularis, 160 frozen shoulder, 323 post-isometric relaxation, 260 syndrome of superior thoracic aperture, 161 trigger points, 359 angina, 350 shoulder pain, 322 unilateral chains of dysfunction, 161 Subtalar (talocalcaneal) joint, 130 manipulation techniques, 196–197 restriction, 321 Supinator lateral epicondylar pain, 324 trigger points, 256, 358 unilateral chains of dysfunction, 161 Supporting collar, 177 Supports, 296–298 carpal tunnel syndrome, 326
434
indications, 177 low-back pain due to muscle/ligament overload, 303 Supraspinatus dysfunction, 125 post-isometric relaxation, 258–259 self-treatment, 259 Surgery active scars see Active scars indications, 178 Surgical patients prophylactic manipulative treatment, 369 remedial exercise, 370 Swimming, 367 Switzerland, 4 Syndrome of superior thoracic aperture, 161
T Tactile perception alteration due to surgical scars, 227–228 assessment, 226–227 generalized reaction, 227 local reaction, 226–227 asymmetry, 229 development, 225–226, 228 individual characteristics, 229 muscle tone relationship, 226 normalization, 227 see also Exteroceptive stimulation Tai Chi, 176, 368 Talocalcaneal joint see Subtalar joint Talocalcaneonavicular joint, 130 manipulation techniques, 196–197 restriction, 321 Talocrural joint manipulation techniques, 197–198 restriction, 321 Tarsal transverse (Chopart’s) joint, 130 manipulation techniques, 195–196 Tarsometatarsal (Lisfranc’s) joints, 130 forward-drawn posture, 160 manipulation techniques, 195–196 restriction, 321 Temporalis, trigger points, 130, 248 Temporomandibular joint examination, 130 functional movements, 130 headache (mandibulocranial syndrome), 331 joint play, 130 manipulation techniques, 201 symptoms of dysfunction, 358 tenderness, 248 Tender painful points low-back pain due to muscle/ligament overload, 303 palpation, 96 thoracic region, 317 Tennis elbow, 324 Tension, 173, 226 locomotor system, disturbance of
function, 34–35 Tension headache, 329 Tensor fasciae latae, 134 lower crossed syndrome, 152 muscle test, 138 nocturnal meralgia paresthetica, 329 post-isometric relaxation, 273 Teres major, post-isometric relaxation, 260–261 Thoracic outlet syndrome, 179, 327– 328, 359 case study, 327–328 clinical signs, 327 pectoralis minor trigger points, 263 reflex tension in scalenes, 253 symptoms, 327 therapy, 327 Thoracic segments, symptoms of dysfunction, 359 Thoracic spine, 21, 58–62 anomalies, 59 examination, 112–115 anteflexion, 113–114, 142–143 hypermobility, 142–143 palpation of mobility, 113 retroflexion, 113, 142–143 ribs, 115–116 rotation, 114–115, 142 screening examination of active movement, 112–113 side-bending, 114, 142–143 springing test, 112–113 functional anatomy, 58–59 functional evaluation, 60–61 functional techniques, 224 high-velocity, low-amplitude thrust, 212–214 intervertebral disk thickness, 58 manipulation techniques, 209–214 middle region, 21, 59 mobility testing, 101 mobilization techniques anteflexion, 210, 241 extension, 209–210 retroflexion, 240–241 rotation, 211–212, 242 self-mobilization, 240–242 side-bending, 210–211 traction manipulation, 209, 212 treatment of one restricted segment, 210 pain, 317–318 respiratory synkinesis, 32 transitional regions, 58 X-ray anatomy, 59–60 Thoracolumbar junction, 21, 45, 47–48, 58 dysfunction, 21 trunk rotation restriction, 359 Thorax deep fascia, rotational shifting, 233 pain, 317–318 sitting movement pattern re-training, 288–289 Thrombophlebitis, 343, 345 Thumb, carpometacarpal join see
Index Carpometacarpal joint of thumb Tibialis anterior, L5 radicular syndrome, 343 Tibiofibular joint, 16, 129 joint play, 129 manipulation techniques, 198 Ticklishness, 227 abdomen, 229 Tinel’s sign, 326 Tlustek, H, 3 Toe extensors forward-drawn posture, 160 post-isometric relaxation, 277 stimulation, 29, 159 Toe flexors forward-drawn posture, 160 post-isometric relaxation, 277–279 self-treatment, 279 S1 radicular syndrome, 343 splay foot, 295 Toes functional diagnosis, 129 joint examination, 130 standing posture retraining, 286 walking, 286 Tongue, tactile sensitivity assessment, 228 Tonic reflexes, 20 Tonsillitis, 349 Traction carpal tunnel syndrome, 326 cervical spine, 218 disk herniation, 310 hip joint, 199 coxalgia, 304 in direction of femoral neck, 200 indications, 170–171 knee joint, 199 lumbar spine, 202–203 Perl apparatus, 203 radicular syndromes lower extremity, 345 upper extremity, 347 self-applied carpal bones, 245 fingers, 245 shoulder, 245–246 spinal column, 202 talocalcaneonavicular joint, 196 talocrural joint, 198 thoracic spine, 209, 212 extension, 212–213 flexion, 213 Training, professional, 2, 3, 379–380 Training weak muscles see Facilitation Transitional lumbosacral vertebra, 56 Translational (gliding) techniques, wrist joint, 189–190 Transverse carpal ligament, stretching, 326 Transversus abdominis, 157, 160 breathing retraining, 293 deep stabilizers of posture, 23 facilitation, 282, 283 muscle test, 135 Trapezium, manipulation techniques, 188
Trapezius arm raising, 30 lower part facilitation, 280 retraining, 296 muscle test ascending part, 135–136 descending part, 139 obstructive respiratory disease, 350 post-isometric relaxation, 252–253, 267–268 self-treatment, 253, 268–269 trigger points, 115, 319, 322, 352, 358, 359 angina, 350 radicular syndromes, 346, 347 unilateral chains of dysfunction, 161 upper crossed syndrome, 152 weight carrying, 30 Trauma compensation issues, 373 expert assessment, 373–375 accident as cause of symptoms, 374–375 with demonstrable degenerative changes, 374 nature of accident, 373–374 extremities, post-traumatic states, 357 patient history, 89 prophylactic manipulative treatment, 369 restriction pathogenesis, 19 Treatment failure, 7, 179 Treatment outcome evaluation, 167 Trendelenburg’s sign, 150, 304 Triceps brachii C7 radicular syndrome, 347 lateral epicondylar pain, 324 painful long head, 323–324 post-isometric relaxation, 258 trigger points, 256, 258, 324 unilateral chains of dysfunction, 161 Triceps surae, S1 radicular syndrome, 343 Trigger points, 4, 5, 12, 35, 159, 357, 358, 377, 378 active, 96 adductor pollicis, 255 biceps brachii, 256, 257 biceps femoris, 275–277, 311, 321, 330 chronic, 36 coccygeus, 107, 332 low-back pain, 314–315 craniocervical junction short extensors, 250–251, 319, 330, 332, 358 definition, 95 diagnostic importance, 97 diaphragm, 264, 322, 327, 330, 332, 347, 359, 360 clavicular breathing, 350 digastricus, 130, 249–250 mandibulocranial syndrome, 331 electromyography, 96
erector spinae, 161, 264–265, 303, 307, 315, 330, 332, 353, 359 finger extensors, 256–257, 358 foot, 295 deep flexors, 321 extensors, 277 soles, 330, 332 forearm extensors, 256 frozen shoulder, 323 gluteus maximus, 272, 360 gluteus medius, 273, 359 hand extensors, 256–257, 358 head and neck muscles, 248–255 headache with cervical component, 330, 331 hip abductors, 272–273 hip adductors, 274, 360 iliacus, 270, 304, 307, 311, 320, 353, 360 iliopsoas, 270, 315 infraspinatus, 259–260, 322, 359 ischiocrural muscles, 274, 320, 360 latent, 96 latissimus dorsi, 260–261, 359 levator ani, 107, 209, 272, 360 coccygeal pain, 304 levator scapulae, 251–252, 319, 322, 358 low-back pain due to muscle/ligament overload, 303 lumbar spine/sacroiliac joint restriction, 306, 307 masseter, 130, 248 masticatory muscles, 248–249, 330, 331 metatarsals, 321 migraine, 332, 333 mylohyoid, 130, 250 needling, 173, 248, 299 palpation, 94–96 pectoralis major, 261–262, 322, 350, 359 pectoralis minor, 263, 322, 327, 359 pelvic floor, 107, 308, 332, 359, 360 piriformis, 275, 304, 307, 308, 320, 343, 360 post-isometric relaxation, 172, 246, 247, 303 psoas major, 161, 270, 307, 315, 352, 353, 359 pterygoids, 130, 248, 250 quadratus lumborum, 161, 269, 303, 307, 315, 330, 353, 359 radial epicondylopathy, 256 reciprocal inhibition, 172 rectus abdominis, 269–270, 303, 311, 321 rectus femoris, 274–275, 307, 320, 359 scalenes, 253–254, 327, 347, 350, 359 serratus anterior, 263–264, 350, 359 soleus, 277, 361 Achilles tendon pain, 321
435
Manipulative Therapy sternocleidomastoid, 254–255, 319, 322, 330, 332, 358, 359 subscapularis, 260, 322, 350, 359 supinator, 256, 358 supraspinatus, 258–259 sustained pressure application, 231 temporalis, 130, 248 tensor fasciae latae, 273 teres major, 260–261 toe deep short flexors, 277–279 extensors, 277 trapezius, 319, 346, 347, 352 horizontal part, 267–268 lower part, 359 middle part, 115 shoulder pain, 322 upper part, 252–253, 350, 358, 359 treatment methods, 6 triceps brachii, 256, 258, 324 ulnar epicondylopathy, 258 wry neck, acute, 319 Trophicity, compensation of restriction, 26 Trunk fascia shifting on both sides, 232 stretching exercises, 237 muscles facilitation, 279–285 post-isometric relaxation, 261–270 reaction chains of statics dysfunction, 156 Trunk rotation, 54, 58, 59 chain reaction pattern, 161, 269 infants, 23 respiratory synkinesis, 32 restriction, 306–307, 359 low-back pain, 315–316 thoracic region pain, 317 sitting movement pattern re-training, 287 Two-scales test, 131, 333
U Ulcer patients, 351 case history, 351–352 Ulnar abduction restriction, 189 Ulnar epicondylopathy, post-isometric relaxation, 258 Ulnar nerve weakness, 328 Uncinate processes, 65, 72, 85 Uncovertebral joints (neoarthroses), cervical spine, 65, 85 United States, 4 Unterberger’s stepping test, 131 Upper crossed syndrome, 152
436
Upper extremities joint treatment, 187–195 post-isometric relaxation, 255–261 radicular syndromes clinical signs, 346 indications for surgery, 347 symptoms, 346–347 therapy, 347 reaction chains of prehension dysfunction, 156–157 referred pain, 320
V Valsalva maneuver, 31, 151 Vasomotor headache, 329, 332 Vasomotor reactions, 5 Velé’s test, 129 Vertebral artery, 21, 64, 72 damage, 169 equilibrium disturbance, 132, 335–336 functional anatomy, 65 Vertebral artery insufficiency, therapy, 336–337 Vertebral artery syndrome, 64, 170 Vertebral fracture, T12/L1, osteoporosis, 315 Vertebrogenic disturbances, 7, 10, 12 clinical aspects, 301–361 conceptual issues, 37–38 patient history, 88–89 psychological factors, 21 reflex processes, 34–35 Vertebrovisceral inter-relationships, 348–354 differential diagnosis, 348 duodenum, 351 gall bladder, 352 heart, 350–351 kidneys, 352 liver, 352 lungs, 349–350 principles, 348–349 psoas major, 352–353 rectus abdominis, 352–353 stomach, 351 thoracic region pain, 317 Vertigo, 20, 333–334, 335, 363 case study, 337–338 examination, 131–132 patient history, 89, 90 see also Equilibrium disturbance Viscera, 4, 5 disease, 348–349 see also Vertebrovisceral interrelationships referred pain to thoracic region, 317
Visual synkinesis see Eye movement Volleyball, 367
W Walking fitness for work assessment, 372 L5 radicular syndrome, 343 leisure activity, 368 lifestyle factors, 364 motor pattern (stereotype) disturbance, 29 re-training, 286–287 see also Gait Weight carrying see Carrying Weight-lifter’s posture, 24 Whiplash injury, 355, 373 post-traumatic cervicocranial syndrome, 355 stiff/frozen neck syndrome, 355–356 Wolff, HD, 3 Work table height, 365, 372 Wrist dorsiflexion restriction, 189 examination, 127 functional movements, 127 manipulation techniques, 189–191 pain, 325 Wrist extensors lateral epicondylar pain, 324 unilateral chains of dysfunction, 161 Writers’ cramp, 324 Wry neck, acute, 12, 319–320 antalgic position, 15 case report of management error, 170 children, 24, 26 clinical signs, 319 differential diagnosis, 319–320 sleeping position, 366 symptoms, 319 therapy, 319 traction indications, 170
X X-rays see Radiography, spinal column
Y Yoga, 32, 176, 368, 370
Z Zygopophysial joint arthrosis, cervical spine, 85
