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uccessor tl) the renowned Manual Medicine: Diagnostics and Manual Medicine: ·Inerapy. this richly illustrated. logically organized book. while clinically oriented. presents both the theory and practice of the expanding field of musculoskeletal medicine. Its aim is to fully integrate and coordinate the relatively young firld of manual medicine with classic medical school teaching, based on currenL biomechanical and evidence-based knowledge. Without pleJudice the book includes the posillve aspects of osteopathic and chiropractic examination and treatment tpchnique within the context of a functionally meaningful musculoskeletal managpment approach. _
Whllt> the particular examination and related treatment techniques are described in detail. tile layour facl1itate both a quick overview and sufficient detaJi, when needed. The accom panying text describes and correlates possible pathologic findings. Other chapters cover the history of manual medi ine, examination and Lreatment principles. and the application of biomechanics and muscle physiology La the variolls non-surgical hands-on approaches, including myofascial trigger point treatmtnt. Emphasis is given to anatomical descriptions of muscles Jnd their palpatory assessment as well as techniques to treat shortened muscles. The concept of muscle imbalance is presented. Relationships between pain and specific variables are juxtaposed Jnd graphically represented. Rarionaltreatmenl approaches are deScribed. ranging from "wait-and-see" recommendations to further medical work-up and indications for surgery. SpecifiC musculoskeletal disorders Jre reViewed in detail.
Highlights: •
•
•
•
•
•
•
Systematic presentation, from three-dimensional anatomy to function and pain Over 1000 illustrations. dispenslllg with [he need for lengthy text passages LogICal presentation of speCific disorders "Action" photographs for examination and treatment Full-color drawings and photographs with superimposed graphics clearly depicting lhe joints and areas of each body region Physiological explanations and further requirements substanliclting the use of m;mipulative medicine Well arranged examination techlllques for the entire person
Muscu/oskeleral Manual Medicine will be indispensable to professionals who treat the person
with acute and chronic musculoskeletal problems, providing access to the broadest possible cumamentarium based on today's knowledge and insights.
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Important note: Medicine is an ever-Changing science undergoing
from the publisher.
continual development. Research and clinical experience are contin ually expanding our knowledge. in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application. readers may rest assured that the authors. editors. and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.
Parts of this book are an authorized and revised translation of the 5th German edition of Manuelle Medizin: Diagnostik and the 3rd German edition of Manuelle Medizin: Therapie. published and copyrighted 1997 by Georg Thieme Verlag. Stuttgart. Germany. This book also includes revised and updated material taken from the 1 st edition of Manual Medicine: Therapy and the 2nd edition of Manual Medicine: Diagnostics. published and copyrighted 1988 and 1990. respectively. by Georg Thieme Verlag. Stuttgart. Germany.
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IV
Copyrighted Material
List of Contributors Hubert Baumgartner, MD
Carl Granger, MD
Former Chief of Rheumatology
Professor of Rehabilitation Medicine
Schulthess Clinic
University at Buffalo
Zurich, Switzerland
School of Medicine and Biomedical Sciences
Daniel Buehler
Uniform Data System for Medical Rehabilitation
Physiotherapist
Amherst
Fluntern High School Sports Center
New York, USA
Executive Director
Department of Physiotherapy Zurich, Switzerland
Dieter Grob, MD
Douglas Chang MD, PhD
Head of Spine Surgery
Professor ,
Assistant Professor
Schulthess Clinic
Chief, Physical Medicine and Rehabilitation
Zurich, Switzerland
Department of Orthopedic Surgery University of California, San Diego San Diego, CA, USA
Norbert Gschwend, MD Professor and Former Chief Surgeon and Chairman Schulthess Clinic
Jill Chomiak, MD, PhD
Zurich, Switzerland
Associate Professor Head of Pediatric Orthopedic Department
Jochen F. Loehr, MD, FRCSC
University Hospital IPVZ and 1 st Medical
Professor of Orthopedics
Faculty of Charles University
ENDO-Clinic
Hospital Na Bulovce
Hamburg, Germany
Prague, Czech Republic Chetan Malik, MBBS Beat Dejung, MD, PhD
Clinical Instructor
Physical Medicine Specialist
Rehabilitation Medicine
Rehabilitation and Rheumatic Diseases
Department of Physical Medicine and Rehabilitation
FMH Swiss Medical Association
University at Buffalo
Winterthur, Switzerland
School of Medicine and Biomedical Sciences
Tomas Drobny, MD
Amherst
Orthopedic Surgeon, Lower Extremity
New York, USA
Uniform Data System for Medical Rehabilitation
Schulthess Clinic Zurich, Switzerland
Anne Frances Mannion, MD, PhD
Toni Graf-Baumann, MD, PhD
Research and Development
Professor
Schulthess Clinic
Managing and Scientific Director
Zurich, Switzerland
Head of Department
German Society of Musculoskeletal Medicine Managing Director
Urs Munzinger, MD
German Society for the Study of Pain
Orthopedic Surgeon FMH
German Pain Society
Head of Orthopedic Surgery. Lower Extremities
Teningen. Germany
SChulthess Clinic Zurich, Switzerland
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v
Manohar M. Panjabi, PhD
Wolfgang Trautmann
Professor Emeritus
Physiotherapist
Former Director Biomechanics Research
Director of Physiotherapy
Yale University School of Medicine
Sports Medical Center Bern
New Haven, Connecticut, USA
Permanence Clinic Bern-Hirslanden Bern, Switzerland
Bogdan P. Radanov, MD Professor
Beat Waelchli, MD, DC
Head of Pain Center
PRISMA Spine Surgery Zollil<erberg
Schulthess Clinic
Center for Chiropractic Zurich
Zurich, Switzerland
Zollikerberg, Switzerland
Pascal Rippstein, MD
Barbara Weber Schneider, MD
Chairman of Foot and Ankle Department
Dietlikon, Switzerland
Schulthess Clinic Zurich, Switzerland
Richard D. Weissmann, PT, OMT I
Beat R. Simmen, MD, PhD
Head of Faculty
Physiotherapy Practice and Clinic Chairman Upper Extremity and Hand Surgery
David G. Simons Academy
Schulthess Clinic
Winterthur, Switzerland
Zurich, Switzerland
Acknowledgements
As editors of a textbook with a history of 25 years and a
In this respect we thank Thieme Publishers for assigning
track record of five editions in German and two editions in
two such skillful collaborators to assist in the project from
English, Japanese, Spanish, and Italian respectively, we
beginning to end.
have been supported, in particular, by Mr. Brian Scanlan,
We would like to thank the Schulthess Clinic Zurich for
President of Thieme Publishers. The idea and concept for
offering
the current, completely reworked book Musculoskeletal
Li.itscher, head of the documentation center of the Schult
its infrastructure.
In particular, Mr. Andreas
Manual Medicine was strongly supported by the Executive
hess Clinic, who supported us since 1986 and who contrib
Director, Dr. Clifford Bergman, who saw the advantage of
uted in a major way in the production process while chang
the new concept.
ing from the classical style to complete digital desktop
Fusing the previous two books, introducing several new
publishing. Those who went through the process greatly
chapters, and enhancing the layout and presentation of the
appreciate such professional help. A special thanks also
material was quite an undertaking. We would therefore
goes to the research assistants from the Schulthess Hospi
like to extend our special thanks to Mrs, Annie Hollins,
tal, Mr. Dave O'Riordan and Mr. Charles McCammon, who
Editorial Assistant, and Ms Elisabeth l(urz, Production Edi
helped us with the references and coordinated contacts
tor, from Thieme Publishers, who did more in the course of
with all of the collaborators.
the translation and production of the book than anyone
We, as editors, experienced that a project of this nature
would expect from a publishing house. Both ladies now
is not just an individual effort. It requires a tremendous
understand the concept of musculoskeletal manual medi
amount of teamwork to produce a textbook such as this.
cine as they not only contributed to the production of the book but also used their intellectual capacity to identify and eliminate mistakes that occurred in the fusion process.
The Editors
VI
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Preface on the Occasion of the 25th Anniversary
The current textbook Musculoskeletal Manual Medicine has,
two authors influenced immensely how we would learn to
in terms of medical publishing, a long and interesting his
think about and approach new research projects that
tory. Although this book has a new format, completely
would investigate principles of mechanisms and how they
reworked and reorganized, the original ideas presented
relate to clinical signs and symptoms. This resulted in a
25 years ago still hold true. To the surprise of many-both
wonderful friendship and thoughtful scientific collabora
within and outside the field-probably no other back pain
tion, and nearly 50 papers in peer-reviewed journals.
treatment interventions have been studied as exhaustively
Knowing the quality ofThieme Publishers, we presented
in biomechanical studies and randomized clinical trials as
them with our hand-made book for consideration. In 1983,
manual medicine procedures.
Thieme Publishers courageously published a book which at
During the past 25 years, interest in the field has steadily
that time appeared to be quite an exotic project: the first
increased, both on the part of the public and patients, and
German edition of Manual Medicine: Diagnostics. We think
on the part of orthodox medicine. Manual medicine has
that this important decision served everyone well.
gone from having an "outsider" role to being a logical part
Soon after the first edition, and being educated within
of the armamentarium of today's musculoskeletal physi
the framework of the rather young Swiss Medical Associa tion for Manual Medicine, we visited well-established edu
cian. Again, history is a good teacher. In the mid 1970s, cr, M RI, SPEcr, and PET scans capable
cational institutions of osteopathic medicine in the USA
of investigating structures and tissues potentially respon
that already held university status, as well as those colleges
sible for primary symptoms such as pain and altered struc
of chiropractic accredited by the Swiss health system to
ture and function were not available to patients presenting
educate Swiss chiropractors. The close exposure and col
with musculoskeletal disorders. However, with the increas
laboration with experts of osteopathic manual medicine
ing interest in and fascination of applications of technology
such as Philip Greenman, Myron Beal, and Bob Ward, and
in patient care, the physician's hands as a diagnostic and
from the chiropractic profession, Scott Haldeman, not only
therapeutic tool were commonly neglected, particularly in
offered us new dimensions and aspects of manual medicine
the assessment of such musculoskeletal disorders as so
but also taught us to respect and collaborate equally with
called nonspecific or mechanical low back and neck pain.
doctors of osteopathic medicine and doctors of chiroprac
In the late 1970s our attention was attracted by a small
tic.
group of Swiss physicians successfully using manual med
Wolfgang Gilliar, DO, currently Professor at the New
icine approaches, both diagnostically and therapeutically.
York College of Osteopathic Medicine of the New York
We became students of the prominent Swiss rheumatolo
Institute of Technology, translated the book, and it was
gist, Dr. Max Sutter, who taught us one-on-one how to use
presented to the English-speaking market in 1984.
our hands to palpate the changes of different tissues in the
Following the experience gained from our exposure to
human body such as the skin, subcutaneous tissues,
osteopathy and chiropractic on the occasion of the 7th
muscles, and tendons. The principle idea was to try to
International Congress of the FIMM (International Federa
identify the anatomical structures and relationships re
tion of Manual Medicine) in Zurich in 1983, we invited the
sponsible for pain and altered function in a joint or spinal
leaders in their particular field to what is now known as the Fischingen Conference. There, within 1 week, the common
region. The first two authors, together with the orthopedic
denominators of manual medicine, osteopathy, and chiro
surgeon Dr. Tomas Drobny, set down their experiences of
practic were openly and collegially discussed. We realized
the nearly 3-year educational process in the first German
that many of the diagnostic and therapeutic approaches
edition of Manual Medicine: Diagnostics (Manuelle Medizin:
appear similar or deviate only slightly from each other-as
Diagnostik), with a print run of a total of 10 copies of a book
far as the biomechanical model is concerned-and their
based on our own hand colored drawings, the starting point
approach and applications may have been shaped, at least
of a long medical journey. Many of the original drawings
in part, by their professional context and philosophy.
from this very first edition in 1980 are still used in the
In the 1980s relationships between exponents of manual
current textbook, now redrawn and following a layout
medicine and classical orthodox medicine were somewhat
that was created, yes, with sophisticated publishing tech
tense. In other words, traditional universities. at least in
nology. At that time we were already impressed by the
Europe, seemed rather reluctant to integrate the diagnostic
seminal research papers and textbook on clinical bio
and therapeutic aspects of manual medicine within the
mechanics by Augustus White and Manohar Panjabi. These
framework of what could be best medical practice. Around
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VII
Preface
the globe, the trend of and call for evidence-based ap
in Switzerland, which offers postgraduate teaching to doc
proaches became more important, not only in academic
tors and physiotherapists in the field of musculoskeletal
practice but in medical practice altogether. In this regard,
manual medicine.
we received quite a strong message from one of the most
The current English edition, Musculoskeletal Manual
prominent and respected pioneers in spine research, Pro
Medicine, has been completely reworked and integrates
fessor Alf Nachemson from Giitheborg, Sweden. After send
the newest aspects of clinical biomechanics. clinical prac
ing him the first edition of the English bool< for review, his
tice. and evidence-based approaches to diagnose and treat
answer was swift and to the point: "I will not read your
musculoskeletal disorders conservatively. including the
bool< unless it has been scientifically proven." Our first
preventive programs.
reaction was quite human, but giving Dr. Nachmeson's
For this new book. we invited Wolfgang Gilliar.
O.
comments a second thought, we were markedly influenced
meanwhile close friend and exponent of osteopathic med
by them, as was our further development. The first author
icine and well-known not only in the USA but also in
returned from clinical practice and started his residency in
Europe. to be coauthor. Having translated our initial texts
neurology to obtain education and particularly scientific
(Manual Medicine: Diagnostics and Manual Medicine: The/'
tools to investigate and fulfil Nachemson's request. In this
apy). being a physiatrist. and ever interested in furthering a
respect, the close collaboration with Manohar Panjabi and
meaningful understanding of principles and mechanisms.
his research team, as well as the opportunity to perform
he developed his own personal approach and expertise
cadaveric experiments in the highly sophisticated labora
from the start. His contribution to the new English edition
tory of the Moris MUlier Institute in Bern was a lucky
has been major and the editors are very thankful that
coincidence to the advantage of the development of Mus
Wolfgang accepted the invitation to help shape and signifi
culoskeletal Manual Medicine, which further contributed to
can tly contribute to the current book.
our personal improvement of understanding and clinical
As editors and authors. we are highly satisfied with the
skills. We realized, thanks to Nachemson's hard lesson, that
several editions in different languages, with the first and
a good starting
current edition spanning 25 years. The new edition. which
point-is not enough, and actually carries a risk of being
clinical
experience-while
serving as
now has become an entirely new book. reflects our per
led in the wrong direction.
sonal development as physicians. and at the same time is
The scientific approach, which we as authors of the
witness to the growing acceptance of this form of medicine
current book implemented in the framework of our think
within the medical community. We realize this brings with
ing, dominated our next steps with the intention to search
it the responsibilities we editors need to take into account
for evidence of those phenomena which we felt by using
when presenting new teaching material.
our hands for diagnosis and treatment. The exposure as
Truly this book has become a "trans" book: transconti
active members of the leading spine societies such as the
nental and transdisciplinary. integrating neurology UO).
International Society for the Study of the Lumbar Spine, the
internal medicine (VO). physical medicine and rehabilita
Cervical Spine Research Society, and the Spine Society of
tion (WG). rheumatology (WS). sports medicine (HS). and
Europe, also influenced our development and, being con
physiotherapy
fronted with spine surgery in particular, we learnt the
contributors. it is our sincere wish that the reader is stimu
(TI).
With the invaluable input from all the
limits of conservative approach including those of manual
lated to move beyond professional boundaries and look at
medicine. We respected the limits and, while understand
the "soul" of the topic at hand.
ing the great advantages of modern spine surgery, we dis
This may be a topic-hopefully with more research re-
cussed and recommended surgical procedures to our pa
suits. ideally with its own new ideas and forms of inves
tients when necessary to reduce pain and improve func
tigation- in a book in another 25 years from now.
tion. In 1997 we completely reworked and restructured the books and invited three new editors to enhance and im-
Jiff Dvorak
prove the fifth German Edition with their experience and
Vac/av Dvorak
expertise.
Wolfgang Ci/liar
In this form the book became a major educational tool
Werner Schneider
within the Swiss Medical Association of Manual Medicine,
Hans Spring
one of the most successful and active medical associations
Thomas Tritschler
VIII
Copyrighted Material
Contents 1 Manual Medicine-An Overview .......
Historical Perspective ..................... .
Somatic Dysfunction and Tender Points .... ......
126
The Spondylogenic Reflex Syndrome .......... ,.
127
Recent International Perspective ...............
Effectiveness, Outcomes, and Open Questions .....
,
2
7 The Structural and Functional
Neuro-Musculoskeletal Examination ... 135
2 Definitions and Principles of Manual
Medicine Diagnosis and Treatment.....
4
.
4
Techniques.......................... .
16
Definitions and General Principles ............
,
Treatment Principles of Various Manual Medicine
3 Biomechanlcal Principles of the Spine
and JOints .........................
135
Observation ("LOOK") . ... .. ... ... ... ......
137
Palpation ("FEEL").... ... ..... ... ..... ....
137
Motion Testing ("MOVE") .......... ..... ....
140
Functional Examination of the Muscles and Myofascial Structures ... . . ... ... .. ....
142
Provocative Tests .... ... ........ ..... ....
144
Rational Selection of the Appropriate Laboratory 41
General Biomechanical Principles...............
41
Clinical Biomechanics of the Spine............. .
41
Biomechanics of the Upper Cervical Spinal joints
(CO-C1-C2) ..........................
44
Biomechanics of the Lower Cervical Spine (C3-C7)....
54
Vertebral Artery ........................ .
61
Biomechanics of the Thoracic Spine .............
64
Biomechanics of the Thorax and Ribs ............
65
Biomechanics of the Lumbar Spine ............ .
66
Biomechanics of the Pelvic Girdle ..............
69
JOint Motion and Biomechanical Correlations
78
4 Neurophysiology of the Joints
and Adjunctive Diagnostic Studies. .. .........
81
Neuropathophysiology of the Apophyseal joints .....
81
Articular Neurology .......................
81
Functional Pathology of Muscle............... .
87
What's on the Horizon - When Manual Medicine 98
144
8 Rational Selection of Appropriate
Low-Risk Treatment Interventions.....
145
Introduction .......... ..... ... .........
145
Examination Levels in Relation to the Diagnosis and Treatment of Musculoskeletal Disorders. .....
148
Correlation of the Various Clinical Parameters .. ....
149
9 Indications and Contraindications for
Conditions with Potentially Increased Risk of Treatment . ................. Diagnosis: Lumbar Disk Herniation .... ... . . ....
and Muscles ...................... .
and Molecular Medicine Meet .............. .
Introduction .. .. ... ... ..... ... .........
160
160
Diagnosis: Lumbar Spinal Stenosis (Central and/or Foraminal Stenosis) .
.
.
•
... ....
161
Diagnosis: Cervical Disk Herniation . ... ..... ....
161
Diagnosis: Cervical Spinal Stenosis... ... ........
162
Diagnosis: Acute Soft-Tissue Injury to the Cervical Spine
162
Diagnosis: Chronic Phase of Soft-Tissue Injury to the Cervical Spine . .... ... ... ..... ....
163
Diagnosis: Cervicogenic Vertigo
5 The Pharmacologic and Psychologic
Treatment of Chronic Pain ........... . 99 B. D. Radanov Understanding Pain Mechanisms. ... ..... .... ..
in the Lumbar Spine. ........ ... .. ... .... 99
Pharmacologic Treatment of Chronic Pain ...... ... 102
Psychologic Aspects of Pain Treatment ......... "
(Including Cervical Migraine) ... ... ...... ...
110
163
Diagnosis: Spondylolisthesis with Spondylolysis 164
Diagnosis: Bony Malformations of the Vertebral Column, Malformations of the Spinal Cord. ... .. ... . . ..
164
Diagnosis: Osteoporosis (in the Presence of Pathologic Vertebral Fractures) . ..... ... .... ........
164
Diagnosis: Ankylosing Spondylitis (Bechterew Disease):
6 Nonradicular Pain: Spondylogenic
and Myofascial Pain Syndromes . .. . ... 113
Referred Pain............. ... ........ ... 114
Myofascial Pain Syndromes .... ... ........ ...
118
The Postural Pseudoradicular Syndrome .... ... ...
122
Acute Inflammatory Changes ... ... ..... ....
165
Diagnosis: Ankylosing Spondylitis (Bechterew Disease)
without Clinical Signs of Acute Inflammation "
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...
165
IX
Contents
Neurologic Disorders Associated with Back Pain. . .... 222
Diagnosis: Inflammation of the Vertebral Column in Association with Chronic Rheumatoid Arthritis.... 166
Cervicogenic Vertigo and Headache ............. 226 Degenerative Disorders of the Spine.
Diagnosis: Abnormal Segmental or Regional Spinal Hypermobility (Congenital or Acquired) ......... 166 Diagnosis: Patient on Anticoagulation Medication..... 166
.
.
.
.
.
.
•
..... 231
Metabolic and Rheumatologic Disorders Affecting the Spine...................... 232 Organ-related Pain and Pseudo Spine Pain ......... 238 Orthopedic Spinal Disorders.................. 240
10 Evidence Base in Manual Medicine for the Treatment of Back Pain Syndromes:
Spondylosis, Spondylolysis, Spondylolisthesis,
Background, Status, and Practice ..... 167 A. F. Mannion, j. Dvorak, W. Gilliar Brief Historical Background. .................. 167 Effectiveness and Cost Considerations: Evidence and Recommendations.................... 167 Requirements for Successful Manual Medicine Management: The Individual Practitioner......... 170
and Spinal Stenosis........ .............. 241 Spinal Deformities........................ 243
Clinical Disorders and Syndromes of the Upper Limb. 252 B. R. Simmen, W. Gilliar General Comments ..... . ... . ............. 252
The Shoulder. .......................... 252 Common Shoulder Disorders ................. 252
The Elbow. ............................ 268 Surgical Interventions: A Brief Overview . .......... 268
11 Informed Consent, Complication
Elbow Disorders ......................... 270
Assessment, Quality Control, and Documentation ................ 171
The Wrist.......................... , .. 276 Wrist Disorders.......................... 276
Clinical Disorders and Syndromes of the Lower Limb. 287
T. Graf-Baumann, W. Gilliar Informed Consent within Patient Care.......... .. 171
The Hip .............................. 287
Complication Assessment ................... 171
j. F. Loehr, W. Gilliar
Quality Control in Manual Medicine; Continuing Education..................... 172 Documentation Requirements................. 173
Disorders of the Hip....................... 287 Hip Disorders in Childhood .....
.
.
•
.
.
.
.
.
.
.
•
.. 289
Hip Disorders in Adults..................... 296
The Knee ............................. 301 T. Drobny, U. Munzinger, W. Gilliar
12 Patient Outcome and Follow-Along Measures. ........................ 174 C Granger, C Malik
Patients Younger than 45 Years...........
.
.
•
.. 302
Patients Older than 45 Years ............. . , .. 307 Disorders of the I
Introduction............................ 174 s ........ 174 The LlFEware M System .. . .. .. . .. .
.
•
The Foot and Anlde. ...................... 317 P. Rippstein, W. Gilliar
LlFEware System Measures ................... 175
Disorders of the Toes ....... . ... . . ......... 317
LlFEware System Domains ................... 175
Heel Pain ............................. 324
Case Study............................. 184
Foot Deformities.
.
.
.
.
.
.
.
.
•
.
.
.
.
.
.
.
.
•
...... 328
Conclusion............................. 185
15 Structural and Functional Diagnosis 13 Imaging Studies of the Spine . ........ 186 Introductory Remarks .
.
.
•
•
.
.
.
.
.
.
.
.
•
•
....... 186
Cervical Spine........................... 187 Thoracic Spine . ......................... 201 Lumbar Spine and Pelvis .................... 203
and Treatment of the Spine, Ribs. Pelvis. and Sacroiliac Joint. .......... 331 Structural Examination and Functional Treatment of the Cervical Spine ..................
331
Palpation of Bony Landmarks:
Bulging Lumbar Disks and Disk Herniations.... . .... 212
Cervical Spine ......................... 331
Nuclear Medicine Studies......... . .......... 213
Irritation Zones (IZ) Associated with the Cervical Spine . 332 Structural Examination of the Cervical Spine........ 335
14 Selected Clinical Syndromes. ......... 214 Clinical Disorders and Syndromes of the Spine. .... 214 D. Grob, j. Dvorak, W. Gilliar
CO through C7 ....... .. ..............
335
Evaluation: Active Motion Testing of Flexion, Extension, Rotation, and Side-Bending. ................
335
CO through C7 .......................
337
Pain and the Spine: A Brief Overview of Approach
214
Evaluation: Passive Motion Testing of Flexion, Extension,
Nerve Roots and Nerve Root Pain...........
216
Rotation, and Side-Bending . ................. 337
x
Copyrighted Material
Contents
C3 through C7 ............... Evaluation: Rotation in Extension ..... CO through C7 ...............
.
.
.
339
C1-C2 .....................
339
Self-Mobilization: Rotation Restriction ....
340
C1-C2 ..................... .
361
NMT 2: Rotation Restriction (Neutral Position) .
361 363
Evaluation: Provocation Position and Motion Testing
360
.
360
of the Vertebral Artery by Rotation and Reclination.
340
C1-C2 ........ ... ............
CO through C3 ..... ........... . ..
341
NMT 3: Rotation Restriction (Neutral Position) .
363
C1-C2 .. .. . .. ..... ......... ...
365
Evaluation: Active Motion Testing for Inclination and Reclination.. ............ . ......
341
NMT 2: Rotation Restriction (with Upper Cervical Spine
CO through C3 ... ... ..... ... .. ... .
342
Fully Flexed) ......................... ,
365
C1-C2 .............................
366
Evaluation: Passive Motion Testing for Inclination and Reclination, ........ ... ... ......
342
NMT 3: Rotation Restriction (with Upper Cervical Spine
CO-C1............ .. ... ........ ....
343
Fully Flexed) . ..........
.. ......
C2-C3 . .............
., ......
Evaluatian: Passive Motion Testing of Axial Rotatian and Evaluation ofJoint Play .........
343
CO through C3 ... ..........
344
C1-C2..................
.
.
Evaluation: Active Motion Testing of Axial Rotation...
367
NMT 2: Rotation Restriction ..
367
C2-C3 ..... .........
368
NMT 3: Rotation Restriction ... ..
368
344
CO through C3 . . ... . . ... ...
369
345
Mobilization without Impulse: Axial Traction .... ...
369
345
CO through C3 . . ..... . .. ..............
370
Evaluation: Side-Bending at the CO-C1 and c/-o Segments .........
366
C1-C2............................ "
346
Mobilization with and without Impulse: Cervical Traction
370
Evaluation: Passive Motion Testing of Axial Rotation .
346
CO through C3 .. ... .. ... .......
371
C1-C2....... .....................
347
Mobilization with Impulse (Thrust): Traction . ... ...
371
CO through C3 ....... ... ... ... ..... ...
372
Evaluation: Passive Motion Testing of Axial Rotation at c/-o and Evaluation ofJoint Play ... ... ..
347
Mobilization with Impulse (Thrust): Axial (Longitudinal)
C1-C2.... .. .............. .....
348
Traction.....................
Evaluation: Forced Rotation of the Axis with Side-Bending, Axis Rotation .........
372
.
CO through C2 .................
373 373
348
Mobilization with Impulse (T hrust): Traction
C2-C3...................
349
C1 through C3 ................
Evaluation: Passive Rotation Testing.... .
349
Mobilization with Impulse (Thrust): Rotation Restriction.
374
CO through C3 .......................
350
CO through C3 .....................
375
Evaluation: Translatory Gliding at CO through 0
. ..
350
NMT 2 and NMT 3: Inclination (Flexion) Restriction .
375
C4 through C7 ... . .. ... ..... .. ... .. ..
351
C2 through C7 . . ..... . ............. .
376
.
.
374
.
Evaluation: Passive Flexion, Extension, Side-Bending,
Mobilization without Impulse: Rotation Restriction. .
376
and Rotation Motion ..................... 351
C2 through C7 .. ... .. ... ... ... . . ... ...
377
C3 through C7 ...... .. ... ........ ..... 353
Mobilization with Impulse (Thrust): Rotation Restriction.
377
Evaluation: Passive Flexion, Extension, Side-Bending,
C1 through C6 .. ........ ... ... ..... ...
378
Mobilization with Impulse (Thrust): Rotation Restriction.
378
and Rotation Motion .. . ......
..... . . ..
353
C3 through C6 .............. ........
354
C2 through C6 .. ..... ... ... ...........
379
Evaluation: Translatory Gliding... ..... ......
354
Mobilization with Impulse (T hrust): Rotation Restriction.
379
Functional Treatment of the Cervical Spine. ......
355
C2 through C7 .. ... .. ... . ....... ... ...
380
CO-C1.... ............. .. ........... 355
Mobilization with Impulse (T hrust): Rotation Restriction.
380
Mobilization without Impulse: Inclination (Flexion)
C2 through C7 ...........
381
and/or Reclination (Extension) Restriction . ........ 355
NMT /: Rotation Restriction ...... .
381
356
C1-C2. ...........................
Mobilization without Impulse: Rotation Restriction .. .. 356 CO-C1.... ..... ..... ... ..... ...
357
NMTI: Inclination (Flexion) and/or Reclination (Extension) Restriction..................... 357 CO-C1
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.
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358
Self-Mobilization: Inclination (Flexion) and/or Reclination
C2 through C7 ... . ..........
382
Self Mobilization: Rotation Restriction
382
C2 through C6 .............
383
NMT 2: Rotation Restriction ...
383
C2 through C6 ..........
.
384
C2 through C6 ...........
385
(Extension) Restriction........ ........
358
NMT 2: Side-Bending Restriction
C1-C2........ . ............ . .......
359
C2 through C6 ...........
NMTI: Rotation Restriction .................. 359
384
.
NMT 3: Rotation Restriction ....
385
NMT 3: Side-Bending Restriction .........
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386
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.
386
XI
Contents
C7 throughT 5....................
387
Mobilization with Impulse: Extension Restriction.
387
Mobilization with Impulse (Thrust): Rotation Restriction. 411
C7 through T6.............
388
T4 through T9......................... 412
Mobilization with Impulse: Traction ........
388
Mobilization with Impulse (Thrust): Rotation Restriction. 412
C6 through T4....................
389
T5 through T12........................ 413
Mobilization with Impulse (Thrust): Rotation Restriction
389
Mobilization with Impulse (Thrust): Rotation Restriction. 413
C5 through T4..................
390
T6 through T12........................ 414
Mobilization with Impulse (Thrust):
13 throughT10........................ 411
Mobilization with and without Impulse (Thrust):
Rotation and Side-Bending Restriction.....
390
Rotation Restriction ......
414
C6 through 13..................
391
Rib I ......................
415
Mobilization with Impulse (Thrust): Rotation Restriction
391
Mobilization without Impulse:
C6 through T5 ........................
392
Exhalation (Inferior) Restriction (Supine) .
415
NMT 1 and Self-Mobilization: Extension Restriction ...
392
Rib I .................... . ..
416
Mobilization without Impulse:
Structural Examination and Functional Treatment of the Thoracic Spine and the Ribs ........
393
Exhalation (Inferior) Restriction (Seated) .
416
Palpation of Bony Landmarks ..............
393
Rib I ......................
417
Irritation Zones Associated with the Thoracic Spine.
394
Mobilization with Impulse (Thrust):
Irritation Zones Associated with the Ribs .......
395
Inferior-Anterior Rib Motion Restriction........... 417
Structural Examination of the Thoracic Spine and Ribs.
398
Ribs VI through XI ...................... 418
398
Mobilization without Impulse:
T1 through T12 .................
Anterior and Lateral Rib Motion Restriction
418
and Extension................. .
398
Ribs IV through XII ....................
419
T1 through T12 ................
399
Mobilization without Impulse and NMT 1:
Evaluation: Passive Motion Testing of Flexion
Anterior and Lateral Rib Motion Restriction .......
419
(Coupling Patterns).............
399
Ribs IV through XII .....................
420
T1 through T12 ............. .
Evaluation: Motion Testing of Side-Bending
400
Mobilization without Impulse and NMT 1:
Evaluation: Motion Testing of Rotation
400
Anterior Motion Restriction.......
420
Thoracic Spine (T1
401
Ribs III through VIII...........
421
Evaluation: Springing Test........
401
Mobilization with Impulse (Thrust):
T1 through T8 ..............
402
Anterior Motion Restriction.................. 421
Assistance (Testing for Resiliency) .
402
Mobilization with Impulse (Thrust):
Evaluation: Passive Thoracic Mobility with Active
Ribs VI through XII ...................... 422
Rib I . . . . . . . . . . . . . . . . . . . . . . . . .
403
Anterior and Lateral Motion Restriction..........
422
Evaluation: Active and Passive Motion Testing .
403
Ribs IV through X..........
423
Ribs III through XII ................
404
Mobilization with Impulse (Thrust):
Evaluation: Testing of Active Rib Motion during Inhalation and Exhalation.............
404
Ribs VI through XII ................
405
Evaluation: Individual Rib Motion Testing during Respiratory Effort................... .
.
.
.
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.
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.
•
..
Anterior-Inferior Motion Restriction............
423
Ribs IV through XII .. ...................
424
NMT 2: Anterior Motion Restriction ............
424
Structural Examination and Functional Treatment of
405
Functional Treatment of theT horacic Spine and Ribs... 406 T6 through T12 ........................ 406
the Thoracolumbar Junction and the Lumbar Spine
425
Palpatory Identification of the Bony Landmarks in the Lumbar Spine.....................
425
Mobilization without Impulse: Rotation Restriction
406
Irritation Zones Associated with the Lumbar Spine.... 425
13 through T1 0 ................
407
Structural Examination of the Lumbar Spine........ 428
Mobilization without Impulse and NMT 2: Extension Restriction.............. T6 through T12 ...............
L1 through L5 ............... . ......... 428 407
Evaluation: Static Examination of Posture of the Lumbar
408
Spine and Pelvis with Patient Standing and Sitting .... 428
408
Evaluation: Active Motion Testing of Lumbar Flexion,
L1 through L5 .......................
Mobilization without Impulse and NMT 2: Rotation Restriction .............
429
13 through T1 0 ........................ 409
Extension and Side-Bending with Patient Standing
429
Mobilization with Impulse (Thrust): Flexion Restriction .. 409
L1 through L5 ..................
430
T4 throughT10 ........................ 410
Evaluation: Passive Motion Testing of Flexion
Mobilization with Impulse (Thrust): Rotation Restriction . 410
and Extension ..................
XII
Copyrighted Material
430
II through l5 ......................
431
Evaluation: Passive Motion Testing of Side-Bending
Evaluation: Position of Pubic Bones......... .
456
Sacroiliac joint ................... .
457
(Lateral Bending)....................
431
Evaluation: Provocation Testing by Pressure
II through l5 .....................
432
on the Zone of Irritation and Nutation Motion at the Sacroiliac joint............
457
Side-Bending, Flexion, and Extension ....... .
432
Sacroiliac joint, Iliolumbar ligament ..
458
II through l5 .....................
433
Iliolumbar ligament ......
460
Evaluation: Passive Motion Testing of Rotation .
433
Evaluation: Functionol Testing........
460
. .. .
461
Evaluation: Passive Motion Testing of Rotation,
lumbar Spine (ll through l5) . ... .... .. .. ... 434
l2-Sacrum .. ... .........
Evaluation: Springing Test ............... .
434
Evaluation: Provocative Testing of the Iliolumbar Ligament by Pressure and Induced Movement
461
and lumbar Spine ..............
435
Sacroiliac joint, Sacrospinous ligament .....
462
T10 through l5 ..................
435
Evaluation: Functional Testing........... .
463
Sacroiliac joint, Posterior Sacroiliac ligament..
464
Evaluation: Functional Testing......... .
465
Sacroiliac joint, Sacrotuberous ligament .
466
Functional Treatment of the lower Thoracic
Mobilization without Impulse and NMT2: Rotation Restriction in the Thoraco-Lumbar junction and the Lumbar Spine............
.
T12 through l5-S1 ..............
435 436
Mobilization without Impulse and Traction: Flexion Restriction ..
.
. .. . .. . ... .
.
T12 through l5-S1 ..............
436 437
Functional Treatment of the Sacroiliac joint and the Pelvic Girdle .....
467
Sacroiliac joint ........ .
467
Mobilization without Impulse: Posterior Motion Restriction ......... .
Mobilization without Impulse and NMT 2: Rotation Restriction ..............
437
Mobilization without Impulse and NMT 1:
II through l5-S1 ...............
438
Anterior Motion Restriction ......... .
Mobilization with Impulse (Thrust): Rotation Restriction. 438
Mobilization without Impulse:
II through l5 ......................... 440
Anterior Nutation Restriction of the Sacrum NMT 1:
Mobilization with Impulse (T hrust): Rotation Restriction. 440
Posterior Rotation Restriction of the Ilium...
II through l5 . ................... ..... 442
Mobilization without Impulse:
Mobilization with Impulse (Thrust):
Anterior Nutation Restriction of the Sacrum/
Rotation and Flexion Restriction ... ......... ... 442
Posterior Rotation Restriction of the Ilium ....
l2 through l5 ........................ ,
Mobilization with Impulse (Thrust) Variation 1:
444
Mobilization with Impulse (Thrust): Rotation Restriction. 444
Anterior Motion Restriction ............ .
T10 through l5 ........................ 445
Mobilization with Impulse (Thrust) Variation 2:
NMT 1 and Self-Mobilization: Rotation Restriction
445
Anterior Motion Restriction ..... .
II through l5-S 1 .....
446
Mobilization with Impulse (Thrust):
NMT 2: Flexion Restriction ....
446
Flexion Motion Restriction ...... .
II through l5-S1 ................ .
447
Mobilization with Impulse (Thrust):
NMT 3: Flexion Restriction .......... .
447
Anterior and Inferior Motion Restriction
Structural Examination of the Pelvis and Sacroiliac Joint.................. .
468
469
470
471
473 475
477
Mobilization with Impulse (Thrust): 448
Palpatory Identification of the Bony landmarks of the Pelvic Girdle and the Sacroiliac joint .
467
448
Anterior and Inferior Motion Restriction
478
Sacroiliac joint and ilium. .. ... .......
479
NMT 1: Ilium Extension Restriction. ....... .....
479
Irritation Zones Associated with the Sacrum, the Sacroiliac joint, and the Pelvis .......
448
Structural Examination of the Sacroiliac joint
16 Structural Diagnosis and Functional
Treatment of the Limbs.
......
480
451
Shoulder joint and Elbow, Hand, and Fingers.
481
Evaluation: Passive Motion Testing Uoint Play).
451
Evaluation: Functional Screening Examination to Give
Evaluation: Leg Length Difference ........
452
a Rough Evaluation of Normality or Pathology in the
453
Upper Limb Within 1 Minute ..............
and the Pelvic Girdle ................
451
Pelvic Girdle. Sacroiliac joint .. ..... ....
Evaluation: Patrick or "FABER-Test" ....... .
.
481
Structural Examination and Functional Treatment
Evaluation: Spine Test, Active Motion Testing for Nutation Movement............ .
.
454
of the Shoulder ..............
Structural Examination of the Shoulder ..........
Evaluation: Standing Flexion Test, Nutation
482 482
in the Sacroiliac joint . .................... 455
Copyrighted Material
XIII
Contents
Shoulder joint ............... .
482
Structural Examination and Functional Treatment
482
Structural Examination of t he Elbow.
Evaluation: Shoulder Surface Anatomy
of the Elbow ......................... 510
and Bony Landmarks ..............
.
....... .... 510
Evaluation: Elbow Inspection.. ............... 510
Evaluation: Active Motion Testing with Emphasis on Muscle Strength Assessment . . .. .. ... ..
484
Evaluation: Active Elbow Flexion and Extension . ....
Evaluation: Passive Internal and External Rotation.
485
Evaluation: Passive Elbow Flexion and Extension...... 512 Evaluation: Varus and Valgus Stress to Elbow joint .. .. 513
Evaluation: Passive Internal and External Rotation of Glenohumeral joint Codman Test.. . .. .... ...
486
(0-120°) . .... ............
487
488
End-Feel and Palpation of the Proximal Radioulnar
Evaluation: Axial Traction. . ..... .... . .... ... 516 Evaluation: Translation of Proximal Radioulnar jOint .
Evaluation: Global Shoulder Strength Test for Rotator Cuff................
517
489
Evaluation: Isometric Contraction of Wrist Extensors against Resistance ...........
518
490
Evaluation: Palpation of Ulnar Nerve
519
Evaluation: Active Abduction, Rotator Cuff Strength Test, including Supraspinatus Muscle jobe Test.........
514
and Humeroradial joint. .. .. ... . .. . ........ 515
Evaluation: Active Motion Testing and Upper Painful Arc
120°-150° (180°) .......................
Evaluation: Active and Passive Pronation and Supination Evaluation: Passive Pronation and Supination,
Evaluation: Painful Arc for Impingement Active Motion Testing. Painful Arc
511
Functional Treatment of the Elbow..
Evaluation: Active External Rotation, Strength Testing
520
of the Rotator Cuff, Testing of Infraspinatus
Mobilization without Impulse: Traction
Muscle Strength......................... 491
Proximal Rad ioulnar joint.......... .
522
Mobilization without Impulse: Anterior and Posterior.
522
Evaluation: Active Motion/Strength Testing of Internal Rotation, Rotator Cuff Strength Test, Subscapularis
.
.
.
520
•
Structural Examination and Functional Treatment
Strength Test ........................
492
while Palpating the Biceps Tendon.....
of the Wrist and Hand ................
523
Structural Examination of the Wrist and Hand.. .. ... 523
Evaluation: Resisted Flexion and Supination at the Elbow 493
Evaluation: General Screen ...........
.
.
.
. .. 523
•
Evaluation: Wrist and Hand General Screening
Evaluation: Instability Apprehension Test (Passive External Rotation Test).....
494
Movements ..........................
524
Evaluation: Wrist and Hand Tests for Active Mobility/
Evaluation: Glenohumeral Instability (Anteroposterior Direction) . .. ..... .. .... ...
495
Neurological Integrity ..................
Evaluation: Glenohumeral Anterior Instability Testing ..
496
Evaluation: Median Nerve Function to Thumb
Evaluation: Laterol Traction.... .. .. . ...... .. . 497
(Bottle Sign)........................
Evaluation: Translation in Inferior Direction
Evaluation: Test of Ulnar Nerve, Abduction
(Glenohumeral joint)...............
498
Evaluation: Translation in Anterior Direction
and Adduction of Fifth Finger . ... .......
525
526
527
Evaluation: Test of Ulnar Nerve Function (Froment Sign). 528 499
Evaluation: Ulnar and Median Nerve Compression Tests
500
Evaluation: Passive Wrist Extension; Extensor Tendon
501
Evaluation: Passive Flexion and Palpation of the Carpal Bones ....... ..... . . ...
531
of the Sternoclavicular joint................
502
Evaluation: Wrist and Hand Palpation of Flexor Tendons.
532
Evaluation: Translation of the Acramioclavicular joint.
503
Evaluation: Passive Flexion and Extension . ........ 533
(Glenohumeral joint)...............
Using Two-point Discrimination and the Phalen Test.
Evaluation: Translation in Posterior Direction (Glenohumeral joint).............
Palpation ..........................
Evaluation: Posterior Translation of the Sternoclavicular joint.............. Evaluation: Inferior-Anterior Translation
Functional Treatment of the Shoulder.
529
530
504
Evaluation: Passive Ulnar and Radial Deviation .. .... 534
Shoulder joint ................... .
504
Evaluation: Passive Motion at Metacarpophalangeal
Mobilization without Impulse: Traction ..... .
504
and Interphalangeal joints .. .......... . . .... 535
Mobilization without Impulse: Inferior Direction .
505
Evaluation: Screening of Finger Power...
Mobilization without Impulse: Posterior Direction .
506
Evaluation: Selective Extension of Fingers
Mobilization without Impulse: Anterior Direction .
507
with Adjacent Fingers Fully Flexed ..........
Sternoclavicular jOint ........ .
508
Evaluation: Dorsopalmar Translation of the Distal
Mobilization without Impulse:
Radioulnar joint ............
Superior and Inferior Direction
508
Evaluation: Dorsopalmar Translation
Acromioclavicul ar joint..
509
at the Radiocarpal joint........
NMT
1:
Superior Direction....
509
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536
537
538
540
Contents
Evaluation: Darsopalmar Translation of the Scaphoid and Lunate ........................
Structural Examination and Functional Treatment 541
and Triquetrum.....................
of the Knee... ... . ... . . . . . .. ....... ..
Structural Examination of the Knee. .. . .... . ..
Evaluation: Dorsopalmar Translation of the Lunate 542
Evaluation: Inspection of the Leg Axes. Screening.
Evaluation: Translation of the Trapezium
Dynamic Active Knee Movements, Especially Pivoting
and Trapezoid Bones, Capitate and Hamate Bone.
543
Evaluation: Knee Squatting Screening:
544
Evaluation: Knee Translation of Patella Medially
Evaluation: First Carpometacarpal joint Translation in the Radioulnar and Dorsopalmar Directions ..
Walking on Toes-"Duck Walk" .......... and Laterally .....................
Evaluation: Dorsopalmar Translation at the Fifth
569 569
569
570
571
545
Evaluation: Inferior/Superior and Medial/Lateral Translation of Patella ................
572
546
Evaluation: Patellar Function........
573
Evaluation: Active and Passive Extension......
574
Interphalangeal joints ...... ..... ..... .. ..
547
Evaluation: Active and Passive Flexion .......
575
Functional Treatment of the Wrist and Hand .... ..
548
Evaluation: Passive Rotation in Various Degrees
Distal Radioulnar joint . . ..... ... .......
548
of Flexion ........................
576
Evaluation: Traction.... . . . .. ..... .. ..
577
Carpometacarpal joint ................ Evaluation: Translation of the Second to Fourth Carpometacarpal joints ..... . .... ..... Evaluation: Selective Translation of All Proximal
Mobilization without Impulse: Posterior-Anterior Direction . . . .. .......... ...... . ...
548
Evaluation: Knee Varus and Valgus Stress-Testing
Proximal and Distal Wrist joint. . .. . . . .. . . .. .. 549
of Medial and Lateral Collateral Ligaments,
Mobilization without Impulse: Traction ........... 549
and for Condition of Medial and Lateral Compartment .
Mobilization without Impulse: Palmar (Dorsal) Direction. 550
Evaluation: Testing for Knee Instability-Lachman Sign
Proximal Wrist joint .... ... .... . .... . ..
551
578
for Anterior Cruciate Ligament (ACL)
Mobilization without Impulse: Ulnar-Radial Direction .. 551
and Posterior Cruciate Ligament (PCL) . . .. .. .....
Carpal BOlles.. .............. . . . .... ... 552
Evaluation: Knee Pivot Shift Test for Anterior Cruciate
Mobilization without Impulse: Dorsal-Palmar Direction
552
Insufficiency (Macintosh)..... ..... .. .. ...
Metacarpophalangeal and Finger joints
553
Evaluation: Testing for Anterior Cruciate Ligament,
Mobilization without Impulse: Traction ...... .. ..
553
Anterior Drawer Sign (ADS) ............. ...
579
580
581
Metacarpophalangeal and Finger joints . . . . ..... 554
Evaluation: Knee Test for Posterior Cruciate Ligament,
Mobilization without Impulse: Palmar (Dorsal) Direction. 554
Posterior Drawer Sign (PDS) ....... . . . .. . ...
582
Evaluation: Knee Translation Proximal T ibiofibular joint .
583
Structural Examination and Functional Treatment 555
Functional Treatment of the Knee. ...
584
Screening Examination of the L ower Limb
555
Mobilization without Impulse: Traction.
584
Structural Examination of the Hip .....
556
Mobilization without Impulse:
of the Hip .................... .
Anterior (Posterior) Direction ..
585
Trendelenburg Test, Duchenne Test ....
556
Femoropatellar Gliding .....
586
Evaluation: Screening for Leg Length Discrepancy ..
558
Mobilization without Impulse:
Evaluation: Static and Dynamic Testing;
Distal, Medial, or Lateral Direction .
586
Evaluation: Passive Motion Testing of Abduction
Proximal Tibiofibular joint ..
587
and Adduction . ..... .... . ...... ...... .. 559
Mobilization without Impulse:
Evaluation: Passive Motion Testing of Hip Flexion .
560
Anterior-Posterior Direction .. . . . .. .... . .
Evaluation: Passive Motion Testing of Extension ..
561
Structural Examination and Functional Treatment
562
Structural Examination of the Ankle and Foot. . .....
588
Evaluation: Static and Dynamic Inspection ... .. . ..
588
Evaluation: Ankle and Foot Passive Extension and Flexion.
589
of the Ankle and Foot . ... .. ....... .
Evaluation: Passive Motion Testing of Intemal and External Rotation in Extension ........ Evaluation: Passive Motion Testing of Internal and External Rotation in Flexion ..........
563
564
on Tibia.. . . .. .. .. ..... .......... ....
Functional Treatment of the Hip ...... ........
565
Evaluation: Passive Inversion and Eversion
Mobilization without Impulse: Traction (Inferior) . ..
565
Mobilization without Impulse: Posterior Direction. .. .. 566 Mobilization without Impulse: Anterior Direction
588
Evaluation: Anteroposterior Translation of Talus
Evaluation: Active Motion Testing of Abduction and Extension ............ .. . .... .
587
567
Mobilization without Impulse: Lateral Direction ... ... 568
(Internal and External Rotation) of Foot .. . . . . . . .
590
591
Evaluation: Dorsoplantar Translation of the Mid-Tarsal joints Navicular on Talus ..
592
Evaluation: Dorsoplantar Translation Cuboid on Calcaneus ...................
Copyrighted Material
593
xv
Contents
Evaluation: Anteroposterior Translation of Mid-Tarsal joints Cuneiform on Navicular
Muscles of the Anterior and Lateral Regions of the Neck . 663 594
Sternocleidomastoid Muscle ................ 664
Evoluotion: Translation of Cuneiform-Metatarsal Joints. . 595
Stretching of the Sternocleidomastoid Muscle ..... 666
.
. ..... .. . .. ...
Evaluation: Dorsoplantar Translation of Cuboid and Fifth Metatarsal.
.
NMT 2.
596
. .. . .......... ...
Evaluation: Test of L5 Innervation: Extensor Digitorum Brevis Muscle
.
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.
. ... . . .. .. ..
Mobilization without Impulse: Traction
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Longus Colli and Longus Capitis Muscles ...
598 598
. . .. ... .. .
599
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.
600
.
.
.
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.
.
.
.
Muscles of the Thoracic Cage and the Abdominal Wall Pectoralis Major Muscle .
.
NMT 2
.
.
.
.
.
.
.
.
.
.
.
.
.
Anterior Serratus Muscles.
Mobilization without Impulse: Plantar/Dorsal Restriction. 600
.
.
.
666
.
.
.
.
.
.
.
.
.
.
.
.
.
669 670
.
672
.... .. 675
.
.
.
.
.
.
.
675
.. .............. 676
Levatores Costarum Longi et Brevis Muscles Diaphragm.
.
.
............. .... 673
Stretching of the Pectoralis Major Muscle .
.
.
NMT2 .
....
.
.
598
joints at the Hindfoot (Tarsal and Tarsometatarsal joints)
.
597
Mobilization without Impulse: Anterior/Posterior Restriction
.
Stretching of the Scalene Muscles............. 669 .
Functional Treatment of the Ankle and Foot Ankle (Talocrural) joint .
.
Scalene Muscles. . .. ....... . .... . ....... 667
.
.. ... 678
.. ....................... 680
Toe joints . ..... .. .. .. . .. .... ......... 601
Muscles of the Abdominal Wall .............. 684
Mobilization without Impulse: Traction
Overview ... ... .... ....... .... .... ... 684
.
.......... 601
Mobilization without Impulse: Plantar or
Stretching of the Quadratus Lumborum Muscle . .. 692
Dorsal Restriction.
NMT2
.
.
............. .. ... ... . 602
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
692
Muscles of the Lower and Upper Extremities. ....... 693 Iliopsoas Muscle. .......... . ........... 694
17 Functional Examination and
.
Treatment of Muscles. . ..... .. .. .. .. 603 Examination and Treatment of Muscles-Overview
.
.
.
Muscles of the Posterior Regions of the Neck and Back Trapezius Muscle
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
603
. 606
.. . 607 .
Stretching of the Trapezius Muscle (Descending Portion) . NMT 2
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
Latissimus Dorsi Muscle .
Levator Scapulae Muscle..
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
. . . .
.
.
.
.
.
.
.
.
.
.
.
.
. . . .. .
.
.
.
.
.
.
Rhomboid Major and Minor Muscles Erector Spinae Muscle Group . Longissimus Cervicis Muscle .. .
.
.
.
610
. . 610 .
NMT 2
.
.
.
.
. . .
Splenius Muscles.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
698
Rectus Femoris Muscle... ............... .. 700 Stretching of the Rectus Femoris Muscle NMT 2
.
.
.
..
.
.
. .. .
.
.
.
.
.
.
.
.
.
.
.
.
NMT 2.
....... 702
.
.
.
.
.
.
.
.
702
.
.
. ..
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
611
Piriformis Muscle .
.
.
.
.
.
.
613
Stretching of the Piriformis Muscle
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
615
NMT2
.
.
.
.
.
.
.
.
.
615
Tensor Fasciae Latae Muscle
.
.
.
.
.
.
.
.
.
.
.
616
Stretching of the Tensor Fasciae Latae Muscle .
.
.
.
.
.
.
.
.
. .. .
.
.
.. .
.
.
.
.
.
.
.
.
.
... .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
619
NMT2
.
.
.
.
.
.
.
.
.
.
.
.
.
627
Ischiocrural Muscles (Hamstring Muscles)
.
.
.
.
.
.
.
.
.
.
...
.
.
.
...
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
633
.
.
633
.............. . . ..... . 634 ................ 636
.
.
.
706
.
.
.
.
.
.
.
.
.
.. .
.
.
712
.
714
. .. 714 .
.
.
.
.
.
715
... 717
.
.
.. 717
.. .. .
.
. 718
Stretching of the Biceps Femoris. Semitendinosus. and Semimembranosus Muscles.
.
.
.
.
.
.
.
.
.
.
Gluteal Muscles .. .. .. ................ .. 707
.
.
.
.
.
.
Posterior Serratus Muscles.
.
.
. . . ... .. . .
.
.
. . .. . . .
.
.
Treatment of Erector Spinae Muscles .
.
.
Iliocostalis Muscle . . .. .. .. . .... .. .. .. ... . 629
in the Lumbar Region
.
.
.
Treatment of the Levator Scapulae Muscle NMT 2
.
NMT2
Hip/Thigh Adductors. .................... 704
. . .
Stretching of the Iliopsoas Muscle. ........ ... 698
NMT 2
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.......... .. 720 .
.
.
.
.
.
.
.
.
.
.. 720
Gastrocnemius and Soleus Muscles (Triceps Surae Muscle). Gastrocnemius Muscle.
Suboccipital Muscles (Overview) . .. .. .. .. .. ... . 638
NMT 2
Transversospinalis Muscle Group
Deltoid Muscle
.
.
.
.
.
.
.
.
.
.
.
.
.
... .... ........... 721
. ... . ...........
.
.
.
.
..
.
.
. ..
.
.
.
.
.
.... 722
.. . .. ... . . .. . . . .. ... . .. 723
(Semispinalis. Multifidus, Rotatores). ..... ... .. . 644
Extensor Muscles of the Wrist .... . ...... . ... 725
Semispinalis Muscle - Overview
Wrist Extensors
Semispinalis Capitis Muscle. Multifidus Muscle .
.
.
.
.. .. ... ....... 644
.. .. .. .. .. .. .... 646
Intertransverse Muscle Group .
.
.
.
.
.
.
.
.
.
.
.
.
.
.. ... .. ... . . ...... . .... 727 . .. .
.
.
.
..
.
...
.
.......
.
.
727
. ....... .. .. .... . .. ... 648
Rotatores Breves and Longi Muscles. .... .. . .. .. . 651 Overview
NMT 2 .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
653
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
653
Thoracic Intertransverse Muscles.
Interspinales Muscles
.
.
.
.
.
.
.
.
.
........ .. ... 659 .
•
.
.
.
.
.
.
.
.
.
.
.
662
18 Myofascial Trigger Point Treatment ... 728 D. Buehler, B.Dejung, R. Weissmann
Rectus Capitis Major and Minor Muscles . Obliquus Capitis Inferior Muscle .
XVI
Copyrighted Material
.
.
....... 728
............ 729
Contents
Semispinalis Capitis and Cervicis Muscles . ....... 730
Psoas Muscle . . .. . . ..... .. . . .. ..... ...
747
Scalene Muscles. . .... ...... ......... ... 73'
Iliacus Muscle. .
..
748
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
•
Sternocleidomastoid Muscle . ... . ... .. ... ... 733
Gluteus Maximus Muscle. . .............. ..
749
Levator Scapulae Muscle .. .... . ..... . . . ... 734
Gluteus Medius and Minimus Muscles. . ..... ...
750
Trapezius Muscle (Upper and Lower Trapezius). ....
736
Piriformis Muscle. ... . . . . ... . . . ...... . ..
752
Serratus Anterior Muscle . ... .. ...... .. .... 738
Tensor Fasciae Latae Muscle. . . . . ... . .. . . . ..
753
19 Home Exercise Program. . ...... .. ..
754
Iliocostalis and Longissimus Dorsi Thoracis!
Introduction . . ..... . ..... ........ .. . ...
754
Lumborum Muscles (Erector Spinae Muscles;
Exercise Section. .. . . ......... .. . . ... ....
756
Index ..... . ... . . ........... ........
775
Quadratus Lumborum Muscle . . . ... ......... 740 External Abdominal Oblique Muscle . . ..
.
.
.
•
. .. 742
Rectus Abdominis Muscle. ..... ......... ... 743
the Superficial Paravertebral Muscles) .......... 744 Multifidi and Rotatores Muscles (Deep Paraspinal Muscles) . .... ..... .. ..... 746
Copyrighted Material
XVII
Documentation of Examination Findings and Treatment Techniques Examination Findings
Spine
rhe following is a scheme for documenting examination
CO-C1,Cl-2
findings, including: Direction of motion
":;= .I I' \\\ "==:;: .
Muscle shortening
.- '
In
Inclination
Rc
Reclination
F
Flexion
E
Extension
SB
Side-bending
R
Rotation
r
To the rjght
I
To the left
N
Nutation
f
In flexing direction
e
In extendinq direction
El
Elevation
IR
//
/
Externa I rotation
Ab
Abduction
Ad
Adduction
DF
Dorsiflexion
PF
Plantar flexion
UD
Ulnar abduction
RD
Radial abduction
S
Supination
P
Pronation
L
Lateral
,' \
i
/
" '';" --,.
, -'
.J/
=
RI
. '--'
4-.-4 , t,-:;'''T
LFI
y: ' \rJ( I \ "; ' 1'1"'"
:: --:; ,
....:I - ,
"
\
- ' L;J...< ,
+
//
«I,
"r"
;
I
.... -,\ " .,J
_
cf:r >rr:' "" ) '
I I
\ /" /I"',l I r, ' ' ' ,I \ ,/:"
,I "
'
i J
\,
)) . ", ' \\ "
r"
"","" . /1
r: <'�'L)
" \,,,(! I
·l· l y(F) ,
/
"
"
r
,-I
w
\'
,I
,
'
-".....
n-\
Il. XVIII
Copyrighted Material
\
\
I
.
RI
r.':\
+
Rr
LFr
E
,
SACRUM
/: \\\e6L c / �.
LFr
ll-l5
1'\
'-S'"
I
Rr
E
LFI
( l..
>tu- )
1,I ''''I
+
LFI
I / /' '/.) , 'J I' " ,\il,.I 1/. / Ii "
r.':\
,,-,"\\ f ""
" -" ., 1--r " ,:',
/ "
I
, -
Rl /,'
J
.,
<'; >
,l'
I
'r
:.LJ-M-" '" , -oy
1\ -''\ I r 1/' '..:..:. ' I ,
LFr
E
' 1'-- .'
:-
Rr
Tl-Tl2
r''-" '1l 1 l I It )Y'( 1\,1 I
Rr
Rc
r.':\
I '- :,}-"r\- r
_" __
In
C3-C7
I
\ \ \\
,
I
H '-. ..x-tt-
----...;. - "-1
Internal rotation
ER
I,
I"'7:':\
RI
I'
"
Muscle weakening Pain
17
\\
Restriction of Illotion
J
=-
Nt
Nt
Ne
Ne
'l\
' . ' - " ' I.f"\'/'_ \/! ,/ (' \
-I,
-\': 'I.L '_' . ' .
\
)1
lower Extremity
Upper Extremity EL
Ad
~ \...:.;/
I {' --! -f!!-
Ad
ER Ab
IR
E \
F
\
p
ER
E
F
\
E
E
5
RD
Ab
Ad
UD
F
Ab
'-Y
5
F
/'7:\+
p
Symbols for Documentation of Motion Restriction, Muscle Weakness, Pain location
I t t t t
Normal range of motion
Shortened muscle
Slightly restricted
Weakened muscle
Very res tricted
Localized pain
Almost completely restricted (and ankylosis)
Referred pain
Pain at end of motion
0
Copyrighted Material
Irritation zone/trigger point
XIX
Symbols for Documentation
Symbols for Documentation
of Examination Findings
of Treatment Techniques
"'V7
Mobilization without impulse
FixationjSta bilization
•
~
Palpation
/:;:::=::J
§
Mobilization with impulse •
•
Mobilization direction
NMT2 Active extension
•
Mobilization direction
•
Stretch direction
NMT3
Active rotation
•
/:;:::=::J
Mobilization direction
NMTl
Active flexion
Mobilization direction
NMT2 and NMT3
Passive flexion
•
Passive extension
Isometric contraction
Trigger point treatment
-.-.----------.------
I Fixation - by therapist
Passive rotation
Fixation - by patient
xx
Copyrighted Material
=
MWOUT
Mobilization direction
=
MWITH
1
Manual Medicine-An Overview
Historical Perspective
understanding of the three-dimensional anatomy, biome
Manual medicine, one of the oldest healing arts, constitutes
comotor system. ClinicaJJy, the practitioner is caJJed upon
that medical discipline in which practitioners apply their
to make as accurate a structural and functional diagnosis as
chanics, neurophysiology, and pathophysiology of the lo
hands skiJJfuJJy in both the diagnostic and therapeutic
possible before instituting the appropriate treatment tech
management of painful neuro-musculo-skeletal disorders
nique for the individual patient.
and various diseases. Over time, the field of manual med icine has developed and refined its own approaches and strategies through specific, and at times unique, examina-
Recent International Perspective
tion and treatment techniques. More recently, various components of the manual medicine armamentarium
During the past 50 years, and in particular since the 1970s,
have been adopted by and integrated into general medical
manual medicine has experienced unprecedented growth
practice, as weJJ as specialties such as Neurology, Orthope
and acceptance not only by the general population but also
dics, Physical Medicine, Rehabilitation, Rheumatology, and
by some of the traditionally orthodox branches of medi
Sports Medicine. At present, primarily four professional
cine. This increase may in part be attributed to the strong
groups routinely rely on using this form of medicine in
interest by a small group of pioneering allopathic physi
patient management, albeit to varying degrees: the aJJo
cians in Europe, who expanded upon the initial teachings
pathic and osteopathic physicians, chiropractors, and phys
by John Menell Sr., M.D. (Mennell, 1951) and some of the
ical therapists (Dvorak et ai., 2001).
techniques brought to Europe by a nucleus of osteopathic
Despite the high number of manipulative procedures
physicians and chiropractors trained in the United States.
performed every year, the number of major complications
The German term "Manuelle Medizin," or manual medi
is rather low. However, when significant complications do
cine, which describes a series of treatment applications
occur, they can assume disastrous outcomes. In particular,
using one's hands, is now the standard term used for
the classic "thrust techniques," more recently defined as
manipulative medicine in most of Europe. The "modern"
the mobilization-with-impulse techniques and in the ver
era can be traced back to the Swiss physician Nageli
nacular referred to as the "pop-and-crack maneuvers,"
(1843-1922), who described a series of "Handgriffe"
carry an inherently greater risk of potentiaJJy severe com
(hand applications) for cervical manipulations in 1894
plications than the low-velocity, low-amplitude soft-tissue
(Harris and McPartland, 1996). This was approximately 20
approaches. Thus, the techniques that are regarded as par
years after the introduction of osteopathy by Andrew Tay
ticularly risky require the practitioner considering their use
lor Still, M.D. in the United States. Sollmann ( 1981) believes
to pay special attention to the indications and contraindi
that Nageli had been introduced to osteopathic treatment
cations, within the context of the entire clinical picture. It
techniques through some of his Swiss patients who had
seems reasonable to suggest that the high-risk thrusting
gone to the United States for treatment.
techniques be performed exclusively by those professio
Professor Robert Maigne of Paris, France, studied under
nals who have received adequate formal training and who
Stoddard and Beal at the London College of Osteopathy, and
have developed the particular skills necessary to perform
introduced his exaggeration technique (Maigne, 1964). An
them correctly.
other French physician, Arlen, introduced what he refers to
In contrast, the non-thrust techniques, recently termed the mobilization-without-impulse techniques and gener ally referred to as the soft-tissue techniques, represent
as atlas therapy, a technique in which the patient remains in the sitting position (Arlen, 1990). In the United J(ingdom, the physician Cyriax (1904
techniques that have been associated with less risk than
1985) (Cyriax, 1984) is arguably the most prominent British
the impulse techniques. The non-thrust techniques have
figure in Manual Medicine and Rehabilitation (Harris,
found useful application in a number of fields that empha
1993). John MenneJJ Sr., M.D. introduced and emphasized
size the functional components of the neuro-musculo
the importance of joint play in the examination and treat
skeletal system. In particular, this is seen in Physical Med
ment of the synovial joints (MenneJJ, 1951).
icine and Rehabilitation, and its associated physical and
Prague in the Czech Republic became a center for stud
occupational therapeutic management approaches. For
ies in manipulation under such prominent physicians as
any of the manual medicine treatment approaches to be
Henner, Jirout, Lewit, and Janda (Harris, 1993; Lewit, 1999).
successful, it wiJJ be indispensable to obtain a precise
The professional exchanges between Lewit and a number
Copyrighted Material
1
Manual Medicine-An Overview
of osteopathic physicians from the United States led to a
communication between a small group of medical doctors
cross-dissemination of knowledge and an amalgamation of
in Europe and their osteopathic colleagues in the United
various techniques. This was particularly the case with the
States (who in the U.S.A. have the same privileges and
non-thrusting techniques based on muscle energy origi
practice rights as their allopathic colleagues) are some of
nally described by Ruddy and Kettler, and later presented
the tangible factors that have contributed to the continued
by Mitchell and Greenman (Greenman, 1996; Mitchell and
international exchange of ideas in both the basic sciences
Mitchell, 1995, 2001). Janda contributed to the field of
and clinical practice.
myofascial pain syndromes by introducing specific muscle
Both the medical (MD's and US-educated DO's) and the
rehabilitative techniques and proprioceptive retraining
nonmedical approaches of manual medicine (chiropractic,
that intend to correct clinical muscle imbalance syndromes
physical therapy, and other forms) have become an integral
Uanda, 1978).
part of today's complementary as well as mainstream med
Evjenth and Hamberg of Sweden (Evjenth and Hamberg,
icine. Probably indicative of developments around the
1985) expanded on Janda's post facilitation stretch tech
globe, a recent Australian study of 2000 general practi
niques of proprioceptive neuromuscular facilitation by in
tioners supports the generally accepted notion that physi
cluding
and
cians are open to further training in complementary and
Thus, the international growth of manual medicine did
form of medicine, there continues to exist the need for
the
antagonist-relax
techniques
(Harris
McPartland, 1996).
manual therapies (Cohen et aI., 2005). As with any other
not take place in a vacuum. While the modern era of
further scientifically based education and research.
manual medicine can trace its history to the seminal im pulses in osteopathy and chiropractic-building on and expanding upon the traditions of the bone setters-the growth and development in recent years is the result of collaborative
efforts
among
the
various
Effectiveness, Outcomes, and Open Questions
international Chapter 10 of this book takes a closer look at the current
groups and different schools of thought. In 1958, representatives from the various international
evidence-based considerations applicable to manual med
medical groups convened at the first international meeting
icine. Here, we present a brief overview of manual medi
in Switzerland. This led to the establishment of the Interna
cine and its use in the area of back pain.
tional Federation of Manual Medicine (FIMM) at a later
To date there exists no double-blind study that has
meeting in London, with society meetings occurring on a
unequivocally "proved" the efficacy of manipulative treat
triennial basis ever since. In September 1983, a group of 34
ment. Some studies, however, appear to support the notion
manual medicine practitioners from 12 countries, repre
that by using a rational management approach that in
senting eight schools, and conversing in seven languages,
cludes a manual medicine component the duration of an
convened at a seminar following the Seventh International
initial painful episode or a recurrent exacerbation may be
Congress of the FIMM in Zurich, Switzerland. Known today
shortened, which in turn can significantly diminish work
as the "Fischingen Conference," this meeting of the world's
absenteeism. In Switzerland, back pain alone causes the
experts began the movement toward standardization of
loss of 1.5 million workdays. Back pain or degenerative
language in the field, and the establishment of study and
changes affecting the spine are the second most frequent
clinical trials in the future (Dvorak et aI., 1984). During the
cause of partial or full disability in Switzerland. In Germany,
1998 FIMM Congress meeting in Australia, the American
80% of the population is reported to suffer from back pain,
Osteopathic Association joined the FIMM. Associations in
and a third of the population between the ages of 35 and 50
South Korea and Canada joined in 2003. Today, the FIMM
years is reportedly affected by chronic lower back pain. A
has a membership basis that spans nearly 30 national
third of all absenteeism is due to symptoms related to the
societies. In the mid-1990s, the founders of the San Fran
musculoskeletal system. Back pain is one of the most fre
cisco International Manual Society, Ores. Friedman, Gilliar
quent reasons for early retirement.
and Glassman helped develop the standards for a medical
During the past 20 to 30 years, the field of manual
osteopathic post graduate teaching program for physicians
medicine has begun to critically analyze its own successes
in the DGOM (Deutsche Gesellschaft fUr Osteopathische
and failures. Efforts have been made to scientifically sup
Medizin). Prior contacts through Ores. Philip Greenman,
port or refute patients' or practitioners' claims of successful
Ed Stiles, Myron Beal, Robert Ward from Michigan State
treatment results obtained with manipulative treatment.
University College of Osteopathic Medicine facilitated the
The elimination and replacement of antiquated and non
international communication.
specific terms such as "subluxation," "osteopathic lesion,"
In summary, the increased interest of and acceptance
and "joint blockage" with scientifically acceptable terms
by the public on one side and the growing international
was a step forward in facilitating communication not only
2
Copyrighted Material
Effectiveness. Outcomes. and Open Questions
around the world but also between the basic scientist and the clinician.
tolerated exercises and activities? Then, would activity alone- that is, any type of physical activity-suffice over
For instance. it remains an open question whether spe cific techniques such as the rotatory manipulative thrust
time to minimize recurrences and maintain the patient's pain-free episodes?
ing maneuvers are-as surmised by some-able to "displace
The rehabilitation approaches for the musculoskeletal
the nucleus pulposus" and "unload" the facet joints or
system have been expanded by the addition of specific.
decompress the affected nerve roots. It remains a matter
individualized training therapy programs that address the
of conjecture whether and to what extent the intradiskal
patient's overall level of functioning, well-being, and fit
pressure is actually increased as a result of manipulative
ness. In addition to addressing the patient's restricted
treatment. It is also not clear whether certain manipulative
range of motion, reduced strength, and cardiovascular
procedures are able to free up a wedged meniscoid in the
and muscular endurance, a detailed coordination and pro
cervical spine. Another hypothesis postulates that manip
prioceptive training program has become an integral part
ulative intervention results in considerable stimulation of
of today's rational approach to a comprehensive rehabil
the mechanoreceptors. with subsequent presynaptic inhib
itative effort.
ition of the nociceptive afferent impulses at the level of the
Possible adverse side-effects and the potential for sig
spinal cord dorsal horn. Experimental studies are under
nificant complications have led the field of manual medi
way to explain the effect of manual medicine intervention
cine to modify the classic (primarily "thrust") techniques.
by invoking the effects of enkephalins.
The good contact between the European schools and the
As increasing numbers of manipulations are performed
osteopathic physicians in the United States has encouraged
annually. it would appear that patients' symptoms might
the learning of mobilization-without-impulse techniques
be improved acutely with manipulative procedures. De
and their integration into the treatment armamentarium of
spite the growing interest and various studies so far. it is
manual medicine physicians in Europe. The non-thrusting
still not clear whether manipulative maneuvers are able to
techniques aim to introduce stretch to the noncontractile
reduce the overall number. frequency, duration, and inten
soft-tissue structures such as ligaments and the jOint
sity of painful recurrences.
capsules. It is postulated, albeit not conclusively proven,
In clinical practice, the following two key questions are
that these mobilization techniques may displace the nu cleus pulposus as well. More recently, there has been a
awaiting more definitive answers:
trend 1. What is the most appropriate frequency with which a
toward
viewing
the
locomotor
system as the
neuro-musculo-skeletal system, a concept that is reflected in the field of manual medicine. The neuromuscular ther
particular joint or body region can be or should be
apy (NMT) approach, for instance, utilizes the reflexogenic
subjected to manipulative maneuvers? 2. Is it possible to prevent or reduce painful episodic re
mechanisms during the post isometric relaxation of the
currences by specific manipulative procedures? And if
agonistiC muscles and the reciprocal inhibition of the an
so, what is (are) the most appropriate type(s) of treat
tagonistic muscles. Such progressive practice has secured a
ment approaches, treatment frequency, duration, and
permanent place within modern manual medicine. Not
intensity?
surprisingly, the active integration of the patient in his or her treatment is of significant benefit.
It is hoped that future state-of-the-art research will provide
According to Isaacs and Bookhout (2002), perhaps the
satisfactory answers to the above and many other ques
greatest contribution from manipulative medicine is the
tions. For instance, the need to help a patient achieve
evolution o f a diagnostic framework defining the various
muscular balance between the tonic postural and the pha
dysfunctions that affect the musculoskeletal system, with
sic muscles is a concept that seems to have been embraced
the goal of restoring function. This requires a thorough
clinically. While the assumption might be correct that
study and understanding of and competence in three
future painful musculoskeletal recurrences can be reduced
dimensional functional anatomy, biomechanics, and neuro
through such a muscular rehabilitation routine, specific
physiology. This is expected to help the treating physician
studies are needed to help us determine the most suitable
view and treat the patient within the context of compre
program of stretching, strengthening, and muscular aero
hensive bio-psycho-social medical care, with an emphasis
bic conditioning. Or would it be sufficient to treat the
on the aspects of both structure and function within the
patient with the appropriate manual techniques, which is
neuro-musculo-skeletal system.
simply followed by appropriately dosed and patient-
Copyrighted Material
J
2
Definitions and Principles of Manual Medicine Diagnosis
and Treatment
has commonly been used in the literature to reflect the
Definitions and Ceneral Principles
"high-velocity, low-amplitude" type of maneuvers applied to the spine.
Manipulation and Mobilization Treatment Techniques
Mobilization Switzerland
"Mobilization" is described in the United States as a soft
(Dvorak et aI., 1984) the following clinical definitions
tissue and articulatory type of treatment, and includes
Following
the
Fischingen
Conference
in
have been utilized in the international community during
other techniques such as myofascial release and muscle
the past 20 years (Dvorak et aI., 2004). In general, a dis
energy. In Europe, this term refers to articular mobilization
tinction is made between manipulation and mobilization
in the absence of thrusting forces.
techniques. Manipulative techniques typically employ a thrusting type of maneuver, known as the classical "manip
Thrust or Impulse Techniques
ulation"; techniques that do not use this maneuver are
Both of these terms describe the same entity, with "thrust"
categorized as mobilization techniques.
being preferred in the English language, and "impulse" being more common in the European schools.
Manipulation
In this text, the terms mobilization-witl1-impulse and
In the United States, manipulation refers to any therapeutic
mobilization-witl1out-impulse are employed, and the indi
procedure in which the hands are used to treat the patient.
vidual treatment techniques are described as manipulative
It is therefore a rather general term in this usage.
or mobilizing procedures, respectively (Dvorak et aI., 1984)
In Europe, manipulation refers to what is described in English or according to American osteopathic terminology
(Table 2.1). A summary overview of some of the most commonly used manual therapy techniques is given in Table 2.2 (after
as "high-velocity, low-amplitude thrust" (HVLA). Spinal manipulation or spinal manipulative treatment
Dvorak et aI., 2004, with permission).
refers to specific manual medicine maneuvers or special hand "applications" directed at the spine. This term that
Table 2.1 Comparison of use of the terms as mobilization and manipulation showing continental differences
Comments Manipulation
Refers usually to the thrusting
A rather general term, which may
When possible. and in order to
techniques. which are also known
refer to any "therapeutic" proce
avoid confusion. the newer ter
as high-velocity/low-amplitude
dure in which the hands are used
minology of mobilization-with
techniques or the mobilization
to treat the patient
or-without-impulse techniques should be used
with-impulse techniques Chiropractic adjustment is a ge neric term with over 100 sub techniques including HVLA thrust and low- force techniques
Mobilization
Refers essentially to any type of
Usually refers to the various non
It is best to qualify the type of
induced tissue or joint movement
thrusting and soft- tissue tech
mobilization used
which is then qualified by de
niques
scribing the presence or absence of impulse forces (thrust versus non-thrust techniques, respec tively)
4
Copyrighted Material
Definitions and General Principles
Table 2.2 Overview of some of the most commonly used manual-therapy techniques
Mobilization with
Mobilization without
Impulse
Impulse
Thrust techniques
Non-thrusting techniques
Chiropractic variations
Soft-Tissue Techniques
Commonly Used Types
Preparatory and/or other
Swedish-type massage
individual
Effleurage (stroking) Petrissage (compression)
Osteopathic variations
Friction massage Tapotement (percussion) Terminology note: Thrust is also known as: High-velocity/low-am plitude technique Manipulation (in gener al) (nonspecific; limited use)
Articulatory technique
Deep pressure technique
Acupressure
Counterstrain technique
Diaphragmatic release
Connective-tissue massage
Craniosacral technique
Lymphatic pump technique
Deep-tissue massage
Facilitate positional release
Mesenteric release
Lymphatic massage
Functional technique
Pectoral release
Shiatsu
Muscle energy technique
Stretch techniques
Sports massage (variation
Lateral, linear, diagonal
Swedish)
Traction
Integrating/movement techniques
Myofascial release technique
Alexander technique
ligamentous sprain technique
Feldenkrais method
Myofascial trigger point tech
Rolfing
nique
Many other approaches that
Neuromuscular treatment I
combine many aspects of
Neuromuscular treatment II
"healing"
Neuromuscular treatment III Others (proprietary/nonpro prietary)
Further Definitions and Principles of Manual
Table 2.3 Clinical motion descriptions as defined by the primary axis of rotation or plane of motion
Medicine Angular Motion The physiologic motion during both active and passive movement in a synovial joint, e. g., the facet or apophyseal joint or the joints of the limbs, is a combination of rolling
Primary Axis
Primary Plane
of Rotation
of Motion
rotation around extension Inclination (flex
=
rotation around
(2)
the x-axis
vidual joint, along with its associated ligaments and
Reclination
muscles, determines the direction and extent of this roll
(extension at CO
the x-axis
and-glide motion (Fig. 2.1).
to
and gliding motions. The architectural shape of the indi
Motion can be described by using a three-dimensional
ion at CO to
rotation takes place. These axes may be designated the
x-,
the y-axis projects vertically, and the z-axis projects fron tally. See Table 2.3
=
rotation around
Sagittal plane
Sagittal plane
(2)
Axial rotation
=
rotation around
the y-axiS
coordinate system with three primary axes, about which
Y-, and z-axes. In this system, the x-axis projects laterally,
Sagittal plane
the x-axis
Side-bending
=
rotation around
the z-axis Abduction.
=
adduction
the z-axis
rotation around
Elevation,
=
depression
the z-axis
Copyrighted Material
rotation around
Transverse plane Frontal or coronal plane Frontal or coronal plane Frontal or coronal plane
5
Definitions and PrInciples of Manual Medicine Diagnosis and Treatment
+y
R ota t i on/ rolling 7 2
+z
0'. l' �i }--z +z
( '. ¥
-z
+x
+x
-y
-y
v
Fig.2.1 Roll and glide motions.
+y -y +x, -x +z, A
-z
=:0
A'
+Y=>
l
=
Traction
=
Compression
=
Trans la tion / gliding
Lateral gliding
Fig. 2.3 Joint crepitus
=
Anteroposterior gliding
1 : RolI-gliding behavior in a "smooth," unaffected "normal" joint.
=
Gliding
2: Roll-gliding behavior when the joint is affected by degenerative
= 0X =
Rotation about x-axis
processes.
The level of the internal coefficient of friction is directly related to the extent of internal resistance to motion. As long as the coefficient of friction is held at a minimum, the internal resistance is low. Friction Can dramatically increase as a function of progressive arthritic degenerative changes that affect the internal structure of the joint. In the ex treme, this is most evident when there is bone-on-bone contact where the coefficient of friction will have risen to a
R
level at which very little joint motion, if any, is possible (Fig.2.2). A change in the internal coefficient of friction from a normal, healthy state will be associated with a discontinuous roll-and-glide pattern of motion (Fig.2.3). Mechanically, this will negatively affect the soft tissues associated with the affected joint, as they have to perform "increased work," due to the uneven and discontinuous motions to which they are subjected.
y
y
Translatory Motion
Fig.2.2 Coefficient of friction.
All of the synovial joints, including the apophyseal or facet
Starting position: The coefficient of friction (R) is increased when
joints in the spine and the peripheral joints, allow passive
there are degenerative changes in the articular cartilage surface.
Phase 1: Onset of angular joint motion. Initially there is a pure rolling motion as the friction resistance is comparatively high.
translatory motion. Translatory motion takes place in a linear fashion, along the axes of rotation.
Phase 2: Continued angular motion beyond Phase 1 will be less
The extent of translatory motion has a direct relation
smooth and will often become quite jerky, while the tension in the
ship with angular mobility. A decrease in angular motion is
tendons overcomes the friction resistance.
always associated with diminished translatory movement and vice verSa (Fig.2.4).
The rolling characteristics of a synovial jOint are deter mined by a number of variables that influence the joint's
Joint Play
internal coefficient of friction. These include the joint's
Joint play is the sum of all possible passive, angular, and
particular geometrical shape and articular surface and
translatory motions within the neutral zone. The clinical
also the mechanical properties of the associated bone,
examination of joint play requires good tactile and palpa
cartilage, ligaments, tendons, muscles, synovial Ouid, and
tory skill.
other relevant soft tissues.
6
Copyrighted Material
Definitions and General Principles
Reduced joint play is associated with diminished angu
Traction/ distracion
lar motion. Joint play is usually increased in the presence of an unstable synovial joint (facet or limb joint). However, an increase in joint play is not always identical with an un stable joint and increased angular mobility. For instance, the joint play can be increased in the presence of dimin ished angular mobility. Thus, it is important to remember that an increase in joint play is independent of and not directly related to the extent of angular motion.
Mechanical Proper ties of the Elastic Str u ctu res
Related to the Joints and Spinal Segments
Anterior translation/ gliding Traction/distraction
The motion characteristics of the synovial joints in the limbs and at the facets are demonstrated conceptually in
Fig. 2.4 Translatory motion directions.
Figures 2.5 and 2.6 in response to different loading forces and induced or available motion. These curves represent
concepts originate from a mechanical-engineering per
the relationship between and effects of the various me
spective in experimental studies using cadavers. Therefore
chanical forces as a result of the interplay between factors
there are several caveats.
such as a joint's architecture, ligaments, joint capsule, and
First, the long-term effects of active muscular contrac
the presence of internal joint friction, among others. These
tion on joint motion have not so far been fully elucidated.
Q,I o
LL.
Q,I t: o N
lJ
.... Q,I Z
Ru ptu re/tearing Q,I t: o N
. .... u
U
'
:;:::;
.... 11\ Q,I o
11\ I'D
i:jj
Physiolog ic movement
<
Q,I t: o N Q,I
Macrotrauma Microtrauma -------;.. .
>
hera e u tic r ang e _ ___ ____ T_ _ _ _ _p_ _ _ _ _ _ _ _ __
<__
Distance
>
r au_ma t_ ic r ang e _ _ _ _ _ __ _ ___ T_ _ _ _
__ _
Fig.2.S Force-distance diagram depicting joint motion for roll-glide motion and translation in the physiologic and pathologic zones as applicable to synovial joints (peripheral joints as well as apophyseal or facet joints).
Copyrighted Material
7
Definitions and Principles of Manual Medicine Diagnosis and Treatment
Secondly, work still needs to be done on the reaction in and
characteristics under different loading situations. They pri
effects on biological materials as a result of the rate of
marily affect the roll-and-glide motion in a synovial joint
loading. Such considerations, at least in theory, are thought
while repositioning the joint's center through the exploi
to explain the potential differences in effect between the
tation of coupled motions (Panjabi, 1992a).
rapid high-velocity, low-amplitude impulsive techniques
When subjected to mechanical stress during the various
and the more slowly performed muscle energy techniques,
loading situations associated with movement, the elastic
for instance. Third, it is important to remember that the
structures are able to respond in a linear fashion, but only
mechanical function of biological tissues depends on phys
up to a certain point. Once the loading forces are removed
ical and chemical properties, which in turn are an expres
again, the elastic structures return to their original length,
sion of their molecular composition and associated inter
or nearly so.
actions. Lastly, it is still unclear how all of these relation ships change as a function of growth and maturation, organ
The Plastic Zone
development, and the aging process, in addition to "nor
If motion proceeds beyond the elastic zone, that is,beyond
mal" degenerative changes. While there is an ever-growing
the elastic extreme allowed by the particular ligaments.
body of knowledge about tissue repair and healing, we are
tendons, and other soft tissues, it will inevitably cause a
still unable to explain clearly why some patients respond to
microtrauma in the elastic structures. Thus, in the plastic
treatment better than others.
zone, the muscles, tendons, ligaments, and disks become essentially overstretched while their macroanatomy re mains essentially intact.
The Load-Displacement Diagram The shape of the load-displacement curve is primarily
The Destructive Zone If a limb joint or spinal segment is carried or forced beyond
determined by the following five factors:
the respective plastic zone, then it will be subjected to •
•
Architectural shape of each particular synovial joint or
anatomic disruption, tears, fractures. or dislocations. This
spinal segment.
typically happens during injuries, where the ligaments and
Mechanical properties of the hard (bone) and soft (car
tendons are excessively engaged or "stressed",for instance.
tilage, ligaments, tendons, joint capsule) tissues.
Thus, when entering this zone, the tendons and ligaments
•
Fluid mechanical properties (synovial fluid, cartilage).
are unable to withstand the stress to which they are sub
•
Joint motion characteristics (displacement type and di
jected and will begin to show structural changes ranging
rection).
from partial tears to complete rupture. In a mechanical
•
Rate of the applied forces.
comparison, a rope, for instance, may tear even under relatively little stress with small loading forces if they are
The load-displacement diagram (Fig. 2.5) can be divided
applied suddenly in a burst-like fashion.
into four different "zones," namely, the neutral, elastic, plastic, and destructive zones. The width of each zone is
The Zero- Force Barrier (ZFB)
subject to large variation due to the following two major
The zero-force barrier marks the junction between the neutral and elastic zones. The internal forces resisting an
variables:
gular and translatory movement account for approximately •
•
Architecture and shape of the individual joint or spinal
2% of those encountered at the extreme of the elastic zone
segment.
as it approaches the plastic zone (Figs. 2.6, 2.7).
Motion directions.
The PhYSiologic Barrier (PhysB) The phYSiologic barrier of a synovial joint lies within the
The Neutral Zone
elastic zone. Thus, as long as the joint is subjected to
In the neutral zone of ajoint or spinal segment, the internal
motion up to but not beyond its physiologic barrier, its
resistance to angular or translatory motion is reduced to a
associated structures undergo only elastic deformation,
minimum. In nonpathologic situations, it is approximately
which is generally reversible. The neutral zone remains
2% of the resistance at the extreme end of the elastic zone
unchanged (Figs. 2.6,2.7). The physiologic barrier represents the extreme of mo
(Panjabi,1992a).
tion that can be reached by the patient's own active move-
The Elastic Zone
ment. Further motion in the direction of the anatomic
This zone reflects the behavior of the elastic properties of
barrier is still possible but requires the introduction of
tendons and ligaments as they influence a jOint's motion
additional force, such as that introduced when the exam
8
Copyrighted Material
Definitions and General Principles
ining physician passively guides the joint toward the ana tomic barrier from where the patient's active movement came to a stop.
The Anatomic Barrier (AB) The anatomic barrier is located in the region between the elastic and the plastic zones. With passively induced movement-movement introduced not by the patient but the examiner-the anatomic barrier can be approached without causing microtrauma. Motion induced in a limb joint or joints of the spinal segment (e.g., facet joints)
"
,
,
beyond the respective anatomic barrier will push the joint
)
into the plastic zone, resulting at least in microtrauma if not macrotrauma (Figs.2.6,2.7).
Fig.2.6 Barriers of motion. AB
Anatomic barrier
APhB
Actual physiologic barrier
The actual physiologic barrier reflects the limit of motion
PB
Pathologic barrier
encountered in the presence of altered, pathologic motion
PhysB
Physiologic barrier
The Actual Physiologic Barrier (APhB)
characteristics in a joint, such as hypomobility or hyper mobility. This barrier can be engaged without necessarily
R
Resting position
ZFB
Zero- force barrier
involving microtrauma or macrotrauma (Figs.2.6,2.7).
The Pathologic Barrier (PB) The pathologic barrier, also known as the restrictive barrier, reflects the deviation from the normal limitation of motion caused by bony and/or soft-tissue changes (Fig.2.6). In a clinical setting, the motion is more often than not de creased in the form of joint hypomobility, while it can also be increased when there is laxity of a joint, for instance with associated hypermobility.
The Resting Position (R) The joint's or spinal segment's resting position is main tained at that point or "range" where the joint play is greatest.
Pathologic structural
changes and abnormal
muscle and tissue tension displace a joint's or a spinal
Fig.2.7 Barriers of motion.
segment's normal resting position. The resting position
AB
Anatomic barrier
marks that location within the arc of normal motion where
PhysB
Physiologic barrier
the joint volume is largest. Usually, in a clinical situation, pain intensity is registered by the patient as minimal in the
R
Resting pOSition
ZFB
Zero- force barrier
resting position, which is also known as the present neutral position.
Joint Localization at the Motion Barrier
Treatment Plane of a Spinal Segment or limb Joint
When the joint or spinal segment is engaged at its respec tive motion
barriers (e. g., in flexion/extension,
side
bending right/left, and rotation right/left), joint play is The plane of treatment is perpendicular to the traction
reduced to a minimum, while at the same time joint stabil
direction. Gliding or articulatory type of mobilization in a
ity is greatest.
limb joint is introduced according to the convex and con cave rules.
Copyrighted Material
9
Definitions and Principles of Manual Medicine Diagnosis and Treatment
Convex Rule The convex rule applies to a joint in which the distal joint surface has a convex shape. If angular motion is restricted due to articular degenerative changes or other structural changes. for instance. the direction of the mobilization without-impulse technique is usually opposite to that of the restricted joint mobility (Fig. 2.8).
Concave Rule The concave rule refers to a joint in which the distal joint surface has a concave shape. If angular mobility is restricted due to articular degenerative changes or other structural changes.
the
direction
of
the
mobilization-without
impulse technique is usually in the same direction as that of the joint restriction (Fig.
2.9).
Mobility Gain With the pathologic barrier as a starting point for treat ment, the mobility gained as a result of treatment is de
Fig.2.8 Convex rule. AB
Anatomic barrier
APhB
Actual physiologic barrier
PB
Patholog ic ba rrier
PhysB
Physiologic barrier
R
Resting position
ZFB
Zero-force barrier
fined as the amount of newly gained angular joint mobility primarily due to increased muscle length upon the induced muscle stretch (Fig. 2.10). When a muscle crosses two or more joints. it may be useful to stabilize one joint while attempting to increase the mobility in the second joint during the stretch.
Provocation Testing Mechanical stress directed to the various components of the locomotor system may lead to a number of nociceptive reactions which. ultimately, are reported by the patient as pain. Depending on the intensity. duration. and extent of
",PhS'
and the neurophysiologic mechanisms evoked by these
pS
nociceptive reactions, the individual patient's perception of the pain. both qualitatively and quantitatively. is subject
Fig.2.9 Concave rule.
to significant variation. Furthermore, the nociceptive reac
AB
Anatomic barrier
tions and pain alter muscle tone and/or autonomic func
APhB
Actual physiologic barrier
tions in such a way that ultimately they contribute to a self
PB
Pathologic barrier
PhysB
Physiologic barrier
perpetuating vicious cycle. The clinical manifestation (sign) of the nociceptive
R
Resting position
ZFB
Zero-force barrier
reactions is the irritation zone. The finding of a specific irritation zone upon clinical examination helps to verify objectively the presence of a segmental dysfunction. Fur thermore. the clinician is able to determine which motion
Biomechanical Principles and Their
direction exacerbates or improves the localized irritation
Clinical Correlation
zone. by introducing specific motions to the affected joint. Thus. the behavior of the irritation zone in response to the
In-vitro studies by Panjabi et al. (1994) and Grob et al.
motions induced by the examiner, and in particular that of
(1993) demonstrate that joint instability is typically asso
controlled provocative motion testing, is a helpful tool in
ciated with an increased neutral zone. Both increase and
the process of rendering a differential diagnosis and choos
decrease in angular and translatory mobility can be asso
ing the most appropriate treatment plan. (Fig. 2.11 a.
b).
ciated with an increased neutral zone. An increased neutral zone is found both with hypomobility and with hypermo bility. For instance. in cases where there are findings of advanced
10
Copyrighted Material
spondyloarthrotic/degenerative
changes.
the
Definitions and General Principles
neutral zone can be increased, even though the segmental
elasticity of the associated soft-tissue joint structures, the
angular motion is diminished, e. g., the joint is found to be
neutral zone is increased. In another example, flexion
hypomobile. However, due to the loss of or reduction in
extension injury to the cervical spine in patients who have known underlying spondylotic changes can lead to traumatic overstretching of the soft tissues, pushing the joint(s) into the plastic zone or, worse yet, into the destruc tive zone. This increases the neutral zone, which can be clinically determined by testing the affected joint(s) for signs of instability: When the usually smooth roll-and glide mechanism is impaired, sudden or abrupt mechanical stress forces will be transmitted directly to the bones, ligaments, and tendons. Because these structures can be viewed as "receptor organs," they play a significant role in the coordination of motion and muscle tone. Any disrup tion in the interplay between smoothness of joint motion and loading forces can lead to clinically relevant nocicep tive reactions and pain, which in turn can lead to changes in the normal movement patterns, ultimately leading to clin ically observable muscular imbalances.
Fig. 2.10 Motion gains.
I Z +0Y
2 Z +0Y
Z
z
I
l
X
Xl
+0 Y
---4-----4-- ��--l_----_+�- x
------�-----r-L- x
Fig.2.11a Provocation testing.
Fig.2.11b Provocation testing.
x', y'
x2, Z2
=
+(2lY
IZ Red
-
=
=
=
Pathologic motion barrier as demonstrated for rotation to
=
The new pathologic motion barrier for passive rotation
the right of the superior vertebral partner in a spinal
to the right of the superior vertebral partner in a spinal
segment
segment: this correlates to the trial treatment using any
Pathologic rotation motion to the left (e. g., left rotation
of the NMT 1, 2, 3, MWITH and/or MWOUT treatment
restriction) of the superior vertebral partner in the spinal
techniques
segment resulting from the muscles that are the agonists
IZ
to left rotation
Red
Irritation zone
Irritation zone =
Shortened rotator brevis muscle on the right side (muscle that is antagonistic to right rotation)
The shortened rotator brevis muscle on the right (note:
=>
Reduction of the irritation zone (IZ) by passive right
the agonist for left rotation becomes the antagonist for
rotation of the superior joint partner of the incriminated
right rotation)
spinal segment
Amplification of the irritation zone (IZ) by increasing left rotation of the superior joint partner of the incriminated spinal segment
Copyrighted Material
11
Definitions and Principles of Manual Medicine Diagnosis and Treatment
Application of the Biomechanical Model to Various Therapeutic Modalities Biomechanically. manual medicine procedures take place in the neutral and elastic zones only. and typically do not
NMT3
enter the plastic zone (Fig. 2.12). Depending on the individual clinical situation. the goal
NMT2
of treatment is to restore normal joint play and/or restore as much of the normal range of motion as possible. If the
NMTl
forces introduced to a joint during a manipulative maneu ver are inappropriately directed or are excessive. there is a real risk of damaging the joint and its surrounding
Mobllizatlon·wlthoul·lmpul...
tissues. especially when going beyond the joint's anatomic barrier. In certain clinical situations however. it may be neces
MobIlizatiQn·wtth·lmpulse/manlpulatlon
sary to move a joint into its plastic zone. for instance in certain manipulation procedures under anesthesia. Apart from this exception. it should otherwise never be the goal 0 N
of manual medicine procedures to thrust any joint into the
"!
plastic zone and run the risk of causing macrotrauma
'5
(Fig. 2.13).
..
01
c:
2
c: 0
1
'i;; IV l5:
i .!
N
v
t;
IV w
i
Tissue response
Potential Risks Associated with Manual
Fig.2.12 T he different force magnitudes utilized in mobilization
Techniques: Biomechanical Considerations
and manipulation techniques.
Treatment Risk as Related to the Velocity of Mobilization Force
.... c: ..
As discussed earlier. there is a fundamental biomechanical
.sIV
difference in the way a tendon is able to withstand varying loading conditions. If the loading force is applied in quick
o (II
and abrupt bursts. e. g., intermittently but with high speed. then relatively little force is necessary to cause the tendon
IWBI
I, :I BI
to tear, either partially or completely. If the loading force is introduced rather slowly and over a period of time. the chance
of
a
tendon
to
tear
is
marked Iy
reduced.
Accordingly. it is reasonable to assume that the high-veloc ity. low-amplitude mobilization-with-impulse techniques (MWITH) have a much greater likelihood of causing irre versible damage than the mobilization-without-impulse techniques (MWOUT). Furthermore, the rapidity
with
which a high-velocity impulse force is introduced to ajoint or spinal segment may be too sudden for the usual protec tive reflexes to respond. These two factors. the biomechan ical properties of the tissues and the elimination of the
Fig.2.13 Forces used in mobilization and manipulation techniques.
I II Treatment force III Treatment force IV Treatment force
Treatment force
protective reflexes. help explain how the MWITH tech niques can thrust the facet joint into the destructive zone with the application of relatively little force.
72
Copyrighted Material
up to ZFB ( Zero-force barrier) up to PhysB ( Physiologic barrier) up to AB ( Anatomic barrier) beyond AB
Definitions and General Principles
Treatment Risk as Related to the Amplitude of Mobilization Force
",
If manipulative treatment introduces excessive forces and pushes the joint(s) beyond its/their respective anatomic barrier(s), there is a great risk of causing tissue damage, which can range from microtrauma to macrotrauma. These changes can include the following:
Microtrauma
:
I
0 ...
!
01 C 0 N
0 N
'! ..
." ..
:::I GI z
\ 01 C 0 N
tiJ 01 c
} ..
2
Microrrauma (Fig. 2.14)
.l:!
t(
11'
i •
Increase of the neutral zone.
•
Reduction in the quality of the roll-and-glide motion.
2: Distance
Fig.2.14 Microtrauma.
Macrotrauma (Fig. 2.15)
• •
Macrotrauma
Increase of the neutral zone.
I
Adaptive, overcompensatory or even decompensatory changes in the associated joint structures, including the joint capsule and muscles, in an attempt control the loss of stability.
\ ! 2 v
i Treatment Risk as Related to Degenerative Changes
--------�--�
Affecting Elastic Tissue Structures
i
Pathologic neutral zone due to macrotrauma
Elastic tissue structures that demonstrate degenerative
Distance
changes are characterized by a reduced ability to withstand stress, with an increased chance of structural failure. This is represented graphically in Fig.
2.16,
Fig.2.15 Macrotrauma.
which depicts a con
densed elastic and plastic zone. Thus, in treating a patient who has known or suspected degenerative joint and/or soft-tissue changes, the mobilization maneuvers should be performed with as much care as possible and with as little force as necessary. This applies to both the thrusting (impulse) techniques and the nonthrusting techniques. Treatment must always pay attention to the specific joint's altered or "reset" anatomic barrier (Fig. 2.16), beyond which treatment should not go. The presence of osteophytes and spondylophytes may
GI
gN '!
l Z
01 C 0 N
." .. tiJ
01 C 0 N v
i .. i£:
GI C 0 N GI .
1::
:::I
ti01
Q
lead to an abrupt stop of the joint gliding motion. Inappro Distance
priate treatment with excessive force application may break these structures, inevitably leading to macrotrauma. The elastic zone is decreased. Clinically, this implies the
Fig.2.16 Motion characteristics as a result of degenerative changes.
following:
•
Hard end-feel.
•
Loss of range of motion.
•
Even small movements can bring the joint into the destructive zone.
Degenerative Joint and Spinal Changes While the Neutral Zone is Increased Instability Degenerative joint changes along with osteophyte forma tion reduce the rOll-and-glide as well as the gliding motion in a joint. Not only the articular surfaces are involved; the stabilizing structures within and surrounding the joint can also become affected. If subject to trauma these structures
Copyrighted Material
13
Definitions and Principles of Manual Medicine Diagnosis and Treatment
Pain Reaction (Nociceptive Reaction) ..
In the presence of pain. and following the hysteresis phe
.£
nomenon (Fig. 2.18). muscle tension may increase very rap id Iy. whi Ie the return is characterized by a less steep curve.
..
§ :;
N "
..
.. c o N U
..
t:
In the clinical situation where the pain becomes appa
g N
rent rather early in the arc of movement (the initial steep
2
described as a "hard-reflexive end-fee!." On the other
portion of the curve). the associated end-feel is usually hand. if the curve is less steep and the appearance of pain
0::
is gradual. the end-feel is described as "soft." A soft end-feel Distance
is usually observed. for instance. when the isotonic muscles responsible for limiting motion have shortened (Fig. 2.18).
Fig.2.17 Instability.
Repetitive Mobilizations into the Plastic Zone and Their Effects on Instability When entering the plastic zone repeatedly. both mobiliza
QI
.£
tion techniques with and without impulse may cause in .. appropriate stretch (i. e.... overstretch ) and thus increase
..
g N f z
,
lJ
..
c 0 N U ..
..
c 0 N U
i
.. 0::
.. c 0 N
the joint's neutral zone. Depending on their structural in
..
tegrity. the soft-tissue structures may withstand the stretch
:::J
stretched beyond their normal length. which would lead to
2 1::
U .!!:
Distance
Fig.2.18 Nociceptive reactions.
(reversible stretch) or may ultimately become irreversibly segmental or joint instability. Therefore one should always remember the potential risk of iatrogenic instability (Fig. 2.19).
End- Feel at the Motion Barrier
QI
If the forces that are introduced with active or passive
.£
motion exceed the resistive forces at the joint's anatomic
§
N
f !i
.. z
barrier. the joint is potentially subject to permanent dam
§
N ..
.. .. c o N U
'i
i
2..
age. In manual medicine. the assessment of the end-feel at the motion barrier is of great clinical significance. as it assists in the appropriate correlation with the structural.
.!!:
functional. or pain perception leve!. Through a careful ex amination the treating practitioner determines how much
Distance
force is necessary to approach but not exceed the anatomic barrier. The patient should be as relaxed as possible. It goes
Fig.2.19 Repetitive mobilization procedures.
without saying that the patient's entire clinical situation should be assessed in a comprehensive and functionally meaningful manner. Thus. the manual medicine assessment is not done in
may be stretched beyond their normal length and ulti mately lose their inherent elasticity (Fig. 2.17).
isolation but rather within the context of other relevant orthopedic. neurologic. rheumatologic. physiatric. and psy-
In the presence of such tissue changes. it is thus possible that upon clinical examination there is reduced range of
chologic examinations and the necessary diagnostic studies.
motion while the joint is unstable and the neutral zone is
The assessment of the end-feel at the motion barrier
increased. For example. pronounced osteoarthritic changes
requires great manual skills. which can only be learned in
can follow from an anterior cruciate ligament tear.
accredited courses and under the supervision of clinically experienced instructors. Only through ongoing practice
14
Copyrighted Material
Definitions and General Principles
will one be able to improve and perfect the manual and clinical skills that are needed. The passive motion examination of the synovial joints (facet and/or joints of the limbs) determines the following three major components:
•
Angular range of motion.
•
Joint play.
•
End-feel at the motion barrier.
The manual assessment of the end-feel at the motion bar
Fig. 2.20 Hard end-feel caused by osteophytes.
rier is of clinical significance as it differentiates between
PB
=
Pathologic barrier
two primary possibilities: •
Hard end-feel:
Shortened muscle
the resistive forces increase rapidly
(steep curve). •
Soft end-feel: the resistive forces increase rather grad ually (shallow curve).
In addition to the joint's anatomic barriers, one differen tiates further between the physiologic and the pathologic motion barriers. Physiologic Barrier •
Fig.2.21 Soft end-feel.
Shape and structural architecture of the joint; its motion
PB
=
Pathologic barrier
limit. •
In particular the behavior of the jOint's related soft tissues, such as tendons, ligaments, fascia, and muscles
•
account for this limit.
Shortened Tonic Muscles
In the unaffected joint, this represents the end of active
A shortened muscle or muscle group typically causes a soft
(e. g., patient-induced) motion.
end-feel as the resistive forces increase gradually rather than abruptly, i. e., subject to plastic deformation (Fig. 2.21).
Pathologic Barrier •
•
•
Changes in/aberrations from the jOint's normal func-
Hemarthrosis
tioning (in the apophyseal joint or in a limb joint).
Hemarthrosis typically sets off nociceptive reactions in the
In the affected joint, this typically represents a reduction or loss of normal physiologic motion (hypomobility).
muscles and other soft tissues associated with the affected joint. The nociceptive reactions become most apparent
However, there may be laxity of the tissues and associ
when the joint is carried toward the pathologic barrier
ated increased motion (hypermobility) due to structural
not only due to the accompanying chemical irritation but
abnormalities (e. g., tendon rupture).
also because of the increase in joint pressure secondary to the increased intra-articular fluid. The internal joint pres-
The following four factors affect the motion barrier: (1) os-
sure is least at the actual or present neutral position, and
teophytes and spondylophytes; (2) shortened tonic mus
any change from that position usually results in an increase
cles; (3) hemarthrosis; and (4) an acute disk herniation.
in pain. Thus, exceeding the critical internal joint pressure
Osteophytes and Spondylophytes
reactions and pain, ultimately causing a hard-reflexive end-
Osteophytes and spondylophytes change the joint's surface
feel (Fig. 2.22).
will lead to an amplification of the patient's nociceptive
structure and therefore impact on the roJl-and-glide mo tion of the incriminated joint. The end-feel is characteristi-
Acute Disk Herniation
cally described as a hard-pathologic end-feel while the
An acutely herniated disk causing sufficient mechanical
range of motion is simultaneously reduced (Fig. 2.20).
compression and/or inflammatory reactions to affect the nerve root, the perineurium. and/or the arachnoid is usu ally accompanied by significant pain. This precipitates a
Copyrighted Material
15
Definitions and Principles of Manual Medicine Diagnosis and Treatment
Treatment Principles of Various Manual
Noci ceptive reaction
Medicine Techniques
Inflammation
+
-0
The following section describes the principles of major manual medicine techniques and related musculoskeletal treatment options.
Overview Fig.2.22 Reflex hard end-feel due to hemarthrosis.
•
Pathologic barrier
PB CNS
Central nervous system
•
MEP
Muscle end plate
•
Mobilization-without-Impulse [MWOUT]. Mobilization-with-Impulse [MWITH]. Neuromuscular Therapy
Mobilization utilizing direct muscle force
-
Mobilization utilizing the post-isometric relaxation
-
Mobilization utilizing reciprocal innervation mecha
phase
massive nociceptive reaction when the incriminated spinal segment is taken to its respective barriers, and also when
nisms
the involved nerve and nerve roots are subjected to addi tional stretch (i. e., the sciatic nerve, femoral nerve, cervico
•
brachial plexus). The nociceptive reactions can become so pronounced that there is no motion possible whatsoever at the incrimi
•
NMT.
-
NMT 2. NMT 3.
Muscle Trigger Point Therapy. -
Manual techniques.
-
Injection therapy.
Training Therapy-Reconditioning and Home Exercise
nated spinal segment. Then the pathologic motion barriers
Program.
for flexion and extension are nearly identical, if not the
-
Stretching exercises.
same, and the end-feel is described as hard-reflexive.
-
Strengthening exercises.
-
Self-mobilization exercises.
In the Lasegue maneuver, the roots of the sciatic nerve are subject to mechanical irritation at the level of the disk
•
NMT 1.
Physical Therapeutic Modalities.
herniation when the straight leg is progressively flexed by
-
the examining physician between approximately 20' and
-
Cold/heat applications. Electrotherapy.
70' of hip flexion. A prominent nociceptive reaction is
-
Ultrasound.
accompanied by sudden radiating pain and a hard reflexive end-feel. If the end-feel elicited with the Lasegue maneuver is rather soft, it may indicate hamstring shortening more so than an acutely herniated disk.
Mobilization- without-Impulse Techniques [MWOUT]
In the reversed Lasegue test, the nociceptive reaction is caused by a pull at the femoral nerve. Similarly to the
The
Lasegue test, the pain increases rather suddenly at one
without-impulse techniques.
following
principles
apply
to
the
mobilization
point in the arc of induced motion. The same maneuver is utilized when examining for muscle length of the rectus
Spine (Apophyseal or Facet Joints)
femoris muscle. Thus, a rather soft end-feel would point
•
Slack is taken up in the facet joints above and below the
more in the direction of a shortened rectus femoris muscle,
affected vertebral segment; i. e., the spinal segments
whereas a hard-reflexive end-feel would represent a find
above and below the restricted spinal segment are guided to their respective barriers.
ing commensurate with mechanical irritation of the femo ral nerve and/or its associated nerve roots.
•
The operator should make every attempt to place his or her hand over those areas that are not painful to the patient; i. e., bony contact should be made only with structures that lie outside of the incriminated irritation zone.
•
Mobilization proceeds in the pain-free direction.
•
The direction of the mobilization forces is determined by carefully dosed provocation or "test" maneuvers in the assessment phase of the examination. The direction of the applied mobilization procedure is the same as
16
Copyrighted Material
Treatment Principles of Various Manual Medicine Techniques
that in which the patients pain and nociceptive reac l Z
tions decrease (Fig. 2.11 a, b, Fig. 2.23). •
Duration of the mobilization techniques ranges between
•
The intensity and frequency of this technique should be
+oy
Z
3 and 10 seconds.
/'
carefully dosed such that the mobility in the individual spinal segment does not exceed the joint's anatomic barrier. •
x
The mobilization procedure is accomplished in a step
,
+oy
wise manner by repeating the procedure three to four
----7-----��-
x
times and with each step starting anew from the newly gained barrier (Fig. 2.24).
Synovial Joints of the Extremities •
The incriminated peripheral joint (extremity joint) is first guided to its present neutral position (resting po sition).
•
The hands are placed as close to the joint as possible. Usually it is the proximal joint partner that is fixated (held stationary) while the more distal partner is being mobilized.
•
The direction of the mobilization follows the convex
•
Traction may be introduced before the mobilization
Fig. 2.23 Provocation testing. Xl, Z 1
=
+0Y
=
IZ
=
Pathologic motion barrier Pathologic left rotation of the superior vertebra Irritation zone
concave rule. AB
technique itself is applied, as it may help reduce pain if it
PhysB
is present (mobilization level l-II). •
The intensity and frequency of this technique should be determined carefully for each particular joint while al ways keeping in mind not to exceed the anatomic bar rier (mobilization level III).
The force-time diagram (Fig. 2.25) demonstrates that while the joint is being prepared for the mobilization technique (positioning and set-up phase), the forces that are being introduced to the particular joint are comparatively small. As the mobilization progresses, the introduced forces in crease slowly until a certain point at which time they diminish again (duration: 3 to 10 seconds).
Fig. 2.24 Stepwise motion gain upon repetitive mobilization. AB
=
Anatomic barrier
PhysB PB
=
=
Physiologic barrier
Pathologic barrier
The distance-time in diagram (Fig. 2.26) demonstrates that the mobilization procedure starts at the joint's patho logic barrier. Furthermore, it shows that the gain in mob ility should be short of exceeding the joint's anatomic barrier. The mobilization-without-impulse technique is re peated several times, while the starting point of each step is the newly gained barrier. With each step, the direction of mobilization increases the joint's mobility toward the ana tomic barrier, thereby increasing the joint's present phys iologic range of motion. When performed correctly, treatment is usually well tolerated by the patient and should not increase the pa tient's initial present pain (if present).
Copyrighted Material
17
Definitions and Prindples of Manual Medidne Diagnosis and Treatment
Q) v ... o .....
Mobilization
Q) c: Q) c: o
OJ c:
Q) c o
N
N
..... ::::J Q) Z
Position
2
:e ::::J
a::
o
u :p VI '"
'" '" w
2
III >
b :G
Set-up phase/"taking out the slack"
Time
Fig.2.25 Mobilization-without-impulse technique. Force-time diagram.
Q) " v c: VI
C
=--
Distance gain
Mobilization
III c:
2 "5 III Z
Position
Q) c: o N U :p VI rc W
Q) c:
S
u 'P VI rc a::
Q) c: o N Q) >
'B ::::J
Set-up phase/"taking out the slack"
Time
Fig,2.26 Mobilization-without-impulse technique. Distance-time diagram,
18
Copyrighted Material
Treatment Principles of Various Manual Medicine Techniques
Mobilization- with-Impulse Technique
Joints of the limbs
(MWITH) (Classic Thrust Technique,
•
The affected peripheral joint (limb joint) is guided to its
•
The operator's hands are placed as close to the joint as
"Manipulation")
present neutral (resting) position.
The mobilization-with-impulse technique is also known as
possible. Usually it is the proximal joint partner that is
the classic "thrust" technique, often referred to in the liter
fixed (held stationary). The direction of impulse force is
ature simply as a "manipulation."
perpendicular to the plane of treatment.
The following principles apply to the mobilization-with
•
The mobilization-with-impulse technique progresses from level II mobilization to level III mobilization.
impulse technique (MWITH).
Spine (Apophyseal or Facet Joints)
The force-time diagram (Fig.2.28) demonstrates that dur
•
Slack is taken up in the facet joints above and below the
ing the positioning of a synovial joint. the forces introduced
incriminated vertebral segment; that is, the spinal seg
to the particular joint are relatively small.
ments adjoining the restricted spinal segment are car ried to their respective barriers. •
The distance-time diagram (Fig.2.29) demonstrates that the mobilization-with-impulse techniques involve
Positioning of the patient and preparation for the tech
very brief but precise maneuvers (high-velocity, low
nique should be performed carefully so as not to intro
amplitude) in which the applied force moves the joint
duce or exacerbate the patient's pain.
beyond its particular or actual pathologic barrier but with
•
Mobilization proceeds in the pain-free direction.
out exceeding the anatomic barrier.
•
The direction of the mobilization forces is determined by carefully dosed provocation testing. The direction of mobilization is that in which the patient-reported pain and the nociceptive reactions decrease (Fig.2.11 a, b,
Zl
Fig.2.27). •
The mobilization-with-impulse technique in which the spinous process or the articular process of the inferior
\
partner of the spinal segment is utilized will introduce vertebral rotation in the same direction as the irritation zone. •
Thus, the inferior vertebra undergoes rotation away from the irritation zone. The opposite is true for the superior vertebral partner, which undergoes a rotation toward the irritation zone (Fig.2.27).
•
Z
+0Y
The force of the impulse should be carefully dosed so as
+0Y --�-------+--�---+�- X --
not to introduce motion beyond the anatomic barrier (mobilization level III. Fig.2.13). •
Mobilization-with-impulse should be performed care fully and with great caution so as not to exacerbate the patient's pain in the incriminated joint, or spinal region.
•
When using the mobilization-with-impulse technique, the affected segment should be treated no more than once during the treatment session. Fig.2.27 Mobilization-with-impulse (MWITH). MWITH-via the superior vertebra MWITH-via the inferior vertebra x', Z1
+0Y
=
Pathologic motion barrier
=
Pathologic rotation to the left of the superior
=
Irritation zone
vertebral joint partner
IZ
Copyrighted Material
19
Definitions and Principles of Manual Medicine Diagnosis and Treatment
QJ U '
o L.&..
Impulse
CLo
! 2
j
QJ I: o N U '.;:0
QJ I: o N u '.0
WJ
c::
2
I
oil
Vl ro
"'
Set-up phase/"taking out the slack"
Position
Time Fig.2.28 Mobilization-with-impulse technique. Force-time diagram.
QJ U c: "'
t; i5
Distance gain
Impulse
CII c: o N .... :::J CII Z
Position
QJ C o N U :.:;
CII c:
2
Vl
VI
"' WJ
"'
2
B S
c::
Set-up phase/"taking out the slack"
Time
Fig.2.29 Mobilization-with-impulse technique. Distance-time diagram.
20
Copyrighted Material
Treatment Principles of Various Manual Medicine Techniques
z
+y
�---X ----r-
-y a
b
Fig. 2.30a, b Neutral position of a spinal segment. Arrangement of the short and long rotator muscles.
Neuromuscular Therapy (NMT)
muscles primarily responsible for motion and those re sponsible for posture. A rather powerful set of muscles is
NMT includes treatment procedures that improve mobility
necessary to maintain the otherwise mobile head in posi
and stretch a muscle by engaging direct muscle action andj
tion.
or the associated neuromuscular reflex mechanisms (refer to Dvorak and Dvorak,
A well-founded knowledge of the functional anatomy is
indispensable for proper neuromuscular treatment. Con
1990).
Trunk rotation is affected by muscles oblique or even
cerning the spinal areas, it is important to remember that
perpendicular to the longitudinal axis of the vertebral col
rotation to one side is caused by the contralateral trans
umn. This is primarily due to the action of the short and
versos pinal system, while rotation may be typically limited
medium-length transversospinal muscles, especially the
by the shortened ipsilateral transversospinal muscles.
rotator and multifidi muscles (Fig. 2.30). Significant trunk
Rotation motion of the superior partner in the vertebral
rotation, however, requires the action of additional trunk
spinal segment is initiated to the left, for instance, by the
muscles, such as the lateral abdominal muscles which con
right rotator and multifidi muscles. Thus, the right rotator
nect the lateral aspect of the thorax with the pelvic crest on
and multifidi muscles function as agonists for left rotation
the opposite side. The abdominal musculature introduces
(Fig. 2.31). When the rotatores and multifidi muscles are
prominent flexion to the spinal column, which must be
shortened in the same spinal segment, however, they di
compensated for by the back extensor muscles. For the
minish rotation to the right (Fig. 2.32).
neck muscles, one has to differentiate between those
Copyrighted Material
21
Definitions and Prindples of Manual Medidne Diagnosis and Treatment
Z
Zl
X,
X
-y b
a
Fig. 2.31 a. b Spinal segmental rotation to the left.
' x , Zl
+0y Red
Motion barrier Rotation to the left of the superior vertebral joint partner Activated rotator muscles-agonists for left rotation
Z
Zl
X,
=--
.......--
x
IZ
-y a
b
Fig. 2.32a. b Pathologic motion barrier for segmental rotation to the right.
' x , z'
Pathologic motion barrier
+0Y Red
Shortened rotator muscles which are the antagonists for right rotation-agonists for left rotation
IZ
Irritation zone
Reduced left rotation (hypomobility) of the superior vertebral joint partner
22
Copyrighted Material
Treatment Principles of Various Manual Medicine Techniques
z
,
x
--�-------+--����--t---�
x
IZ
-y a
b
Fig. 2.33a, b Pathologic motion barrier for se g me ntal rotation to the ri ght . x', Zl
=
Pathologic motion barrier
=
Pathologic segmental rotation to the left (left rotation hypomobility) of the superior vertebral joint partner
Red
=
Shortened rotator muscles which are the antagonists for right rotation
IZ
=
Irritation zone
+0Y
•
NMT 1:
Since this type of movement is often new to the patient and at times difficult to learn, it may be of benefit to use
Mobilization Utilizing the Agonist Muscles
passive motion to guide the joint to the pathologic barrier.
Starting from the pathologic barrier, the patient contracts the appropriate agonist muscles to mobilize beyond this
•
When teaching certain movements, it may be of benefit
barrier. The slack is taken up in the spinal segments next to
to have the operator touch the skin overlying the par
the restricted joints. Since it is often difficult for the patient
ticular muscles that need to be contracted.
to learn these new movements, the operator can help both
•
This type of procedure is repeated several times in one
•
The patient should also perform the movements rou
quantitatively and qualitatively by using palpatory assis tance and verbal feedback to the patient. NMT 1 teaches patients those mobilization techniques
session under supervision by the operator. tinely on his own (Fig. 2.36).
that they can usually perform on their own in a home exercise program. The following considerations are of significance when utilizing the NMT 1 technique: •
•
•
NMT2: Mobilization Utilizing the Postisometric Relaxation
The restricted jOint must first be carried to its present pathologic barrier (Fig. 2.33). The segments distal to the restricted joints are fixated
Phase of the Shortened Muscles If muscle testing reveals shortened tonic muscles then there will always be diminished associated regional or
(slack is taken up).
segmental mobility in the corresponding spinal area(s) or
The patient introduces some very slight movement be
the peripheral joints (Fig. 2.33). Isometric contraction and
yond the pathologic motion barrier by contracting the
subsequent stretching during the postisometric relaxation
appropriate muscle groups (Fig. 2.34).
phase may return the muscles to their normal length. By
•
Stepwise gain of movement (Fig. 2.35).
engagement of the specific muscles, the corresponding
•
Duration of sustained muscle contractions is typically
joint or spinal segment is mobilized passively.
between 3 and 5 seconds.
Copyrighted Material
23
Definitions and PrInciples of Manual Medicine Diagnosis and Treatment
ziz'
+y
X,
-
\
/
I
-1=
-y
+-
=
Direction of induced mobilization
=
Pathologic motion barrier
Red
=
Recruited rotation agonists
=
Fixation of the inferior vertebra
ZI
Fig. 2.34a, b Mobilization using NMT 1. ZI
6.
y
xix2
<J=::l
a
x'.
-0
AB
Z2
x'
x?
=
-elY
=
b
Mobility gain
PhysB
PB
Fig. 2.36 Self-mobilization technique to improve segmental right
Fig. 2.35 Stepwise mobility gain. AB
=
PhysB PB
=
rotation.
Anatomic barrier =
Physiologic barrier
Pathologic barrier
The following considerations are of clinical significance when utilizing NMT
•
2:
The muscle is subsequently stretched for 3 to 10 seconds during the postisometric relaxation phase (Fig. 2.39).
•
The incriminated muscle is stretched to near maximum.
•
tient, away from the pathologic barrier (Fig. 2.37). • •
•
In most of the cases the patient needs to learn an in dependent stretching home exercise program.
The distal lying vertebra is fixated. Isometric relaxation of the incriminated muscle (Fig. 2.38).
Stepwise stretching: starting from this new position, the muscle is again stretched maximally and isometrically.
Optimal isometric contraction is introduced, by the pa
•
In many cases, however. there is weakening of the phasic muscles in addition to muscle shortening. and as
24
Copyrighted Material
Treatment Principles of Various Manual Medicine T echniques
Z
l
Z
x,
--�---r-L---��-=�-r�---t--.
x
IZ
-y
a
b
Fig. 2.37 a, b Pathologic motion barrier for segmental rotation to the right. x I, Z 1
=
+0Y Red
=
Shortened rotator muscles which are the antagonists for right rotation
=
Irritation zone
Pathologic motion barrier Pathologic segmental rotation to the left (left rotation hypomobility) of the superior vertebra
IZ
IZ
-y
+y
a
b
Fig. 2.38a, b Isometric contraction.
l Xl, Z
=
Pathologic motion barrier
6
=
Fixation
-+
=
Dire ction of is ometric contra ction
Green
=
Shortened right rotation antagonists which are isometrically contracted
IZ
=
Irritation zone
Copyrighted Material
25
Definitions and Principles of Manual Medicine Diagnosis and Treatment
X,
x/x'
-y
a
Fig. 2.39a, b Mobilization/stretching. ' ' Pathologic motion barrier x, z
6.
Yellow
Right rotation antagonists that are relaxed/ stretched in the postisometric relaxation phase in response to induced right rotation
Fixation Direction of induced mobilization/stretching
a rule the muscles should be stretched before being
Z®
Z2
x,
X2
-0Y
Mobility gain
•
The restricted spinal segment is guided to its pathologic
•
The restricted spinal segment or peripheral joint is fix
•
The first step of treatment includes pure isometric
strengthened. •
b
barrier (Fig. 2.40).
NMT 2 is most helpful in cases in which there is a soft
ated, thus barring further movement.
end-feel with angular motion restriction.
contraction in the direction of motion restriction (as suming correct fixation). This leads to a reciprocal in
NMT3:
hibition of the shortened rotator antagonists.
Mobilization Utilizing Reciprocal Inhibition
•
of the Antagonists
Duration of the isometric contraction is between 5 and
10 seconds (Fig. 2.41).
Isometric contraction occurs in the same direction as the
•
In the second step, careful passive mobilization is per
motion restriction. The muscles antagonistic to those
formed beyond the pathologic motion barrier (Fig. 2.42).
muscles that need to be relaxed are isometrically con
This mobilization requires significantly smaller forces
tracted. With this technique, the incriminated segment is
than those applied with the stepwise stretching proce
the fixated. This is in contrast to the NMT 1 and NMT 2
dures during the postisometric relaxation phase of
techniques, in which the spinal segments that are above
NMT 2.
and below the restricted spinal segment are fixated. The following considerations are of clinical significance when utilizing NMT 3:
This technique is utilized when isometric contraction of the shortened tonic musculature is painful, a condition often found with acute radicular syndromes.
26
Copyrighted Material
Treatment Principles of Various Manual Medicine Techniques
z
x
--�------�r-��-r�---t--'r-L-
,
x
IZ
-y
a
Fig. 2.40a, b Pathologic motion barrier for right rotation.
Red
' x , Zl
Pathologic motion barrier
+0Y
Pathologic segmental rotation to the left (left rotation
b
Shortened rotator muscles which are the antagonists for right rotation
IZ
Irritation zone
hypomobility) of the superior vertebra
+y
IZ
-y
a
Fig. 2.41 a, b Isometric contractioll.
' x , Zl
Pathologic motion barrier
6
Fixation
t-
Direction of isometric contraction
Green
b
Right rotation agonist muscles, which are isomet· rically contracted
IZ
Copyrighted Material
Irritation zone
27
DefInitions and Principles of Manual Medldne Diagnosis and Treatment
+y
Zl
X,
xix'
-y
a Fig. 2.42a, b Mobilization/stretching.
Orange
f::, +-
x'
=
The right rotation antagonists that are reciprocally inhibited are being stretched
Fixation =
b
Direction of induced mobilization/stretching
Muscle Trigger Point Therapy
•
x2
Z'
Z2
= -0
Y
=
Mobility gain
A myofascial trigger point is described as a hyperirrita ble spot, usually within a taut band of skeletal muscle or the muscle's fascia, that is painful upon compression.
While the primary objective of this section is to describe the four major manual trigger point techniques, a brief gen
Snapping type of palpation of the myofascial trigger
eral overview of the standard approaches to trigger point
point usually induces a twitch response in the incrimi nated muscle.
treatment is presented here. Travell and Simons (1983a, 1992) in their classic texts (both of which are comprehen
•
The patient usually reports pain or discomfort in an area
sive and superbly illustrated) describe a number of differ
that is characteristic for a particular muscle. There may
ent techniques that can be utilized to treat and inactivate
be reports of autonomic phenomena as well.
the various trigger points primarily concentrating on the
•
In clinical practice, and in particular when dealing with
Muscles that harbor a myofascial trigger point are often shortened.
"spray-and-stretch" and the various injection techniques. •
Myofascial trigger points can be associated with dis
seemingly "untreatable" chronic pain syndromes, the var
eases that are identified with the structural Ie . vel
ious approaches have been well received, albeit on an
described in Chapter 2), with either systemic or local ized disorders or both.
empirical basis. The injections can be done by using a saline solution or a
•
Contraindications to treatment of a myofascial trigger
local anesthetic agent or utilizing a "dry needling" tech
point must always be kept in mind, and such should be
nique (in which no substrate is actually injected).
meaningfully integrated in the overall treatment plan.
The different manual techniques go hand in hand with
•
As the treatment may be painful, the operator should
the other trigger point treatment approaches as they di
take the time to explain the procedures, their benefits
rectly address the potential connective-tissue reactions
and potential side-effects, including pain.
and joint dysfunctions arising from the particular trigger points (Table 2.4). The following represents but a brief description of the characteristics of the myofascial trigger points and their relevance in clinical practice:
Manual Trigger Point Techniques The manual approach to a myofascial trigger point includes primarily four different techniques, which are described in detail below (Dejung et aI., 2006).
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Treatment Principles of Various Manual Medicine Techniques
Table 2.4 Trigger point management considerations Common Myofascial Trigger Point Treatments •
Spray and stretch technique
•
Trigger point injections: - Local anesthetic injections (e. g., bupivacaine, etidocaine, lidocaine) - Steroid injections with local anesthetic (e. g., region of frozen shoulder - Sterile water/saline injections - Botulinum toxin injection - Dry-needling - Combination or stepped-sequence approach utilizing the above (e. g., local anesthetic injection series followed by botulinum toxin injection to maximize time between injections with maximal improvement in functional abilities)
• •
Specific muscle stretching exercises after injections/or other treatment techniques Correction of underlying/associated biomechanical aberrations (e. g., correction of postural abnormalities, correction of sacral-base unlevelness/short leg syndrome)
•
Physical therapeutic management as part of the entire treatment approach rather than as passive, stand-alone treatment (e. g., ultrasound, electrophoresis, electrical stimulation, biofeedback)
•
Restoration of muscle balance (appropriate stretching, strengthening, balance, endurance, etc.)
Manual Treatment •
Specific manual treatment techniques: see this chapter for more details as well as Chapter 18.
•
Various osteopathic manual medicine techniques may also be useful, especially when utilized In combination with appropriate
•
Specific techniques that might be useful include, among others:
injections and/or active exercise regimens - Articulatory techniques/high-velocity/low-amplitude techniques - Balance-and-hold techniques - Muscle energy techniques - Myofascial release techniques - Release-by-positioning techniques - Soft-tissue release techniques (disinhibition, decompression techniques) - Combinations of various techniques Alternative/Complementary Techniques •
Myotherapy ("ischemic-stretching" technique; Prudden,
•
Acupuncture treatment
1980)
Pharmacologic Treatment •
Examples of medications that might help, but should only be used judiCiously within a comprehensive evaluation and treatment regimen that takes advantage of an active approach based on specific muscle involvement and particular functional goals to be accomplished with the overall treatment approach):
•
Muscle relaxants Oudicious use, if at all)
•
Nonsteroidal anti-inflammatory medications Oudicious use, if at all)
•
Tricyclic antidepressants
Technique I: Active Repetitive Contraction and
Manual trigger point technique I is based on classical man
Relaxation
ual medicine approaches (Knott. 1968; Cailliet, 1977; Lewit,
The rationale behind the use of this treatment is the reduc
1981; Rubin, 1981). Trigger point technique I has been
tion of muscle tone in the muscie that harbors the myofas
shown to be particularly useful in patients whose muscles
cial trigger point. The goal is to restore the original resting
have become so shortened over time that they cannot be
length of the muscie by reducing its resistance to stretch.
stretched to their normal resting length. This technique, in
Step 1: After exact and careful localization. the incrimi
a sense, employs a "protective" mechanism of the muscle,
nated myofascial trigger point is carefully com
as the pain will stop the patient from overstretching the
pressed.
muscle. In performing the stretch under the supervision of
Step 2: The patient is requested to rhythmically contract
the operator, the patient learns how to correctly stretch a
and relax the incriminated muscle that harbors the
specific muscle, which is necessary if the independent
particular myofascial trigger point.
home exercise program is to be successful. This also may
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29
Definitions and PrInciples of Manual Medicine Diagnosis and Treatment
foster the patient's confidence in the type of treatment
ollr experience, should be typically 0.3 to 1.0 mL of injec
rendered.
tate per trigger point at any one time.
Technique II: Passive Muscle Stretch
•
Usually no more than six to eight different muscles
Step 1:
Compression of the incriminated myofascial trigger
Step 2:
The muscle that harbors the myofascial trigger
fascial trigger point (over time), unless clinically indi
point is passively stretched within the patient's
cated. Good documentation about the particular muscle
point after it has been carefully localized.
Step 3:
should be injected per treatment session. •
Maximally three to five injections into the same myo
pain tolerance.
injected, immediate and follow-up response, any com
The muscle and fascial tissue surrounding the in
plications, and initial and follow-up range of motion is essential.
criminated myofascial trigger point are then ad dressed through a deep stroking type of massage.
•
Sufficient time between successive injection sessions, with at least 3-4 days between sessions.
Technique III: Fascial Release
•
Step 1:
Compression of the incriminated myofascial trigger
Step 2:
Application of the so-called "fascial release tech
No more than a total of 15-20 mL of 1 % lidocaine per session.
point after it has been carefully localized. Associated Ultrasound Applications
nique," in which the fascia between muscle and
Ultrasound treatment may be used as adjunct treatment in
skin is "freed up," resulting in easier displacement
the presence of myofascial trigger points, and may be par
of the fascia along the overlying skin.
ticularly useful in the presence pain at the myotendinous junction, enthesopathies, and peritendinopathies. Contra
It is important that the particular myofascial trigger point is
indications to ultrasound include malignancy and treat
carefully localized by palpatory examination of the muscle.
ment around fluid-filled cavities (e. g., the eyeball), near a
The palpatory pressure should be great enough to ensure
pacemaker, a joint prosthesis,
or
a laminectomy site.
adequate treatment of the trigger point, on the one hand, while at the same time one should be careful not to use
Criteria and Goals for Effective Treatment
excessive pressure so as to avoid irritation of the surround
•
A high degree of manual skill is necessary (significant amount of practice is necessary to gain the necessary
ing tissues.
clinical experience). Technique IV: Myofascial Release
•
("Fascial Separation") Step 1:
Step 2:
A detailed medical and pain history and a careful ex amination are the sine qua non of the initial assessment.
Compression of the incriminated myofascial trigger
The most appropriate diagnostic studies, if indicated,
point after it has been carefully localized.
should be chosen: (1) according to the additional in
In a process similar to the one described for tech
formation one expects to find; and (2) keeping in mind
nique III, manual trigger point technique IV utilizes
whether any of the information thus gained would in
the concepts of the "myofascial release" technique,
fluence the specific treatment approach.
(originally an osteopathic manual medicine tech
•
Careful patient positioning often facilitates treatment.
nique). Here, the goal is to "separate" fascia from
•
The instructions given to the patient should be as spe
muscle. While inherently using forces greater than
cific as possible and should include a description of those
that required for manual trigger point technique III,
activities and movements that should be avoided or are
the overall amount of force should be gauged ac
expected to facilitate recovery (e.g., "do's and don'ts" as well as specific supplementary stretching exercises).
cording to patient tolerance. •
Injection Therapy for Myofascial Trigger Points
In the absence of definitive guidelines as to the exact
Treatment should be unhurried. Both patient and therapist should be as relaxed as possible (not always as easy as it may sound).
•
Specific treatment/management planning with periodic
intensity, frequency, and duration for trigger point injec
monitoring should be based on objectively verifiable
tions, a common-sense approach is useful. Based on the
goals (range of motion improvement, "muscle tension
fundamental work by Travell and Simons (1983a, 1992),
signs," reduction in medications, ability to perform
and our own experience, the following approach is sug
certain activities for longer periods of time, etc.) and
gested, always keeping in mind the patient's response and
functionally meaningful medical "end-points" (activities
projected outcome based on objectively verifiable and
of daily living, [ADLsj vocational and nonvocational ac
functionally meaningful information. Each injection, in
tivities, etc.).
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Treatment Principles of Various Manual Medicine Techniques
•
The s pe cific trigger points. releva(lt clinical and (unc
essary, a reconditioni(lg program should be accompanied
tional findings. overall clinical status. treatment, and
by adequate pain treatment.
patient response should be adequately documented in
•
The treatment goals, however, may be different for the patient and for the treating practitioner (Table
the medical record.
2.5):
Specific goals, medical end points and parameters of progress should be established by the practitioner in
•
Typically patients want their pain reduced or abolished
•
The practitioner's goal is to reduce or eliminate the
discussion with the patient. If there is insufficient
as it may be affecting their overall well-being.
progress, the treatment should be continued, revised, or terminated depending on the overall clinical situation.
pain-associated nociceptive reaction in order to have the patient return to as high a functional level as pos
In clinical practice and in our experience, "unsuccessful"
sible.
treatment can usually be ascribed to one of three factors or to a combination thereof:
If there are objective signs or indications of instability and/ or inadequate strength and endurance, referral should be
1. Wrong diagnosis.
made to a qualified therapist (e.g., an experienced phys
2. Inappropriate treatment.
iotherapist) for a detailed assessment and treatment rec
3. "Out-of-sequence" treatment: that is, areas other than the painful/or treated area need to be addressed first.
ommendations including the
most appropriate trunk
stability exercise program. The individual program is tai lored according to patient's pain level, functional status,
There may be additional factors that either have not been
tolerance and motivation to participate in such a program.
clearly elucidated or take on a significance different from
In general, such a program approach is divided into three
that which the clinical context would initially suggest (for
phases.
instance: perpetuating factors, remote or recent trauma,
In Phase I, the exercises should not cause any pain whatsoever and should integrate the patient's usual ADLs
patient motivation, and many others).
as much as possible. In Phase II, the exercises are "more intense" than in Phase I and may just approach the patient's pain threshold, but should not go beyond it. Only when the
Reconditioning and Training Therapy
patient has progressed to the point where pain and noci ceptive reactions are minimal or absent, is he or she able to
Pain; Nociceptive Reactions; Functional Deficits
enter the phase III of the program. The goal in this phase is
Within the field of manual medicine, two primary consid
to train for maximal strength, muscular and aerobic endur
erations determine the selection of a rational recondition
ance, speed, and coordination.
ing program: 1. The patient's pain and associated nociceptive reactions.
2. The impact the pain has on the patient's functioning.
Muscle Function and Stabilization Exercises According to Bergmark (1989). the trunk muscles can be grouped into two general categories:
The goal of a reconditioning program is to maximally im
scale or "macro") muscles; and
(1) the global (large
(2) the local (confined,
prove the patient's level of function. The type and intensity
"micro") muscles, depending on their main mechanical
of a particular program are chosen according to specific
properties in the stabilization-mobility spectrum of their
objectively verifiable and functionally meaningful data
action (Table
gathered in the detailed structural and functional evalua tion.
2.5).
The large-scale or global muscle system comprises muscles that have a large cross-sectional diameter and
The nociceptive reactions associated with a patient's
that produce large torque upon the trunk, spine, and pelvis
pain often reduce not only muscle strength but also affect
without direct attachment. This group is then further div
muscular and aerobic endurance and coordination as well.
ided into those muscles that primarily act upon the
This can be objectively documented with an appropriately
shoulder girdle and arm and those that act upon the pelvis
designed functional capacity evaluation, for instance, in
and leg.
which the patient is requested to give his or her best effort.
The local or confined muscles are those that attach
Depression, fear, and secondary gain issues, among others,
directly to the lumbar spine and are primarily responsible
can negatively influence even the most carefully executed
for segmental stabilization. These are the members of the
assessment, and therefore, the results of such tests must
transverso-spinal system, namely the multifidi and rota
always be interpreted with great caution. Whenever nec-
tores muscles.
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31
Definitions and Prindples of Manual Medicine Diagnosis and Treatment
Table
2.5 The three phases of a reconditioning training program Training Therapy Principles
Phase I
Gravity
Acute
The incriminated joint or region is usually
Determine the position of the incriminated
painful in certain positions, therefore one of
joint or region at its present neutral position
the primary goals is to reduce ·stress" upon
("unloading")
the joint/region by unloading through careful repOSitioning the joint to a nonpainful position: •
Supine position/side-lying
•
Sling table
•
Medicine ball
•
Water buoyancy
Move
Avoidance of exercises that cause pain:
ment
• •
Dynamic slow exercises
•
Isokinetic exercises
•
low force or resistance
( 30% of maximal
Emphasis is on an individually tailored ex ercise program
force) •
Determine in which direction the pain di minishes
Isometric exercises
High number of repetitions
(20-30)
Phase II
Move
Allow exercises up to but not beyond pain
Keep the nociceptive/painful reactions at a
Subacute
ment
tolerance:
minimum while emphasizing the need to
•
Dynamic slow exercises
•
Iso kinetic exercises
• •
improve/maximize muscular balance
30-50% of maximal force or resistance 20 repetitions
Phase III
Move
Motion up to the motion barrier. Any compo
Chronic
ment
nent of the training therapy can be utilized: •
Dynamic fast
•
DynamiC slow
•
Resistive force between
•
Make sure that nociceptive/painful reac tions are kept to a minimum, if there are any at all
•
30% and 90% of
Do not start with coordination/proprio ceptive training components (i. e., back school training) unless Phase II has been
maximum
completed. It is virtually impossible to adequately train coordination in the pres ence of pain due to compensatory move ments or pain inhibition •
When entering Phase III, modalities/appa ratus such as free-weights or strengthen ing machines can be added
•
Take into consideration the patient's over all health status and particularly such variables as the condition of the patient's intervertebral disk, tendons, and ligaments
•
To maintain the gains made (·steady state"), the training frequency should be between 1 and
3 sessions per week
Movement of the head and neck in reference to the
In Figures 2.43-2.67, the muscles that act to stabilize the
pelvis is accomplished by the large-scale muscle system,
spine are depicted in green, while those muscles that act to
whereas the local muscles adjust or "fine tune" the asso
induce motion are depicted in red.
ciated localized spinal motion with the primary goal of
The complex three-dimensional motion patterns and
stabilization. The large-scale muscles are able to induce
muscle actions have been analyzed and described by Kurt
spinal motion while the limbs are held stationary ("stabi
Tittel, who coined the term "muscular chain" (Tittel, 2003).
lized"), or conversely they induce motion at the limb while
The unencumbered interplay between agonists, synergists,
the spine is stabilized.
and antagonists is required for unrestricted movement of the variolls body parts in space.
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Treatment Principles of Various Manual Medicine Techniques
Functional Correlation between Various Muscles and Their Effect on the Trunk and Spine Table 2.6 Muscle fu nctio n
M uscle
Muscle Action When Trunk/Spine
Muscle Action When Extremity is Stabilized
is St abi lized Trapezius (descending portion)
Elevation of shoulder
•
Side-bending of the neck
Sternocleidomastoid
Inhalation
•
With neck extended: reclination (extension) of (0-C2
• Unilateral contraction: side-bending, extension and rotation to the opposite side Pectoralis
Adduction and internal rotation of
•
Trunk rotation
the arm Latissimus dorsi
Oblique abdominal muscles
Adduction and internal rotation of
•
Bilateral action: trunk flexion
the arm
•
Unilateral action: trunk rotation
Valsalva maneuver
•
Bilateral action: trunk extension
•
Unilateral action: trunk rotation
Rectus abdominis
Valsalva maneuver
•
Trunk flexion
Quadratus lumborum
Exhalation, Valsalva maneuver
•
Unilateral: trunk side-bending
Tensor fasciae latae
Abduction of the thigh
• Ipsilateral stabilization of hemipelvis or lifting/ raising of contralateral hemipelvis
Gluteus medius and maximus
Rectus femoris and sartorius
•
Hip extension
Hip flexion
•
Flexion of the pelvis
•
Decrease in lumbar lordosis'
•
Extension of the pelvis
•
Increase in lumbar lordosisa (i. e., ·swayback")
Due to their insertion at the pelvic girdle . these muscles affect the lumbar spine indirectly. both statically and dynamically.
Cervical Spine Side-bending Motion Shoulder Elevation
Fig.2.43 Shoulder elevation.
Fig. 2.44 Side-bending of cervical spine.
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Fig.2.45 Inh a latio n motion.
33
Definitions and Principles of Manual Medicine Diagnosis and Treatment
Latissimus Dorsi Muscle
Fig. 2.46 Depression of arms.
Fig. 2.47 Side- bending of trunk.
Fig. 2.48 Exhalation motion/coughing.
Abdominal Oblique Muscles
Fig. 2.49 Valsalva maneuver.
Fig. 2.50 Trunk rotation.
Fig.2.51 Lumbosacral flexion (sit-ups with knees bent).
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Treatment Principles of Various Manual Medicine Techniques
Quadratus Lumborum and Tensor Fasciae Latae Muscles
Fig.2.52 One-legged stance.
Fig.2.53 Side- bending at trunk and pelvis.
Fig.2.54 Two-legged stance.
Gluteus Medius and Maximus Muscles
Fig.2.55 Hip extension.
Fig.2.56 Lumbosacral extension.
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3S
Definitions and Principles of Manual Medicine Diagnosis and Treatment
Iliopsoas Muscle
Fig. 2.57 Hip flexion-one-Iegged stance.
Fig.2.58 Hip flexion at the trunk.
Fig.2.59 Trunk and hip flexion (supine sitting).
Complex Muscle-Chains of the Trunk: Extension and Rotation
/j.
Fig. 2.60 Trunk extension and rotation.
Fig.2.61 Trunk
flexion
and
standing.
36
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rotation
Treatment Principles of Various Manual Medicine Techniques
Trunk-Side- bending Movements
This is important clinically. When the deep paraspinal
The deep paraspinal muscles of the back constitute the
muscles are involved, even small loading forces may cause
fourth, and deepest, muscle layer and extend over one
or exacerbate the patient's pain, a fact it is important to
spinal segment or only a few segments. Characterized by
remember during the initial and second phases of a recon
a relatively small cross-sectional area, they are usually
ditioning program. This requires the judicious selection
innervated
and execution of the various exercise components.
unisegmentally or plurisegmentally. While
they "fine tune" the spine on a segmental level and/or a
Thus, it is of paramount importance that the individual
specific spinal region, they do so in coordination with the
exercise program be tailored according to each patient's
action of the other large muscles that act directly upon the
specific and general needs. The appropriate exercise pre
trunk and the spine. The deeper paraspinals can become
scription
very painful, especially when they are called upon to fulfill
stretched and which should be strengthened, and at what
dictates which
muscle
group(s)
should
be
a "protective" function in which they attempt to limit
point in time, with what frequency, and at what level of
("block") potentially abnormal segmental vertebral motion.
intensity (Figs. 2.65-2.67).
The associated palpatory findings include increased muscle tone ("spasms") and associated segmental hypomobility.
Fig. 2.62 Trunk side-bending-standing
Fig.2.63 Trunk side-bending-standing;
Fig.2.64 Trunk side-bending-standing;
initial side-bending motion.
end- range to the left.
end- range to the right.
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37
Definitions and Principles of Manual Medicine Diagnosis and Treatment
Fig. 2.65i1, b Phase I. Extremity muscles, single and multiple s egmental muscles.
L_ --', ____ __ __ ____
iI
b
Fig. 2.66i1, b Phase II. Oligo- and segmental muscles and extremity muscles.
b
Fig. 2.67i1, b Phase III. Oligo- and segmental muscles and extremity muscles.
b
iI
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Treatment Principles of Various Manual Medicine Techniques
Physical Therapeutic Modalities
Heat Treatment Heat when used in conjunction with manipulative proce
When indicated and appropriately prescribed, physical
dures is usually applied in the form of localized treatment
therapeutic modalities serve as a useful adjunct to the
only, with the following effects:
various manual medicine procedures, the myofascial trig ger point treatments, and the training therapy program.
•
Increased soft tissue elasticity.
Within the context of this text, the primary goal of
•
Reduction of increased muscle tone ("spasm").
physical therapeutic intervention is to help reduce noci
•
usually used for patient preparation before, or sometimes
Pain reduction (partial explained by the "gate-control" theory).
ceptive reactions and thus pain. The various modalities are •
Reduction of the viscosity of the tissues and synovial fluid.
after, the various manual medicine techniques (both the impulse and non-impulse techniques) or in association with the various trigger point treatment approaches.
Contraindications to heat therapy include acute hemor
Physical therapeutic modalities primarily address the following symptoms and signs:
rhage and inflammation, bleeding disorders, malignancy, insensate skin, and atrophic skin. Caution must be exer cised in patients who are pregnant or who have a signifi
Table 2.7 Symptoms, signs, and possible physical therapeutic modalities Symptoms and Signs
Treatment Modality
Acute pain
Cold
Subacute pain
Heat. elec trotherapy . ultra
cant medical disease such as multiple sclerosis.
Electrotherapy
TENS (Transcutaneous Electric Nerve Stimulation) The low-frequency impulses generated by a small portable
sound
device (the TENS unit) are delivered via two to four electro
Acute inflammation
Cold
Subacute inflammation
Heat
perceived pain. It is postulated that by stimulating the
Electrotherapy
A-nerve fibers one is able to induce pain inhibition at the
des applied over the patient's skin to reduce the patient's
Ultrasound Increased muscle tone.
Heat
"hypertonic muscle"
Classic massage
level of the medulla oblongata. TENS units have been found more useful in acute than in chronic pain situations, and in particular when there are
Elec trotherap y
known anatomically identifiable sources such as an acute
Trigger point therapy
disk herniation or recent spinal fracture (due to osteopo
Cr y otherapy ( nitrogen gas)
rosis, for instance, and often acute conditions).
Treatments Using Low-frequency Current (50-100 Hz) current treat
Thermotherapy-Cold and Heat Treatments
The goal of these low-frequency
Cold Treatment
ments is to reduce soft-tissue pain. While it is postulated
Localized treatment using cold modalities has the following
that this form of treatment increases blood flow to the
effects:
tissues, another explanation may in part be based on mech anisms described by the gate-control theory.
•
Pain reduction through presynaptic inhibition of noci
TENS and other forms of electrical stimulation are con
ceptive transmission.
traindicated in patients with advanced cardiac disease and in patients with a pacemaker, because it may interfere with
•
Reduction in nerve conduction velocity.
•
Reduction of increased muscle tone ("spasms").
the pacemaker's functioning. It should not be applied over
•
Reduction of inflammatory processes.
the eyes, carotid sinuses, or gravid uteri.
[n clinical practice, the application of cold as a treatment modality is usually restricted to the acute painful episodes
Ultrasound Treatment
0.8
or nociceptive/pain reactions. Cold is contraindicated in the
Ultrasound treatment uses sound waves between
setting of ischemia, insensate skin, severe hypertension, or
8
and
cold sensitivity syndromes (e.g., Raynaud syndrome, cryo
capsule. the myotendinous junction, and the tendons.
globulinemia).
Some practitioners advocate the use of ultrasound as part
MHz. It can be quite useful for pain arising from the joint
of preparation for myofascial trigger point treatment or
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39
Definitions and PrInciples of Manual Medicine Diagnosis and Treatment
manual medicine treatment in general. especially immedi-
areas. or areas of acute infection. It should not be applied
ately before performing stretching techniques to a partic-
over the eyes. or near a pacemaker. joint prosthesis. or
ular muscle or muscles.
laminectomy site.
Ultrasound is contraindicated in patients with ischemic tissue.
acute
hemorrhage.
malignancies.
anesthetized
Schematic Representation of the Various Treatment Modalities and Their level of Action
1 Cortex
[
2 Thalamus 3 Reticular formation
2
Patient interview Patient consent Reassurance Tranquilizer
•
Myotonolytica
Anesthesia. posterior root
----«
-4
'
PM
-_! J
T',2,]
Anasthesia. spinal nerve
Anasthesia. peripheral nerve
-< Anasthesia. joint receptor Prostaglandin inhibitor Trigger point therapy Massage Myotonolytica Physiotherapy
Mobilization with/without impulse
<
Connective-tissue massage Anasthesia. skin receptors; electrotherapy (TENS)
Heat. cold
Fig.2.68 Schematic representation of the various treatment modalities in correlation with the level of application (adapted from H.D. Wolff. 1980).
40
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3
Biomechanical Principles of the Spine and Joints
General Biomechanical Principles A weJl-founded understanding of spinal biomechanics is
r-- -
helpful in the clinical and radiographic assessment and
I I I I I I I I
on the fundamental work by White and Panjabi (1978, 1990) and Panjabi (2003). It places particular emphasis on those biomechanical princi pies that are particularly relevant clinically in the assessment of the various neuro
(NMSK)
---
I
treatment of tile spine and the limbs. This chapter is based
musculo-skeletal
--
disorders.
I
Types of motion and the barrier concepts as related to
I
the clinical practice of manual medicine have been de
I
xz
scribed in the previous chapter.
yz
--1 I I
I I
I I I I I I
Clinical Biomechanics of the Spine The Axial System Any movement in space can be defined within the frame work of a three-dimensional coordinate system. Derived from general principles in the field of mechanical engineer ing, this system has also found general acceptance and ap plication in biomechanics, ensuring precise description and definition of body movement or individual parts in space.
xy
The three-dimensional coordinate is based on the three fundamental component axes constructed perpendicular to each other. By convention, the human body in its neutral, anatomic position is placed in space, with the anteropos terior view being the standard examination view (Fig. 3.1).
The point of intersection (O-point) of the three axes is
Fig.3.1 Three-dimensional coordinate system.
yz xz xy
Sagittal plane Horizontal plane Frontal plane
hypothetically placed between the sacral horns. By con vention, a set of three reference arrows is arranged such that they point in the positive direction, whereas arrows
The combination of any two of the three axes defines one of
pointing in the opposite direction are, again by convention,
the three major planes in this coordinate system (Fig. 3.1):
designated as negative. The three primary axes are defined as follows (Figs. 3.1,
3.2,3.3):
The
•
The
• •
The transverse (horizontal) x-axis. The direction to the left from the center point is designated as +x, whereas
•
•
sagittal plane is formed by the y- and z-axes. horizontal plane is formed by the x- and z-axes. The frontal plane is defined by the x- and y-axes.
•
This system then allows one to analyze any spinal motion
the direction to the right is designated as -x.
in general, or a particular vertebral motion segment in
The vertical y-axis, which is perpendicular to the x-axis.
terms of rotation about a particular axis, or motion with
The superior direction is designated as +y, while the
reference to or within a particular plane, or as a combina
inferior direction is designated as -yo
tion of different axes or planes.
The sagittal z-axis, which is perpendicular to the x-axis
In regard to axial rotation, clockwise rotation is desig
in the horizontal plane. The anterior direction is desig
nated as the positive (+) direction, whereas counter-clock
nated as +z, whereas the posterior direction is desig
wise rotation is designated as the negative (-) direction.
nated as
-z.
Copyrighted Material
47
Biomechanical Principles of the Spine and Joints
y
,I
t
III
Foe" Mom'"t
- T"nslation Rotation
} }
Load
Displacement
Z
x Fig.3.2 A three-dimensional coordinate system has been placed at
forces or moments, can act on theses axes: the application of any
the center of the upper vertebral body of a vertebral unit (motion
one of the load components (linear or rotatory) produces displace
segment). An applied force (compression or distraction) or a rotary
ment of the upper vertebra with respect to the lower vertebra. This
moment (along an axis either clockwise or counterclockwise) sub
displacement consists of translation and rotation. With permission
stitute a loading force that will result in displacement of a vertebra.
from White and Panjabi, Clinical Biomechanics of the Spine, Lip
A total of 12 load components, that is either linear or rotatory
pincott Williams & Wilkins, 1990.
•
Flexion (+0X)
describes positive rotation around the
x
axis in the sagittal plane. •
•
Extension
Using this convention, it is possible to break down the more complex movements into individual uniformly defined
(-0X) describes negative rotation around the
movement components. In other words, any movement
x-axis in the sagittal plane.
can be described as a function of a rotational movement
Side-bending (lateral bending) to the right (+0Z): positive
around a particular axis. Clockwise rotation is designated
rotation around the z-axis in the frontal plane.
as +0, and the counterclockwise rotation is designated as-0
•
Side-bending (lateral bending) to the left (-0Z): negative
(Fig. 3.3).
•
Axial rotation
•
Axial rotation (-0Y),
rotation around the z-axis in the frontal plane.
left
(+0Y), positive rotation to the
Side-bending movement to the right is described as around
the y-axis in the horizontal plane.
to the description of -0Z. Forward flexion motion in the
negative rotation to the
around the y-axis in the horizontal plane.
rotation +0Z, while side-bend ing to the left corresponds
right
sagittal plane corresponds to +0X, and spinal extension is denoted by -0X. Axial rotation to the left is described by +0Y, whereas rotation to the right corresponds to -0Y.
42
Copyrighted Material
Clinical Biomechanics of the Spine
/
Y
/
/
/
/
/
/
-<
/
I I I I I I I I-y
t Fig.3.3 Three-finger model applied to the three-dimensional coordinate system.
Other Motion Description Conventions
•
Motion between two adjacent vertebrae (the two part ners of a spinal segment, also called the vertebral mo
In recent years, additional conventions have been intro
tion unit or motion segment) is described by convention
duced to further assist in establishing a "common lan
as movement of the superior partner of the two verte brae in relationship to its inferior vertebral partner.
guage" for the description of both gross spinal motion and individual segmental movement:
•
Degrees of freedom: Each spinal facet joint has six degrees of freedom. This is in contrast to the six motion
•
Vertebral rotation around a particular axis is defined in
directions just described above (flexion-extension,
reference to the superior or the anterior portion of the
side-bending left and right, axial rotation left and right).
particular vertebra (Fig. 3.4). For example, axial rotation
Each degree of freedom, based on motion in relation to a
of the vertebra to the left (+I1lY) denotes that the anterior
particular axis, is defined in terms of: (a) motion
aspect of the vertebral body moves to the left direction.
around one axis (rotation);
and (b) motion
about/ along an axis
(translatory motion).
Copyrighted Material
43
Biomechanlcal PrInciples of the Spine and Joints
Thus, rotation about and translation along the x-axis for
y
instance would define two degrees of freedom in rela tionship to the x-axis. This can be applied equally to the other two axes, giving six degrees of freedom for all three axes. Although individual physiologic movement components should, in theory, be amenable to a well-defined analysis using the descriptive mathematical-mechanical model, it
x
"
x
11;;.
should always be remembered that the vertebral column is both anatomically and functionally a rather complex sys tem that simultaneously has to fulfill dual roles-namely, assuring sufficient stability while at the same time allowing sufficient motion. Movement in the individual spinal segments is a combi nation of translatory and rotatory movements around a particular axis as defined by the three-dimensional coor dinate system (refer to Fig.3.2).
(5
Coupled Motions Axial rotation
(±0y) and side-bending (±0Z) in a spinal seg
ment usually do not take place in a single motion direction in a "pure" plane type of motion, as these two movement directions are coupled to each other. This linkage has be come known as coupling patterns (Lysell, 1969; White and
Fig. 3.4 Definition of rotation movement.
Panjabi, 1978, 1990; Stoobey, 1967). The individual coupled motions are governed by the architecture of the vertebrae (smooth, rough, etc.), their joint surface inclination, the associated ligaments, and the interactive functioning of the paraspinal muscles. The physiologic anteroposterior curvature of the spine in the sagittal plane is of great significance as well.
Biomechanics of the Upper Cervical Spinal Joints (CO-(1-(2)
Atlanto- Occipital Joint (CO-C1) The articulation between the skull and the atlas is formed by two paired structures, each of which consists of the occipital condyle and the superior facet of the atlas. The articulating surfaces are oval, resembling a beanlike con figuration. The upper surface of the condyles is convex, while the surface of the superior facet of the atlas is con
Fig.3.5 Sagittal angle of the joint axes for the OCCipital condyles
cave. In the adult, the sagittal axial angle of the joints
(after Ingelmark, 1947).
measures between 50° and 60° (Ingelmark, 1947; Bernhard, 1976) (Fig. 3.5).
1
Occ ip ita I condyles
2
Foramen magnum
44
Copyrighted Material
Biomechanics of the Upper Cervical Spinal Joints (CO-Cl-Q)
t
i.t1 :' :: :
"
Fig.3.6 Frontal angle of the jOint axes for the occipital condyles (after Stoff, 1976a) is 124' for men, 127' for women (blue: artic ulating surface).
"
l··
:
('i'
..
'
..
.\3 .
The frontal axial angle of the joints (Fig, 3.6) results from lines drawn parallel to the articulating surfaces of the con dyles. On the average, it measures 1 24.2° (Stoff, 1976). This axial angle is increased in the presence of condylar hypo plasia and basilar impression. Von Lanz and Wachsmuth (1979) describe the joint between the occiput and the atlas as a modified spherical articulation, with motion taking place around two axes according to the anatomic arrangement. The left and right joints actually appear to function with greater motion F ig .3.7 Axes of motion of the occipito-atlanto-axial and cervical
around the transverse axis than the sagittal axis. Flexion and extension movements take place around the
joints. (After Knese, 1947.)
transverse axis, whereas side-bending is around the sag ittal axis (Fig. 3.7).
Function of the Upper Cervical Spinal JOints (CO-C1) At the atlantoaxial articulation, rotation takes place around the transverse axis, measuring an average of 240• It is limited by the bony and surrounding soft-tissue structures (Panjabi et at. 1988; White and Panjabi 1990) (Table
3.1).
Rotation about the transverse at this spinal level has been
Table 3.1 Li mi tati on of range of motion about the transverse axis in the upper cervical spinal joints Flexion (Inclination)
Extension (Reclination)
Nuchal ligament
Bony structures
Alar liga ments
Anterior neck muscles
specifically termed inclination and reclination motion,
Anterior longit udinal
analogous to forward nexion and extension, respectively,
ligament
Cervical spine nexion takes place in two stages (Oul, 1982; Arlen, 1977; Gutmann, 1981). During the first stage, only a positive rotation around the x-axis in the CO-C1
Alar liga m e nt s
spinal segment has been observed, This forward movement of the head in relation to the atlas is approximately 80,
Posterior neck muscles
which has also been assigned the speCific term of nutation motion ("nodding"). The spinal segments below this point remain in the neutral position.
Anterior longitudinal
ligament Lig amentum f1avu m (res t rains hyperflexion)
It is not until the second phase that rotation (+0X) takes place in the remaining cervical spinal segments below CO-C1: C1-C2 is tilted forward; C2-C3 to C6-C7 undergo flexion. The axis rotates 450 with respect to C7.
45
Copyrighted Material
Biomechanical Principles of the Spine and Joints
t
v
-x
-- - -
-
,-
I I tt-
y
'I
-
-
' . y'
.
---
m
I
Fig.3.8 Gliding movement of the atlas with side- bending to the right.
Furthermore, during this second phase a positional
spine. Lewit's (1986) findings vary from those reported by
change occurs in the CO-C1 segment at the same time as
Werne and Fielding, while Gutmann (1985) and Kamieth
the head rotates backward (in relation to the atlas). This
(1987) emphasize that there is virtually no atlas rotation
relative negative rotation of the head with reference to the
with pure side-bending movement.
atlas and the axis (i. e., backward rotation) prevents exces
Various mechanisms have been proposed to explain the
sive cervical spine extension (e.g., avoiding an abnormal
cause of this forced rotation. Most authors agree that it is
kyphotic component) thus preventing potentially adverse
due to the unique anatomic architecture of these articula
position of the spinal canal.
tions in the cervical spine.
Side-bending, also commonly referred to as lateral bend
Werne (1957) suggests that the forced rotation of the
ing, takes place around the sagittal axis and amounts to
axis is the result of the eccentric insertion of the alar
approximately 5° to either side (Panjabi et aI., 1988; White
ligaments. Jirout (1973) postulates that, in addition to the
and Panjabi, 1990; Penning 1976). It is greatest when the
influence of the articular processes, the muscles in the head
head is slightly flexed and is reduced due to the function of
and neck region with their insertions at the spinous pro cesses play a specific role in achieving forced rotation dur
the alar ligaments. With side-bending, Gutmann (1981) reports a trans
ing the second phase.
verse gliding movement of the atlas between the condyles
In the atlantoaxial joint, in addition to axial rotation,
and the body of the axis (in the atlanto-occipital and at
there is displacement of the atlas in the same direction as
lantoaxial articulation). The gliding movement occurs in
side-bending (in the frontal plane). This becomes apparent
the same direction as the gross side-bending movement
on the anteroposterior radiographic view, where the dens
(Fig. 3.8).
of the axis is located asymmetrically, on either side of the
Reports published in the literature that have investi
center between the two lateral masses. The offset is termed
gated the biomechanics of side-bending movement at
positive when the surface of the atlas projects beyond the
CO-C1 have also not been consistent. Pure cervical spine
surface of the axis, and is negative when the surface of the
side-bending motion without simultaneous rotation of the
axis projects beyond that of the atlas. Furthermore, the
head would indeed represent a rather biomechanically
appearance and degree of offset are dependent upon the
complex movement. In addition to segmental tilting, there
changes stemming from the rotation of the axis itself.
is always forced coupled rotation in the same direction as
According to Gutmann (1985) and Lewit (1986), it is the
that of side-bending in the C2-C7 vertebrae. Starting at the
wedgelike anatomic arrangement of the atlas that causes it
superior end of the cervical spine, the degree of this forced
to be displaced toward the side of lateral bending.
rotational movement decreases in the inferior direction.
Reports about the lateral displacement of the atlas have
Werne (1957) and Fielding (1957) report that with maximal
been equally inconsistent. Keim (1953) found that with
side-bending the axis actually rotates to a greater degree
maximal side-bending, lateral atlas displacement occurred
than during maximal rotation of the head and cervical
in all of the 25 cases studied. Lewit (1986), studying a group
46
Copyrighted Material
Biomechanics of the Upper Cervical Spinal Joints ((o-0-C2)
of
30
healthy persons. found in four cases a paradoxical
lateral atlas displacement; that is. where the atlas was
Anterior
displaced toward the side opposite to that of lateral bend ing. In both of these studies, the side-bending motion was introduced actively by the study participants. Jirout (1973) found that atlantoaxial movements are more pronounced during passive than during active side
-+--+---'-- 2
bending motion. Kamieth (1986) postulates that the dis
'r---3
placement is due to induced or forced motion at the axis. We hypothesize that the lateral atlas displacement may
Right
Left
actually result from engaging the anterior portion of the alar ligament as it wraps itself around the dens. Assuming the course of the alar ligaments follows that described by Ludwig (1952), our hypothesis for the lateral atlas displace ment also postulates that the lateral displacement is sec ondary to the forced rotation of the axis (Fig. 3.9).
-+--+--'--- 2
In all of the 30 adolescents studied by one of the authors
"r-""'--- 3
(Reich and Dvorak, 1986a,b) the gliding movement of the
"
atlas occurred in the same direction as the induced side Posterior
bending motion. This gliding movement became even more pronounced in patients with demonstrated atlan toaxial instability secondary to rheumatoid arthritis. The
Fig. 3.9 Atlas displacement with side-bending; hypothetical mech
distance between the dens of the axis and the lateral mass
anism. Coupled rotation of the axis causes the anterior portion of the right alar ligament to be wrapped around the dens, thus bring
of the atlas was used for measurement. Not surprisingly, reports about the rotation movement in the atlantoaxial joint are also not consistent. Fielding (Fielding, 1957; Fielding and Hawkins. 1978), White and
ing the right-sided lateral mass of the atlas closer to the dens. The anterior portion of the left alar ligament does not become tight until its insertion has been rotated into the posterior position. (After Werne. 1957.)
Panjabi (1978). and Penning (1968) reported that rotation
1
in this joint is nonexistent. whereas Depreux and Mestdagh
2
Dens of the axis
3
Atlas (lateral mass)
(1974) described approximately 5° of motion. with values
Alar ligament
being significantly higher in persons who had undergone atlantoaxial fusion. Gutmann (1981) reports that when the head is turned, both the head and atlas rotate simultaneously
(±0Y)
with
respect to the axis. The lateral portion of the fibrous joint capsule associated with the facet joints in the upper cer vical spine is taut, allowing for particular control of rotation
three-dimensional motion patterns in the upper cervical spine. It was found that the atlanto-occipital rotation mea sures 7° to either side. Table 3.2 summarizes the mean range of motion values at the atlanto-occipital articulation as presented by various investigators.
and side-bending, in conjunction with the other limiting anatomic factors, namely, that of facet joint inclination. Caviezel (1976) clinically utilizes a so-called "springing
Atlantoaxial Joint ((1-(2)
test" to assess passive rotation at the extreme of opera tor-induced rotation.
The atlantoaxial articulations are of great clinical signifi
Using functional computed tomography (CT) scans of
cance in the field of manual medicine. Here, motion takes
the upper cervical spine in fresh cadavers, rotation be
place within four articular spaces, one of which is desig
tween the occiput and the atlas was unequivocally demon
nated as the atlantodental bursa and is represented by the
strated (Dvorak and Hayek, 1986) with reported mean
space between the transverse ligament of the atlas and the
values of 4.5° and 5.9° for rotation to the right and to the
dens of the axis.
left. respectively . In healthy adults, rotation between the
The medial atlantoaxial joint is located between the
occiput and the atlas was also clearly demonstrated via
dens of the axis and the posterior surface of the anterior
functional CT scans, with an average value of 4° (Dvorak
arch of the atlas. The two articular spaces of the lateral
and Hayek, 1987).
atlantoaxial joint are of particular importance (Fig. 3.10).
The in-vitro studies by Panjabi et al. (1988) and Crisco et
The joint surfaces are usually round. but sometimes
al. (1991) utilized stereophotogrammetry to evaluate the
triangular, and are covered with cartilage that is 1.4 to
Copyrighted Material
47
Blomechanlcal Principles of the Spine and Joints
Table 3.2 Range of motion at the occipitoatlantal (OA) joint according to various authors
•
Author Fick Poirier et al. Werne
--
Dvorak et al. Clark et al. Dvorak et al. Penning et al.
Side- bending
1904
50
30-40
1926
50
14-40
1957
= --.
1978
Panjabi et al.
1988
Dumas et al.
1993
-=......:::-.-..
-
.-=-=-�-
30
---
10
�=.-=-=� -
22.7
-==
---
__
24.5
0 0 5 0
.--- -
. .. . __ .. .
5.2
_______
11-
�.=.......:..
0
-
- .-
...JL.=I [ -'
1987 1987
--_.. _-------
8
13
1985 1986
Axial Rotation l/R
(lateral Flexion) l/R
1974
Depreux et al. Penning
Flexion/Extension (Total)
4.8
-_.
4 =
5.5
7.2
b
a
Fig.3.10 a
Atlas. superior view; the superior joint surfaces are oval. sometimes with double formation (right).
b Atlas . view from inferior; round joint surfaces. c
Axis. superior view; the joint surfaces point inferiorly (convex).
1
Transverse process
2
Anterior tubercle
3
Superior articular facet of the atlas
4
Transverse foramen
5
Posterior tu bercle
6
Inferior articular facet of the atlas
7
Spinous process
c
3.2 mm thide The articular surfaces of the axis are convex.
The joint capsule is wide and flabby. and from the me
and those of the atlas are relatively flat. causing an anterior
dial wall a cuneiform synovial fold invaginates into the
and posterior gap of 2-5 mm (Knese.
1947)
(Fig.
3.11).
articular space. which is described as meniscoid (Dvorak and Aebi.
48
Copyrighted Material
1987).
Biomechanics of the Upper Cervical Spinal Joints (CO-C1-C2)
Function of the Atlantoaxial Joint Flexion and Extension The bony structures of the articular surfaces and the mo tion-limiting ligaments allow movement around the trans verse axis that can be as large as
10°
and
15°
(Figs. 3.10.
3.11). Using lateral radiographic projections. the effective ness of the ligaments can be determined by measuring the distance between the posterior portion of the anterior arch of the atlas and the dens of the axis. Side-bending Side-bending between C1 and C2 is only possible with simultaneous rotation around the axis. This is described as forced rotation and is thought to be the result of the physiologic function of the alar ligaments. Lewit (1970) and Jirout
(1973)
report displacement of the atlas in the same
direction as that of the forced induced Side-bending.
Fig.3.11 Paramedian sagittal section of the upper cervical spine.
1
Occipital condyle
2
Atlas
3 4
Axis
5
Great occipital nerve
6
Meniscoid
Vertebral artery
Axial Rotation
62
3
The head and atlas rotate simultaneously on the axis
4
around the dens. The axis of rotation passes through the dens of the axis and is clinically "secured" by the transverse ligament of the atlas (Fig. 3.12). Average rotation in the young. healthy adult is 43° (SO
=
6°).
which amounts to
approximately half of the total cervical spine rotation (Dvorak and Hayek
1987).
Normal values for axial rotation in the upper cervical
spine are listed in Table 3.3. Cinematographic studies by Fielding (1957.1978) clearly demonstrate that. starting with the head in the anatomi cally neutral position. head and cervical spine rotation occurs first in the atlantoaxial joints. Once their motion is
Fig.3.12 Schematic representation of the ligamentous apparatus
completed. the lower cervical spine segments can begin to
at the craniocervical junction.
rotate. The limitation of the rotation is primarily deter mined by the alar ligaments (Figs.3.n. 3.14).
Coupled Movement •
Motion between segments is primarily a coupling be
1
Atlas
2
Dens of the axis
3 4
Atlantal portion of the alar ligament
5
Transverse ligament of the atlas
6
Anterior atlantodental ligament
Occipita l portion of the alar ligament
tween that in the frontal plane (±0Z) and the transverse plane (±0y). This may occur in either two or three di mensions. According to Gutmann
•
(1981).
axial rotation
of the head (±0y) and atlas rotation in the opposite
movement. Axial rotation is accompanied by a vertical
direction occur with side-bending. while C2 undergoes
translatory gliding movement (y-axis). The literature
axial rotation toward the same side as in side-bending.
relating to the motion of the atlantoaxial joint is sum
Translatory gliding: Minimal lateral translatory gliding
marized in Table 3.3.
of up to 2-3 mm takes place in the sagittal plane (z-axis) and the transverse plane (x-axis) (Hohl.
1964).
These
two movements are always coupled to axial rotation
Copyrighted Material
49
Biomechanical Principles of the Spine and Joints
Table 3.3 Range of motion at the atlantoaxial joint according to various authors
Author
Side- bending lateral
Axial Rotation L/R
Flexion (unilateral)
1904
Fick --
0 --
11
1926
Poirier et al. -=--
Werne Penning
1957
10
1978
30
-
- -�- ==-==-=---=�
--
--
1986
--
Penning et al. -
--
1987
--
-
30-80
--
47
10
70 32.2 14.5
- --
-
22.4
1988
-
-
--=- -=-==-=----=-"=--=... -:
1987
Panjabi et al. Dumas et al.
10 --
Dvorak et al.
60 --
. --.
--
Clark et al.
0
:::- -:-='---- -= :
1985
Dvorak et al.
0
--
-
- --
1993
--
-
6.7
=
- --_. - .- --
43.1 40.5 38.9
_.-
37
j)jJ.
. :.::.:.. . ; ;
":' ':' '.:!'v
l
')
I\ ' 1)/1 a
IL_ _______ _____ ______ ______ __
'•
...
I..
., .
.'
•
'f .
c
,
--:- :.-
.: .... ' '.
. : : ,. ..
-
"
'.
.,.
"
.
\
'fI
-
'i .
-"
."
•
,
'i' .
"-
, 'I", ,
,, " t1!I ';"
J\
It
.
,
!'
•
..."f
, Al
.
•
.
Fig.3,13a-c The alar ligaments. seen (a) from superior and (b) from anterior, (After Ludwig, anteroposterior view_
1
Left alar ligament
3
Right alar ligament
4
Longitudinal ligament
2
, -. < ':; " -
•
Dens of the axis
•
', ' ,
' . ..... "'. q,t.
'.
;.
'r{I
,
-
.
50
Copyrighted Material
1952,)
c Anatomic specimen in the
b
Biomechanics of the Upper Cervical Spinal Joints (CO-Cl-C2J
Ligaments of the Upper Cervical Spine (CO-C1 and C1-(2) The ligaments that are of particular interest with regard to the function of the atlanto-occipital and atlantoaxial joints are the alar ligaments and the cruciform ligament of the atlas (Fig. 3.12).
Alar ligaments Ludwig (1952) describes the alar ligament as an irregular, quadrilateral pyramid-like trunk. The rectangular base lies against the supenor two-thirds of the lateral surface of the
Fig.3.14 Ligamentous interconnection between the dens of the
dens. The superior, posterior. and anterior surfaces connect
axis and the atlas. View from superior onto the ligaments associ
the dens with the occipital condyle, while the inferior and lateral surfaces connect the dens with the lateral mass of the atlas (Fig. 3.13). The orientation of the fibers in the sagittal plane is
ated with the upper cervical spinal joints. The probe is on the anterior atlantodental ligament.
1 2
Anterior atlantodental ligament
3
Alar ligament
Anterior arch of the atlas
primarily a function of the height difference between the tip of the dens of the axis and the occipital condyles (Fig. 3.13). The ligament that connects the dens of the axis with the anterior arch of the atlas is part of the alar liga ment as well (Fig. 3.14). Occasionally, the presence of an other ligamentous connection between the base of the dens of the axis and the anterior arch of the atlas has been reported, and has been referred to as the anterior atlantodental ligament.
Biomechanics of the Alar ligaments The mechanical properties of the alar ligaments depend primarily on three factors:
•
Fiber orientation.
•
The proportion of collagenous versus elastic fibers.
•
The mechanical properties of the collagenous and elastic
Fig.3.15 The alar ligaments are made up of collagenous fibers
fibers.
(Giemsa stain).
1
Dens axis
2
Left alar ligament
3
Right alar ligament
The collagenous fibers will be irreversibly stretched if sub jected to a stretch beyond 6-8% of their resting length, and will ultimately start to tear when stretched beyond that
Function of the Alar ligaments
limit (Abrahams, 1967). Elastic fibers, in contrast, can be
The function of the alar ligaments can be straightforwardly
stretched to 200% of their resting length, beyond which,
inferred from their course by following them from their
however, they will rupture abruptly. It can thus be said that
attachment at the occipital condyles to that at the atlas. The
ill essence the collagenous fibers do not undergo any per
p rimary role of the alar ligaments is to limit axial rotation
ceptible stretch.
in the upper cervical spine, particularly at the (0-C1 and
The alar ligaments are made up almost entirely of col
(1-(2 articulations. Rotation to the right is limited by the
lagenous fibers (Fig.3.1S). At their attachments they run
left alar ligament and, conversely, rotation to the left is
parallel, while at the center they tend to be interdigitated
limited by the right alar ligament. Rotation to one side
in a criss-cross pattern (Dvorak et aI., 1988a). Saldinger et
causes the contralateral ligament to become more taut
al. (1990) report that the alar ligaments begin to tear at 200
(Fig. 3.16). During side-bending motion toward one side
newtons.
(
=
rotation around the z-axis), the occipital portion of the
ipsilateral ligament is relaxed whereas the atlas portion
Copyrighted Material
51
8Iomechan/cal Prlndples of the Spine and Joints
z
+ oy
x
x
x
Fig.3.16 Function of the alar ligaments during rotation in the atlantoaxial joint ((1-(2).
y-y ' Side-bending to the right y-y" Side-Bending to the left
z-z ' Rotation to the right z-z " Rotation to the left
-oz
+ oz
y y
-x
/ /
I,
'
\ Lv.
/
C2
4J -o
Oy
Fig.3.17 Function of the alar ligaments during side-bending in the atlantoaxial joint ((1-(1).
becomes taut. This mechanism then limits the gliding mo-
the same direction as the convexity (Fig. 3.17) (Reich and
tion of the atlas in the same direction as the induced side-
Dvorak, 1986; Dvorak and Panjabi, 1987b). Despite a num-
bending movement. At the same time, the occipital portion
ber of experimental studies, it cannot be conclusively
of the opposite alar ligament becomes tighter, which limits
stated whether the alar ligaments are alone responsible
gliding of the occipital condyles in the opposite direction
for the described forced rotation of the axis. This is espe-
(Fig. 3.17).
cially true since the joint architecture and in particular the
The tight occipital portion of the alar ligament with its
surface inclination, may play an inherent role. More studies
posterior and eccentric origin at the dens of the axis, to-
are necessary to clarify the complex function of the alar
gether with the atlantal portion and its anterior eccentric
ligaments.
origin at the dens, induces forced rotation of the axis in the
Flexion in the upper cervical spine is chiefly limited by
same direction as the side of induced side-bending. Clin-
the nuchal ligaments, the posterior longitudinal ligaments,
ically, and according to the convention of motion descrip-
the tectorial membrane and the longitudinal fascicles of the
tion using the anterior portion of the vertebral body as the
cruciform ligament. Increasing tension in the alar liga-
reference, the spinous process of the axis moves oppositely
ments as the spine gradually moves toward the extreme
to the induced Side-bending. In other words, it moves in
52
Copyrighted Material
Biomechanics of the Upper Cervical Spinal Joints (CO-C1-C2)
of exion also participates in the limitation of nexion (Pan jabi et al.. 1991 ). The alar ligaments are subject to great tension forces and are therefore more likely to be irreversibly stretched or may ultimately rupture. This is especially true in a situation where the head is rotated maximally (rotation around the y-axis) followed by nexion and extension movements (ro tation arollnd the x-axis). A similar position has been ob served in people involved in rear-end motor vehicle colli sions. It can therefore be surmised that under similar cir cumstances it is the alar ligaments that are subject to damage. whereas the transverse ligament might remain unaffected. During rotation motion of the atlantoaxial joint. the alar ligament on the opposite side is stretched and "rolled up" arollnd the dens of the axis; the alar ligament on the same
Fig.3.18 Prepared specimen at the transverse ligament of the atlas between the articular process of the atlas.
side relaxes. Thus. during rotation to the right. the left alar ligament is wrapped around the dens while the right liga
Function of the Cruciform Ligament of the Atlas
ment is relaxed (Figs. 3.9.3.16).
The function of the cruciform ligament is to regulate and
During Side-bending motion, the ipsilateral alar ligament relaxes. and the stretched ligament of the opposite side
limit physiologic rotation between (1 and (2 and to protect the spinal cord form the dens of the axis.
causes a forced rotation of the axis in the direction of the bending. due to its attachment to the dens of the axis. In the clinical examination. the spinous process of the axis rotates contralaterally (Fig.3.17). Thus. the strong alar ligaments are able to limit the rotation motion of the atlantoaxial articulation (Panjabi et al.. 1991).
Injury to the Ligaments Associated with the Upper Cervical Spine (CO-C1, (1-C2) The transverse ligament of the axis ruptures at approxi mately 350
N. Histologic examinations reveal that the pri
mary site of rupture is at the bone-cartilage insertion inter face (Saldinger et al.. 1990).
The Cruciform Ligament of the Atlas
Macalister (1893) found that the transverse ligament of
The cruciform ligament consists of two differently directed
the atlas tears at a load of 1275
components: the horizontal transverse ligament of the
(1974) examined the tensile strength of the alar ligaments
atlas and the vertical longitudinal fasciculi (Fig. 3.18). The
and the cruciform ligament of the atlas in 20 corpses. They
N (130 kg). Fielding et al.
transverse ligament of the atlas arises from the medial
found that theses ligaments tear at a load of 400 N to
surfaces of the lateral masses of the atlas. while some fibers
1800 N (average. 1100 N).
also attach to the tip of the dens. In its central portion. the
The transverse
ligament of the
atlas
tears
when
cruciform ligament is approximately 10 mm high and
stretched beyond a length between 4.8 and 7.6 mm. Over
2 mm thick and is covered by a thin layer of cartilage. The
stretching will lead to tearing of the collagenous fibers.
lo ngitudinal fascicles are comparatively weak and are
which is represented on radiographs as an increase of
present
more than 3 mm between the dens and the posterior sur
inconsistently.
They merge with the atlanto
occipital membrane (Saldinger et aI., 1990).
face of the anterior arch of the axis (more prominent in radiographs taken in the flexed position). When there is an
Biomechanics of the Transverse Ligament of the Atlas
increased distance of 7 mm, complete separation of the
The transverse ligament of the atlas consists primarily of
transverse ligament from the atlas should be suspected.
collagen fibers that may become irreversibly stretched
while distances greater than 10-12 mm would be a clear
when subject to excess tension (Kennedy et aI., 1976). The
indication of a torn alar ligament.
collagenous fiber bundles are oriented in parallel at the
The spatial relationship between the bony structures of
insertion only to form a criss-cross pattern at the center
the atlas. the dens of the axis. the spinal cord. and the free
of the ligament. which is also the thickest portion. The
zone is designated as an anatomical constant. Generally,
portion facing the dens of the axis may reveal fibrocarti
the rule of "thirds" due to Steel (1968) has proved valuable
lagenous changes.
(Fig. 3.19). One-third of the space is occupied by the dens, one-third by the spinal cord, and one-third by a free space, the so-called safety zone of the spinal cord.
Copyrighted Material
53
810mechanlcal Principles of the Spine and Joints
Considering the significance of the anatomic position of the cardiac and respiratory centers in the medulla oblon gata, it is plausible to hypothesize that there are not one
ZJ ""· ·t p 1'11 '' . I
I
.
.
but two sets of ligaments that assist in the prevention of a .
I
.
1 I1': ."I I
1 I
I . . I I I I I I
I I
a
I
I I I I I I I II I I ---
c
b
.
.
verse ligament of the axis. Huguenin (personal communication,
:
: ;
I
I
.
dens dislocation, namely, the alar ligaments and the trans
1980)
points out
the clinical symptomatology and the potential changes seen on radiographs as a result of either partial or complete
c
tears involving the ligaments in the occipito-atlanto-axial joint region, both in functional tomograms and CT scans.
Fig.3.19 Steel's rule of thirds (Steel, 1968):
a =
b
=
2c
=
16(a + b + 2c)
a =
dens axis
b
spinal cord
c
=
=
Biomechanics of the Lower Cervical Spine (0-C7)
safety zone
The axis represents a transitional vertebra between the upper and lower cervical spine. The greatest range of mo tion takes place in the mid-cervical spine region with the following possible motion directions: cervical flexion and extension, side-bending (e. go, lateral bending or lateral flexion), and rotation. The vertebral motion units (i. e., spinal segments) inferior to the axis represent the typical cervical vertebrae, They have a similar joint and vertebral body architecture, which aids in the load distribution. In contradistinction to the thoracic and lumbar vertebrae, the cervical vertebrae exhibit the uncinate processes laterally (Fig. 3.20) (Luschka,
1858; T6nduri
and Theiler,
1990).
The inclination of the mid- and lower cervical spine facets is approximately 450 with respect to the horizontal plane. The lower segments are sloped more steeply than the upper segments (Fig. 3.21). Panjabi et al. (1993) describe the three-dimensional Fig. 3.20 Drawing of the uncovertebral jOints. (After Luschka, 1858.)
anatomy of the apophyseal joints (synonyms: zygapophy seal joints or facet joints). In the cervical spine, the vertebra with the largest joint surface is the axis (C2:
200 mnl); the (101-107 mm2), and C6 and surfaces (79 mm2). The facet
next largest are C3 through C5 C7 show the smallest joint
joint inclination, however, is smaller in the upper cervical spinal joints than in those of the lower cervical spine. The articular processes are located relatively laterally which reduces motion due to the bony restrictions imposed by the
"transverse processes."
The transverse processes,
flanked by the anterior and posterior tubercles, form the sulcus for the spinal nerve. They also contain the transverse foramina to allow passage of the vertebral artery. ,/
/'
The close proximity of the articular processes, sulcus, x
and transverse foramina is of particular clinical relevance in the presence of a progressive spondyloarthropathy, for in stance, as the spinal nerve and vertebral artery may be preferentially compressed (Fig. 3.22).
Fig.3.21 Facet joint inclinations and axes of motion for vertebra
C4. (After White and Panjabi, 1978.)
In the adolescent, the articular processes are covered by a thin cartilage layer. The irregularities of the individual
54
Copyrighted Material
Biomechanics of the Lower Cervical Spine (0-C7)
articular processes are, in part, evened out by so called meniscoids. Originally described by Penning and Tondury (1964), the meniscoids are composed of fatty and connec tive tissue, which is richly vascularized and innervated (Fig. 3.23). The meniscoids appear to play a particularly important role in the extension motion of the cervical spine. Ricken bacher et at. (1982) describe the meniscoids functioning as a sort of "plastic filler material" for the otherwise dead space and to compensate for the relatively thin cartilage layer. It is not clear to what extent, if any, the mensicoids are responsible for recurrences and exacerbations of neck pain associated with segmental or somatic dysfunctions. Pen ning and Tondury (1964) do not believe that the menis coids would be the cause of such painful situations. How ever, Rauschning (personal communication, 1995), on the
Fig.3.22 Axial section through the cervical spine at the level of the fourth cervical vertebra. One can see the intervertebral canals that allow transit of the vertebral artery. Also. this specimen clearly demonstrates the very close spatial relationships between such
basis of his detailed anatomic preparations of the cervical
important structures as the intervertebral joints, the spinal nerve,
spine, believes that such meniscoids may play a role to
and the vertebral artery. (Courtesy of Prof. W.
some extent.
Uppsala.)
Rauschning.
The anatomy of the cervical disk is similar to that in the other regions of the spine as it contains an inner nucleus pulposus that is surrounded by the outer annulus fibrosis. The disk in the cervical spine is subject to lateral tears at ages as early as 9 years and certainly within the first 20 years of life. In the adult, as a result of the repetitive stresses introduced over time with each movement, the tears may advance to become true joint spaces, namely. the joints of Luschka (uncovertebral joints; Luschka. 1858) (Fig.3.24). Tondury and Theiler (1990) hypothesize that the disk tears and joint formation are observed as early as child hood. and it is postulated that these changes may be a result of the upright posture. They call this a transitional period. Lateral diskal tears may increase in size in the medial direction to a point where the tears are large enough to form full-sized gaps ultimately spanning the entire diam
Fig.3.23 Vascular supply and innervation in the cervical spine of a young man. This macrophotograph of the cranial-cervical region was obtained with the head turned 90·. (Courtesy of Prof. S. Kubik.)
eter of the cervical intervertebral disk. Particularly in the lower cervical spine. such gaps can progress to involve the entire thickness of the disk. literally halving it. Such changes have also been observed in otherwise healthy adults as young as 20 and 30 years of age (Fig.3.2S). Given these dramatic changes in the cervical disk as early as the second and third decades of life. it would be safe to assume that there is an ever-increasing instability in the affected spinal segment or segments. Thus. stability in the motion units then comes to rely progressively more on
Fig.3.24 Frontal section of the cervical spine of a 9-year-old child. Remnants of the primary cartilage of the joint/synchondrosis are visible. The arrow indicates the fissure formation in the lateral portion of the intervertebral disk of C3-C4. (From T6ndury and Theiler, 1990.)
Copyrighted Material
55
Blomechanical Principles of the Spine and Joints
Fig. 3.25 Frontal section through the cervical spine of a 33-year
Fig.3.26 Frontal section through the intervertebral disk of a 24-
old man. Both intervertebral disks reveal transverse fissures. (From
year-old man. One can see the ruptured disk with the laterally
Tiindury and Theiler,
1990.)
displaced prolapsed nucleus pulposus, which is held back from being extruded by only a few annular fibers. This conformation then results in the compression of the associated spinal nerve (5). (From Ttindury and Theiler,
1990.)
b Fig.3.27 Hom-shaped progressive changes of the uncinate pro cesses between (4-(5 and (5-(5 (- )
b R
l a .... ,)'-
-..,f --;-';T
--T'
en"
.
.
With anterior osteophyte formation.
a
With posterior osteophyte formation. =
=
Right left
•
the passive elements such as the longitudinal ligaments
a sudden, acute disk herniation. At the same time, the
and the loose connective tissue, and even more so on the
uncinate processes start to change their shape, assuming
active components, namely, the postural muscles.
a "bull's horn" appearance, and the vertebral bodies appear
It is possible then that subsequent to a complete diskal
to approximate each other. This can be seen in the standard
tear, the gelatinous material of the nucleus pulposus will be
AP and lateral radiographs. The surface end-plates undergo
extruded dorsolaterally resulting in compression of the
prominent sclerotic changes, which are best seen in the
associated spinal nerve. Clinically this can lead to classic
lateral projection. There may sometimes be a small but
signs of disk herniation (Fig. 3.26).
noticeable step-off or increased angulation above the area
Beginning around age 25 years, the nucleus pulposus
of sclerosis, which is known as the Guentz sign (Fig. 3.27).
begins to desiccate, which in turn reduces the likelihood of
56
Copyrighted Material
Biomechanics of the Lower Cervical Spine (C3-C7)
Tondury and Theiler (1990) have demonstrated that continued disk dehydration reduces the facet joint's ability to adequately withstand the normal mechanical loading forces, thus reducing its ability to adequately maintain the position of the head. With progressive dehydration, the uncovertebral struc tures assume a greater and greater role in bearing the weight in the cervical spine.
Again,
these structural
changes can be seen in standard radiographs where the uncovertebral joints demonstrate a bull-horn appearance. With continued dehydration, the weight of the superior vertebral body is increasingly borne by the uncinate pro cesses of its inferior joint partner. The uncinate processes subsequently show signs of sclerosis and form a shallow joint space in the form of a pseudoarthrosis. Ultimately the uncinate processes become the major weight-bearing structures. These structural changes bring the vertebral artery and the individual spinal nerve into even closer proximity. The age-related "normal" changes described above must be differentiated from those that result from trauma.
Fig.3.28 Sagittal section through the zygapophyseal (facet) joints
Trauma to the cervical spine may actually tear the disk
at the lower cervical spine. The orientation of the articular process
off the vertebral end-plate. A hematoma may then form
is approximately 45°. (Courtesy of Prof. W. Rauschning, Uppsala.)
between the disk and end-plate (Taylor and Twomey,
1 2
Spinal nerve
1993).
3
Ganglion
Meniscoid
Facet Inclination and lVIovements The inclination of the facets in the mid- and lower cervical spine is approximately 45° with respect to the horizontal
(1
plane. As one proceeds down the cervical spine, the facet inclinations become progressively more steep, with the upper ones being comparatively flat and the lower cervical facets being more vertical (Figs. 3.21, 3.28). The motions that are possible between the two vertebral
(4
partners in each spinal unit or vertebral segment are ac tually are a combination of translatory and rotatory move ments about the various axes in the three-dimensional coordinate system. For flexion and extension, Lysell (1969) describes a ra dius of curvature upon which the individual segments
C7
move. The so-called segmental arch is nearly flat at (1 and almost semicircular at G, with that of (4 having an intermediate configuration (Fig. 3.29). The top angle is a function of the facet joint inclination angle and the shape of the intervertebral disk. Flexion-extension motion (±0X) is greatest in the mid cervical spine (Table
3.4
and Fig. 3.30). It is largest at the
Fig.3.29 The segmental arches. (After Lysell,
1969.)
(5-(6 segment where the flexion-extension motion mea sures approximately 17°. Arguably this may explain the
Translatory motion in the cervical spine is a gliding
high incidence of cervical spondyloarthropathy in the
motion in the sagittal plane (±) and amounts to approxi
mid-cervical spine.
mately 2.0-3.5 mm (White, 1975).
Copyrighted Material
57
Blomechanical Principles of the Spine and Joints
Table 3.4 Range of motion at the various cervical spinal levels. The average values were derived from Dvorak
(1988d.
e) and Penning
(1976. 1987a)
Flexion/Extension
Spinal Segment
Side- bending (Rotation)
-Vb
WV
Range (degrees)
5-23
8
11-20
C3-(4
7-38
13
9-15
11
10-28
11
(4-(5
8-39
12
0-16
11
10-26
12
(5-(6
4-34
17
0-16
8
8-34
10
(6-C7
1-29
16
0-17
7
63-15
9
C7-T1
4-17
9
0-17
4
5-13
8
(2-(3
is accompanied simultaneously by rotation about the y-axis and vice versa. Again. by convention. the point of
CO/C1
reference for describing vertebral motion between two adjoining vertebrae is the anterior portion of the body of
C1/C2
the superior vertebra.
C2/C3
In the past. some authors have described motion by
C3/C4
inferring movement of the spinous processes. This is no
C4/C5
pleteness it is included here. Assuming that side-bending
longer the standard international description. but for com
C5/C6 C6/0
motion is being introduced to the cervical spine to the left.
E -
the associated convexity of the cervical spine is to the right. Thus. when describing motion of the spinous processes. side-bending introduced to the left will be accompanied
C7/T1
by the spinous processes rotating to the right. that is. o
10 20
30 40
50
toward the convexity. Again. description of vertebral mo tion using the spinous processes is no longer the standard.
II Rotation •
and it is recommended to utilize the current motion de
Side-bending
scription conventions.
[] Flexion/extension
At the second cervical vertebra. there is 2° of coupled axial rotation for every 3° of side-bending. At the seventh
Fig. 3.30 Schematic representation of the values of range of mo
cervical vertebra. there is 1 ° of coupled rotation for every
tion (degrees) in the three major planes (rotation. side-bending.
7.5° of side-bending (Figs. 3.31, 3.32). The osteopathic liter
flexion/extension). Values are those contained in
Table
3.4. In the
upper cervical spine it is axial rotation that is the major motion
ature describes this coupling of movements as type II or
component. In the mid-cervical spine the major motion compo
nonneutral type motion (Fryette. 1954; Ward and Sprafka.
nent is flexion and extension motion.
1981). In clinical practice. the patient's active and passive range of motion in the cervical spine can be assessed with the
Coupling Patterns: Side- bending
assistance of a compass-like or gravity-activated gonio
and Rotatory Motion
meter. Alund and Larsson (1990) employed an electronic goniometer for their measurements of three-dimensional
Lysell (1969) measured the coupling patterns for cervical
range of motion. This improved the accuracy and reproduc
side-bending and rotation. The coupling patterns are of
ibility of spinal motion testing. in particular that of axial
significant clinical relevance and are routinely evaluated
rotation. Since the measurements can easily be stored elec
during the functional examination of the spine. When the head undergoes side-bending toward one
tronically and retrieved quickly for comparison. this system is useful for monitoring patients' progress.
side. there is simultaneous rotation in the cervical verte
Berger (1990) presents another attempt to quantify the
brae toward the same side. Thus. rotation about the z-axis
vertebral range of motion in the cervical spine. In this
58
Copyrighted Material
Biomechanics of the Lower Cervical Spine (O-G)
Left lateral bending
•••••
Neutral
I I I
I I
I I
I I I I I I I
Right lateral bending
••••
Fig.3.31 The major coupling patterns as related to the cervical spine. With permission from White and Panjabi, Clinical Biomechanics of the Spine, Lippincott Williams & Wilkins, 1990.
proposed procedure, the patient is requested to move her
y
or his head while the examiner fixates one vertebra at a time. The range of motion at a specific vertebral level is then obtained simply by subtracting the various values obtained between two adjoining vertebrae. Utilizing the CA6000 Spine Motion Analyzer (Fig.3.33), Dvorak et al. (1992 b) systematically examined the active and passive range of motion of a group of nonsymptomatic persons between the ages of 20 and 70 years. Based on the data obtained from six well-placed precision potentiome ters, the three-dimensional motion characteristics were stored electronically and analyzed using a computer. The
Primary
L---v'
movement
_
Coupled movement
various motion directions were analyzed according to age and sex (Table 3.5, Fig.3.34). The following motion direc tions were specifically examined:
Fig.3.32 Coupled movements in the cervical spine: for example, +0Z
is accompanied by -0Y.
1. Flexion and extension (motion in the sagittal plane).
2. Side-bending (lateral bending).
reliable and clinically relevant information, and serves as
3. Rotation in neutral position.
a baseline for monitoring and follow-along of a patient's
4. Rotation with the spine maximally tlexed.
course over time (Table 3.6).
5. Rotation with the spine maximally extended.
In summary, our own studies demonstrate a significant difference between a person's actively performed range of
As well as obtaining reliable, objectively reproduCible re
motion and that induced or guided passively by the exam
sults for cervical spine gross motion, this study also pro
iner. The reproducibility of the passive range of motion
vided additional information about coupled motions. This
turned out to be significantly better than that of active
computerized assessment may assist in obtaining more
motion.
Copyrighted Material
59
BIomechanlcal Prlndples of the Spine and Joints
,.". '!.
I .
.-.
.f)
�··b
Fig. 3.33 Measurement set- up for obtaining range-of-motion val
d
Side-bending left
ues with the assistance of the Spine Motion Analyzer. Note: the test
e
Rotation right
subject's trunk is held stationary.
f
Rotation left
g h
Rotation with maximal flexion
a
Flexion
b
Extension
c
Side- bending right
'It
•
.h
Rotation with maximal extension
Table 3.5 Normal range of motion values and standard deviations (in parenthesis) in the cervical spine, according to age and sex (Dvorak et al., 1992b)
Age (Years) 20-29
30-39
40-49
50-59
60
136.3 (15.7)
116.3 (8.7)
126.9 (14.8)
133.2 (7.6)
88.3 (29.1)
74.2 (14.3)
76.1 (10.2)
79.6 (18.0)
FlexlonlExtenslon -
=
Men
152.7 (20.0)
141.1 (11.4)
131.1 (18.5)
Women
149.3 (11.7)
155.9 (23.1)
139.8 (13.0)
101.3 (13.3)
94.7 (10.0)
83.7 (13.9)
106.3 (18.1)
88.2 (16.1)
11
Side-bending --
Men Women
Axial rotation
100.0 (8.6) ---
"-
-
-=
IJ II
=
- ----
Men
183.8 (11.8)
175.1 (9.9)
157.4 (19.5)
166.2 (14.1)
145.6 (13.1)
Women
182.4 (10.0)
186.0 (10.4)
168.2 (13.6)
151.9 (15.9)
154 (14.6)
Rotation with flexion =
Men
75.5 (12.4)
66.0 (13.6)
71.5 (10.9)
77.7 (17.1)
79.4 (8.1)
Women
72.6 (12.7)
74.6 (10.5)
85.2 (14.8)
85.6 (9.9)
81.3 (21.2)
161.8 (15.9)
158.4 (16.4)
146.2 (33.3)
145. 8 (21.2)
130.9 (24.1)
11 171.5 (10.0)
165.8 (16.0)
153.9 (22.9)
132.4 (28.8)
154.5 (14.7)
Rotation with extension Men Women
..
60
Copyrighted Material
Vertebral Artery
Table 3.6 Examination findin gs of passive range of motion testing of the cervical spin e of a healthy adult
left
Average Normal
Percentage
(Flexion)
Population
of Normal
Flex i on/ extension
69
75
144
153
94%
Si de - bending
50
42
92
101
91%
Axial rotation
86
89
175
184
95%
Rotation from flexion
35
38
73
76
97%
Rotation from extension
84
80
164
162
101%
Fig. 3.34 Graphic representation of the various ranges of motion
Fig.3.35 Course of the vertebral arteries.
measurements in a normal population between the ages 20 years and older than 60 years. The representation is based on the data presented in Table 3.6 (Dvorak et al.. 1992b.)
With the exception of rotation motion with the spine
superiorly up to the level of the axis. After a slight postero
nexed. the range of motion in all other directions decreases
lateral curvature it leaves the costotransverse foramen of
progressively with advancing age. One explanation for the
the atlas to continue in a posterosuperiorly directed loop
slight. albeit apparently paradoxical. increase in rotation
that ultimately punctures the atlanto-occipital membrane
while the spine is held in the flexed position. and in
and the dura mater in the region of the foramen magnum
particular at the atlantoaxial articulation. may be that this
at the occiput (Fig.3.35).
area is least affected by degenerative or spondylotic
Extreme rotation of the head can lead to neurological
changes. which allows for some compensation of the loss
symptoms. such as dizziness. nausea, and tinnitus. These
of motion lower down in the mid-cervical and lower cer
are often caused by a transiently decreased blood supply in
vical spine.
the basilar region. since rotation of the head between 30° and 45° to one side causes the blood flow to be diminished in the opposite vertebral artery at the atlantoaxial junction
Vertebral Artery
(Fig.3.36) (Fielding. 1957 ) .
The vertebral artery is an important structure in the cer
either the congenital or acquired form (e. g.. by trauma).
vical spine. not only when approached from a structural
may result in a mechanical reduction of the blood supply.
biomechanical aspect.
Furthermore. due to the close anatomic proximity of the
Rotational instability in the upper cervical spine. in
but also when considering the
various functional examination and treatment procedures
vertebral artery with the margins of the (1 and (2 facet
employed in the field of manual medicine. The vertebral
joints during rotation. mechanical irritation is possible.
artery enters the costotransverse foramina at the level of
which can potentially lead to reflex spasms (Fig.3.37).
(6 on either side. occasionally that of (5. and extends
Other factors such as spondylotic degenerative processes
Copyrighted Material
61
Biomechanical Prindples of the Spine and Joints
Fig.3.36a-c Course of the vertebral artery as a result of atlas rotation to the left and to the right
(c); (b)
(a) neu
tral position.
b
a
b
a Fig.3.37 a
Rotation of C1-C2 to the right.
b c
Exposed vertebral artery on the left side with induced rotation
1
Atlas
2
Axis
Rotation of C1-C2 to the left. to the right.
3
Dens of the axis
4
Articular process on the left
5
Vertebral artery
6
Posterior arch of the atlas
c
may also cause reflex spasms, especially in the advanced
is any suspicion for potential complications, the routine
state (Fig. 3.38).
examination procedures should be complemented by the
Figure
3.39
demonstrates the close spatial relationship
appropriate provocation tests, and if necessary the patient
between the vertebral artery and the uncovertebral and
should be referred for the appropriate diagnostic evalua
zygapophyseal (facet) joints.
tion of the vertebral artery.
Though extremely rare, it has been reported that the "high-velocity, low-amplitude" thrust techniques can po
Reclination or Cervical Extension Provocation Test
tentially lead to disastrous results (Dvorak and Orelli,
With the patient sitting, the examiner carefully and slowly
1982).
introduces rotation to the head and cervical spine of the
It is therefore recommended that whenever there
62
Copyrighted Material
Vertebral Artery
patient (passive motion). both in the anatomic neutral
artery, in particular in response to cervical spine motion.
position and with the neck extended. The patient is queried
With an ultrasound probe approximately 15 em long in
as to the presence or appearance of any symptoms associ
serted into the oropharynx, the vertebral arteries can be
ated with the induced movements.
visualized on either side at the (3-(4 level.
Kleijn Hanging Test The patient is supine with the head beyond the examining table supported by the examiner. From this "hanging" po sition, the head is passively rotated to both sides, While the examiner observes the patient's eye movements (nystag mus). the patient is again asked to report any subjective symptoms.
Ultrasound Examination Noninvasive ultrasound examination of the carotid and vertebral arteries can be helpful when one suspects verte bral basilar insufficiency. subclavian steal syndrome and a hypersensitive carotid sinus syndrome, or risk factors for cerebral vascular disease. The ultrasound examination pro
Fig,3.38 Prominent degenerative change s affec ting the axis of a
vides additional objective information about the vertebral
64-year-old woman.
a
b
c
d Fig.3.39 Representation of the vertebral artery at the level of the atlas and the mid-cervical spine.
Intervertebral jOint
a
At the level of atlas.
2 3
b
Axial cross-section in the mid-cervical spine.
4
Spinal ganglion
Coronal section in the mid-cervical spine.
5
Vertebral artery
c
d
Uncovertebral joint Nerve root
Detailed view of the intervertebral canal. (Courtesy of Prof. W. Rauschning. Uppsala.)
Copyrighted Material
63
8/omechonlcal Prindples of the Spine and Joints
The following four study parameters are diagnostically
T7-T8 level, nexion and extension movement increases
relevant:
progressively in the inferior direction.
1. The direction of blood flow.
Side- bending (Lateral Bending)
2. Differences between the vertebral arteries (diastolic
This motion occurs to essentially the same degree at all
phase and pulsation amplitude).
thoracic spinal segments. There is very little intersegmen
3. Response to carotid compression/massage.
tal variation.
4. Changes noted upon induced rotation, flexion, and ex
Axial Rotation
tension to the head and neck.
Axial rotation in the thoracic spine is opposite to that Since it is physiologically normal for blood flow to decrease
encountered for the flexion and extension movement.
in response to normal cervical rotation, it is important to
The segments from T1 through T7 and T8 can undergo
verify as soon as possible any abnormal blood flow changes,
significantly greater rotational motion than their more in
especially if there are findings of complete interruption of
ferior counterparts (e.g., those segments below T7-T8).
flow (Adorjani, personal communication, 1980; Keller et aI., 1976).
Biomechanics of the Thoracic Spine The facets of the individual vertebrae show a twofold in clination, that is, inclination around the x-axis of 60° and around the y-axis of 20° (Fig. 3.40). Nonetheless, these doubly inclined facets allow rotation about all three axes: that is, flexion and extension, side-bending, and axial ro tation (Table
3.7).
'-./
Flexion and Extension The flexion/extension range of motion in the upper seg
/'
Fig. 3.40 Facet joint inclination and axes of motion in a typical thoracic vertebra. With permission from White and Panjabi, Clinical
ments of the thoracic spine is rather limited. Starting at the
Biomechanics of the Spine, Lippincott Williams & Wilkins, 1990.
Table 3.7 Range of motion at the various thoracic spinal levels. The average values were derived from White and Panjabi (1990)
Range (degrees) 3-5
T1-T2 T2-T3
5
4 --
-
Mean (degrees)
Range (degrees)
Mean (degrees)
5
14
14
-
5-7
4
3-5 2-5 --
4
6
2-5
T4-T5 ---;-
2-7
T7-T8
3-8 3-8 -
T9-T10
3-8
6
8
6
5-11
8
6
6
4-11
8
3-8
6
4-11
8
6-7
7
3-5
4
2-3
2
--
4-7
;..=--:- =-
6
8 -
._.
-.
-
5-11 4-11
5-6
6 -
--
6
"
5
-
8
4-12
- --
--
4 - - -
T6-T7
T8-T9
_.
---
6
5-6
4 - --
3-5
T5-T6
3-7 =-=:=
_._..
- -
_.-
-
T3-T4
x
6 -
-_.-
4-7
--
6 -
nO-T11
4-14
9
3-10
7
T11-T12
6-20
12
4-13
9
2-3
2
T12-L1
6-20
12
5-10
8
2-3
2
64
Copyrighted Material
Biomechanics of the Thorax and Ribs
y
Coupled Movements According to Panjabi et al. (1978), coupled motion behavior characteristics in the thoracic spine are similar to those described for the cervical spine. Side-bending (lateral bending, ±0Z) to one side is accompanied by axial rotation to the same side (+0y) (Fig. 3.41). Greenman (2003) and Mitchell and Mitchell (1979) based on the work of Fryette (1954) distinguish two types of coupled movements: Type J:
Primary movement
(neutral motion characteristics): side-bending to one side (± 0Z) is accompanied by axial rotation
-
(± 0Y) to the opposite side. This can occur in both the thoracic and lumbar spine as well as at the craniocervical and lumbosacral junctions. Type II: (nonneutral motion characteristics): side-bending
Coupled movement
Fig.3.41 Coupled movement in the thoracic spine. With -0Z, there is +0Y.
to one side (± 0Z) is accompanied by axial rotation (± 0Y) to the same side. It is noted here that, according to the osteopathic literature, type II
tension
2S
mechanics can occur in all regions of the spine, and
20
exclusively in the cervical spine.
15
-
Side·bendlng
-
I
Axial Rotation
10
According to the above criteria, and considering the normal kyphotic curvature in the thoracic spine, side-bending in duced to the thoracic spine is typically accompanied by coupled type I movement.
o
.
T1T2
.
T2-
13
13T4
T4T5
T5 - ' T6T6
T7
17T8
T8T9
' T9- Tl0- T11- T12T10 T11 T12 L1
Fig.3.42 Segmental range of motion measurements For the tho racic spine. The representation is based on the data presented in Table 3.7.
Biomechanics of the Thorax and Ribs It is well known that vertebral motion in the thoracic
rigidity and stability of the longest portion of the vertebral
spine is small compared to that in the cervical and lumbar
column. Strong ligaments further stabilize the costoverte
spine. The range of motion between the individual velte
bral and costotransverse joints (Fig. 3.43).
brae is limited due to the restrictive effect of the longi
The relatively firm union between the sternum and the
tudinal ligament, the anulus fibrosus. and the spatial ar
thoracic spine by way of the ribs markedly increases the
rangement of the spinous processes and the connections
resistance of the spine against forces that cause rotation. An
to the ribs.
interesting experiment was conducted by Schultz et al.
The ranges of motion for axial rotation, side-bending,
(1974a,b): while loads were applied to individual ribs
and flexion/extension in the thoracic spine are graphically
from different directions their mobility was measured. It
represented in Fig. 3.42.
was noted that the second rib exhibited the greatest resis
Kumar and Panjabi (1995) studied the motion character
tance when the force was applied from the posteroanterior
istics of the thoracic spine of healthy adults. Measurements
direction. The lowest stiffness or resistance (highest flexi
were obtained with the subject having the eyes closed,
bility) was exhibited by the tenth rib when loaded either
actively, passively and passive assisted. Active range of
from the superior or from the inferior direction.
motion for the thoracic spine was approximately 60° to
According to White and Panjabi (1990), the costoverte
either side (48.8-88.5°); passive motion was increased by
bral joints play a crucial role in the thoracic spine by
approximately 14°, with the greatest range possible in the
maintaining the stability yet allowing sufficient segmental
more inferior thoracic segments. The authors discussed the
mobility. Their function, in addition to the action of stabi
role of muscle coordination during passive loading situa
lizing the entire trunk, is verified in a mathematical model
tions and whether those muscular influences may influ
by Andriacchi et al. (1974). Due to its connection to the stern um anteriorly through
ence or prevent injury. The union of the thoracic spine with the ribs posteriorly
the ribs, the thoracic spine is able to withstand relatively
and with the sternum anteriorly significantly increases the
high loading forces when subjected to various physiologic
Copyrighted Material
65
Biomechanical Principles of the Spine and Joints
movements, in particular the extension component. The ...,
,
SpIllOU p!OCl!i.l
thorax as a whole also enhances axial mechanical stabiliza
COSt(t1111lBj ·/!r14l.1
IiTt1£.d.J.tf.la1
CosIOlfIlll1J\'t!fJ.: 1
1In1
J.
tion, particularly when subjected to anteroposterior com
iIorllcuia �",IIIIU
ct
,
pression forces at the expense of mobility.
1 -."
IOfCO tl:l1llfl
Biomechanics of the Lumbar Spine
Cm.I IU
kDlr1:J
C.o- IOI:rlll'l.
......
HNdofr1b
Motion in the lumbar spine is possible in all directions with
fl.."". -,
flexion-extension being the primary direction and rotation 'C:WlmR!
being the least, with side-bending somewhere in the mid
Vet'teb<.II1 ""'"
dle. These motion characteristics are easily be explained on account of the inclination of the facet joints, which in the
Fig.3.43 Schematic representation of the costovertebral and the
lumbar spine, "stand" vertically while facing forward at an
costotransverse joints. (From Schuenke, Thieme Atlas of Anatomy
angle of 45° (Fig. 3.44). In general, and depending on the
Vol. I, 2007.)
specific segmental level, lumbar flexion and extension mo
1
Radial ligament of the head of the rib
2
Costotransverse ligament
3 4
Costotransverse articulation
z-axis) is between 3° and 6°, with the smallest excursion
5
Articulation of the head of the rib
being measured at the lumbosacral junction. The reverse is
tion in the sagittal plane (defined by motion about the
x
axis) is between 10° and 20°. Side-bending (coronal plane;
Ligament of the rib tubercle
true for axial rotation (about the y-axis), which shows greatest excursion at the lumbosacral junction (Lumsden and Morris, 1968) but otherwise measures only about 2°
y
throughout the remainder of the lumbar spine. The specific values are listed in Table 3.8 and are graphically repre sented in Fig. 3.45.
/ /
/ / <'" ...... / / .
Coupled Movements Side-bending (±0Z) is strongly coupled to axial rotation
z
(±0y) (Miles and Sullivan, 1961; White and Panjabi, 1990).
/ / / "/
In the lumbar spine, with its normal lordosis, side-bending x
to one side in the neutral position is accompanied by rotation to the opposite side (Fig. 3.46).
Fig. 3.44 Facet inclination and axes of motion (degrees) of a typical lumbar vertebra. With permission from White and Panjabi, Clinical Biomechanics of the Spine, Lippincott Williams & Wilkins, 1990.
The osteopathic literature (Mitchell et aI., 1995; Green man, 2003) describes a more complex coupling of motion depending on whether motion occurs with the spine in the neutral or in the nonneutral position (that is, the spine is either flexed or extended). When, for instance, the lumbar spine is flexed (±0X) and side-bending is being introduced
30
toward one side (±0Z), there is coupled rotation (±0y) to the
25
same side as the induced side-bending (Fig. 3.47). Trans
20
•
15 10
Axial Rotation
•
Side-bending
o
Flexion!
latory gliding in the sagittal plane (±y-axis) coupled to axial rotation, although very uncommon, has been reported to occur (Rolander, 1966).
Extension
5
o L3L4
L4L5
Objective Documentation of lumbar Range of Motion
L5Sl
Lumbar range of motion measurements, while routinely Fig. 3.45 Average values for segmental ranges of motion in the
used in the assessment of patients with a low back pain
lumbar spine. The representation is based on the data presented in
syndrome, may vary considerably depending on the way
Table 3.8.
they are obtained. According to the American Medical As
66
Copyrighted Material
Biomechonics of the Lumbar Spine
Table 3.8 Range of motion at the various lumbar spinal levels. The average values were derived from Dvorak 1991 c, d.
Flexion/Extension (Rotation about x-axis)
Axial Rotation (Rotation about y-axis)
(degrees)
Mean (degrees)
Range (degrees)
Mean (degrees)
Range (degrees)
Mean (degrees)
9-16
12
3-8
6
1-3
2
11-18
14
3-9
6
1-3
2
l3-l4
12-18
15
5-10
8
1- 3
2
l4-l5
14-21
17
5-7
6
1-3
2
l5-S1
18-22
29
2-3
3
3-6
5
Range
y
y
-oy
Primary movement
Primary movement -
Coupled - movement
Coupled movement
Fig.3.46 Coupled movement in the lumbar spine. +02 is accom
Fig. 3.47 Coupled movement in the lumbar spine. With +0X, there
panied by +("y
is +02 primary movement accompanied by -oy.
sociation guidelines (Cocchiarella and Andersson, 2001)
There were no significant sex differences for flexion
the measurements should be as objective as possible, es
extension or for side-bending motion. There was also no
pecially when dealing with medicolegal or disability deter
side-to-side difference noted at the various segmental
minations.
levels for side-bending and rotation motion.
In clinical practice, the range of motion is determined by
Not surprisingly, there is progressive motion loss with
use of various kinds of inclinometers, goniometers, and
advancing age. The reduction of motion is statistically dif
computer-generated data obtained with such machines as
ferent from one decade to another (Fig. 3.49). Our own
the Isostation 8-200. In our own studies (Dvorak et aI.,
studies also revealed a progressive increase in lumbar
1995), we studied 104 healthy persons (52 men, 42
range of motion as the day progresses, with the greatest
women) ranging from 20 years to 70 years in age using
increase noted in the morning hours (Dvorak et aI., 1995).
the CA5000 Spine Motion Analyzer. The lumbar range of motion was thus measured in all directions and according
The ranges of motion in the different directions accord ing to various authors are listed in Tables 3.9-3.11.
to the three fundamental planes as described by the corre
Passive range of motion for flexion-extension and rota
sponding primary axis: flexion-extension in the sagittal
tion movement is greater than that of active range of
plane with motion about the x-axis; side-bending in the
motion. While passive motion testing provides more reli
coronal plane with motion about the z-axis; axial rotation
able numbers, active motion testing provides valuable in
in the horizontal plane with rotation about the y-axis.
formation about the coupled movements. An increase in
Similarly to the experimental set-up described for the cer
movement was demonstrated after the examinees had
vical spine, six potentiometers were placed on the patient's
performed stretching exercises (Dvorak et aI., 1995).
back (Fig. 3.48).
Copyrighted Material
67
Blomechanical Prlndples of the Spine and Joints
50_
Fig.3.48 Examination arrangement for measuring lumbar range of
Fig. 3.49 Graphic representation demonstrating the age- related
motion in using the Spine Motion Analyzer (Dvorak et al., 1995).
reduction in thoracolumbar flexion-extension and side-bending motions. There appears to be a rather drastic reduction in the flexion-extension motion after the second decade of life and a prominent reduction in side- bending after the fourth decade.
Table 3.9 Range of motion at the different lumbar spinal levels according to various authors (flexion/extension)
Author Tanz Allbrook
--In vivo -
12-L3
L3-L4
L4-LS
8.6
12.2
1953
14
5.6
7.6
1957
In vivo 20
6.0
8.0
Clayson et al.
1962
In vivo 26
12.6
Froning and Frohmann
1968
In vivo 30
9.0
Pearcy et al.
1984
In vivo
13.0
: II : II
15.8 11.0 14.0
=
Hayes et al Dvorak and Panjabi Yamamoto et al.
1989 1991a. c 1989
In vivo 59 In vivo 41 In vitro 10
9.0
7.0 11.9 10.1
= II -
11
14.5
--
=
15.9 13.0 13.0
--
17.7 16.0 16.0
._.
10.0
13.0 =-
=
I
1 8,2
-. -
I
18.0 18.7 17.0 14.0 14.0
=-
18.2
15.3
::-
10,8
19.0
13,0
LS-S1
11.2
14.5
-
17.0 17.8
Table 3.10 Range of motion seen with side-bending (lateral flexion)
Name Tanz Pearcy et ai.
1984
In vivo
13.0
14.0
13.0
16.0
14.0
Dvorak and Panjabi
1981a.(
In vivo 41
11.9
14.5
15.3
18.2
17.0
Yamamoto et ai.
1989
In vitro 10
10.1
10.8
11.2
14.5
17.8
Table 3.11 Range of motion seen with axial rotation
Name
Year
n
L1-12
U-L3
Yamamoto et al.
1989
In v itr o 10
2.1
2.6
68
Copyrighted Material
Biomechanics of the Pelvic Girdle
Biomechanics of the Pelvic Girdle The functional unit of the pelvic girdle comprises the sa crum. the ilium one either side. and the fifth lumbar ver tebra with their corresponding articulations at the sacroil iacjoints and the symphysis pubis. The sacroiliac joints are representative of a diarthrosis but function as an am phiarthroses allowing some movement. albeit very mini mal. The sacroiliac joint takes on an auricular or a "C" shape. with the convex side facing anteriorly and inferiorly (Fig. 3.50). There is significant variation in size of the sa croiliac joint ranging from 5.3 cm to 8.0 cm in length and 1.8 cm to 4.1 cm in width (Schunke. 1938).
Microscopic Joint Anatomy
Fig.3.50 Anatomic representation of the sacroiliac joint.
The sacroiliac joints are practically vertically oriented but also have an oblique orientation with respect to the sagittal plane. In an axial cut through the mid-portion of the sa-
First decade. In children. the cartilage on the sacral side is
croiJiac joint. the posterior border of the sacrum is wider
three to four times thicker than that on the iliac side. On the
posteriorly than anteriorly. The opposite relationships are
iliac side. the bone and cartilage are interdigitated in a
seen in the inferior portion of the sacrum (Fig. 3.51).
manner similar to that found in the cartilaginous growth
There are a number of significant differences between
plates of the vertebrae or the symphysis pubis during the
the sacral and iliac surface of the sacroiliac joint. On the
growth period. The joint capsule, even though already well
sacral side, the articular cartilage is about 2-3 mm thick,
developed at this age, allows for great mobility of the joint,
whereas on the iliac side it is not thicker than 1.5 mm. In
with gliding movement possible in any direction.
chemical composition, the sacral cartilage is primarily made up of hyaline material, whereas the iliac cartilage
Second decade. In the sacral cartilage of a 15-year-old, the
is comprised of fibrous material. Sacral cartilage contains
divisions into cell-rich and cell-poor areas have become
large chondrocytes which are grouped in pairs and fill the
even more pronounced, particularly in the deeper layers.
lacunae completely. These lacunae are distributed evenly
The columnar appearance of the iliac cartilage remains
throughout the hyaline matrix
unchanged. By the second decade, a cartilaginous joint
of
the cartilage. The
ground matrix on the sacral side is homogeneous, with
space has developed behind the joint surface on each
little fibrous tissue present except in areas of degenera
side. The joint space is perpendicular to the joint line. The
tion (Bowen and Cassidy. 1981). In contrast, the ground
pronounced changes observed in the cartilage of this joint
matrix of the iliac cartilage is made up of thick bundles of
space are more likely to be due to mechanical stress and
collagenous fibers. The lacunes, surrounded by colla
potential damage to the growing cartilage than due to the
genous fibers. are filled with chondrocytes that tend to
growth process itself (Putschar, 1931).
clump. The function and thus the biomechanical behavior of
Third decade. Growth-related changes cease to occur on
the sacroiliac joint are closely tied to the histologic
the sacral side before they cease on the iliac side. It is not
changes that occur over time as a function of age. Early
until the third decade that the iliac surface assumes a
anatomic studies have relied primarily on anatomical
convex shape and the sacral side the corresponding con
specimens obtained from older persons whose joints had
cave shape. While the deeper layers appear to remain
likely undergone a certain degree of degeneration. Thus.
histologically unchanged. the superficial joint surface starts
early reports of "normal" sacroiliac joint function may
showing a number of crevices with rough edges and ero
have inadvertently been based on faulty assumptions.
sions, more so on the iliac side than on the sacral side
that is, by inferring the same function to be present in a
(Bowen and Cassidy, 1981).
young healthy adult. It is therefore helpful to describe the sacroiliac joint's function systematically according to dif
Fourth decade. The capsule grows still thicker, accompa
ferent age groups.
nied by a proportional increase of the fibrous material in
Copyrighted Material
69
Biomechanical Principles of the Spine and Joints
being diminished in the presence of significant build-up of chondrocytes. The ground matrix is infiltrated with fi brous material. Osteophytes at the sacroiliac joint have been observed in 85% of men and 50% of women in the fifth decade (Frigerio. 1974). Sixth decade. thicker and
Capsule and synovium continue to grow
stiffer. In particular. the iliac portion has lost
a significant share of its cartilaginous substance to the
a
point of exposure of the subchondral bone. A thick layer of flaky amorphous debris now covers both joint surfaces.
and the iliac surface can no longer be distinguished by its blue appearance (Bowen and Cassidy. 1981). The sacral portion is less affected. although superficial erosions and fibrillation have been noted. Osteophytes. which are espe cially prominent on the superior and anterior margins of the joint. continue to broaden and invade the joint space in
b
an interdigitating fashion. Thus. motion in the sacroiliac joint is reduced significantly to a point where no motion whatsoever is possible. Partial or complete ankylosis at this age has been observed to occur in 60% of males. in contrast to 15% of females (Frigerio.1974). Seventh decade.
Cartilage continues to undergo further
atrophic changes on both sides. While the process may
c
have progressed to erosions and fibrill atory changes at some locations. thus leading to only bone being present Fig.3.51 Horizontal sections through the sacroiliac joints at vari a
at those portions of the articular surface. some of the cartilage may show material primarily devoid of living
ous levels. Superior level.
b
Mid level.
c
Inferior level.
cells. as well as signs of necrosis. The remainder of the cartilage reveals an increase in collagenous material and clustering of chondrocytes. There is more amorphous ma terial in the joint space. and fibrous degenerative changes
the synovial layer. There is. however. a decrease in the vasculature associated with the joint. The joint surface is microscopically
irregular and discontinuous. with flat
tened. longitudinal cells. At
this age. the iliac cartilage
reveals clumping of chondrocytes into bundles. In
contrast.
and except for discrete rough edges at its margins. the sacral hyaline cartilage appears unchanged. A number of osteophytes may have developed at the margins. especially on the iliac side. The joint cavity contains flakelike clumps
have led to intra-articular fibrous interconnections. The joints may have undergone complete ankylosis in as many as 70% of the case (MacDonald and Hunt. 1952). Calcifications at the capsular attachments have also been observed on both joint surfaces. Eighth decade. At this age. the joints
have ankylosed in the
majority of cases. with significant calcification at the pe riphery of the fibrous capsule. Subcapsular osteophytes are
of yellow amorphous debris (Bowen and Cassidy. 1981).
present in almost all of t he joints. and their interdigitation
Despite the apparent loss of elasticity at this age. overall
is so pronounced that essentially any movement is prohib
joint mobility continues to be good.
ited. Diminished movement may be further compounded by the presence of intra-articular fibrous connections (Bo
Degenerative processes continue to become
wen and Cassidy. 1981). Erosions and necrotic changes.
increasingly prominent.with signs of irregular joint surface
exposure of the deeper layers. and fibriJlatory changes
Fifth decade.
due to erosions. Eosinophils and amorphous clumps of
are found to a significant degree in all joints. though less
exfoliated material have accumulated in the joint space. The iliac cartilage is more affected. with joint thickness
so on the sacral side. Subchondral bone has become thin and atrophied (Fig. 3.52).
70
Copyrighted Material
Biomechanics of the Pelvic Girdle
Ligaments Associated with the Sacroiliac Joints Of great importance. in addition to a taut joint capsule. are the ligaments associated with the sacroiliac joint. There are two major sets of ligaments. an anterior and a posterior group. The anterior group is made up of the relatively weak anterior sacroiliac ligament. whereas the posterior group comprises stronger and thicker ligaments. the long and short sacroiliac ligaments as well as the interosseous sa croiliac ligament. The very thin and weak anterior sacroiliac ligament represents the thickened portion of the joint capsule. a
With sacroiliac joint motion it undergoes a laterally di rected stretch. The sensory innervation of the anterior sacroiliac joint occurs via the anterior rami of the spinal nerves of L2 and L3. The short and long sacroiliac ligaments are sensorily supplied by the anterior rami of LS through S2 as well as the posterior rami of L1 through LS and Sl througll S3. The interosseous ligament receives its sensory supply from the dorsal rami of LS-S2. According to Sutter (1977). the sacrum is suspended from tile posterior prominence of the iliac tuberosity by way of the interosseous sacroiliac ligament. The sacrum is tightly secured by two factors: (1) by the safeguarding function of the sacroiliac ligaments. which limit excess motion; and (2) by the shape of the jOint itself and its keystone-like arrangement wherein the sacrum is wedged
b
between the two sides of the ilium. Forces that are directed toward the sacrum and the innominate bones are coun tered by a "clamp down" mechanism due simply to the anatomic arrangement of the joint with its inferior con vergence. This mechanism remains intact only as long as the short sacroiliac ligaments allow the mechanically im portant posterior closure to occur between the sacrum and the ilium on either side. If these ligaments are fail or become weak. the affected iliac bone can deviate laterally to a minor extent. When lateral movement of the iliac bone occurs. the upper pole of the sacrum is obligatorily pulled into a more posterior position. which in turn approximates the prominence of the iliac tuberosity. This mechanism is mediated by the short yet very strong interosseous sacroil iac ligament (Fig. 3.53). c
Fig. 3.52 Age- related degenerative processes observed at the sa croiliac joint (Bowen and Cassidy. 1981). a
First decade.
b
Fourth decade.
c
Seventh decade.
Copyrighted Material
71
Biomechanlcal Prindples of the Spine and Joints
2. It has been extremely difficult in the past to design the appropriate experiments, let alone to reach conclusive interpretations of studies investigating the mechanics of 2
2 3
this joint. Despite worldwide research effort and a number of first-rate conferences devoted to this topic, a final, all encompassing description of the physiology of the sacroiliac joint has not been presented thus far. A brief review of the literature reveals that Hippocrates and Vesalius believed that the sacroiliac joint is mobile. It is interesting to note that Hippocrates had already surmised a certain degree of mobility to occur at the sacroiliac joint during pregnancy. In the 19th century, those in the field of obstetrics and gynecology became particularly interested in the function and mechanics of the pelvic girdle. Some
a
authors report changes in measurement of the pelvic inlet that could only be explained on the basis of apparent motion in the sacroiliac joint. A decrease in the diameter of the pelvic inlet was always found to be associated with an increase in the pelvic outlet. This led to the conclusion that the sacrum rotates around a --...-'l. 2
horizontal axis. This rotational movement of the sacrum has been termed nutation ("nodding") movement in the literature. However, the anatomic location of this axis varies greatly according to the various authors.
·3
Pitkin and Pheasant (1936) describe two types of rota tion based on measuring the angle between a line that
b
connects the superior iliac spines and various lines con structed through the sacrum. In one type, the axis of rota Fig.3.53 Ligaments associated with the sacroiliac joint. (After
between the superior and inferior joint surface (Fig. 3.54,
Kapandji 1974.) a
b
tion is at the center of the sacroiliac joint at the tubercle
Superior view.
the point labeled a).
Medial view.
The second type is that in which the center of the axis is
Anterior sacroiliac ligament
located at the level of the symphysis pubis (Fig. 3.54, the
2
Interosseous sacroiliac ligament
3
Sacrum
point labeled b). Duckworth (1970) refers to a nutation
4
Ilium
movement with the axis of rotation being at the site of the shortest and strongest portion of the interosseous lig ament (Fig. 3.54, the point labeled c). Beal (1982) reported
Function of the Sacroiliac Joint
that the axis of rotation is at the inferior pole of the sa croiliac joint (Fig. 3.54, the point labeled d).
A detailed literature review of the sacroiliac joint in the
As early as 1937, Lloyd pointed to the close relationship
medical aspect has been presented by Rudolf and Benecke
between architectural shape and the stability of the sac
(1985).
roiliac joint. When the sacrum is more rectangular in shape,
Arguably the function and pathologic motions of the
the associated sacroiliac joint has a rather vertical arrange-
sacroiliac joint have been the subject of more controversy
ment, which is clinically more often associated with rela
and more hypotheses than for any other joint in the human
tively increased instability. This concept was developed
body. This may be primarily for two reasons:
further by Delmas (1950) and confirmed by Sandoz (1981).
1. The role and significance of the sacroiliac joint and
two main prototypes of sacroiliac jOint shapes have been
motion in the lumbopelvic mechanism are not as read
described: (1) the so-called tight-profile shape; and (2) the
ily evident as those of the hip or knee joint, for instance.
open-profile shape.
According to these and other functional considerations,
72
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Biomechanics of the Pelvic Girdle
•
Tight-profile-shaped sacroiliac joint. Here, the joint surfaces between the sacrum and ilium are practically
\
congruent, and the retroarticular space is relatively small. The short and strong interosseous ligaments span the entire narrow joint. In this type, the balance be tween mobility and stability is unquestionably shifted in the direction of stability at the expense of mobility. This configuration is more typical of the male pelvis
(Fig. 3.55). •
Open-profile-shaped sacroiliac joint. The joint surfa ces are less congruent, the retroarticular space being
+b
wider and the interosseous ligaments longer than in the
---/
tight-profile type. This configuration allows greater mobility while stability is, not surprisingly, reduced. This type is found predominantly in women, often in
Fig.3.54 Different positions for axis
association with an exaggerated lordosis (Fig. 3.56).
nutation
("nodding")
of rotation a llowing
sacroiliac
motion.
Again, with this type of joint shape there is a greater preponderance of instability. Either of these two archetypes occurs in approximately
25% of the population, with the remaining 50% being of the mixed or intermediate type. Weisl (1954), using controlled radiographic studies, abandoned the conventional concept of a fixed axis to describe sacral rotatory motion. Based on his carefully performed geometric measurements, he concluded that while the primary location of the axis of rotation is approx imately 10 cm below the promontory, it can undergo an up-and-down movement of up to 5 cm. This description
Fig.3.55 Sacrum: flat type.
implies that movement of the sacrum is not only rotatory around one stationary axis but follows a translatory path as well. Kapandji (1974) and Colachis (1963) came to similar conclusions. Both investigators confirmed that motion at the sacroiliac joint is a combination of rotation and gliding (e.g., translatory) movement. Sutter (1977) postulates four axes of movement for the sacroiliac joint around which movement can take place either unilaterally or bilaterally
(Fig.3.57). Various other authors, applying modern diagnostic techniques such as CT and three-dimensional modeling, have shed some additional light on the three-dimensional
Fig.3.56 Sacrum: wide type.
biodynamic mechanisms in the sacroiliac joint (Frigerio,
1974: Egund et al., 1978). Even though these studies would fulfill the require ments of modern research, adequate clinical studies are
than scientific "prooL" with many questions remaining
still lacking, especially with regard to sufficiently high
unanswered.
patient numbers.
Such
investigations are
needed
to
Lewit (1973) views the sacroiliac joint as an elastic
conclusively answer the question of sacroiliac joint move
buffer zone between the spine and the lower limbs. Sandoz
ment, both qualitatively and quantitatively. Thus, the final
(1981) suggests a similar concept. Rather than viewing the
answer regarding the physiology, the biomechanics, and
joint purely in terms of translation (e. g.. gliding) and rota
the clinical relevance of sacroi I iac joint movement remains
tion, movement at the sacroiliac joint may more appropri
a matter of interpretation, hypotheses, and projection more
ately be viewed as that causing compression in a specific
Copyrighted Material
73
Biomechanical Principles of the Spine and Joints
a
IL-
____________________ ______ __ __ ___ __ ________________
L__________________________________________
Fig. 3.57 The various axes of motion for the sacroiliac joints. (After Sutter, a
Anterior view.
b
Posterior view.
I b
1977.)
be further separated into two unit-vector components, as indicated by the two motion forces labeled F, and F2 in Fig. 3.58. Fl is the force causing nutation (nodding, specific motion of the sacrum), a movement controlled by the sacrospinous and sacrotuberous ligaments, as well as a portion of the superior sacroiliac ligaments (force Bl)' Translatory displacement along the joint's longitudinal axis (F2 in Fig. 3.58) is counteracted by the inferior portion
F2
of the sacroiliac ligaments (force B2, Fig. 3.58). At the same time, the reactive ground force (R), trans mitted through the femur to the hip combines with the body weight (G) to form a rotatory couple. This force causes the iliac bone to tilt posteriorly (N2; also known as "coun ter-nutation"), which is a rotation in direction opposite to that of sacral nutation (N" Fig. Fig.3.58 Loading force vectors associated with trunk weight and its unit vectors. (After Kapandji,
C F, F2 8, 82
1974.)
3.59).
This interaction of the different forces applies to a per son standing on one foot or to the stance phase during a person's gait cycle. The forces in that instance act upon the
Body weight (gravity) Nutation motion
ipsilateral sacroiliac joint of the supporting or stance (non
Translatory force (displacement)
swing) leg (Beal,
Pulling force exhibited by the superior interosseous ligament
ground (R). transmitted by the supporting limb. elevates
Pulling force exhibited by the inferior interosseous ligament
1982; Kapandji, 1974). The reaction of the
the corresponding hip and bony pelvis. whereas the con tralateral hip tends to be pulled down by the weight of the
region while simultaneously producing distraction at an other point or region along its path. The cushioning or
pelvis on the side of the unsupported leg. The resultant forces thus described introduce a shearing
3.60). Tile descrip
buffering function of the sacroiliac joint in erect posture
type of pull at the symphysis pubis (Fig.
may therefore be best viewed within the context of the
tion thus far takes into account passive (static) forces with
sum of all forces that are directed toward the pelvic girdle
out taking into account the important influence and actions
(Kapandji,
1974; Beal, 1982).
of the various muscle groups (Kapandji.
The vertical vector of the gravitational force caused by
1974).
Under physiologic conditions. the sacroiliac ligaments
the weight of the trunk is directed toward the superior
exert such a strong force that they substantially limit gross
surface of the sacrum, that is, Sl (Fig. 3.58). As a result of
movement. making objective measurements of particular
the anatomic arrangement of this joint, this vector (G) can
motions extremely difficult. It should not be difficult. how
74
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Biomechanics of the Pelvic Girdle
Fig. 3.59 Body posture and its effects on the sacroiliac joint. (After Kapandji,
G R
1974.)
Fig.3.60 Shearing forces encountered at the symphysis pubis dur ing one-legged stance phase. (After Kapandji,
Body weight (gravity) Reaction of the ground
N, Nutation motion of sacrum N2 Counter-nutation by the innominate bone
1974.)
Body weight (gravity)
G R
Ground reaction
5,,52
Shearing forces
ever, to imagine how the various force vectors correspond ingly alternate and interplay during the walking cycle, repetitively causing a temporary and physiologically "nor mal"-that is reversible-pelvic torsion (Lewit, Grice
1968). (1980) points out that the general elastic give of
the pelvic articulations, together with the ilium's ability to undergo respective flexion or extension movement (ac
cording to the various motions during the gait cycle), re D
duces the torsional forces at the spine to a minimum during walking. The force interplay described above (forces G and
R)
brings about alternating movement with each step at the sacroiliac joint such that there is nutation movement at the sacrum while the ilium is counter-nutated. The force dis tribution described applies to the stance leg.
b
a
Additional forces are introduced with active muscle action: during the early stance phase the major active muscle groups are the gluteus maximus and the hamstring
Fig.3.61 Early stance phase (a) and swing phase
muscles (Fig. 3.61 a, labeled A and B, respectively). Due to
1980.)
the attachments of these muscles at the pelvis and lower
A
limb, the posterior superior iliac spine is pulled posteriorly,
a movement correlating with that described above as "counter-nutation" (Fig. 3.61).
B
(b).
(After Grice
.
Gluteus maximus muscle Biceps femoris, semitendinosus, and semimembranosus muscles
C I liop soas muscle D Qu a driceps femoris muscle
The other leg, now in swing phase, activates primarily the iliopsoas muscle and quadriceps femoris muscle (Fig. 3.61 b, labeled C and D, respectively). The forces
motions including those at either sacroiliac joint. Move-
generated through this action cause the pelvis on the
ment between the sacrum on one side and the ipsilateral
same side to rotate anteriorly (Fig. 3.61 b). During the gait
ilium is such that the sacrum typically moves in a direction
cycle, there is then a rather dynamic and a predictably
opposite to that of the ilium. Motion is more in an anterior
repetitive interplay between a number of relatively small
and inferior direction on the stance side, and more poste
Copyrighted Material
75
Blomechanlcal Principles of the Spine and Joints
Jacob and Kissling (1991 ,199 6) examined sacroiliac joint motion clinically. USing a stereophotogrammeter, they de termined an average range of motion of1 .7° and translation of 0.7 mm. This in-vivo study is in agreement with that of Egund (1987).
Innervation of the Sacroiliac Joint Except for the studies by 5010nen (1957), Fortin et al. (1994a,b), and Grob et al. (1995), there are few, if any, conclusive studies regarding the innervation of the sacroil iac joint. 5010nen (1957) reports that the innervation of the sa croiliac joint occurs via the anterior rami of the obturator nerve. Grob et al. (1995) report that the sacroiliac joint is Fig. 3.62 Innervation of the human sacroiliac joint and the asso
ciated ligaments. (From Kissling,
Left: The long
spinal nerves, 51 and 52. The posterior ligaments are in
1997.)
posterior sacroiliac ligament is shown.
Right: The superficial layer of the posterior sacroiliac ligame nt has been r efle cted
1
exclusively innervated by the posterior primary rami of the
.
nervated by the dorsal rami of 53 and 54. The dorsal rami of 51 through 54 penetrate the sacroiliac ligaments, where they give off fine branches to the gluteus maximus muscle
Medial cluneal nerves
2
Long posterior sacroiliac ligament
and continue to the skin as the medial cluneal nerves
3
Sacrotuberous ligament
(Fig. 3.62).
4
Sacrospinous ligament
Grob et al. postulate that the painful irritation zones associated with a symptomatic sacroiliac joint can be ex
rior and superior on the swing side. This introduces a rota
plained by the fact that the joint and the origin of the
tional component at the sacrum, which is transmitted to
gluteus maximus muscle are innervated by the same dorsal
the lowest lumbar vertebra via the intervertebral disk. Due
rami. In clinical practice, the irritation zones are diagnos
to the counter-nutation of the ilium and the recruited
tically ascertained through manual medicine approaches.
action of the iliolumbar ligament, this vertebra is actually
Furthermore, Grob et al. believe that the diffuse buttock
rotated in the opposite direction (1IIi, 1951).
pain may be explained either by direct irritation or by
Thus, it would be plausible to assume that rotation at the lower lumbar spine during the gait cycle can be held to
pseudoradicular referred pain related to the spinal seg ments of 51 and 52.
a minimum as long as there is unrestricted motion at the sacroiliac joint. Dejung (1985 ) describes the sacroiliac syndrome or sa croiliac joint dysfunction in 58 patients predominately in
Biomechanical Principles and the Clinical Examination of the Sacroiliac Joint
the age range 2 0-40 years. In many cases, the patient reported a history of low back pain, occasionally radiating
One of the aims the manual medicine approach within the
to the buttock but rarely to the knee. The radiation of the
neuromusculoskeletal examination process is to determine
pain is usually on the same side as the side of joint restric
the presence of an anatomically identifiable structure or
tion. The symptoms are often related by the patient to
lesion referable to the pelvic girdle that would explain the
either a previous fall onto the sacrum or concurrent preg
patient's pain.
nancy. A similar description is given by Greenman (1986).
The field of manual medicine has developed a number
Mobility at the lumbosacral junction is often remarkably
of particular examination techniques for the sacroiliac
decreased.
joint, which are routinely guided by the functional-struc
Joint motion restriction due to a somatic dysfunction in
tural approach. The functional-structural approach uses,
this area must be diagnostically differentiated from the loss
among other examinations, the evaluation of the quality
of motion due to antalgic posture secondary to a herniated
and quantity of possible range of motion, palpatory soft
disk. In the latter case, the surrounding muscles may reveal
tissue assessment,
localized muscle "spasm" or a hard palpable band, in par
strength, and specific or provocation tests.
ticular in the gluteus maximus, longiSSimus lumborum, adductor longus, iliopsoas, and piriformis muscles.
76
Copyrighted Material
muscle
evaluation
for length and
Biomechanics of the Pelvic Girdle
The Functional-Structural Examination as Applied to
tually moves superiorly when the patient flexes the thigh at
the Sacroiliac Joint
the hip. During this test, in the "normal" unobstructed
1. Range of motion testing-quantity and quality of
situation, hip flexion is associated with a "drop" of the PSIS on the side of the flexed hip.
motion assessment. The goal with this examination step is to determine not only active and passive range of
Bernard and Cassidy (1991) and Herzog et al. (1989)
motion but also the quality of movement, in particular
examined the reliability of the flexion test and spine test
the end-feel. The examiner also observes which section
in a symptomatic population. They found a high correlation
of the motion is painful along the arc of motion. While
between the examination findings and their causative
the overall range of motion is relatively small, especially
pathology.
when compared to any limb joint or even motion in the
Dreyfuss et al. (1994) examined a group of nonsympto
vertebral facet joints above, a detailed examination is
matic adults in order to determine the incidence of false
useful nonetheless as it may help localize the side of
positive findings that might be encountered when using the various sacroiliac screening tests. A large number of
dysfunction. 2. Palpation of soft tissues. This examination component assesses the soft tissues associated with and surround
false-positive findings would reduce the specificity of a particular test.
ing the sacroiliacjoint as well as the irritation zones that
At least one of the three tests (standing and seated
are correlated with the jOint. Specific provocation tests
flexion tests, spine test) was found to be positive in 20% of
may be required to further delineate the patient's pain.
the nonsymptomatic persons, and when analyzed accord
3. Muscle testing for length and strength. The relevant
ing to the sex distribution, positive findings were present in
key muscles and those associated with the sacroiliac
26% of the female participants and 12.5% in the male par
joint are examined not only for their maximal strength
ticipants. The authors concluded that, given the relatively
but also for any reduction in their normal length
high level of false-positive findings, the presence of a pos itive finding upon sacroiliac joint screening should be in
(Dvorak and Dvorak, 1991).
terpreted very carefully and clearly should not be viewed as
4. Special tests and provocation tests. These routinely include the standing and seated flexion tests as well as the spine test during the initial examination approach to
the "sine qua non" finding for a sacroiliac joint dysfunction. As in other fields of medicine, it is useful to combine multiple tests in order to arrive at a meaningful diagnosis.
pelvic girdle dysfunctions.
As Griner et al. (1981) indicate, the specificity of the indi vidual test can be enhanced when a number of relevant
The Standing and Seated Flexion Tests
tests are employed simultaneously rather than using a
The patient, either standing or sitting, is requested to ac
single test in isolation.
tively flex and extend the thoracolumbar spine while the
Leboeuf (1990) examined the sensitivity and specificity
examiner palpates the posterior superior iliac spine (PSIS)
of seven lumbopelvic orthopedic tests in 20 nonsympto
on either side and compares the presence or absence of any
matic and 39 symptomatic persons but was unable to
movement of the posterior superior iliac spines with re
predict the specific localization or dysfunction in the symp
spect to each other. The test is denoted as positive when
tomatic patients.
one PSIS moves more superiorly on one side in comparison
Mior et a\. (1990) studied the inter-examiner reliability.
with the other side. The side on which PSIS motion is more
While the intra-examiner reliability was very good, the
superior is denoted as the side of "positive" finding, as this
inter-examiner reliability was unsatisfactory. The authors
is the side that is interpreted as the side of sacroiliac joint
concluded that what appears to matter more than the
restriction of dysfunction. One of the potential explana
individual practitioner's experience is the choice of the
tions for this is that the sacroiliac joint is "hung up" on
appropriate combination of the relevant diagnostic tests.
that side-that is, motion is not free-and while bending
McCombe et a\. (1989), examining the usefulness of pain
forward the ilium on the restricted side "pulls the PSIS" in a
provocation tests, conclude that, with a determined kappa
more superior direction as the pelvis rotates anteriorly.
value of 0.16-0.63, the potential use of such tests can be supported. Laslett and Wil.liams (1994) examined 51 pa
The Spine Test
tients using six different provocation tests including the
The spine test is performed with the patient standing while
pelvic distraction and compression tests, pelvic torsion test
the examiner compares one PSIS with the center of the
with left and right hip rotation, anterior sacral compression
sacroiliac joint. Taking the center of the sacroiliac joint as
test, and a superiorly directed shearing test. Their findings
the point of reference, a positive test is one in which the
indicate that the pelvic distraction and compression tests
PSIS does not move inferiorly, remains stationary, or ac-
are quite reliable. as is the pelvic torsion test.
Copyrighted Material
77
Biomechonlcol Prindples of the Spine and JOints
In a study of 72 pregnant women, and using the poste
the neutral zone observations and their relationship to
rior pelvic pain provocation test, Oestgaard et al. (1992)
vertebral range of motion, Panjabi (1992a) has redefined
report sensitivity and specificity values of 81 % and 80%,
the term clinical instability as follows:
respectively. While these figures appear to be rather high, it
"Clinical instability is defined as a significant decrease in the
is noted that the provocation test was correlated with the
capadty of the stabilizing system of the spine to maintain the
patient's subjective symptoms.
intervertebral neutral zones within the physiologic limits so
Adjunct Examinations of the Sacroiliac Joint
and no incapacitating pain."
that there is no neurologic dysfunction, no major deformity, Radiographic studies and laboratory studies have but a
Based on in-vitro and in-vivo studies, the basic hypoth
very limited usefulness in the initial work-up of sacroiliac
esis proposed by Panjabi is that the size of the neutral zone
joint-related pain and dysfunction (Davis and Lente, 1978;
may serve as a better and more sensitive indicator of
Sturesson et aI., 1989).
clinical spinal instability than does the overall range of
Sacroiliac joint injections, although technically demand
motion.
ing, may reduce the patient's pain and thus serve both a
The neutral zone increases significantly after trauma
diagnostic and a therapeutic purpose at the same time
and fracture, while it is prominently decreased in situations
(Fortin et aI., 1994a, b).
of increased muscular activity and internal spinal fixation.
Interim Summary
spine specimens, both the neutral zone and range of mo
Although it is currently not clear which specific test would
tion were found to increase with the severity of injury
In a high-speed trauma experiment using porcine cervical
be the most appropriate for a particular patient or presen
(Panjabi et aI., 1989a,b). However, the same study further
tation, it is safe to say that the use of multifunctional tests
demonstrated that the increases in the neutral zone (mea
can be expected to enhance the reliability of the entire
sured as a percentage of the intact behavior) were signifi
examination routine. When rationally chosen, and inte
cantly larger than the corresponding increases in the range
grated within the entire clinical musculoskeletal diagnostic
of motion for the same injury.
approach, manual medicine examination techniques for
In another study from the same institute, spinal speci
range of motion, soft-tissue assessment, and muscle eval
mens were subjected to high-speed trauma of increasing
uation should all assist in delineating as specific a func
severity. The investigators found the increase in f1exion
tional and structural diagnosis otherwise not obtainable
extension neutral zone to be the first indicator of the onset
through orthodox assessments.
of injury (Panjabi and Oxland, 1993). In an in-vitro experiment (Panjabi et aI., 1989a,b) and a
JOint Motion and Biomechanical
mathematical model of the spine (Nolte and Panjabi, 1989) the application of an anteriorly-inferiorly directed force
Correlations
vector to the middle of the spinous process decreased the
Clinical Instability-A New Hypothesis
motion did not decrease. The important conclusions that
The graphic representation of the tissue behavior in the
Panjabi (1992a) as follows:
neutral zone to the near intact value, while the range of can be drawn from these two studies are summarized by different joints and vertebral motion segments reveals a
"If there was an increased passive neutral zone-for example,
distinctly nonlinear shape. The response to imposed loads
due to degeneration or trauma-then the muscles would be
and forces is rather complex owing to the intricate inter
potentially capable of decreasing it and bringing it within the
play between a joint's architecture, friction, and the inher
normal values. The same was not true for the range-of-mo
ent tissue properties of the various soft-tissue components
tion parameter."
including the tendons, ligaments, joint capsules, and
Grob and Dvorak (1991) applied a small external fixator
muscles. In general, as described at the outset of this chap
in order to stabilize a spinal motion segment temporarily in
ter, joint motion behavior can be broadly categorized into a
the cervical spine. The fixator was used as a diagnostic tool
therapeutic and traumatic region (see Chapter 2, Fig. 2.5).
to determine whether and to what extent its application
Panjabi (1992a) convincingly and elegantly presents a
would diminish or even extinguish the patient's pain at a
new concept of spinal motion and instability. Previously
particular segmental level. Once the pain-generating level
clinical instability has been defined as the loss of ability of
had been successfully determined as the source of the pain,
the spine to maintain its pattern of displacement under
the temporary application was exchanged for a permanent
physiologic loads so that there is no initial or additional
one.
neurologic deficit, no major deformity, and no incapacitat
To quantify the underlying motions responsible for the
ing pain (White and Panjabi, 1990). Within the context of
pain, Panjabi et al. (1994) conducted an in-vitro study using
78
Copyrighted Material
Joint Motion and Biomechanical Correlations
fresh cadaveric human cervical spine specimens. The stabi lization was tested in the spinal segments of C4 through C6 (Fig. 3.63). Combining all of the results, the range of motion decreased on average by only
Movable frame
38%, whereas the neutral
zone decreased by 71 % (Panajbi, 1992a). The basic hypothesis originally presented by Panjabi (1992a) proposes that the size of the neutral zone could represent a better, more useful indicator of clinical spinal instability than does the overall range of motion. He also
Cervical external
argues that while the neutral zone in vivo has not been measured directly, there is significant indirect evidence to support the hypothesis.
Immovable frame
In summary, on the basis of the above studies, the spinal column exhibits nonlinear load-displacement behavior (see Fig. 3.64), and the behavior is such that the spine is highly flexible in the vicinity of the neutral posture. It is hypothesized that in adverse conditions, the decrease in neutral zone may be better correlated with the pain, and that ultimately the reduction in the neutral zone is a better indicator of instability than is the previously described increase in gross spinal range of motion. Motion within the neutral zone is rather free and unre stricted and involves minimum expenditure of muscular energy (Panjabi, 1992a), whereas in the elastic zone, sig nificantly greater forces are required to induce motion. As a descriptive demonstration, Figures 3.65 and
3.66
attempt to represent the above concepts graphically. A
Fig. 3.63 An external fixator is applied to the cervical spine speci
rather broad, almost flat container (e. g., a flat bowl) would
mens. The light-sensitive markers are placed on the vertebral
be correlated with a relatively large neutral zone in a spinal
bodies, where they register the three-dimensional intervertebral
segment, which would represent a rather unstable condi
motion via light sensors (Panjabi et aI., 1994).
tion (Fig. 3.65a). A high-walled, steep container (e. g., wine glass) would have a small neutral zone, indicating relatively good spinal stability. As graphically represented in Figure 3.66, the neutral
Force
zone in the "normal" situation is smaller than the pain free zone. When the spinal column becomes symptomatic,
ROM •
..
the neutral zone is increased beyond that of the pain-free zone, which may be correlated with the patient's sensation of pain, for instance. The assumed increase in the neutral zone in the pres ence of clinical instability may be corrected by appropriate fixation or ankylosing procedures, such as an external fixation or spinal fusion, or conversely, and if possible,
NZ ..
•
through a coordinated muscle strengthening program, Range of motion
which may then decrease the pathologically enlarged neu tral zone. This restoration of the normal neutral zone may then reduce or extinguish the patient's pain.
Fig. 3.64 The load-displacement curve demonstrating the non
In application to a clinical presentation, Klein (2001)
linear relationships between the range of motion (ROM) and force
examined patients with symptoms of whiplash-associated
in a spinal segment. The entire range of motion can be subdivided
disorder (WAD). He used EMG of the sternocleidomastoid
into a neutral zone (NZ) and an elastic zone (EZ).
muscle and simultaneously used the C A-600 analyser to measure the range of motion (ROM) of the cervical spine. For the WAD patients it was impossible to reach even the
Copyrighted Material
79
Biomechanical Prindples of the Spine and Joints
Force
Force ROM
NZ
NZ
a
c==:::
:--:---. b
b A narrow drinking-glass-like structure is representative of a
Fig.3.65 Comparison model of instability versus stability.
a A flat bowl-like structure has a rather large neutral zone, corre
relative stability with a small neutral zone. ROM
sponding to relative instability.
Range of motion, NZ
Neutral zone
Fig.3.66 Interpretation of the hypothesis of mechanically induced pain as presented by
Range of motion (ROM)
•
Panajabi et al. (1994) .
..
Top:
D-,in_fr£:'le zone
In the normal, nonpainful situation, the neutral zone is smaller than the pain free zone.
Normal -
I
eutral
zoni
.
Center:
I
In the painful situation, as may be the case in pain-induced with movement, the neutral zone is larger than the pain free zone.
Bottom: In the pain-free situation, as may be
•
Painful
..
..
I
an external or internal fixator, or
-i==7
.
Pain-free
accomplished with fixation, by use of through muscular activity, for instance, the neutral zone has been reduced once again to fall below the level of a pain-free zone.
..
I.
I.1
)
elastic zone. They were "trapped" in the neutral zone,
This hypothesis therefore represents the "next step,"
either unable or unwilling to move the cervical spine into
wherein biomechanical factors are correlated with neuro-
a position that would seem to require additional muscle
physiologic changes in order to look at a patient's pain not
activity, either due to the concomitant pain or to the fear of
as an "isolated clinical fact" but rather as the expression of
precipitating it.
their combination by the individual patient.
80
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Neurophysiology of the Joints and Muscles
4
Neuropathophysiology of the Apophyseal joints
Articular Neurology The following presentation is based mainly on the funda
The past
30 to 50 years have witnessed constantly increas
mental work by Wyke and co-workers.
ing interest by physicians in manual medicine approaches.
Articular neurology can be defined as that branch of
At the same tiine there has been an equal amount of
neurology that deals with the morphology, physiology,
skepticism and overt criticism of the reported, primarily
pathology, and clinical aspects of the innervation of the
empirical studies, since definitive basic and clinical re
joints of the entire skeleton and the limbs. Within this
search was lacking. For a long time more hypothetical
chapter, we will concentrate primarily, but not exclusively,
postulates than real science had been proposed in an at
on the apophyseal joints, which are also referred to in the
tempt to explain the possible mechanisms of action that
literature as the zygapophyseal ("Z-joints") or facet joints;
were thought to underlie the different manual medicine
in this text the terms will be used interchangeably.
techniques. Despite recent notable progress and intensive
Wyke's major contribution to the field of articular neu
international efforts with better scientific designs and im
rology was the identification of the structures and inner
plementation of solid research protocols, little is still
vation patterns of the four major joint receptor types, as
known today about the specific neurophysiologic processes
well as their distribution and characteristic physiologic
or specific biochemical or biomechanical mechanisms that
behavior. Furthermore, Wyke's work has shown that these
are initiated with or follow manipulation or mobilization
reseptors can be found in all synovial joint capsules, and
maneuvers applied to the joints of the spine and the limbs.
that they have an effect on static and dynamic reflex con
One of the major initial steps was taken in
1975,
when
upon the recommendation of the National Institutes of
trol mechanisms of the skeletal muscles in response to normal and pathologic conditions.
Health, the National Institute of Neurological and Commu nicative Disorders and Stroke (Goldstein,
1975) held a con
ference on the topic "The Research Status of Spinal Manip
Receptors of the Joint Capsule
ulative Therapy." References here are mainly to Sato's
(1975) (1975)
work on the somatosympathetic reflexes, Perl's
It is now accepted that the human synovial joints contain
work on pain and spinal and peripheral nerve fac
three types of mechanoreceptors (nociceptive-free) and
tors, and White and Panjabi's
(1990) fundamental work on
the biomechanics of the spine. In
1978,
the free nerve endings-the nociceptors. Their organization was visualized in neurohistologic studies (Wyke and Pola
a symposium was held in Pisa, Italy on "Reflex
Control of Posture and Movement" (Granit and Pompeiano,
cek,
1973, 1975; 1979).
Freeman and Wyke,
1967;
Vrettos and
Wyke,
Even though manual medicine per se was not dis
The mechanoreceptors are proprioceptors and can be
cussed, this symposium offered a broad basis of the theo
further subdivided into three specific groups (types I. II. and
retical research in this field up until that time.
III), while the
1979).
In
1982,
the College of Osteopathic Medicine at Michi
gan State University held a symposium entitled "Empirical
nociceptors make up the fourth group (type
IV). They are depicted in Figures 4.1 and 4.2 and are de scribed in more detail below.
Approaches to the Validation of Manual Medicine" (Green man and Buerger,
1984).
Here, researchers and clinicians
Type
I
Receptors (Mechanoreceptors) I mechanoreceptors are found
from the fields of biomechanics and neurophysiology dis
The type
cussed their basic and clinical research findings in relation
outer layers of the fibrous joint capsule. These receptors
to the field of manual medicine.
primarily in the
consist of three to eight globular corpuscles measuring
Based on his basic experimental research with Freeman
approximately
100 i-lm
by
40 pm.
Thinly encapsulated and
(Freeman and Wyke, 1967), Wyke coined the term "articu
thinly myelinated afferent nerve fibers
lar neurology." Wyke's publications from
these corpuscles with the corresponding articular branches
1967, 1975
(to
gether with Polacek), presented by Jayson
1979, and 1980, and the information (1980) expand on this term and thus
(6-9 i-lm)
connect
of the dorsal rami of the spinal nerves.
provide a basis for a better understanding of the neuro physiologic processes that are potentially involved in man ual medicine. These will now be described in more detail.
81
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Neurophysiology of the Joints and Muscles
#' r,;;:J.,
h: -:- '
,
f'
,
J'
'
/,
\---::; .../';/
Type II
Type I I I
Type IV
Fig.4.1 Schematic representation of the four joint receptors. The type I, II, and III receptors are mechanoreceptors. Type IV receptors are nociceptors (Polacek, 1966).
Function •
Rapidly adapting mechanoreceptors with a low thresh old reacting to changes in tension of the fibrous joint capsule (less than 0.5 seconds).
Type I
Type II Type III
•
Phasic and reflexogenic effects on neck, limb, jaw, and eye muscles.
•
Transitory inhibition of the nociceptive activity of the joint capsule.
Type III Receptors (Mechanoreceptors) Mechanoreceptors of the type III category play a significant role in joint function. The type III receptors are typically embedded in the ligaments and the terminal portion of the· tendons close to the joint capsule. They are not found in the
Fig.4.2 Location of the various joint receptor types demonstrated for the knee joint. (After Freeman and Wyke, 1967.)
joint capsule itself. Morphologically, they consist of broad, fusiform corpuscles (600 11m by 100 11m) and usually ap pear singly. Occasionally, they occur in clusters of one to three and are found at the end of a ligament or tendon.
Function •
•
•
The type III receptors are innervated by large myelin
Slowly adapting receptors: they control tension of the
ated (13-17 11m) fibers that are connected to the articular
outer layers of the joint capsule.
branches. The shape of the type III receptors resembles that
Transsynaptic inhibition of the centripetal flow of the
of the Golgi tendon organs. It is postulated that the type III
activity of the nociceptive afferent receptors (type IV
mechanoreceptors may have a function similar to that of
nociceptors); in other words, inhibition of the impulses
the Golgi tendon organs. Furthermore, it is believed that
arising from pain receptors.
these slowly adapting receptors have an inhibitory reflexo
Tonic reflexogenic effects on the motor neurons of the
genic effect on motor neurons (Freeman and Wyke, 1967).
necl<, limb, jaw, and eye muscles (Wyke 1975, 1977; Molina et aI., 1976; Biemond and Dejong, 1969; Igarashi
Function
et aI., 1972; Hikosaka and Maeda, 1973; Dejong et aI.,
•
Inhibitory reflexogenic effects on motor neurons.
1977).
•
Function similar to the Golgi tendon organ.
Type IV Receptors (Nociceptors)
Type II Receptors (Mechanoreceptors) The type 1\ receptors consist of oblong, conical, thickly
Nociceptive fibers are sensitive to noxious substances in
encapsulated corpuscles (about 280 11m by 100 11m) that
the tissue. Nociceptors are free, very thinly myelinated or
most often appear singly in the deeper layers of the fibrous
nonmyelinated plexiform nerve endings. They are ubiqui
joint capsule. These receptors are connected to the articular
tous in the fibrous portion of the joint capsule. This recep
rami by way of thickly myelinated nerve fibers.
tor system is activated by depolarization of the nerve fibers. For instance, depolarization occurs with constant pressure on the joint capsule as would be the case with nonphysio
82
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Articular Neurology
logical position or as is seen with abrupt, jerky, uncon
Innervation of the Joint Capsule
trolled movement. They are set off by such tissue altera tions as disk narrowing or compression, acute vertebral
The joint is innervated by the dorsal rami of the associated
fracture, or a dislocation of the apophyseal joints, In addi
spinal nerves. It should be emphasized that the articular
tion to mechanical factors, the nociceptors can also be
ramus of a nerve root contributes not only to one segmen
stimulated by chemical irritation via such substances as
tal joint capsule: its collateral rami above and below also
potassium ions, lactic acid, 5-hydroxytryptamine, and his
supply the neighboring joints as well. Therefore, the joint
tamine, among others. Interstitia.1 edema of the joint cap
capsules are innervated bisegmentally or even multiseg
sule, often associated with acute or chronic inflammatory
mentally (Auteroche, 1983).
processes, is also known to activate the fibers, resulting in
The cross-sectional representation at the level of the
pain.
thoracic spine is depicted in FigA.3. This depiction dem
Function
sponding joints, tendons, paravertebral muscles, and the
onstrates the course of the nerve as it supplies the corre •
Pain generation.
•
Tonic reflexogenic effects on neck, limb, jaw, and eye
periosteum.
muscles. •
Respiratory and cardiovascular reflexogenic effects.
6.
6
a
L-________________________________________ __
Apophyseal joint
periosteum in the thoracic spine region. (After Wyke, 1967.)
2
a Innervation of the vertebrae and disks, lateral view. Note that
3
Costotransverse joint
typically each facet joint receives its innervation of at least two
4
Spinal ganglion
5
Anterior ramus of the spinal nerve (left)
neighboring branches.
b
____________________________ ______ ____
Fig. 4.3a, b The nerve supply of the joints, muscles, ligaments, and
Costovertebral joint
b Cross-sectional schema of the localized vertebral, disk and facet
6
Posterior ramus of the spinal nerve (left)
joint innervation as demonstrated in a thoracic vertebra. Note
7
Anterior longitudinal ligament
that typically the posterior primary ramus innervates the para
8
Posterior longitudinal ligament
vertebral muscles of the back, whereas the anterior primary
9
Paravertebral muscles
ramus innervates the extremities. Note the relationship of the
10
Interspinous ligament
spinal ganglion with reference to the facet joint posteriorly and
11
Ventral nerve root of the spinal nerve
the costovertebral joint anterolaterally.
12
Dorsal nerve root of the spinal nerve
Fig.4.3c
C>
83
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Neurophysiology of the Joints and Muscles
Fig.4.3c Innervation of the disk with emphasis on the Nucleus pulposus ------ .
�------
Sympathetic ganglion -----.. Gay ramus-----communicans Sinu-vertebral nerve Anterior primary division Posterior primary division-
Dorsal root ganglion --
sinuvertebral nerve (Halde
longitudinal ligament
mann et aI., 2002).
.,v-.A
Annulus fibrosis
:
Posterior longitudinal
.?!
Spinal nerve
Anterior
7
.
_I
ligament Dura mater
Central Interactions of the Mechanoreceptors and Nociceptive Impulses
other sensory modalities, such as that of light touch, re mains intact, however (Yoshimura and North, 1983). It is possible that opioids inhibit those cells of the sub stantia gelatinosa that function as interneurons in the
The nociceptive and mechanoreceptive fibers enter the
transmission of pain. Electron-microscopic studies showed
posterior horn in the gray matter of the spinal cord via
an endogenous en kephalin in the substantia gelatinosa
the dorsal root. Once in the spinal cord, the nociceptive
(Benett et ai., 1982), which again would support the idea
fibers divide into a number of collateral rami.
of the interneurons performing an inhibitory function. The
Some of these rami extend through the gray matter di rectly to the basal nuclei (basal spinal nucleus or laminae IV
enkephalins have been surmised to function as inhibiting neurotransmi tters.
and V after Rexed). From there, they run through the lateral
It also appears that strong stimulation of the type II
spinothalamic tract (anterolateral portion) to ultimately ter
mechanoreceptors can lead to a depotlike increase of the
minate in the limbic system, where the actual perception of
enkephalins in the dorsal horns (Wyke, personal commu
pain occurs. Pain cannot be subjectively perceived unless
nication, 1983).
depolarization of the synapse has occurred at the level of the basal nuclei following the initial nociceptive impulses. Similarly to the nociceptive afferent fibers, the mecha
Mechanoreceptors and I\lociceptive Reflexes
noreceptive afferent fibers enter the posterior horn of the gray matter of the spinal cord through the dorsal root
As outlined earlier in this chapter, one of the major con
(Fig. 4.4).
tributions to the current understanding and the basis for
It is important for this theory that some of the many
further research of the clinically observed nonradicular
divided rami form synapses at the level of the apical spinal
pain syndromes, and the spondylogenic reflex syndrome
nucleus or lamina II (after Rexed). The apical spinal inter
(SRS: see Chapter 6) in particular, came from Wyke and his
neurons arising from this level conduct the activity of the
co-workers. This experimental work is of particular rele
mechanoreceptive afferent stimuli to the basal spinal nu
vance for clinical practice and for our current understand
cleus, where they are thought to inhibit presynaptically the
ing of the various proposed mechanisms.
pain-inducing nociceptive neurons. Thus, they interrupt
The joint capsule and the articular nerve of C3-C4 were
conduction to the spinothalamic tract and the limbic sys
microsurgically exposed in anesthetized cats. The joint
tem (Wyke, 1979a,b; Bonica and Albe-Fessard, 1980).
capsule was irritated using a probe and a stimulator. A
Experiments on adult cats demonstrate that a portion of
substantially lower voltage was necessal)' to stimulate
the thinly myelinated afferent fibers end in the substantia
the mechanoreceptors (2 V) than to stimulate the nocicep
gelatinosa of the dorsal horns. The transmission of noci
tors ( 8 V). Wyke's results, as reproduced here, very clearly
ceptive impulses-as initiated by peripheral stimulation of
show the reflex relationships between the receptors of the
the nociceptors, for instance-can be blocked by applica
fibrous joint capsule, the apophyseal (facet) joints, and the
tion of opioids to the substantia gelatinosa. Transmission of
peripheral musculature (Figs. 4.5-4.8).
84
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Articular Neurology
Afferent fi ber
s
from nociceptors
Affe re nt f ib er s from mec ha no rece pto rs (Ap-fibers)
Lim bi c s y st em
(AO. (-fibers)
t
h l
i
Spi not a am c t r a ct Neurons In dorsal hom
t
Inhibiting intemeuron Basal nucleus
Dorsal root
Anterior spinothalamic tract
t Nociceptors
Fig.4.4 Arrangement of the fibers of the mechanoreceptors and nociceptors in dorsal horn of the spinal cord. (After Wyke. 1979 a.)
] ] 11.... .....It••'"''''1'1 ....,.... I nW'." •. Wit..... ] ..ruu"..'t......* t tt_.I••tll'l.t!... ]
Left sea lene Right scalene Left sternocleidomastoid
"J4�
Right sternocleidomastoid
�4��.�'���ii�il.f.fIIoWA� ]
Left trapezius Right trapezius
......... "1 ·"
Left digastric Right digastric
'r"
«
"!rI
S
+,! "., I ,""-< I "" . •
' { f. r1''' '' ''' ' "'.'f4I41 ""· fofIr'-"'.""."'''' '''' ''",''' ''''''''''.''•••''''''
] ] l
.J
..... 2 VIS Hz/S ms
Fig.4.5 The reflexogenic mechanoreceptor effects of a cervical apophyseal joint on the muscles of the neck. At the location indicated by the arrow. a single articular nerve of the left (3-(4 apophyseal joint was stimulated for 3 seconds with an electrical impulse (2 V. S Hz. S ms) that selectively excited the mechanoreceptive afferent fibers in the exposed nerve. The simultaneous electromyographic tracings show a long-lasting effect on the homologous pairs of the neck muscles. (After Wyke. 1979a.)
Akio Sato (1975) made similar observations in his inves tigation of the somatosympathetic refiexes. A refiex type of
Possible Neural Mechanisms Involved in Back
relationship between soft-tissue changes or segmental
Pain
(i.e., somatic) dysfunctions and diseases of internal organs has been suggested on the basis of clinical observations
The free nerve endings associated with the nociceptors are
(Beal. 1984; Beal and Dvorak. 1984; Larson, 1976). Perl
found in the joint capsules, muscles (Mense and Meyer.
(1975) partially explains the phenomenon of referred
1985), the intervertebral disks (Bodgduk, 1993), and the
pain by this refiex mechanism. Wyke (1979b) suspects
dorsal nerve root ganglia. They are all sensitive to pressure.
that multisynaptic intraspinal tracts may be involved.
A sensory volley up to 25 minutes after compression of
which both ascend to the brainstem and descend to the
the ganglion was detected. The ganglion may be a signifi
basal nuclei of the lower levels of the spinal cord.
cant source of a patient's pain. especially when considering
85
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Neurophysiology of the Joints and Musdes
1"".1.''''4� ,•• I..... 1:1,......... i4....,
Left scalene
.. �4
Left sternocleidomastoid
I
._,.....
., •• 11.'""11,'.,_1 ]
Left trapezius Left digastric Right scalene
.,.....
Rightstemocleidomastoid
....
. ,'"
'I '--,.,.
J
•
n. If. F It. "..,..w..,On1••'JQII. f,.P"".04I••
Right trapezius Right digastric
...
,
,.'. &1>'" PI' 't
•
p" . .... t
_It
•
] ]
T.""
5
]
..
100
8 VIS Hz/S ms
V
Fig.4.6 The same experimental arrangement as in Fig. 4.5, except with a stimulus of 8 volts, 5 hertz, 5 milliseconds, in which both the afferent fibers of the mechanoreceptors and nociceptors were stimulated. (After Wyke 1979a.)
Left biceps brachii
...... .1
-----
Left rectus femoris
Left biceps femoris
Left biceps brachii
...
Left triceps brachii
'
---.ollll rill __•• '
""'
ll
]
Left triceps brachii
_�i\� t
]
Left rectus femoris
""'404••I':_,(I1'I$ J
Left biceps femoris
•
Right biceps brachii
'W .It •
Right triceps brachii
"MIa' Is'
Right rectus femoris
,U
2s
Right biceps femoris
Fig.4.7 Reflex effects of the mechanoreceptors of the cervical
.I•• ] '''b *It 4 ]
lit......ti•• ] ..
.I "c... J
.' J
' J.. . "''''' . ..' ' _ ,
'.'_Plat'••• I.I.". t d J
apophyseal joints on limb muscles. At the signal (5), a single,
.
50 v
'---'--.J
2s
exposed branch of the articular nerve was repetitively stimulated for 3 seconds, selectively exciting the mechanoreceptor afferent fibers in the corresponding nerve. The simultaneous electromyo graphic tracings of the upper and lower limb muscles display the reflexogenic effects of varying duration. They demonstrate that such stimulation has an affect not only on the muscles of the neck but also on the muscles of the extremities. (see also Fig.4.5). Interestingly, stimulation that generates a nociceptive impulse produces a different muscle potential response. (After Wyke 1979a.)
Fig.4.8 The reflex effects of an induced manipulative procedure directed at the (3-(4 articulation. At the signal, brisk vertical cervical traction procedure was applied to the isolated jOint. The simultaneous electromyographic traCings of the homologous pairs of the upper and lower limb muscles display the reflex effects of such cervical manipulation on the peripheral musculature. (After Wyke, 1979a.)
its close proximity to the disk and in particular when there
It has been postulated that the nucleus pulposus may
is a significant disk herniation (e. g., prolapse, protrusion).
contain chemical substances that, when released from the
The dorsal nerve root itself does not appear to be partic
disk after a tear, for instance, may induce inflammatory
ularly pressure sensitive unless there is concomitant in
neurodegenerative reactions. Furthermore, it was thought
flammation or irritation. In a rabbit model, sensory dis
that in the acute phase these chemical irritants are excita
charge lasting up to several minutes after induced com
tory rather than inhibitory.
pression of the nerve root by the autologous nucleus pulposus was observed.
Olmarker and Rydevik (1993) believe that the immuno globulin G or stromolysin may be one of the chemical
86
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Functional Pathology of Muscle
irritants. These observations may. at least in part, explain the unabated pain reported by a significant number of
Human Skeletal Muscle Fiber Types
patients, even when decompressive spinal surgery had
Muscle fibers are categorized according to their biochem
been deemed successful after nerve root compression, for
ical, histochemical, mechanical, and metabolic character
instance.
istics (Barnard et aI., 1971; Dubowitz, 1985; Cumming et al" 1994). Until quite recently, striated muscles had simply been classified according to their primary metabolic ac tivity as either aerobic or anaerobic muscle, or red and
Functional Pathology of Muscle
white muscle, respectively. Recent research, however, in
Morphology and Function of the Slow-Twitch
dicated that further subclassifications was necessary, es pecially for the "white" fibers, which are more accurately
(Type I) and Fast-Twitch Muscle Fibers (Type II)
known as "type 1/" fibers. While the literature had re
Human skeletal muscle is characterized by a high degree of
properties of both the aerobic and anaerobic fiber types,
ported "intermediate" muscle fibers that appear to share plasticity. This plasticity is accomplished by a wide array of
specific staining techniques have allowed separation of
different muscle fiber types, which allows the various
the various fibers according to their particular metabolic
muscles to respond to the many different functional re
and contractile properties. Despite the advent of more
quirements placed upon them (Pene, 1990). This explains,
detailed histochemical profiles, this has also led to
at least in part, the muscles' abilities to respond to different
fusing nomenclature for the different types of muscle
demands. On the one hand, a person is abl.e to perform
fibers (Cumming et aI., 1994). The salient characteristics
high-speed activities of short duration such as a hundred
are listed in Table 4.1.
a
con
meter dash, while on the other the same person is able to
The primary categorization distinguishes between the
run at slower speeds over long duration as is required in a
slow-twitch, oxidative, fatigue-resistant type I fibers, and
marathon. The ability to develop sufficient strength for
the fast-twitch, glycolytic type" fibers, which are further
activities such as lifting a 200-kilogram weight is yet an
subdivided according to their fatigability. The type IIA fi
other aspect of the muscles' functional plasticities to re
bers are the fast-twitch, fatigue-resistant, glycolytic fibers,
spond to different demands.
while the type liB fibers are also fast-twitch and glycolytic
Fluck and Hoppeler (2003 ) present a state-of-the-art
but fast-fatiguing fibers.
review of muscle structure and function in which they
Recent studies seem to indicate that human type liB
describe a muscle's plasticity in response to various stimuli
fibers may correspond to the II-x fibers described for ani
as well as developing a paradigm for studying gene regu
mals (Ennion et aI., 1994; Smerdu et aI., 1994), and the
latory phenomena in humans.
nomenclature has recently changed accordingly.
The following section on muscle fibers is based on the excellent review presented by Weber (1995), which is re produced here with kind permission.
Table 4.1 Histochemical, biochemical, and phys i o l ogi c classifications of the three major muscle fiber types (after Barnard et aI., 1971; Cumming et aI., 1994, Dubowitz, 1985)
H istochemica l
Bioch emica l!
Classification
Physiologic Classification
Brooke, Kaiser (1970)
Barnard et al. (1971)
Peter et al. (1972)
Slow-twitch
SO
Red
Slow twitch oxidative
S -
Slow twitch -
Fatigue-resistant Fast-twitch intermediate
IIA
liB
FOG
FR
Fast-twitch
Fast-twitch
Fast oxidative glycolytic
Fatigue- resistant
Fast-twitch
FG
FF
White
Fast-twitch glycolytic
Fast-twitch Fast-fatiguing
50
slow oxidative, FOG
fast oxidative glycolytic, FG
fast. glycolytic. 5
slow, FR
fast, fatigue-resistant. FF
fast-fatiguing.
87
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Neurophysiology of the Joints and Muscles
These characteristics account for the "red" color of such fibers and their predominant mode of metabolism,
General Properties •
Aerobic type I muscle fibers:
which is aerobic, or slow oxidative. (Wheater et aI.,
While varying from muscle
to muscle, the type muscle I fibers are generally small in cross-section, contain abundant mitochondria, and have
•
1979). Anaerobic (glycolytic) type 1/ muscle fibers: Again, keep ing variation of size in mind (depending on the muscle
a large content of myoglobin and a rich blood supply.
in question), the type II fibers are typically larger in
-
\, ) \
- \
-{
�l<
-.
r
r�1 -'
."
liB
'1'-- "
)
.0 ,
cross-section than the type I fibers. They contain few mitochondria and little myoglobin, and have a relatively
' '--)
poor blood supply. These characteristics account for the "white" color of such fibers and their predominantly anaerobic mode of metabolism. These muscle fibers are rich in glycogen and glycolytic enzymes. Anaerobic fi bers predominate in muscles responsible for intense but sporadic contraction such as the biceps and triceps
IIA
muscles of the arm (Wheater et aI.,
' - ',
\____..1
'\
1979).
As Frontera (2000) points out, the various muscle fiber type groupings should be viewed on a continuum with dynamic
Fig.4.9 Cross- section of a human multifidus muscle and incubated for alkaline ATPase, The muscle had been incubated prior at a pH
10.5 (x 200 magnification),
properties rather than as static or separate and discrete classes. This continuum is defined by the presence of the different isoforms of both the contractile proteins (e.g., myosin heavy and light chains) and the regulatory muscle proteins (e. g., troponin and tropomyosin) (Billeter et aI.,
1981;
Billeter and Hoppeler,
Schiaffini and Reggiani.
1994; Heizmann et aI., 1981; 1994), The expression of these
proteins is reportedly controlled at the gene level (Moss' et al. .
1995).
Fiber Type Determination The histochemical method for distinguishing the various muscle fiber types under the light microscope is the myo fibrillar ATPase stain. It takes advantage of three different ATPase isoforms. which react differently to specific pH variations (Cumming et al..
•
Fig. 4.10 Acid ATPase with prior incubation at a pH 4.3.
pH
1994).
10.5: When the muscle biopsy section (e.g.. 14
m
frozen section) is incubated in a basic solution at a pH of 10.5. the subsequent ATPase reaction will stain only the
,.
, •
I,
with the result showing dark-brown coloration of the
.
type liB and intermediate brown coloration of type IIA fibers. The ATPase of type I is inactivated at a pH of
,; )
1113 I.,.
type II fibers (anaerobic muscle fibers-fast myosin).
I
•
" ..
pH 4.3: The reverse is true when a biopsy muscle section is incubated at a pH of 4.3. In this instance. the type I
f'I
"
10.5
(Fig.4.9), giving them a pale appearance.
fibers (slow myosin fibers) stain dark whereas type IIA fibers stain the lightest and type liB as intermediate
'
(Fig.4.10). •
pH 4.6: When incubated at pH 4.6, the type I fibers stain dark whereas type lIB stain in a medium brown color
, \
while the type IIA fibers remain pale (Fig.4. 1 1).
Fig. 4.11 Acid ATPase with prior incubation at a pH 4.6.
88
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Functional Pathology of Muscle
The physiologic characteristics of the different fiber types are not as easily differentiated as the ATPase stain may indicate. since the results of this method may not only vary but may also be influenced by a pathological condition that can render the fiber's type indistinct (Cumming et al.. 1994). It has therefore become standard practice to take advantage of the property of the myofibrillar ATPase reac tion to show different staining patterns at different pHs and to perform the reaction on serial sections. following acid pre-incubation conditions. usually at or around pH 4.3.5 (Cumming et al.. 1994). The fiber composition in terms of the percentage dis tribution of the different fibers ultimately determines the Fig.4.12 Characteristic "type grouping" predominates in the right
characteristics of the individual muscle. The muscle fibers that are innervated by a single motor neuron make up the fibers of one motor unit. With the
muscle fascicle and is less prominent. but present. in the left fascicle.
exception of a few sporadic cases and a few transitional types of fibers. the muscle fibers associated with one motor unit are usually of the same muscle fiber type. Due to the presence of various motor units next to each other. the associated muscle fiber assumes the appearance of a chess board pattern (Burke et al.. 1971; Kugelberg and Edstrom. 1968). Johnson et al. (1973) point out that human skeletal muscle is subject to great variations. which may explain the rather large range for "normal values." According to the same authors. the composition of the erector spinae muscle. for instance. is by no means uniform; when exam ined for the presence of type I fibers. the proportion varied between 30% and 80%. A similarly large variation was found when using mean fiber diameter measurements
Fig.4.13 Selective atrophy of the type II muscle fibers.
(Polgar et al.. 1973). Thus. at least two different samples collected at two
Engel (1968) coined the term "type grouping" for the phe
different time points are needed in order to follow over
nomenon. which has been associated with a chronically
time any possible changes in a person's muscle composi
denervated state (Morris and Raybold. 1971) (Fig.4.12).
tion or the progression in response to particular activities or possible pathologic processes.
Selective Atrophy of One Fiber Type
Atrophy of exclusively one fiber type only is not thought to be due to typical neurogenic process. This form of atrophy
Pathologic Changes in Muscle Morphology as a Result
is thought to be the result of immobilization or disuse or
of Neurogenic Processes
underuse of a particular muscle or muscle group (Fig. 4.13).
"Type Grouping"
Atrophy of a Large Fiber Group
The stain of a biopsy section reveals rather large. relatively
When one fascicle is characterized by atrophic fibers while
uniform groups of one muscle fiber type next to another.
the neighboring fascicle is almost normal. one should con
Denervated muscle fibers are re-innervated by collateral
sider the possibility of denervation (Fig. 4.14).
sprouting of
the neighboring axons (Harrimann
and
Taverner. 1970; Kugel berg et al.. 1970; Grinnell and Herrera.
"Target Fibers"
1981; Wernig and Herrera. 1986; Edstrom and Larsson.
In the presence of a denervation process. the type I fibers
1987).
may assume the appearance of a "target." There is a rela
The appearance of the fibers grouped by type in this way
tively clear and empty central zone that is absent of any
can thus easily be distinguished from the otherwise unaf
enzyme activity and is surrounded by a dark. strongly
fected. normal-appearing chessboard pattern. Karpati and
oxidative ring (middle zone) and a relatively normal outer
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Neurophysiology of the JOints and Muscles
Fig.4.14 Muscle fascicle with atrophied fibers and "type grouping."
Fig.4.15 "Target
Fig.4.16
Fig.4.17 "Moth-eaten fibers" (x 200
a
b
fiber" (arrow).
(x 250
magnification).
magnification).
Core-targetoid fibers (x 50 magnification). " •
Core-targetoid fibers
(x 200
magnification).
Target fibers.
peripheral zone. Again the type I fibers are more frequently
"Split Fibers"
involved. showing this type of pattern as a result of dener-
On occasion the muscle fibers can undergo splitting.
vation. However. a similar appearance has been described
Extensive splitting can cause a large muscle fiber to be-
for fibers during re-innervation after initial denervation
come divided into small subfibers. As a normal variant.
(Dubowitz. 1967) (Fig.4.15).
such changes have been observed in particular at the
"Core-targetoid Fibers"
served in progressive muscle dystrophies as well as
Primarily type I fibers show this type of stain. again due to
chronic denervation processes (Hall-Craggs and Lawrence.
denervation processes (Fig. 4.16). The central core does not
1970) (Fig. 4.1 8).
myotendinous junction. Similar changes have been ob
stain. however.
Bagnall and co-workers (1984) studied biopsy sections from the multifidus muscle in patients who were known to
"Moth-eaten Fibers"
have a disk herniation. They demonstrated no difference
The "moth-eaten" appearance is due to aberrations in the
between the side of disk herniation and the opposite "nor
intermyofibrillar network. An oxidative enzyme reaction is
mal" side and thus used these findings as the "nollllal"
able to demonstrate this histochemically. The "moth
control. Mannion et al. (1997) also did not find any patho
eaten" character has only been found in type I fibers. and
logic changes in the musculature. in contrast to the reports
hence this pattern has been seen in various types of myo
of Mattila et al. (1986) and Zhu et al. (1989).
pathy. The finding is rather nonspecific. however (Fig. 4.17).
Sirca and Kostevc (1985) compared cadaveric biopsy sections obtained from the multifidus muscle of 21 men
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Functional Pathology of Muscle
with those of 12 men and five women obtained during disk herniation surgery. They found that the fiber diameter was smaller in the biopsy samples obtained during live surgery than in those obtained at autopsy. The percentage fiber composition was similar in both study groups. Mattila et al. (1986) compared biopsy samples of the multifidus muscle obtained from a group of 41 patients who had a demonstrated disk herniation with 12 control subjects (autopsy). In both groups the type II fibers were prominently smaller than the type I fibers. The disk hernia tion group also had findings of core-targetoid and/or "moth eaten" fibers among the type I fibers. Since the control samples did not show any of these findings, they were considered to be the result of pathologic changes. Type grouping was found in only a few cases. Zhu et al. (1989) studied the biopsy samples of 22 pa
Fig.4.18 "Split fibers" after Hall-Craggs and Lawrence (1970) as seen in this basic ATPase stain and neighboring "type grouping"
(
x
160 magnification).
tients who were undergoing disk herniation. The sample was obtained from the erector spinae muscle on the same
multifidus muscle (54.1 %, Jorgensen et aI., 1993; 54.9%,
side as that of disk herniation (L3-S1). Eighteen of the 22
Johnson et al. 1973; 66.6%, Sirca et a!. 1985; 60.6%, Mattila
patients revealed a typical atrophy of fiber type II, three of
et al. 1986; and 57. 4%, Rantanen et al. 1994).
whom had type liB atrophy only. The type II atrophy corre
Mannion et a!. ( 1997 a) report that the percentage con
lated well with the patient's age and symptom duration.
tribution of type I fibers in sections obtained from patients
The atrophy of the type II fibers was significantly higher in
who had undergone surgery was approximately 51%, while
patients older than 40 years and those who had a long
that in the control group was 66%. Mannion et al. (2000)
duration of symptoms (longer than one year). In addition
report the percentage contribution of type I fibers for pa
to the atrophy, a number of pathologic changes were ob
tients with low back pain as 65% for men and 73% for
served upon histochemical examination. No significant dif
women.
ferences were demonstrated between biopsies obtained at different segmental levels.
Fiber composition in samples obtained from the multi fidus muscle of the lumbar spine did not reveal a clear
After these studies in 1993, Rantanen and co-workers
correlation between patient age and percentage fiber com
reported their findings of biopsy samples from the same
position. The older the patient, the greater the proportion
patient at two different time points (Rantanen et aI., 1993).
of type I fibers at the expense of type lIB fibers. Mannion et
The first sample was obtained at the time of disk herniation
a!. (2000) found that with increasing age there is a decrease
surgery with a total of 18 patient biopsy samples harvested
in fiber size, especially type II, while there is an increase in
from the multifidus muscle. The second biopsy samples
the percentage of type I fiber. Comparing the different
from the same muscle were obtained from the same per
published data, it appears that while the type lIA fiber
sons 5 years later. Interestingly, the muscle biopsy exami
composition was higher than the type liB in healthy sub
nations revealed a change in pattern in those patients who
jects as well as those found in autopsy, the opposite was the
had later become pain-free and who had been satisfied
case in samples obtained from symptomatic patients. Uhlig
with their surgical outcome.
et a!. (1995) examined biopsy samples obtained in the
Evaluation of the multifidus muscle showed a greater
cervical spine and found that the type lIB fiber type was
proportion of type I fibers (56 .7%) than type II fibers. Ac
higher in patients with respect to longer symptom dura
cording to Weber (1995) the proportion of type liB fibers
tion. The same was reported by Mannion et al. (2000) in
was higher than that of type IlA fibers (24.6% and 17.1%,
patients with nonspecific low back pain.
respectively), but this difference was not statistically sig
One study reported that the ratio of type lIB to type A
nificant. There was no significant difference in fiber com
fibers was increased in patients who had been immobilized
position between men and women. Mannion et al. (1997 b)
(Haggmark and Ericksson, 1979). It is therefore plausible
found no differences in the percentage of fiber types ac
that the relatively higher proportion of type liB fiber type in
cording to race or sex; but there was a significant difference
our studies and those of other workers may be the result of
in relative size of the type I and type II fibers, such that
immobilization/disuse and thus decreased loading on the
women had a greater proportional area of the muscle
back musculature.
occupied by type I fibers. The percentage of type I was
The study reported by Johnson et a!. (1973) found a
similar to values reported from autopsy samplings of the
relatively greater percentage of type liB than of type IIA
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Neurophysiology of the Joints and Musdes
fibers in six young, healthy subjects. This finding may
Since these findings are nonspecific and have been
reflect the study subjects' ages, as they were between 17
found in a number of pathological conditions, their patho
and 29 years old. According to our own studies, the per
genesis has not been unequivocally established. Fiber atro
centage of type liB fibers is reduced with advancing age,
phy has been shown as a result of disuse or immobilization
while that of type I and type IIA fibers increases (Mannion
(Brooke and Kaplan, 1972) as well as denervation (Carpen
et aI., 2000). A similar finding had been presented in a large
ter and Karpati, 1984; Dubowitz, 1985; Jennekens, 1982;
study that used the vastus lateralis muscle as a source of
Lindboe and Presthus, 1985). Other muscle diseases have
the biopsy (Larsson et aI., 1978).
also been invoked (Carpenter and Karpati, 1984; Dubowitz,
Zhu et al. (1989) examined the multifidus muscle via
1985).
biopsy samples obtained from patients who were under
"Core-targetoid" fiber changes have been observed in
going disk herniation surgery. They differentiated their
such conditions as ischemia (Heffner, 1978), polymyalgia
samples according to two age groups and found an increase
(Carpenter and Karpati, 1984; Dubowitz, 1985), denerva
in type I fibers at the expense of type liB fibers with
tion (Carpenter and Karpati, 1984; Dubowitz, 1985), or as
advancing age; however, the differences were not statisti
result of muscle training (Brooke and Kaplan, 1972). Type II fiber atrophy was observed in biopsy samples
cally significant. Interestingly, Rantanen et a!. (1994) did not detect any
obtained from control subjects in studies presented by
significant difference in the examination of samples of the
Mattila et a!. (1986) and Mannion et al. (1997b). The ques
multifidus muscle of 21 individuals between the ages of 23
tion arises whether the observed changes should be inter
and 65 years. Thus, we believe that it is important to
preted as a "normal" finding in a "healthy" population or
determine the presence or absence of back pain in subjects
whether this is the expression of insufficient use of the
whose samples would serve as control, and the lifestyle of
back muscles and the relatively sedentary activity of the
the control subjects should be included in the study profile.
"modern" population. Mannion et a!. (1997b) suggest that
The majority of these examinations of the back muscles of
the data from their study could be of use in assessing
"healthy" persons were performed in the Scandinavian
deviations from the norm in clinical material acquired
countries. It is known that there many people regularly
from patients with various upper and lower back disorders.
participate in such activities as cross-country skiing, which
The
utilizes the back musculature and therefore may influence
muscle fiber size could be employed to evaluate the degree
relationship established between body size and
the "normal" control group. It is possible that similar ca
of atrophy in muscle samples collected from individuals
daveric samples obtained from persons who lived else
with widely differing anthropometry. The same authors
where (e. g. Switzerland) might have produced different
(Mannion et aI., 1997b) conclude that when assessing the extent of any pathological change in the muscle of low
results. A central questions, then, remains whether the increase
back pain patients, it seems clear that:
(1) sex cannot be
of type I fibers at the expense of type liB fibers is the same
disregarded; and (2) "atrophied" (by the criteria used to
or similar in patients who experience low back pain and
assess other muscles) type II fibers are not necessarily
those who remain nonsymptomatic but are relatively in
abnormal for the erector spinae muscle, particularly in
active. Both groups are thought to share a similar lack of
women.
use of the back muscles.
Rantanen et al. (1993) proposed that the "modern indi
It would appear that only a few of the biopsy samples
vidual" uses his or her back muscles so sparingly that the
obtained in the various studies revealed no pathologic
different muscle fibers, in particular the type II fibers, have
changes. The most frequent finding was that of type [J fiber
no chance of developing their normal fiber caliber. This
atrophy (40% in symptomatic patients) and a relative in
view appears to be supported by an earlier study by Polgar
crease of "core-targetoid" fibers in 29% of symptomatic
et a!. (1973), who found that the erector spinae muscles of
patients.
five healthy men contained a type II fiber diameter that was
Both Ford et a!. (1983) and Rantanen et a!. (1993) report
larger than usual (53.6 [lm). Further delineation would be
type II atrophy and "core-targetoid" fibers in multifidus
required, however, and it would be interesting to see the
muscle obtained from patients with disk herniation. While
comparison between inactive individuals and highly active
Ford et al. interpret this as a variation of normal muscle
athletes.
fiber, Rantanen et a!. (1993) believe that these changes are
The study presented by Rantanen et a!. (1993) presents a
actually disease specific. Zhu et al. (1989) share the latter
number of findings that merit mention in this context.
view as his group also found type II fiber atrophy in 18 of 22
Patients who underwent surgery for disk herniation were
patients with demonstrated disk herniation. Furthermore,
subjected to comparative biopsy studies with the initial
they believe that the atrophy was not only due to disuse or
sample taken at the time of surgery and the second sample
immobilization and bed rest, but also to denervation.
5 years after. Those patients who had a "positive" surgical
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Functional Pathology of Muscle
outcome, that is, improvement after surgery, were found to
Muscle Receptors
have a significant increase in the type II fiber size, In other words, while in pain, patients in general revealed type II
Skeletal muscles contain the following five types of recep
fiber atrophy at the time of surgery. Similar atrophy
tors:
patterns were found 5 years later only in those persons who reported either unresolved and continued pain or
•
Muscle spindles.
those who were dissatisfied with their operative outcome.
•
Golgi tendon organs.
Thus it would be reasonable to assume that the decrease in
•
Pacinian corpuscles.
the type II atrophy in the "positive" (improved) group
•
Free nerve endings (nociceptors, type IV receptors).
might reflect a successful result with medical training ther
•
Mechanoreceptors (type III proprioceptors).
apy. On the other hand, the continued presence of type II atrophy in the "negative" (poor outcome) group may be the
The two principal "muscle receptors" are the muscle spin
result, at least to some extent, of immobilization, disuse, or
dles and the Golgi tendon organs. They will be described in
pain, or of a combination of these and potentially other
detail in this section. A description of the three-dimen
factors.
sional free nerve endings and the type III mechanorecep
Mannion et a!. (1997 a) come to different conclusions. They found that there is a greater fast-twitch, glycolytic
tors, which are principally located at the tendon-bone junction, was presented earlier.
profile for the lumbar spinal musculature of patients with low back pain than for that of patients classed as normal controls (of similar sex, age, and size). They conclude that
Muscle Spindles
this is likely to have a detrimental effect on the fatigue
Distribution and location
resistance of the back muscles, They further conclude that
Morphologic studies of the muscle spindles (Richmond and
while it cannot be ascertained whether the abnormality
Abrahams, 1979) indicate a rather large variation in num
precedes or follows the onset of low back pain, once this is
ber, distribution, and location. A pronouncedly high con
identified attempts should. be made to remedy the situa
centration of spindles is found in muscles thought to be
tion with exercise therapy to bring the fiber type character
responsible for fine and precise movements, such as the
istics more in line with that displayed by pain-free controls
hand and eye muscles. In the spine, the small suboccipital
(Mannion et a\., 1997 a, 2000).
muscles, for instance, have approximately 150-200 muscle
In summary then, an increased percentage of type 11
spindles per gram of muscle tissue. There is also an excep
fibers is often found in symptomatic patients and type 1\
tionally high concentration of muscle spindles in the para
atrophy appears to increase with advancing age. It further
spinal musculature, such as the intertransverse muscle of
appears that the type II atrophy may be a reversible phe
the cervical spine, where it is not uncommon to find
nomenon, especially when patients are able to return to
200-500 spindles per gram of muscle tissue. In contrast,
pain-free and normal movement. Whether the type II atro
the total number of spindles is comparatively small in the
phy in the back muscles can be reversed through specific
larger muscles responsible for gross movement, such as the
exercise training routines and by increasing one's physical
rectus femoris muscle, which has only 50 muscle spindles
patterns should be the subject of further studies (Weber et
per gram of muscle tissue. Thus muscle spindles are infre
al.,1996).
quently present in biopsies from large limb muscles, where
At this point it is unknown whether intramuscular pres sure can alter or change fiber composition in the paraspinal
they may be confused with pathological features (Cum ming et aI., 1994).
musculature. It has been reported that increased intramus
In terms of their distribution, there is a preponderance
cular pressure may co-exist with back pain or may lead to
of muscle spindles in the postural, oxidative slow-twitch
chronic compartment-type syndrome of the paravertebral
muscles (Richmond and Abrahams, 1979). Arguably, this
muscles (Konno et aI., 1994).
fact may support the notion that the postural muscles
With regard to the relationship between muscle capil
play a particularly important role in spinal mechanics
lary supply and fiber size or fiber type, Ahmed and co
when subjected to abnormal loading conditions. As noted
workers (Ahmed et aI., 1997) calculated the local capillary
previously, there is a greater proportion of slow-twitch
to fiber ratio or density based on area, rather than number
fibers in those muscles whose primary task is that of main
of fibers. Their results suggest that, in human skeletal
taining posture.
muscle, capillary supply is primarily scaled according to fiber size and is relatively independent of fiber type.
From a clinical perspective, and this is mostly empirical Uanda, 1986) there is the notion that the postural muscles tend to shorten in response to a joint-related dysfunction. This is in contrast to the phasic muscles with a high density
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Neurophysiology of the Joints and Muscles
ming et aI., 1994). The muscle spindles are imbedded
8 r::
within the regular muscle bulk in a parallel arrangement with respect to their contractile counterparts, the extra fusal muscle fibers (Freeman and Wyke, 1967). Muscle contraction is characteristically accompanied by shorten ing of the extrafusal muscle fibers, which in turn reduces the tension in the noncontractile portion of the muscle
Decreased tension
Stretch --.
spind Ie (Fig.4.19). However, the length of the muscle spin dle is continually adjusted in order to register muscle
EFMF
length from moment to moment. Both the extrafusal and intrafusal fibers are subjected to increased tension when the muscle is stretched (Brodal, 1981; Simons, 1976a).
IFMF Increased stretch
Goigi Tendon Organs
Fig.4.19 Schematic representation of muscle spindle function. EFMF Extrafusal muscle fibers IFMF Intrafusal muscle fibers
The Golgi tendon organs are clusters of large myelinated nerve fibers (12-18
m) (Cooper and Daniel, 1963; Schoultz
and Swett, 1972). They are typically found at the muscle tendon junction where they terminate with free endings between the collagen fibers of the tendons. In contrast to the muscle spindles, the Golgi tendon organs are arranged in series with the extrafusal muscle fibers. This important anatomic difference is mirrored in the functional proper ties of these two receptors. The tendon organs primarily detect any changes in tension and are activated not only upon muscle contraction but also upon relaxation. In other words, the Golgi tendon organs function primarily as ten sion receptors, whereas the muscle spindles first and fore most register changes in muscle length (Granit, 1955, 1975).
Motor End Plates Fig.4.20 Histologic section of motor nerves and their terminations in the motor end plate (dark brown). a
The motor end plates are arranged along a line or within a certain lone.
A motor neuron and all the muscle fibers it innervates constitute a motor unit (Cumming et al., 1994). The alpha motor nerve fibers terminate at the muscle through a
b This macroscopic view of the medial muscle group of the arm
single motor end plate. Typically the motor end plates are
demonstrates how the end plates are arranged along superficial
located near or in the center of the extrafusal muscle fibers
rows which show up in this photograph as dark blue lines. The
they innervate. The arrangement of the end plate-muscle
course of the row or zone of end plates depends on the muscle Fiber direction.
junctions can be visualized both microscopically and mac roscopically by various means (Fig.4.20). In the aggregate,
(With kind permission of Dr. J. (homiak, Prague)
the motor end plates form essentially a band or zone that helps demarcate the muscle. With a simple esterase stain, of fast-twitch fibers, which tend to become weak before
these markings are readily discernible to the naked eye on
they shorten in response to dysfunction.
the muscle's surface. Using an indigo stain will render the motor end plates and myotendinous junctions visible as
Anatomy and Function
blue dots, and they can also be easily noted on the muscle's
The muscle spindles consist of 3-20 slender specialized
surface (Fig.4.21). Since the location of the motor end
muscle fibers. which have been specifically termed the
plates appears to remain relatively fixed throughout life,
intrafusal muscle fibers. They are enclosed for most of their
the examination of fetal muscles is a preferred method of
length by a connective-tissue capsule. Normal features of
study (Chomiak et al.. 1995).
these structures are great variability in intrafusal fiber size
In clinical practice. there are a number of situations that
and histochemical type, centralized myonuclei, high ester
require a thorough understanding of the localization of the
ase activity. and prominent nervous-tissue elements (Cum
various motor end plates. For instance, the electromyogra
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Functional Pathology of Muscle
pher is very careful in localizing the specific motor end plates for particular electrodiagnostic needle studies. Cer tain kinesiologic studies require specific placement of the electrodes for motor-evoked potentials. Most recently. the injection of botulinum toxin into areas of the myoneural junctions requires a good understanding of their location in a particular muscle. To date there have been no studies able to correlate the motor end plate function or changes and the myofascial trigger points described by Simons (1983a. b). and Travel! and Simons (1992).
Fig.4.21 Schematic representation of the different types of pin nate muscles according to the course of the motor end plates.
Alpha-Gamma Coactivation
a
Nonpennate muscle with parallel muscle fiber direction.
b
Nonpennate muscle with oblique muscle fiber direction.
c
Simple pennate muscle.
d
Bipennate muscle.
the alpha and gamma motor neurons and their role in
e
Multipennate muscle.
manual medicine (Granit, 1955.1975). A graphic represen
Despite its complexity. this mechanism is presented here because of its importance in understanding the function of
tation is reproduced in detail in Fig.4.22 (after Hassler.
Fig.4.22 Schematic repre sentation of mechanisms re
Normal circuit
sponsible for control of
. Muscle tension
muscle length (circuit on the right) and muscle tension (circuit on the left). (After Hassler, 1981.)
tIb
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Neurophysiology of the Joints and Muscles
1981). In the diagram, the right half represents the circuit
muscle tension, even under the influence of external
responsible for reflexive muscle length changes, while the
stretching forces, is regulated by a feedback mechanism
left half represents events associated with the circuit of
between the regular stretch reflex (originating from the
muscle tension control and external stretching force appli
secondary endings) and the so-called relief reflex (Hassler,
cation.
1981).
Components of the reflex arc of the phasic propriocep
Rethelyi and Szentagothai (1973) observed that the af
tive reflex include the nuclear bag and the intrafusal
ferent fibers originating from the muscle spindles send off
muscle fibers, which undergo contraction when stimulated
collaterals to more than one spinal segment at the dorsal
by the gamma-1 neurons. This causes the noncontractile
root level. This is particularly helpful when considering the
central portion of the muscle spind Ie, the nuclear bag, also
principles involving the alpha-gamma co-activation sys
to become stretched. Subsequently, the surrounding spiral
tem (Brodal, 1981). This information may have clinical
endings of the la fibers (the primary or annulospiral end
relevance as it may help explain, at least in part, such
ings) also become distracted. This mechanism is responsi
entities as the "facilitation" of dysfunctions, or if unre
ble for the proprioceptive reflex, which, via the la fibers and
solved, the maintenance of a segmental (somatic) dysfunc
the direct reflexive collateral branches, connects with the
tion and the various spondylogenic reflex syndromes. Thus,
alpha-1 motor neurons, resulting in contraction of the
it would appear that the afferent information from one
extensor muscles. By way of innervation through the
muscle spindle is able to affect motor neurons associated
gamma-1 system it is assured that the very sensitive nu
with more than one or several spinal segments (Brodal,
clear bag can be "reset" in response to a shortened sur
1981 ).
rounding muscle, which is then automatically maintained through the proprioceptive reflex. The strength of the pha sic proprioceptive reflex is directly dependent on the ex
Postcontraction Sensory Discharge
ternal stretching force, as well as on the activity of the Several authors have investigated the rol.e of the postcon
gamma-1 system.
traction sensory discharge in clinically shortened postural
Circuit for Muscle Tension Control
or tonic muscles (Brown et aI., 1970; Eldred et aI., 1976;
Upon stimulation of the tonic gamma-2 fibers, the intra
Hnik et aI., 1973). Buerger (1983) suggests that this phe
fusal muscle fibers of the thin nuclear chain fiber will
nomenon may explain some of the therapeutic effects of
contract. The spindle afferents of the smaller size (type II)
various manual medicine techniques.
fibers terminate primarily on the polar segments of the
Single-fiber studies using single annulospiral endings,
nuclear chain fibers via the secondary or flower spray
as well as studies from the entire root portion, have indi
endings (II in Fig. 4.22). External stretch induces these end
cated that a tetanic stimulation of a single muscle spindle
ings to fire; this is ultimately relayed to the alpha-2 motor
or its gamma-efferent fiber can cause an increased dis
neurons in the anterior horn cells via the afferent type II
charge pattern at the respective annulospiral ending. A
fibers and their multiple synapses at the spinal cord level. It
shortening in the respective muscle spindle led to a de
is these alpha-2 motor neurons that cause the slow pos
crease in discharge. Rapid overstretch of the involved
tural muscles to contract. The length of the postural
muscle spindle, however, prevented the discharge pattern
muscles is maintained as long as the nuclear chain fibers
otherwise seen upon tetanic gamma stimulation.
are held at a particular length through the influence of the gamma-2 neurons.
The clinical relevance of these experimental observa tions, especially as they relate to the mechanism of short
Besides the feedback provided through the tonic stretch
ening of the postural muscles, cannot be conclusively as
reflex, another major regulatory component, if not the
certained at this time. However, one may postulate that the
singularly decisive component of muscle tension, is the
postcontraction
Golgi tendon organ. Originating from the tendon organs
somehow be involved in the event of muscle shortening
sensory
discharge
phenomenon
may
are fast Ib fibers that convey the incoming information to
and/or with the process of transformation of the fast
the spinal cord and, by way of several interneurons, have
twitch fibers to slow-twitch fibers.
an inhibitory effect on both the alpha-l and aJpha-2 motor neurons. This leads to the inhibition of the contraction of the postural muscles via the alpha-2-efferent neurons, thus
Nociceptive Muscle Af ferents; Muscle Pain and
countering the effect of the tonic stretch reflex (a "relief
Regulation of Muscle Tone
reflex," in a sense). The alpha-1 efferent motor neurons terminate on those contractile muscle fibers that are in
Reviewing the above, it is the la fibers that supply the
volved in the phasic extensor action. The conclusion is that
primary muscle spindles, and it is the Ib fibers that inner
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Functional Pathology of Muscle
vate the Golgi tendon organs. In addition. the muscle spin dles are further innervated by type II muscle afferents, which have appropriately been referred to as the secon dary spindle afferents. However, to date, very little is known about the three dimensional free nerve endings of the nociceptors associ ated with muscles and their afferent circuits. One would be safe in assuming that at least one of the roles of the free nociceptive nerve endings is to register and respond to actual tissue damage or toxic stimuli that could potentially lead to tissue damage. Studies by Mense (1977) indicate that the muscle nociceptors are present relatively incon sistently. They can be activated either mechanically (hyper algesia associated with pressure) or chemically (bradyl
(2001) and contrary to former
belief, the sensitization of muscle is not an unspecific pro cess. These authors further believe that the sensitization process is caused by endogenous algesic substances binding to highly specific receptor molecules in the membrane
Fig.4.23 Vicious cycle resulting in an increase in muscle tone upon
of the nociceptive ending. The sensitization process by
chronic irritation of the small nOCiceptor afferents from skeletal
endogenous substances that are likely to be released dur
muscles. (After Schmidt et al.,
1981.)
ing trauma or inflammatory injury is probably the bestestablished peripheral mechanism for muscle tenderness and hyperalgesia (Graven-Nielson and Mense,
2001).
neurons at the spinal cord level. This study further dem
(2004) evaluated painful and non
onstrated that this type of transmission occurs with note
painful pressure sensations from human skeletal muscle by
worthy intensity and is by no means only a marginal oc
comparing sensations when: (1) the skin was anesthetized;
currence.
Graven-Nielsen et al.
and
(2) the skin was anesthetized in combination with a
Mense
(2003) describes the continuum of the involve
block of large-diameter muscle afferents. Their data show a
ment of nociceptors peripherally and their influences on
marginal contribution of cutaneous afferents to the pres
spinal cord and medullary level changes that lead to hyper
sure pain sensation while there is relatively more depen
excitability and hyperactivity, and thus spontaneous pain
dence on the contributions from deep tissue group 111 and
and hyperalgesia. Due to central sensitization-especially
IV afferents. Furthermore, the same authors note that a
in light of the spinal cord's demonstrated neuroplastici
pressure sensation can be elicited from deep tissue, prob
ty-one must differentiate between short-term or one
ably mediated by group III and IV afferents involving low-
time pain and pain that extends over time and is associated
threshold mechanoreceptors.
with
Most recently, Gibson et al. investigated referred pain
changes
from
functional
changes
to
structural
changes.
and hyperalgesia in human tendon and muscle belly tissue
Based on the information provided by the laboratory of
2006). I n the 18 subjects, they found that the
Schmidt et al. (1981), we may theorize that the small
proximal tendon bone joint junction and tendon sites are
caliber muscle afferents can have a profound influence on
(Gibson et aI.,
more sensitive and susceptible to sensitization by hyper
the overall degree and the extent of muscle tone in both in
tonic saline than the muscle belly site. Furthermore, the
static and dynamic situations.
propose that there may be site-specific
The findings of these animal studies appear to indicate
central changes reflected in the differences in the results
same authors
that the stimulation of the nociceptive muscle receptors,
regarding sensitivity and summation over time.
either as a result of pain or due to some chronic or recur
Schmidt et al. (1981) studied the alpha motor neuron
rent irritation,
can produce a permanently increased
system in response to painful muscle stimulation in ani
muscle tone via the interaction with the small-caliber
mals. These authors found that in response to painful stim
muscle afferents of the type III and type IV and the gamma
uli the small-caliber muscle afferent fibers (nociceptive
loop.
afferents) have direct access to the alpha and gamma motor
97
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Neurophysiology of the Joints and Muscles
At this time it can be argued that this mechanism may
ciates (2006), Maeda et al. 2007, and Skyba et al. (2003),
play a specific role in humans as well, especially in relation
describe a reduction of hyperalgesia through joint manip
ship to the so-called localized "muscle spasm" that is often
ulation or the use of high-frequency TEN S .A recent clinical
associated with a segmental (somatic) dysfunction. This
study (Moss et al. 2007) reports that mobilization of an
mechanism may also explain reports of progressive muscle
osteoarthritic knee joint is associated with both local and
damage caused by chronic hypertonic muscles or spasms
widespread hypoalgesic effects.
(Fassbender, 19 80)
Thus, with the arrival of new investigative techniques at
.
Figure 4.23 graphically illustrates the vicious cycle that
the molecular level (e. g. biomarkers) and ever-refined clin
is initiated by some primary disturbance and activates and
ical diagnostic possibilities (e. g. fMR (2003), greater reso
perpetuates the firing of the various nociceptive receptors
lution of MRI and dynamic applications, etc.) new venues to
in skeletal muscle, subsequently invoking transmission via
study physiologic mechanisms attributable to manual
the associated small-caliber nociceptive afferents. This in
medicine have opened up and are expected to further our
turn activates the gamma loop, ultimately increasing
understanding of what really happens during and after
muscle tone via the alpha motor neuron through the la
treatment.
and II afferents.
Ultimately it may be possible to connect the dots," that is the biomechanical principles, neurophysiologic, humoral
What's on the Horizon - When Manual Medicine and Molecular Medicine Meet Based on the recent advances in the human genome se quencing and proteomics, new diagnostic and therapeutic opportunities are anticipated for individualized orthope dic/musculoskeletal management of various disorders, all the while both surgical and nonsurgical decisions will in creasingly accommodate molecular criteria (Evans et al. 2005). In the field of manual medicine, Degenhardt et al. (2007) report that various nociceptive (pain) biomarkers were altered in response to osteopathic manipulative treatment (OMT) while the degree and duration of these changes were greater in subjects with chronic LBP than in control subjects without the disorder.
In another recent study, a single spinal manipulation therapy (SMT) application to the thoracic spine was dem onstrated to down-regulate inflammatory-type responses as observed by a reduction of proinflammatory cytokine secretion (Teodorczyk-Injeyan 2006). While not mentioned specifically in the seminal papers on the cholinergic anti-inflammatory pathway - a newly described neural circuit thought to be involved in cytokine dependent immunomodulation (Pavlov et al. 2003, Tracey 2007), it stands to reason, that manual medicine interven tions, like other complementary approaches, may play a role in central mechanisms that modulate systemic and/or peripheral inflammatory responses. Based on their extensive research experience in inves tigating hyperalgesia using animal models, Sluka and asso
and hitherto-unknown pathways: all of them within one functional unit, the human body.
"What's on the Horizon" - Further Reading Degenhardt BF, Darmani NA, Johnson]C (2007) Role of osteo
pathic manipulative treatment in altering pain biomarkers: a pilot study. JAOA. 107:387-400. Evans CH, Rosier RN (2005) Molecular biology in orthopaedics:
the advent of molecular orthopaedics. J Bone Joint Surg Am. 87(11 ):2550-2564. Maeda Y, Lisi TL, Vance CG, Sluka KA (2007) Release of GABA and acti vation of GABA(A) in the spinal cord mediates the effects of TENS in rats. Brain Research. 1136(1):43-50. Malisza I
98
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The Pharmacologic and Psychologic Treatment
5
of Chronic Pain
Understanding Pain Mechanisms
process following tissue damage in which chemical medi ators emerge (e. g., histamine, serotonin, bradykinin, pros
Several aspects should be considered in pharmacologic and
taglandins, ATP, H+, nerve growth factor, TNF-a, endothe
psychologic treatments of pain that are related to the mod
Iins, interleukins). These chemical mediators, frequently
ulation of nociceptive impulses or signals. In addition, in
referred to as "inflammatory soup" (Besson, 1999; Scholz
the case of chronic pain, neither pharmacologic nor psy
and Woolf, 2002), act on free nerve terminals and generate
chologic treatment, employed in isolation, leads to satis
an action potential (i. e., nociceptive impulse or signal). A
factory results for patients. Based on this clinical experi
complex reaction of small vessels from the surrounding
ence the combination of pharmacologic and psychologic
tissue cells also occurs in the inflammatory tissue (e. g.,
treatment of chronic pain is usually the best choice. For
mastocytes) to activate or to modify the stimulus response
these reasons pharmacologic and psychologic aspects of
of nociceptor afferents. In summary, tissue damage, due to
pain treatment are discussed in the same chapter.
trauma or inflammation, initiates biological processes re
Some knowledge of the basic mechanisms of pain is
sponsible for generating the nociceptive impulses or sig
necessary to understand the possibilities of pharmacologic
nals. Acute pain is therefore considered to result from
and psychologic treatment of pain. It is important to under
noxious (i. e., potentially harmful) messages are derived
stand the molecular mechanisms involved in generating
from the activation of free unmyelinated or thinly myeli
impulses or signals, referred to as nociception, and the
nated terminals found in cutaneous, muscular, and joint
processes of translation and modulation of these impulses
tissues and in certain visceral structures (Besson, 1999).
in the central nervous system, in particular the complex
Finally, different mechanisms in the peripheral or central
processes of modulation that may be crucial to chronic pain
nervous system have to be considered for neuropathic pain
development. A comprehensive summary of the complex
(Fields et aI., 1998). Sensitized nociceptors may induce
processes involved in generating and experiencing pain is
changes in central processing, possibly leading to spinal
beyond the scope of this chapter. Several recent reviews
cord hyperexcitability by which input from mechanorecep
concern the biological basis of pain, and the interested
tors by the A -fibers (i. e., touch) is perceived as pain. This
reader is encouraged to consult some of these (e.g., Besson,
phenomenon explains essential features of neuropathic
1999; Julius and Basbaum, 2001; Scholz and Woolf. 2002.
pain such as hyperalgesia (intensity of pain being higher
Only a rough summary of the mechanisms will be provided
then expected) and allodynia (pain that is perceived due to
here.
an influence which is usually not perceived as pain, e. g., a slight blow on the skin). Reorganization in the dorsal horn, considered to result from C-fibers degeneration, seems to
Pain Mechanisms
be responsible for allodynia and is provoked by the activity
Three different mechanisms of pain need to be considered:
ular, the sympathetic system may interact with spinal af
nociceptive, inflammatory, and neuropathic pain (Scholz
ferent neurons, further sensitizing nociceptors (Fields et aI.,
and Woolf, 2002). Nociceptive impulses or signals originate
1998; Baron, 2000).
of A -fjbers. Furthermore, following nerve lesion in partic
from the electrical activity (action potential) of the periph
One of the central mechanisms in the generation of pain
eral terminals of unmyelinated C-fibers and thinly myeli
impulses that has been studied in great detail (Fig. 5.1), and
nated AS-fibers. Although no identifiable anatomical struc
is best understood, is the synthesis of prostaglandins. Be
ture in the periphery deserves the term receptor, these
cause this process considerably affects pain treatment,
fibers are considered to contain receptors that are indeed
some aspects are briefly mentioned here.
ion channels sensitive to mechanical stimuli, hydrogen
Damage to the cell's phospholipid membrane leads to a
ions, cold, or heat. Under circumstances potentially danger
release of eicosanoids (e. g., free arachidonic acid), which
ous for tissue, these factors may generate a nociceptive
are metabolized as shown in Figure 5.1. P rostaglandins are
impulse or signal, which is an action potential perceived
synthesized from phospholipids during this metabolism. As
as pain. This pain is referred to as nociceptive pain. Inflam
indicated in Figure 5.1. the enzyme cyclooxygenase (COX)
matory pain, in contrast, is the result of a more complex
plays a central role in this process. It is important to note
99
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The Pharmacologic and Psychologic Treatment of Chronic Pain
Fig. 5.1 Biosynthesis of eico sanoids. (Adapted from Brune
Membrane phospholipids
Lipoxins
1
Phospholipase A2
lXA.
Free arachidonic acid
-t=
Cyclooxygenase
and Hinz. 2001.)
1
-15-HPElE -15-HETE O(B. 5-Lipoxygenase
NSAlDs
I
PGE, 1 PGF2
Cyclic
5-Hydroperoxy
endoperoxides
eicosatetraenoic acid
PGD,
Prostaglandins
lXA, 1 lXB, Thromboxanes
ILl . LTB. LTC. 1 LTD. 1 LTE.
!
PGI, 1
6-keto-
PGF,Cl
ProstacyC/ins
5-Hydroxy eicosatetraenoic acid
Leukotrienes
that various compounds emerge in the process of metabo
offered a framework that contributed to the comprehen
lism of phospholipids. Some of these are important for
sive understanding of how chronic pain can develop. This
organisms' function (e. g .. renal flow. function of the endo
theory works with anatomical structures and uses a so
thelium and gastric mucosae). Others, such as prostaglan
called gate-system in the dorsal horn of the spinal cord, in which processing and modulation of the nociceptive im
dins, are involved in inflammatory reactions. Prostaglandins play a major role in acute pain due to
pulse takes place. The following very simplified summary
sensitization of receptors (free nerve terminals of C-fibers
(see also Fig. 5.2) may be helpful in understand this process.
and Ali-fibers) to other chemical mediators making up the
As mentioned earlier, the nociceptive impulse reaches the
"inflammatory soup" (Besson, 1999). In particular, because
dorsal horn of the spinal cord through unmyelinated
prostaglandins are involved in the sensitization and acti
C-fibers and thinly myelinated Ali-fibers, where they are
vation of free nerve terminals and prostaglandins are syn
switched on to the second neuron (labeled "WDR neuron"
thesized by the enzyme cyc]ooxygenase (COX), COX inhib
for 'wide dynamic range neuron' in Figure 5.2 as it receives
itors have become a frequent choice in treatment of acute
afferent input from different fibers). In addition, C- and Ao
pain. Prostaglandins also
help to establish structural
fibers give simultaneous, collateral impulses to GABA-ergic
changes in the synapses, thereby increasing transmission
and opioidergic neurons of the spinal cord (Fig. 5.2). These
in the synapses of the central nervous system, particularly
GABA-ergic and opioidergic neurons reduce the excitatory
in the dorsal horn of the spinal cord.
influence on the WDR neuron by their action, and raise the
COX is therefore important for pain in the acute phase.
stimulus threshold (i. e., the WDR neuron becomes inhib
However, according to recent research, many mechanisms
ited). At the same time, descending pathways from the
remain elusive. In chronic pain, i. e., when there is no
midbrain also act on WDR, GABA-ergic and opioidergic
apparent tissue lesion or when an inflammatory reaction
neurons via norepinephrinergic
is not evident (for which rheumatoid arthritis may be an
(5HT) pathways. These descending pathways then addi
(NE) and serotoninergic
exception), COX may be of limited importance. Other
tionally contribute to the inhibition of the WDR neuron.
grounds for chronic pain must accordingly be considered.
The nociceptive impulses are modified due to these pro cesses, and pass up the spinal cord and through the thala mus to the cerebral cortex where they are perceived as
Gate- Control Theory
pain.
In 1965 Melzack and Wall set a milestone in the under
system (i. e., "gate open") this information is spread out
Once nociceptive impulses enter the central nervous standing of the pain phenomenon with their gate-control
to different parts including spinal cord, medulla, and cor
theory (Melzack and Wall. 1965). This theory was the first
tex. Reflex phenomena are triggered (e. g., on the level of
to integrate nociceptive impulses as well as emotional and
the spinal cord) due to spreading of the nociceptive im
cognitive aspects of pain experience. Gate-control theory
pulses and endocrine reactions may follow (e. g., induced
100
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Functional Pathology of Muscle
by the hypothalamus). In terms of triggering cognitive and emotional activity, the same impulses are finally processed in the brain cortex. Regarding descending modulation due to NE and 5HT, it is important to note that these neuro transmitters are critically involved in psychologic function ing, in particular the regulation of the emotional and affec tive status of a person. Conclusions of importance for a treatment strategy in chronic pain that can be drawn from the processes involved in the modulation of pain are: (a) Insufficient inhibitory modulation of the centripetal nociceptive impulses is cen tral to the development of chronic pain; and (b) both physiologic and psychologic influences exert an inhibitory modulation on the nociceptive impulses by the appropriate
Fig. 5.2 Gate-control theory: scheme of modulation of the noci
pathways and are responsible for the development of
ceptive impulses.
chronic pain. The modulation of nociceptive impulses as outlined
tioned above, nonnociceptive impulses may excite this
(2) as a result of
above is a restraining of the nociceptive impulse. Experi
neuron and be perceived as pain; and
mental investigations have shown that inhibitory modula
biological changes, the WDR neuron shows an unusually
tion is insufficient with therapy-resistant and/or chronic
high spontaneous discharge which, once again, is perceived
1999). Research has also demonstrated that
as pain. These biological changes are also known as the
pain (Besson,
neurobiological changes of the WDR neuron may take place
"wind-up" phenomenon and represent the basis of central
1999; Hoheisel et al.. 1994) because of inadequate
sensitization (Besson, 1999; Dickenson, 1995). Considerable
(Besson,
inhibitory modulation of the nociceptive impulse. These
importance is currently given to the process of central
changes may occur in a very short time and can briefly be
sensitization in the development of chronic pain. Given
described as follows: The nociceptive impulses arise, for
this central sensitization, and in particular the fact that
example, from an inflammation or a peripheral lesion in
the biological changes of the WDR neuron that have been
which the chemical mediators in the so-called "inflamma
described can take place rapidly (Hoheisel et aI.,
tory soup" play a role. These mediators generate the noci
important aspect of pain treatment is the prevention or
ceptive impulses (C- and A8-fibers), thereby stimulating
reversal of central sensitization.
1994), an
the WDR neuron. The sustained nociceptive stimulation
It is known that under some circumstances the WDR
of the WDR neuron (mainly by the glutamatergic C-fibers)
neuron may change its biological properties either to fire at
results in a sustained depolarization (i. e., excitation) of this
a higher rate or to fire under the influence of many other
neuron. In this case, the binding of glutamate in the
afferent impulses. In this case even nonnociceptive im
C-fibers on
pulses may lead to pain (such as simple limb movement,
the
WDR
neuron's
N-methyl-D-aspartate
(NMDA) receptor is crucial. This receptor is responsible
slight tissue pressure). This gives the impression of over
for controlling calcium ion channels. Opening calcium ion
sensitivity when pain results from mild
channels, among other actions, sets the second-messenger
pain-inducing) stimuli, and may be seen as a psychologic
(i. e.. usually non
system in motion, followed by the transcription of the
problem of the patient. Indeed this frequent clinical obser
genetic information and increased gene expression (by
vation is based on hypersensitivity of the central nervous
the so-called immediate early genes). This expression is
system. Once hypersensitivity is established, treating pain
followed by increased reproduction of NMDA receptors
with pharmacologic agents may only increase problems.
on the WDR neuron. This appears to be a biologically sig nificant mechanism that should protect the WDR neuron from excessive stimulation. However, changes in biological
Conclusions
characteristics of the WDR neuron can result from an increased density of NMDA receptors on the neuron. This
Given that chronic pain results from changes in biological
(1) since there is a
properties of the WDR neuron, the principal issue will be to
may have the following consequences:
higher density of NMDA receptors on the WDR neuron,
act on modulation (i. e., downregulation of the impulse
many presynaptic impulses (which are often numerous)
ratio). Careful consideration of the facts outlined above in
can contribute to the sustained depolarization of this neu
treating chronic pain leads to the conclusion that prescrip
ron. In relation to chronic pain, the most important con
tion of prostaglandin synthesis inhibitors alone is of limited
sequence is that due to changes in the WDR neuron men-
value. These chronic pain agents may have some influence
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The Pharmacologic and Psychologic Treatment of Chronic Pain
on nociceptive impulses (e. g.. in rheumatoid arthritis
cord. p-Endorphin is mainly found in the hypothalamic
where continuous tissue damage may take place). COX
arcuate nucleus and the midbrain periaqueductal gray mat
inhibitors may have an additional positive effect in reduc
ter. Dynorphins have similar distribution to enkephalins
ing the rate of synaptic transmission in the central nervous
(Fields. 1987).
system. which is under the influence of prostaglandins. It is
To summarize: According to the distribution of opioid
more important to consider that treatment of chronic pain
receptors and endogenous opioids. the main site of action
using only pharmacologic agents may fail because the doses
of opioids is at spinal and supraspinal levels. Spinal and
required for complete analgesia may be greatly exceed the
supraspinal mechanisms of opioid actions are synergistic.
level at which toxicity occurs. The treatment benefit for
In addition. the fact that opioid receptors exist in the pe
chronic pain while using NSAIDs is only very limited be
riphery suggests that opioids are likely to act on structures
cause influence on downregulation of the WDR neuron
outside of the central nervous system as well. Opioids
cannot be provided. This indicates that in chronic pain
should be used for moderate or severe nociceptive pain.
the pharmacologic treatment will have to focus on different
Their efficacy in neuropathic pain seems to be poorly sup
pharmaceutical substances. and that other nonpharmaco
ported by clinical routine.
logic strategies may be helpful. Given that in many chronic
It is well established that there are genetic variants of
pain syndromes the downregulation of the WDR neuron is
the
required. NSAlDs may be employed rather than opioids.
sidered responsible for differences in receptor affinity of
receptor (Pasternak. 1999) and this variation is con
different opioids and contributes to their analgesic poten tial. It has been suggested. although not yet proven
Pharmacologic Treatment
(McQuai. 1999). that side-effects of opioids (nausea. vomit
of Chronic Pain
ing. sedation. in some cases hallucinations) are connected with the different receptor affinities of opioids.
Opioids
These agents are categorized into the following groups according to their affinity for opioid receptors: agonists.
In acute pain. particularly postoperative pain or other se
partial agonists (e. g.. buprenorphine). agonists/antagonists
vere pain. or moderate to severe chronic pain opioids ap
(e. g.. butorphanol. nalbupbine. pentazocine. and dezocine).
pear to be the drug of choice. This is clearly supported by
and antagonists (naloxone. naltrexone. and cholecystoki
extensive clinical experience. The choice of opioid. route of
nin). Not all substances with opioid-receptor affinity ate
administration. and sometimes variation between the
employed in treatment. mainly on the basis of cost
drugs should be carefully considered. Opioids (from opium.
effectiveness analysis in which the balance between effect
which is the Greek term for juice. i. e.. extract from the
and side-effects is crucial. Most of the widely used opioids.
poppy plant) are a group of morphinelike substances
as well as doses and additional comments. are summarized
with primarily analgesic properties.
in Table 5.1.
The pharmacologic effects of all opioids are based on
The main advantage of opioids in treatment of pain is
their interactions with the three opioid receptors mu (Il).
their excellent and quick acting analgesia in moderate and
( K ) . and delta (8). which were discovered in the early
severe pain. An experienced professional with the proper
1970s. The mu receptor is the principal structure in the
equipment should administer opioid treatment. especially
analgesic action of opioids. Opioid receptors exist in the
if the parenteral route of administration is preferred.
kappa
periphery. in the spinal dorsal horn. in the brainstem. in the
There is usually no ceiling effect with opioids (increased
thalamus. and in the cortex. The main effects of opioids
dosage provides increased analgesia). Opioids are available
include a decrease of presynaptic transmitter release. hy
in different forms and can be given by oral. sublingual.
perpolarization of postsynaptic neurons. and disinhibition.
parenteral. rectal. intraspinal. or transdermal:
The discovery of opioid receptors encouraged the search
enteral administration (preferably intravenous. providing
for endogenous substances that might be responsible for
the possibility for better titration) should undertaken in
modulation of action. This research identified enkephalins.
severe acute pain. In chronic pain. parenteral administra
endorphins. and dynorphins. In the 1980s precursor mol
tion of opioids should give way to preferred long-acting
ecules of endogenous opioid-receptor agonists were iden
opioid forms. Morphine is still the standard and the belief
proadrenocorticotropic hormone
that other drugs act faster or longer or possible have fewer
(pro-ACTH). ACTH endorphin (propiomelanocortin). and
side-effects is unsupported by clinical evidence (McQuai.
tified:
preenkephalin.
prodynorphin. The localization of the endogenous opioids
1999). The choice of opioid. the matter of tolerance. pain
was identified. Enkephalin is found in the amygdala. hypo
sensitivity to opioids. and the decision to switch one opioid
thalamus. the midbrain periaqueductal gray matter. the
for another. or to change the mode of administration. re
rostroventral medula and the dorsal horn of the spinal
main matters of contention (McQuai. 1999).
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Pharmacologic Treatment of Chronic Pain
Table 5.1 Opioids in chronic pain treatment Comment
Recommend ed Average 24 ho ur b Dosage -
Opioids for mild to moderate pain Codeine
15-50 mg
200mg
4-6 h
Short-acting. weak analgesic
Dextropro-
65 mg
150-300 mg
8-12 h
60-120 mg
120-240 mg
3-4 h (12 h)
poxyphene Dihydrocod e ine Tilidin
Tramadol
Controlled in some countries: release form available with 12 h dosing interval
50-100 mg
50-100 mg
200-300 mg
2-3 h
Controlled in some countries: release form available with
(8-12h)
recommended 8-12 h dosing interval
up to
2-4 h
Different forms available in some countries (oral.
400-600 mg
(8-12 h)
subcutaneous. intravenous. rectal. and controlledrelease). Easily prescribed in some countries due to lack of particular prescription regulations. Potent sedation. Frequent nausea/vomiting
Oploids for moderate to severe pain Buprenorphine
0.2-0.4 mg
Fentanyl
SO-lOOl1g
?
Doses over 4 mg do not show higher analgesia
6-8 h 0.5-1 h
Quick onset of action. short half-life. Very potent analgesic. Respiratory depression may not be obvious for minutes. Several application forms. High comfort with transdermal application form in different doses with 72 h analgesic action. Considerable side-effects in some patients (e. g
Hydromor-
l.Smg
phone
(oral 7.5 mg)
Levophanol
2mg
100mg
nausea/vomiting)
Quick-action onset with a short half-life. Very potent
3-4 h
analgesic. Several application forms High analgesic potential. Careful dose titration. May
6-8 h
(oral 4 mg) Meperidine
.•
accumulate considerably 300mg
Toxic metabolite that may provoke seizures
2-3 h (8-12 h)
Methadone
10 mg
30-40mg
6-8 h
Morphine
Short analgesic action. long half-life. May accumulate with dose increase to cause toxic effect
(oral 20 mg) 10 mg
3-4 h
Standard opioid. In many respects the "gold standard" to which analgesic effect of other opioids is compared in
(oral 30 mg)
terms of equianalgesic potential. Several application forms include controlled release with long- term action Pethidine
Propoxyphene
SOmg
Recommend-
(oral 150 mg)
ed max.
dine is potentially toxic. First- pass effect is significant.
SOOmg
Caution in hepatic failure
3-4 h
3-6 h
Several application forms. Active metabolite Norpethi-
Not recommended for routine administration. Toxic metabolite
·Considerable differences in the recommended average single dose should be conSidered in drugs with different application forms where, for example. intravenous, subcutane ous, or intramuscular doses are usually significantly lower then oral doses. bOpioids have no ceiling effect. For this reason the recommended average 24·hour dosage should be taken as a guideline only. Some opioids in the table are not available in every country. Drugs exist in different application forms (e. g., for intravenous. rectal, or transdermal use, or in controlled-release form) not all of which are available in all countries. All countries have their own specific restrictions for opioid prescription that need to be followed. Furthermore, in every individual patient. general prescribing aspects side-effects and adverse effects and development of tolerance and dependence should be taken into consideration and related to the patient's disposition. It is strongly recommended that opioid treatments, in particular those with high analgesic potential. be restricted to experienced professionals. This is particularly so for initial opioid treatment. No opioid analgesics should be taken in combination with monoamine oxidase inhibitors (MAOI) due to possibly dangerous side-effects (e. g., respiratory depreSSion, hypertension) some of which may be fatal.
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The Pharmacologic and Psychologic Treatment of Chronic Pain
It is known that in some patients the therapeutic po
istration. or 90 minutes of subcutaneous administration.
tential of a given opioid may diminish over time. In such
Respiratory depression is a very dangerous side-effect due
cases a change from one opioid to another (so-called rota
to the subsequent
tion) may be necessary. This is usually done as follows: first
system; it can be predicted using other symptoms such
the equivalent dose to that of the replaced opioid should be
as drowsiness. mental clouding. or severe sedation. Some
depression of the central nervous
found using existing equivalency tables. Equivalencies are
opioids (e. g.. meperidine) can cause excitation or seizures.
based on intramuscular morphine doses in opioid-naive
possibly as a consequence of its metabolite normeperi
individuals. which may differ considerably in patients
dine. Other relatively frequent side-effects at higher doses
treated with opioids over a long period. For this reason.
include myoclonus or clonic spasm of a single muscle or a
the treatment should be started with 50% of the equivalent
group of muscles. Emetic side-effects. causing nausea or
dosage and the dosage of the new opioid increased step by
vomiting. usually occur in the initial phase of treatment
step according to analgesic effect and side-effects. How
and tolerance is obsetved in most patients (McQuai. 1999).
ever. improvement of the analgesic effect has been shown
Nausea and vomiting are caused by chemoreceptor trigger
to be possible by change in the route of administration.
zone stimulation. They can be managed by antiemetics but
making rotation unnecessary (Kalso et al.. 1996). and this
there are a few cases with unmanageable nausea or
should also be considered.
vomiting that could require a change to another opioid or even the discontinuation of opioids altogether. The proportion of patients showing tolerance and de
Side- Effects of Opioids
pendence following prolonged use of opioids is not known
The main side-effects are seen in central nervous system
exactly for various reasons. Clinical experience suggests
activity (euphoria or suppression/inhibition of different
that tolerance to opioids develops more rapidly with a
kinds) as well as nausea. vomiting. and constipation. These
parenteral route of administration. in particular with
can be understood from the fact that the same opioid
drugs with short half-life. In addition. favorable psycho
receptors mediate both analgesia and physiologic phe
logic effects
nomena. Active metabolites may also contribute to these
tolerance and the requirement for higher doses. Patients
may be responsible for development of
adverse effects (e. g .. norpethidine causing tremor or con
who develop tolerance usually complain of decreased du
vulsions; normeperidine with its seizure potential; or the
ration of analgesic effects. Clinical experience shows that
possible toxicity of morphine-6-glucuronide. particularly
drug-seeking behavior does not occur in patients whose
in patients with impaired renal function). Compared on
relief of pain is achieved by the use of opioids (Porter and
the basis of the same degree of analgesia. adverse effects
Jick. 1980). Abrupt discontinuation of opioids introduces
do not seem to differ between opioids (McQuai. 1999).
withdrawal syndromes including agitation. anxiety. in
Constipation. a side-effect of all opioids. is based on cen
somnia. tremor. tachycardia. muscle cramps. yawning.
tral and peripheral receptor affinity. Tolerance to the con
lacrimation. fever. and signs of hyperexcitability of the
stipatory effects of opioids has not so far been confirmed.
sympathetic
calling for adequate treatment for affected patients (e. g..
although infrequent. may still occur in cancer patients
stool softeners or laxatives). Patients are also known to
and as non-cancer-related pain (usually nerve compres
experience
sion or nerve destruction).
problems
in the
urinary
system
(bladder
nervous
system.
Opioid-insensitive
pain.
spasm. urinary retention. or urgency). Muscular problems including spasms may cause agitation or anxiety. Fre quently the introduction of opioids in the treatment of
COX Inhibitors; NSAIDs
chronic pain is compromised by the beliefs that these drugs cause respiratory depression and frequently and
Prostaglandin synthesis inhibitors (i. e.. inhibitors of cyclo
unavoidably lead to tolerance and dependence. However.
oxygenase) play a key role in the treatment of acute pain
it is suggested that nociceptive input in the respiratory
given that prostaglandins are critically involved in the
center counterbalances the respiratory depressant poten
generation of nociceptive impulses. Many of these substan
tial (Borgbjerg. 1996). indicating that patients suffering
ces show excellent analgesic effect in mild to moderate
from severe pain may be at lower risk of respiratory
pain as well as to some extent in acute pain. In such cases
depression. Carefully titrated. appropriately sized. and
NSAIR drugs show a similar analgesic potential to weak
well-timed doses of opioids can prevent respiratory de
opioids. The use of NSAIDs is not followed by development
pression (McQuai. 1999). Observation is recommended
of tolerance and subsequent dependence. These substan
while using fentanyl intravenously. If at all. respiratory
ces are easily available and inexpensive (as in the case of
depression usually occurs within 10 minutes of intrave
nonselective COX inhibitors). However. their specific an
nous administration. 30 minutes of intramuscular admin
algesic effect. especially in nonrheumatoid pain. is fre
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Pharmacologic Treatment of Chronic Pain
Activated by physiologic stimuli
NSAIDs
Activated by inflammation stimuli
COX-l
COX-2
Constitutional enzyme
Inducible enzyme
Target tissue
Macrophages, synoviocytes
1
1
Thromboxane
Proteases
(thrombocytes) Prostaglandins
Prostacyclin (endothelium. gastric mucosae) Prostaglandin E2
Mediators of
(kidney)
inflammation
1
!
Physiological functions
Inflammatory reaction/pain
Fig.s.3 Regulation of prostaglandin synthesis by COX-1 and COX-2 (according to Vane, 1994).
quently poorly documented as studies with NSAIR have
resulting from inflammatory process are essential in gen
mainly been conducted with patients suffering from rheu
erating pain, COX-2 inhibitors showed fewer of the side
matoid arthritis. Parameters other than pain (e.g., inflam
effects frequently observed with classical NSAlDs, i. e.,
mation of joints) were the main measures in these studies.
upper gastrointestinal tract effects (Bombardier et aI.,
It is well known that the anti-inflammatory action and
2000; Silverstein et aI., 2000) or bleeding (FitzGerald and
analgesic effects do not remain in a linear relationship
Patrono, 2001). COX-2 inhibitors were also introduced into
(McCormack and Brune. 1991). This makes it difficult to
treatment of other pain conditions because of their anti
understand the analgesic effect of NSAlDs mainly on the
inflammatory action. Selective inhibition of prostaglandin
basis of inhibition of prostaglandin synthesis. Prescription
synthesizing COX-2 may provide important advantages in
of NSAlDs in chronic severe pain, which might be thought
the treatment of pain, whereas possible side-effects result
useful from the introductory material to this chapter, is
ing from COX-1-inhibition may be prevented. However,
likely to need careful reassessment. There are studies in
selective COX-2 inhibitors (i. e., inhibitors of prostaglandin
dicating that the analgesic affect of NSAIDs may result
synthesis) did not show a superior analgesic effect when
from action in the central nervous system (Fabbri et aI.,
compared with nonselective COX inhibitors (Mazario et aI., 2001) and therefore did not fulfill the expectations of them.
1992). COX appears to have at least two isoforms (COX-1 and
Recent views suggest that selective COX-2 inhibitors are
COX-2) between which there are important differences in
less analgesic then nonselective COX inhibitors (FitzGerald
biological properties (see Fig. 5.3). COX-1 primarily acti
and Patrono, 2001; Mazario et aI., 2001; Bensen et aI.,
vates physiologic functions in different tissues, whereas
1999). The role of selective COX-2 inhibitors in pain may
COX-2 is responsible for inflammatory reactions. Adverse
be further complicated by the fact that acetaminophen, a
effects of traditional nonsteroidal anti-inflammatory drugs
potent analgesic drug, has negligible inhibitory properties
(NSAlDs) and salicylates inhibiting both COX-1 and COX-2
on COX-lor COX-2. In addition, the previously assumed
are related to their inhibition of COX-1, which among its
long-term safety of COX-2 is becoming increasingly ques
other physiologic functions synthesizes gastroprotective
tionable (I
substances (Bombardier et aI., 2000; Silverstein et aI.,
et aI., 2003). One of the COX-2 inhibitors (rofecoxib) has
2000). The anti-inflammatory and analgesic effects of
been removed from the market
NSAlDs were accordingly attributed to the inhibition of
While the deliberations by the US Food and Drug Admin
(BMJ 2004; 329; 816).
COX-2-dependent pathways. This led to the development
istration (FDA) resulted in the decision that other COX-2
of COX-2 inhibitors, which were then introduced into treat
inhibitors (celecoxib and valdecoxib) also carry serious
ment of rheumatoid arthritis. Apart from anti-inflamma
risks of heart attack and stroke, the panel did not recom
tory action and the assumption that chemical mediators
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The Pharmacologic and Psychologic Treatment of Chronic Pain
mend that these drugs bei withdrawn from the market
Considering the recent critical reviews of the develop ment of improved pain-relieving drugs and the biological
(Lenze.2005). COX-3. a variant of COX-1. has recently been identified
basis of chronic pain discussed earlier in this chapter. the
as an inducible isoenzyme in later stages of inflammation
prescription ofNSAIDs in patients with chronic pain (due to
(Willoughby et al.. 2000). Interestingly acetaminophen, a
obvious reasons apart from rheumatoid arthritis) should be
substance with analgesic effect, has some of activity to
questioned seriously (Scholz and Woolf. 2002; Curatolo
block the COX-3-variant. which gives rise to speculation
and Bogduk, 2001).
that this COX-variant is significantly involved in pain. In
Some commonly used NSAlDs are summarized in Table
addition, nonselective COX inhibitors (e. g.. diclofenac. ibu
5.2, which also contains some recommendations for doses
profen) show powerful COX-3 inhibition. indicating that
and comments with regard to more substance-specific
inhibition of this COX-variant is important in the treatment
side-effects.
of pain. It is interesting also that this COX-variant occurs
The most prominent disadvantage of NSAlDs is their
not only in tissue but also in the brain and the spinal cord
toxicity. predominantly in terms of long-term gastrointes
(Chandrasekharan. 2002). This may raise doubt about the
tinal intolerance and ulceration. However. this is mainly
explanation of the analgesic effect of nonselective COX
observed during unusual chronic prescription over months. Because of the physiological action of COX. its inhibition by
inhibitors or acetaminophen. NSAlDs are rapidly absorbed and are highly protein
NSAlDs also compromises renal flow and has related con
bound and have a low tissue distribution. NSAlDs are me
sequences. These drugs do not show higher analgesic po
tabolized in the liver with low clearance (Denson and Katz.
tential with increaSing doses (i. e.. they show ceiling effects).
1992). It is important to acknowledge that salicylates com
and their full efficacy usually occurs after several days.
pete with other NSAlDs for protein binding sites and may
Furthermore. NSAlDs are usually not helpful in severe pain.
increase the concentration of some of these drugs to toxic
It is important to reiterate that in contrast to acute pain,
level. Toxicity of NSAIDs is poorly documented as most
where chemical mediators play an important role. these
studies have been conducted with elderly patients. Because
substances are not evidently involved in chronic pain. Pre
of the influence on physiologic processes in the organism.
scription ofNSAlDs in chronic pain stages is poorly justified
with chronic prescription of NSAlDs a laboratory-con
by the evidence base. The lack of therapeutic efficacy might
trolled examination of physiological parameters. with em
frustrate the patient and only contribute to additional
phasis on renal function. should be performed periodically.
problems in treatment.
Table 5.2 Nonopioid analgesics in chronic pain treatment Comments
Overdose leads to hepatotoxicity. Careful administration is needed in cases of
.JI
Acetylated
'L__ --.r--
Ii
Sallcylates
= Aspirin
4000 mg
500-1000 mg
chronic alcoholism
-
4- 6 h
Inhibition of platelet aggregation. Competes in protein binding with NSAIDs. causing a potential toxic effect. Gastrointestinal bleeding and ulceration
Nonacetylated
Diflunisal
1000 mg
1500 mg
12 h
Gastrointestinal intolerance and bleeding (less than aspirin)
Salsalate
1500 mg
2000-3000 mg
8-12 h
occur
= Salsalate
1500 mg
Common side-effects of NSAIDs may
2000-3000 mg
8-12 h
Common side-effects of NSAIDs may occur
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Pharmacologic Treatment of Chronic Pain
Table 5.2 Nonopioid a na lges ics in chronic pain treatment (co ntinued)
Comments
Average Single Dose
Propionic acid
Ibuprofen
400-600 mg
2400 mg
4-6h
Common side-effects of NSAIDs may occur. Better tolerated than aspirin, with
derlvates
fewer gastrointestinal side-effects. Low incidence of hepatotoxicity Arylacetlc acid
Naproxen
250-500mg
1250 mg
Common side-effects of NSAIDs may occur. Long-term safety unknown
derlvates Fenoprofen
200mg
800mg
4-6h
Common side-effects of NSAIDs may occur
Ketoprofen
50-75mg
300mg
6-8h
Common side-effects of NSAIDs may occur
Phenylalka-
Flurbiprofen
100mg
200mg
6-8 h
Common side-effects of NSAIDs may occur
nold acid derivates Acetic acid
Indometa-
derlvates
cin
25-50 mg
100-200 mg
6-12h
Gastric mucosal inflammation, or necrosis with bleeding. Careful administration in positive history of gastric bleeding. Irritation possible in some patients
pyranocarbox-
Etodolac
300-600 mg
Tolmetin
200-6oomg
1800 mg
6-8h
Sulindac
150-200 mg
400mg
12h
600-1200 mg
yllc acid derivates
Indene derivates
High gastrointestinal toxicity may occur Common side-effects of NSAIDs may occur
Diclofenac
50-75mg
200mg
68h
Good analgesic, usually well tolerated. Frequently considered as a first-choice NSAID
Anthranilic acid derlvates Fenamate
Mefenacid
500mg
500-1500 mg
6-8h
May cause upper gastrointestinal problems. Shows good analgesia if tolerated
Keto- enol acid derlvates Oxicams
Piroxicam
20mg
20-40 mg
24h
Monitoring of renal parameters recommended in cases with longer administration
Tenoxicam
20mg
20-40mg
12-
Upper gastrointestinal tract side-effects
24h
may be frequent, leading to intolerance and compliance problems
Meloxicam
7.5mg
7.5-15 mg
12-
Must be avoided in hepatic failure. Careful
24h
control of renal parameters is recommended
Pirazolldlne-
Phenylbuta-
dlones
zone
200mg
200-60mg
12h
GastrOintestinal, renal side-effects or bronchial spasms may be frequent
J07
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The
Pharmacologic and Psychologic Treatment of Chronic Pain
Table 5.2 N onop io i d analgesics in chronic pain treatment (con ti nu ed) Recommend
Comments
ed 24-nour Dose
Other derivates Nimesulid
12 n
400mg
200mg
Snould not be taken by patients with positive history of gastrointestinal bleeding or renal failure
Pyrazollnones
Pnenazone
600-800mg
200mg
4-6h
Must be avoided in hepatic or renal failure. May cause allergy
Propypne
4-6 n
500-750 mg
250mg
Contraindicated in a number of gastrointestinal problems including
nazone
porphyria (list of disorders indicating restriction in use should be taken into account On an individual basis) Metamizole
500-1000mg
4000 mg
4-6 n
May cause thrombocytopenia, leuko penia or agranulocytosis
6-8h
Pyrldyl carbamate
Flupirtin
100mg
300mg
Coxlbs
Rofecoxib
12.5-25mg
25-50mg
(COX-2 inhibitors)
Once
Different doses for acute or chronic
daily
pain are recommended. Advantages depend mainly On selectivity or lack of inhibition of COX- 1 (e. g., gastroin testinal or renal side -effects)
Celecoxib
100-200mg
100mg
Once
May have Significant interactions due
daily
to blockage of different lines of the cytochrome- P-450- enzymes. Precise information of all medications used by the patient is necessary. Advantages of COX-2-inhibitors. Clinical experi ence may indicate lower analgesic effect.
Valdecoxib
Side-effects seen in other coxibs may
10-40mg
occur. Caution in renal or hepatic failure Note: Table 5.2 contains the routinely used nonopioid analgesics. frequently referred to as nonsteroida l anti·inflammatory drugs (NSAIDs). Some are not available in certain countries. In addition. some of these drugs do not belong to the group of NSAIDs in the strict sense. Not every probable side effect or toxic effect can be considered. Most possible side-effects can be better u n derstood if the NSAID mechan i s m of action is also understood (see also Fig.
5.1
for the b i osynthesis of eicosanoid s ). Before treatment is given to patients with a history of adverse effects or presumed risk for
adverse effects (in p a rticular gastrointestinal or renal problems or asthma). careful choices of the drug and frequent clinical and laboratory monitoring are imperative. Particular care in the use of NSAIDs is recommended in early pregnancy (it is recommended that many of these drugs are avoided. with the possible exception of acetaminophen). With all NSAIDs monitoring of gastrointestinal. vascular. blood. and renal parameters is particularly important in chronic use. Coxibs are frequently considered to show few gastrointestinal side-effects. Newer research may support the view that coxibs have advantages mainly in patients with a history of gastrointestinal bleeding. Many substances in this table may cause allergic reactions.
Acetaminophen and metamizol have numerous advan
usually well tolerated with few toxic or other side-effects;
tages: they show no adverse effects on gastrointestinal
these are often exaggerated and poorly supported by
tract mucosa, on kidney, or on platelet aggregation. How
clinical routine. Possible adverse effects are mentioned in
ever, they may have an analgesic effect in cases with mild
Table 5.2.
and sometimes moderate pain chronic pain. Both drugs are
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Pharmacologic Tff!C1tment of Chronic Poin
Other Pharmacologic Interventions
larger clinical studies such as pregabalin) show consider able
advantages
in
treating
neuropathic
syndromes
In adjuvant treatment, a heterogeneous group of pharma
(Sindrup and Jensen, 1999). Gabapentin is usually well
ceuticals, based on clinical observation, play a role believed
tolerated with few side-effects, such as limited-duration
to show some beneficial effect in the treatment of chronic
headache and dizziness, and has high efficacy in neuro
pain. However, recent reviews seriously question the em
pathic pain. However, the maximum effect requires suffi
pirical basis of employing these different pharmaceuticals
cient doses (e. g., above 1600 mg/day: most patients re
in the treatment of chronic pain (Curatolo and Bogduk,
quire doses of 2400-3600 mg/day): in clinical routine this
2001). However, adjuvant pharmacologic treatment seems
is unfortunately frequently neglected, and syndromes that
to show considerable advantages especially when taken in
are difficult to treat continue. Clinical observations indicate
combination with other pain-relieving substances.
that a combination with tricyclics (effective in diabetic
Most attention in adjuvant treatment of pain has been
neuropathy), codeine, and newly developed anticonvul
placed on antidepressants. The introduction of antidepres
sants such as gabapentin may show more benefit. Admin
sants in pain treatment is based on the association of
istration of antidepressants, anticonvulsants, and local
(i. e., noradrenergic and serotoner
anesthetics is supported against neuropathic pain (McQuai,
descending pathways
gic) in the modulation of nociceptive impulses. Since these
1999).
neurotransmitter pathways are inherently involved in the
In systematic reviews, only muscle relaxants or muscle
regulation of patients' emotional status, their involvement
relaxants in combination were identified as an effective
could be of particular importance in patients who, in
treatment of pain associated with muscle spasm (Aker et
addition to pain, suffer from affective symptoms. Biolog
aI., 1996). However, their effect seems to be better sup
ically, these symptoms may indicate a comparative insuf
ported in acute rather than in chronic musculoskeletal pain
ficiency of descending modulatory neurotransmitter path
(Van Tulder, 1997). Baclofen has recently been shown to be
ways (i. e., serotonin and norepinephrine). However, a
effective using specific indications such as neuropathic
systematic review did not confirm benefits in treating
pain associated with dystonia (von Hilten, 2000).
chronic low back pain with these agents (Turner and
Corticosteroids are a further group of substances with
Denny, 1993). Nevertheless, the antidepressants, in partic
analgesic effect, usually in combination with other potent
ular tricyclic agents (e.g., amitriptyline, usually in doses
analgesics, and may be used for quite specific indications.
lower than those used for treating clinical depression) are
These indications may include bone metastases, spinal cord
considered important adjuvant agents in the treatment of
compression, acute nerve compression, and increased in
chronic pain (Watson, 1994). It is believed that these
tracranial pressure. Corticosteroids may further be indi
agents may lead to the relief of pain while showing an
cated with epidural injections in disk herniation pain, spi
improvement in mood, reduction in the level of potential
nal stenosis, or foraminal stenosis, both lumbar or cervical
depression, and promotion of sleep. It is important to add
(Curatolo and Bogduk, 2001).
that sleep is Frequently disturbed in chronic pain patients
In recent years antidepressants and neuroleptics were
and sleep deprivation may contribute to this vicious cycle.
frequently introduced into the treatment of chronic pain.
It is also proposed that tricyclic antidepressants may have
Usually a combination of haloperidol and tricyclic antide
a direct effect on nociceptive afferents (e. g., by blocking
pressants (e.g., amitriptyline) was used. This is no longer a
sodium ion channels) and that they are particularly effec
standard in the treatment of pain syndromes. Currently
tive due to the augmentation of analgesic response to
neuroleptics or benzodiazepines are rarely introduced in
opioids.
the treatment of pain syndromes. Sometimes in severe
Specific treatment may be required for neuropathic pain
cancer pain, neuroleptics (e.g., haloperidol in individually
syndromes (postherpetic, diabetic, or due to damage of a
titrated doses between 1 and 10 mg or more) may be
plexus, nerve root, or single nerves). NSAIDs are usually
required to help relieve patients. Lately, neuroleptics are
ineffective in neuropathic pain, with even opioids not al
being used as a single substance in combination with
ways showing sufficient analgesia. On the basis of the
highly potent opioids. Benzodiazepines (e.g., alprazolam)
underlying mechanism of pain in neuropathic syndromes,
may be prescribed on a carefully timed, limited schedule in
which have been treated using classical anticonvulsants
patients who suffer from anxiety in combination with their
(e.g., phenytoin, carbamazepine, clonazepam, gabapentin),
pain.
these agents are considered important in treating neuro pathic pain (e.g., following surgical treatment or posther petic, poststroke, or trigeminal pain or in diabetic neuro pathy). Newly developed anticonvulsants (e.g., gabapentin or the even more recently developed substance entering
109
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The Phannacologic and Psychologic Treatment of Chronic Pain
known as transduction. The action potential ascends to the
Psychologic Aspects of Pain Treatment
cortex (transmission). In this process the signal.
or
electri
cal impulse, first reaches the dorsal horn of the spinal cord. According to the International Association for the Study of
At this site the afferent nerve synapses with the neuron of
Pain (IASP). pain is "an unpleasant sensory and emotional
the spinothalamic tract below the WDR neuron. The signal
experience associated with actual and potential tissue
continues to travel to the thalamus along the spinothalamic
damage. and is described in terms of such damage" (IASP.
tract and from there to various areas of the cortex. Pain is
1979). This definition includes the psychologic aspect in
perceived as soon as the signal reaches the cortex (percep
both acute and chronic pain. but in clinical routine the
tion). The nociceptive signal is modulated under the influ
investigation of a pain patient requires first the search for
ence of different structures in different levels of the central
a possible organic cause. Although pain is frequently con
nervous system. Depending on the process of modulation
sidered as an exclusively nociceptive phenomenon (Turk
in particular. subjects will experience pain in different ways
and Okifuji. 1999). individual differences in pain reporting,
and show various somatic, psychosocial. and functional
following the same potentially pain-provoking procedure;
manifestations. These phenomena will influence behavior.
impressively indicate that nociception is not always asso
i. e., how people react to (e.g.. avoidance. withdrawal) and
ciated with pain experience. In contrast. pain experience in
communicate (e.g.. shouting. crying) experiences of pain
the absence of nociception is a well-acknowledged phe
and related distress. Finally, pain may cause suffering,
nomenon. Indeed, pain is a perceptual phenomenon in
mainly resulting in the loss of aspects inherently connected
volving different eNS mechanisms for which nociception
with the individual (understood in terms of being indivi
may be a requirement. If an organic cause for pain is not
sible and unique) such as functional ability, social status, or
found. an underlying psychologic cause is usually assumed
social role. Suffering is indeed a psychologic or inherently
and the patient is referred to psychologic or psychiatric
emotional reaction to pain and may explain why people
treatment. The introduction of a psychologic dimension
suffering from pain display exaggerated behavior (fatigue.
in the experience of pain by the IASP definition shows
exhaustion. lack of concentration. etc.).
that pain cannot be evaluated or treated irrespective of a person's disposition. To understand a person's disposition
The
important
aspect
of
psychologic
intervention
should focus on suffering. Initially an improvement of emo
and to incorporate these aspects into the treatment. one
tional status using medication should be sought. followed
must consider their past and current situations. Different
by the search for strategies for the compensation of the loss
aspects of the patient's past. in particular circumstances
experienced: alternative functions. supportive activities,
under which the emotional development occurred. are
possibly providing acknowledgment in the social environ
very important. Personality factors (i. e.. traits) established
ment, helping to identify new roles and gathering positive
on the basis of how a person copes with different difficul
experiences; all of these with gain of emotional status in
ties are also important (Engel. 1959; Blumer and Heilbronn,
mind. Ultimately, in patients in whom pain cannot be suf
1982). Assessing these may increase understanding of cur
ficiently influenced. the improvement of quality of life may
rent psychosocial dispositions (e. g., marital and family sit
become the main focus of psychologic therapeutic inter
uation, job-related factors). These very specific aspects of
vention.
pain experience may require the involvement of an ex
Initially. the assessment of the patient's emotional sta
perienced psychotherapist, particularly during treatment.
tus is necessary. A number of chronic pain patients suffer
Recent studies clearly indicate that cognitive aspects may
from the conditions discussed above and will develop so
play the most important role in pain (Pincus and Morley,
called emotional or affective disturbances. There are many
2001). The focusing of attention also appears to be of
studies indicating patients suffering from chronic pain
particular relevance (Petrovic and Ingvar.
2002) and dis
without demonstrating symptoms of clinical depression
traction of attention is one of the most important psycho
(Novy et ai.,
logic interventions in the cognitive behavioral treatment of
nov et ai.,
1995; Williams and Richardson. 1993; Rada 1996). However, these symptoms may be sum
pain. Although distracting attention from-pain related fac
marized as a chronic form of adjustment disorder with
tors can be helpful in acute pain conditions. it may become
mixed emotions according to DSM-IV (American Psychi
difficult in chronic pain for which continuous attention
atric Association.
distraction is required.
inent symptoms are dysphoria, irritability. anger, and sad
1994). This means that the most prom
The following brief summary outlines the psychologic
ness; it is important to treat these symptoms since affec
and behavioral aspects of pain and the need to integrate
tive nonequilibrium may lead to vegetative symptoms
these into a treatment strategy. The nociceptive process
such as somatic hypelvigilance. sleep disturbances (non
starts where tissue damage occurs. causing the generation
restorative sleep), poor concentration. and reduced libido.
of an initial stimulus in the afferent nerve fibers; a process
Many of these symptoms can eventually lead to a vicious
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Psychologic Aspects of Pain Treatment
cycle with a nontreatable chronic disorder. For this reason
ment has been comprehensively summarized (Turk and
the first step at this stage might be pharmacologic treat
Meichenbaum, 1994) and will therefore be dealt with in brief . Cognitive behavioral therapy focuses on disruption of
ment of the affective problem. Antidepressants may chiefly be required. The choice and doses of drug should,
the vicious cycle generally outlined above. An initial re
however, be carefully considered in order to avoid side
quirement is for the patient to learn that pain is manage
effects in patients with frequent suffering from severe
able to the point that at least some improvement of quality
forms of somatic hypervigilance. Tricyclics may show anti
of life is possible. This is a main goal of treatment rather
cholinergic effects and selective SSRI may cause gastro
than focusing on total pain relief . The following techniques
intestinal problems in men who, due to pain. may suffer
are used in this treatment.
significant libido loss and, due to further action on post
Education is a fundamental part of the treatment. The
synaptic terminals, additional sexual problems. Given that
patient should know the essentials of pain such as how it is
clinical depression is not seen in the greater part of these
generated and modified and what might improve the mod
patients, lower doses of antidepressants may be the treat
ification of this pain. In particular, patients should know
ment of choice. Substances that positively influence sleep
about the factors or activities that might may aggravate as
(e. g., amitriptyline, trimipramine) may be the best choice
well as alleviate the pain. This may enable the patient to
to start with, particularly as an initial positive effect may
analyze his or her own behavior, uncover which activities
strengthen therapeutic aUiance and profound Iy influence
might aggravate or alleviate the pain, and foster positive
the course of treatment.
aspects crucial to developing further activities and helping break out from isolation. Additional positive effects of this may include increased participation in physical activities
Cognitive Behavioral Therapy
that do not provoke pain, a gain of physical fitness, social reintegration, and development of distractors.
Apart from treatment with antidepressants. and where
Distraction is a refocusing of attention away from the
necessary with other drugs, modern psychologic therapy
pain experience (McCaffery and Beebe, 1989). The most
of chronic pain is mainly based on cognitive behavioral
favorable distractors are those that are enjoyed by the
therapy. The basis of this therapy that pain is not simply
patient and therefore add to the affective benefit. One
a sensory event but that experience of pain also includes
should avoid giving patients suggestions or prescriptions
affective, cognitive, and behavioral aspects. The main as
of what to do in order to distract. In this regard, an analysis
pects of cognitive behavioral therapy are to enable the
of behavior under close observation of the therapist is
patient to control this pain and alleviate consequences
crucial. This should include the analysis of aggravating
previously summarized under what is referred to as suffer
activities (to be avoided if possible) or those alleviating
ing. The achievement of these goals may significantly im
symptoms (to be fostered). This is the best way to find
prove the quality of life. The therapy is based on the expe
individual distractors, with a preference for those with
rience of chronic pain patients who had the increasing
positively affective reactions. These should be pleasurable
belief that they had done everything to control the pain
activities or stimuli that correspond to particular situations
without success and were consequently afraid of the pos
The patient should engage in finding these activities and, in
sibly serious underlying cause of pain and its degeneration.
the case of positive effects, should be encouraged to per
In many patients this leads to the reduction of both phys
severe in them.
ical and social activities in the belief that these may be
Relaxation techniques are increasingly being employed
painful or may cause an increase the pain. In these cases
in cognitive behavioral treatment. Relaxation may help to
the onset of vita minima (minimal life activity) is a frequent
reduce fear and anxiety, thereby introducing additional
consequence that enhances suffering. This inevitably leads
positive feelings. Many pain patients show increased levels
to an increased loss of muscle strength and joint mobility,
of negative affects (such as anxiety and fear). leading to
and a continuous decrease in fitness. Many of these pa
increased activity of the autonomous nervous system with
tients develop a defeatist attitude and rely on the hope that
potentially pain-provoking consequences. Indeed, many
by a "miracle" their pain might vanish. At this stage, pa
patients under sustained stress show increased muscle
tients focus on themselves in fearful expectation without
tension, an important aspect of pain promotion. Techniques
distractors or positive experiences. In terms of cognitive
of
behavioral psychology, these individuals show dysfunc
relaxation, imagery, biofeedback (e. g.. muscular, respira
tional behavior in which pain controls the patient rather
tory), or hypnosis can prove useful. Many of these tech
autogenic
relaxation
training,
progressive
muscle
niques, in particular imagery and biofeedback, should be
than vice versa (Pincus and Morley, 2001). Cognitive behavioral treatment is the standard thera
performed under the assistance and supervision of an
peutic measure for chronic as well as acute pain. This treat-
experienced therapist; working on different aspects of
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The Phannacologlc and Psychologic Treatment of Chronic Pain
emotional experience may be essential for a change of
Family involvement or systemic intervention in the
behavior. Some authors suggest music therapy as an addi
treatment of chronic pain is also very important. Pain af
tional aspect of cognitive behavioral treatment. It is be
fects family life in many ways, as it affects the social role of
lieved that music relaxes and has similar effects to other
the patient. Although there is limited research on this
relaxation techniques.
aspect, personal experience supports this type of interven tion.
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6
Nonradicular Pain: Spondylogenic and Myofascial Pain Syndromes
Prior to the landmark article by Mixter and Barr (1934),
spective, this is understandable (Dvorak, 1982b, 1983;
who described the characteristics of sciatica following disk
Gibson, 1980; Wardwell, 1980). The scholarly work and
herniation with subsequent surgical correction, legion pa
scientific language used by such pioneering investigators
pers were published attempting to explain the different
as Korr (1975) and Wyke and his colleagues (1967, 1979b)
musculoskeletal pain syndromes, often on the basis of
have fundamentally contributed to a better understanding
empirical descriptions and hypothetical postulates. Partic
of some of the neurophysiologic principles underlying
ular interest in the source of pain originating from soft
musculoskeletal pain phenomena.
tissue structures such as muscles, ligaments, tendons, and
Other articles have addressed the various clinical pre
the various articulations,in particular the sacroiliac joint, is
sentations in an effort to come up with a consistent corre
evident in the literature up to the 1930s and 1940s. Prob
lation of the various functional disturbances that affect the
ably all of the anatomic structures known have at one time
spinal column or the peripheral joints (Brugger 1962,1977;
or another been considered as the source of pain. Mixter
Feinstein et aI., 1954;
and Barr (1934), however, rather than presenting a single
Mitchell et al., 1979; Sutter, 1975; Sutter and Frohlich,
Hohermuth, 1981; Jones, 1981;
case study or a listing of empirical observations, introduced
1981; Waller, 1975; Dejung, 1985; Dvorak et aI., 1987c;
a well thought-out series from the "base of the skull down,
Southwick and White, 1983; Herron and Turner, 1985;
covering the 'waterfront.' Cervical, dorsal and lumbar le
Mattie, 1986). Simons (1976 a, 1988) has presented an ex
sions were all included in this first article" (Barr, 1977).
haustive summary of the many reports in the literature that
Attention and effort thereafter, so it seems, were pri
relate the muscles and fascia to the various pain syn
marily directed toward the subject of the herniated inter
dromes, while at the same time posing the question
vertebral disk and its role in the radicular pain syndromes.
"Why should so common and serious a problem be so
This ultimately steered attention away from muscle and
neglected by modern medicine?" (Simons, 1988).
other soft tissues and toward nerve root compression as a
The ideal is to identify those clinically meaningful pa rameters and diagnostic criteria that would unequivocally
cause of pain (Gerwin, 2000). In the most recent two or three decades,however, there
assist in distinguishing from true radiculopathies the pain
has been a noticeable trend in which both the "old" or
ful nonradicular musculoskeletal syndromes that mimic or
orthodox branches of medicine and the "new" or alterna
are similar to the explicit radicular syndromes. This should,
tive health-care counterparts alike have shown particular
at least in theory, facilitate the proper choice of therapy for
interest in investigating many of the nonradicular pain
a particular disorder, clinical presentation, or syndrome.
syndromes. The exact reasons for this rising interest are
For the field of manual medicine this means that one goal is to determine which approach or technique(s) are best
not entirely clear. Many published reports have attempted to organize and
suited for a particular patient, ranging from such varied
categorize the seemingly countless descriptions of the ap
maneuvers as the high-velocity, low amplitude manipula
parently diverse painful soft-tissue disorders and nonra
tions (thrusting techniques) to the "gentle" approaches of
dicular pain syndromes. The terminology seemed to get in
soft-tissue techniques, including the various trigger point
the way, as many previous accounts had been categorically
and tender point approaches, myofascial release tech
lumped under such nonspecific terms as inflammatory
niques, muscle energy or facilitatory techniques, among
soft-tissue rheumatism. Although seemingly similar so
many others. There already exist a number of good, rational
matic phenomena appear to have been described by the
rehabilitation approaches that ultimately should allow the
various authors over the years, the language and terminol
patient to undertake the transition to an independent
ogy used often seemed to reflect more the individual au
home exercise program as soon as the clinical situation
thor's opinion or that of a particular school of thought than
allows.
a common scientific language. The sheer number of the
At an international manual medicine seminar in Swit
many neurophysiologic hypothetic al postulates, coupled
zerland in 1983, now known simply as the "Fischingen
with the often confusing, nonstandard language, which
Conference," an attempt was made to collate, correlate,
also varied from country to country may, at least in part,
and unify the different terminologies used by the many
explain why even clinically relevant observations might
schools of thought and practice (Dvorak and Dvorak, 1984).
have been lost or hitherto ignored. From a historical per
In this chapter we want to present five models that deal
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Nonradicular Pain: Spondylogenlc and Myofascial Pain Syndromes
with the various components of the nonradicular spondy
structures. When injecting hypertonic sodium chloride so
logenic or musculoskeletal pain syndromes as they relate
lution into the paravertebral muscles, the ligaments, and
to the field of manual medicine:
the apophyseal joints (also referred to as the facet or zyg apophyseal joints), or when scratching the periosteum
1.
with a needle, localized and referred pain was consistently
Referred pain.
2. Myofascial pain syndromes.
elicited that was in accordance with the segmental inner
3. Postural pseudoradicular syndromes.
vation (Kellgren 1938, 1939; Lewis and Kellgren, 1939)
4. Somatic dysfunction and tender points.
(Fig. 6.1).
5. Spondylogenic reflex syndromes.
When the deep structures were stimulated, a rather diffuse pain distant from the origin of stimulation was
Despite the diversity in terminology, the attentive reader
observed. When certain areas of the thoracic spine were
will readily recognize the overlap of, and the similarities
stimulated, pain was referred to both the anterior and
among. the different descriptions of the various clinically
posterior portions of the trunk in a patchwork pattern
observed phenomena and the postulates of the proposed
that is similar to skin hypersensitivity (Fig. 6.2) (Hockaday
neurophysiologic mechanisms.
and Whitty, 1967). This is in distinct contrast to other types of thoracic pain that may follow a band like or girdle dis tribution as seen in some neuropathic pain states, such as
Referred Pain
pain associated with herpes zoster.
Referred pain, in the simplest terms, may defined as pain
junction produced a deep pain both in the gluteal region
that is perceived by the patient at a location distant from or
and in the thigh, albeit, rarely below the knee.
Stimulation of various structures at the lumbosacral
different from the structure that is presumed to be the pain
Skilled palpatory assessment of the muscles, ligaments,
generator. This broad definition includes pain referred
and fascia can help differentiate those tissue components
from visceral structures and somatic structures either di
that are affected as a result of the referred pain and those
rectly or via reflex pathways. Here we describe observa
that remain untouched by it. It appears that local anesthetic
tions on referred pain originating from somatic skeletal
agents applied to the secondarily affected tissues (the
(nonvisceral) structures.
muscles, ligaments, fascia, etc.) can reduce the referred
Keligren (1938), Sinclair et al. (1948), and Hockaday and
pain level at the referral site. However, the injection of a
Whitty (1967) demonstrated in clinical experiments that
local anesthetic agent into the secondarily affected tissues
local and referred pain can be elicited upon mechanical or
does not alter the original or spontaneous local pain of the
chemical stimulation of the diverse spinal and paraspinal
structure that was initially stimulated (e. g., the supraspi-
Point of stimulation
Point of stimulation
"T�
o o o o
L1
L10.....
"'" -r
rv r) ,I --+-
Point
:.
+ •
b
_
I c
I \
Fig.6.1 Pain pattern upon injection of hypertonic sodium chloride solution into (a) the superficial and arches, infraspinous fossa of the scapula). (After Kellgren,
1939.)
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Copyrighted Material
V (b. c) the deep structures (vertebral
Referred Pain
Fig.6.2 Diagram of the patchwork distribution of referred pain after stimulation of deep structures of the thoracic spine (vertebral arches, joints). (After Kellgren,
1939.)
T4 T6
T8 T10 T12
L2 L4
T10 T12 L2
L1
L4
L3 L5
Sl
nous or interspinous ligaments). In contrast. when a local
tile vertebral segments between (1 and 53, such as the
anesthetic is applied to the area of tile initially stimulated
deep muscles and ligaments. The manifestation of referred
ligament, both the local and the referred pain may disap
pain and the localization of zones with decreased sensitiv
pear (Kellgren, 1939). Kellgren summarized his experimen
ity to pain did not always correspond to known radicular
tal observations as follows:
innervation patterns such as the zones described by Head,
"The superficial fascia of the back, the spinous processes, and
for instance. In Feinstein's studies, the pain was felt mostly
the supraspinous ligaments induce local pain upon stimula tion, while stimulation of the superficial portions of the in
in the reflexly hypertonic muscles upon injection of the
terspinous ligaments and the superficial muscles result in a
symptoms, such as paleness, excess perspiration, decreased
diffuse type of pain. The deep muscles, ligaments, and peri
blood pressure, fainting, and nausea, among others.
sodium salt solution. This was accompanied by autonomic
osteum of the apophyseal joints, as well as the joints them
Figure 6.3 depicts the various observed patterns of re
selves, can cause referred pain according to the segmental
ferred pain according to the level of segmental stimulation
innervation when sufficiently stimulated."
at (4, T4, T6, T11, L2, L4, and L5.
Feinstein et al. (19 54) also injected a hypertonic sodium solution into tile paravertebral structures associated with
115
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Nonradicular Pain: Spondylogenlc and Myofascial Pain Syndromes
(4
T6
T4
T6
T4
Tl1
Fig.6.3 Schematic representation of referred pain after injection of hypertonic sodium chloride solution into the deep somatic soft tissues. (After Feinstein et aI., 1954.)
116
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Referred Pain
Fig. 5.3
L2
(cant.)
Fig. 5.3
(cant.)
L5
L2
L4
L4
L5
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Nonradlcular Pain: Spondylogenic and Myo(ascial Pain Syndromes
1981). This may be of importance for documentation re
Myofascial Pain Syndromes
quirements. for instance, in the patient's medical record, as
The myofascial pain syndrome is a muscle pain disorder in
tified but also any noticeable functional changes, such as
not only must the incriminated MTrP be adequately iden one or more muscles or groups of muscles accompanied by
associated loss of joint range of motion or specific muscle
local and referred pain, and is associated with decreased
weakness, or particular objectively verifiable functional
range of motion, weakness, and often autonomic phenom
deficits (standing, reading, etc.).
ena. Patients are readily recognized by their history of characteristic muscle pain and the presence of myofascial trigger points, which are specific areas of hyperirritability
Types of Myofascial Trigger Points
in a muscle that cause local and referred pain on palpation
The active MTrP has a low threshold for mechanical stim
(Meyer. 2002).
ulation. With normal physiological motion. local pain ap
Research during the past 20 to 30 years has provided valuable information for clinical practice about the painful
pears, but it is the referred pain in the reference musculature and fascia that is perceived by the patient as symptomatic.
syndromes associated with the myofascial trigger points
The clinically nonsymptomatic latent MTrP refers pain
(Melzack. 1978; Reynolds, 1981; Rubin, 1981; Simons 1975,
only when a certain amount of palpatory pressure is ap
1976b; Travell and Rinzler, 1952; Travell 1976; Travell and
plied or when an acupuncture needle is inserted into the
Simons. 1992).
MTrP (Melzack, 1981). The primary MTrP develops independently and not as the result of trigger point activity elsewhere (Rachlin, 1994).
Myofascial Trigger Points
Secondary MTrPs may develop in antagonistic muscles and neighboring protective muscles as the result of stress
The trigger points may be spontaneously painful or may be
and muscle spasms (Rachlin, 1994). We have also observed
elicited upon digital pressure. In the presence of a true
secondary MTrPs to develop in synergistic muscles or
myofascial trigger point, the patient describes the per
muscles of the same functional group, that is, in either
ceived pain in an area that follows a pattern that is
the phasic or tonic muscles when one or the other is
characteristic for the particular muscle harboring the myo
affected. It is common for patients to experience the pain of a secondary trigger point after a primary trigger point is
fascial trigger point (Fig. 6.4). Similarly to the phenomenon described as the irritation
eliminated (Rachlin, 1994).
zone (described below), a specific anatomic or histologic
Satellite MTrPs can develop in the area of the referred
substrate has not yet been identified nor have any particular
pain as the result of persistent resting motor unit activity in
neurophysiologic interactions that would unequivocally be
the muscle (Travell and Simons, 1983a,b). For instance, a
able to explain the development, presence, or perpetuation
MTrP in the sternal portion of the sternocleidomastoid
of the individual myofascial trigger point or points.
muscle can cause satellite MTrPs in the sternalis muscle,
Hubbard (1993) found spontaneous needle-EMG activ
pectoralis muscle. and the serratus anterior major muscle.
ity in the myofascial trigger points, which he explained on
Little is known about the etiology of the MTrP, but the
the basis of the contraction of the intrafusal muscle fibers.
list of the many proposed causes includes direct muscle or
Less convincing were studies that examined local oxygen
joint injury. chronic muscle overload, or lengthy periods of
levels, tissue damage, and sympathetic activity in those
hypothermia (Travell. 1981). Latent MTrPs can be activated
muscle believed to harbor a trigger point (Bengtsson et
by small impulses. such as the overstretching of a muscle, a
al.. 1986, 1989; Bennett, 1989; Boissevian and McCain,
sudden burst of muscle activity associated with overload,
1991; Lund et aI., 1986; Simons, 1988; Yunas et aI., 1981).
or immobilization. The development of MTrPs in the seg mental musculature has been known to occur with com pression of the nerve root (Travell, 1976). As a rule, they are
Palpation of Myofascial Trigger Points
not reversible, even after successful operative management
The myofascial trigger point (MTrP) is described as a small
(e.g., postlaminectomy syndrome) (Travell, 1976).
area (0.5-1 cm) of muscle that is hypersensitive to pressure
There are reports that joint motion restriction (hypomo
and is noticeably different from the surrounding region
bi lity) in the presence of a segmental or somatic dysfunction
when palpated. In normal muscle, a MTrP cannot be dem
or inflammatory processes can contribute to the formation
onstrated and pain cannot be elicited with normal palpa
of a MTrP in a muscle or exacerbate it (Reynolds, 1981).
tory pressure. Characteristics of a muscle with a MTrP are weakness of contraction but no atrophy. Contraction leads
Fig.6.4 Examples of trigger points and referred pain in the reference
to decreased motility of the corresponding joint (Travell,
sites (pain reference pattern; after Travel! and Simons,
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1983 a).
I>
Myofascial Pain Syndromes
Muscles of the Shoulder and Arm
Muscles of the Head and Neck Sterno
Splenius capitis
Infra
Supraspinatus
spinatus
cleidomastoid
Temporalis
Masseter
Trapezius
Tra pezius
Supinator
Extensor carpi radialis
Levator scapulae
Rectus capitis
posterior maj or
Interosseus
Adductor pollicis
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Nonradlculor Poin: Spondylogenic and Myofascial Pain Syndromes
Muscles of the Chest and Back Pectoralis major
Pectoralis major and minor
· ;i/
+
(,4f \ J )
:'::.
)( Trigger point
Fig. 6.4
,,fir' . !li'
i:: "".,/ .:;';'. Pain pattern
(cont.)
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Muscles of the lower Extremity
Myofascia/ Pain Syndromes
Myofascial Trigger Points and Pain Referral
Myofascial Trigger Points:
Patterns
Treatment Options
Referred pain, in the presence of either an active or a latent
In general, and in addition to standard pharmacologic care
MTrP, is usually very well-localized by the patient. Using
(e. g., nonsteroidal anti-inflammatories [NSAIDS], analge
palpation, the painful muscle or part of the muscle ("myo
sics), the activity of the MTrP can be addressed specifically
tenone", for definition see below) can be demarcated. The
in three ways: (1) introduction of maximal stretch with or
MTrP is described as a "palpable band" (Simons, 1975,
without a cooling spray; (2) injection or "dry-needling" of
1976b), which should be palpated perpendicular to the
the trigger points; and (3) specific manual medicine tech
direction of the incriminated muscle fibers (similar to the
niques applied to treat the MTrP to the incriminated
"myotendinoses" also defined below). Palpation often
muscle or muscles.
causes a local, painful twitch response in the muscle in volved (Simons, 1976a; Travell, 1952).
The "spray-and-stretch" method is commonly used to treat the MTrP (Travell, 1981). With the help of a cooling
A MTrP may cause pain in one or in several reference sites (Fig. 6.4).
spray (e.g., fluoromethane), afferent nociceptive impulses of the skin can be invoked, which in turn appear to reflexly
The induction of several so-called satellite MTrPs by a
reduce the muscle's resistance to stretch, thereby facilitat
primary MTrP is described by Travell (1981). For instance, a
ing the lengthening of the shortened muscle in the direc
MTrP in the sternal region of the sternocleidomastoid
tion of the normal resting length. This "stretch stimulus"
muscle can cause satellite MTrPs in the sternalis muscle,
appears to be able to reduce the activity of the MTrP,
pectoralis muscle, and the serratus anterior major muscle.
presumably via the reflex pathways within the spinal
MTrPs can be found in any skeletal muscle; in orthope
cord, or possibly in higher central nervous system (CNS)
dic practice, a set of common muscles has been regularly encountered and described (Rachlin, 1994):
centers. The MTrP activity can be reduced or even extinguished by injection of local anesthetics such as procaine or lido caine. The muscle that harbors the incriminated MTrP
1. Posterior neck muscles 2. Sternocleidomastoid muscle and scalene muscles
should be carefully stretched passively during the injec
3. Trapezius muscle (the most commonly encountered
tion. Another form of treatment entirely avoids the need
MTrP in general)
for any injectant by approaching the MTrP simply using an
4. Infraspinatus muscle
injection needle, a course of treatment known as dry nee
5. Supraspinatus muscle
dling.
6. Levator scapulae muscle, rhomboid muscles, and tho racic erector spinae muscles
Recent reports of the use of botulinum toxin (botox) injections have shown some promising results, but further
7. Lumbar paraspinal muscles and quadratus lumborum muscle
studies are needed to substantiate the use of this rather costly procedure. Currently, the use of such injections is
8. Gluteal muscles (minimus, medius, maximus muscles), tensor fasciae latae, piriformis muscle
considered as "off-label" due to diagnostic restrictions. Efforts are under way to determine further specific indica
9. Rectus femoris muscle and vastus medialis muscle
tions and contraindications for the use of botox in muscle
10. Flexor and extensor muscles of the forearm ("golfer's
"spasms" and painful myofascial syndromes. Due to the reported duration of up to 3 months, a possible therapeutic
elbow" and "tennis elbow" syndromes) 11. Pectoralis minor and major muscles
window is being opened for patients with recalcitrant myo
12. Interossei foot muscles.
fascial pain syndromes, as it would not be reasonable to inject local anesthetics for prolonged or even open-ended
Other muscles have also been identified as occurring more
periods, especially when there is lack of anticipated func
commonly in the presence of headaches and facial pain.
tional progress.
In addition to causing referred pain, the active MTrP can
The manual approach to the treatment of various myo
influence autonomic functions in the reference site, includ
fascial trigger points is detailed in Chapter 18. A recent
ing cooling by local vasoconstriction or via increased per
monograph (Dejung et aI., 2003) provides an exhaustive
spiration and amplified pilomotor activity.
and well-organized treatise of these methods and the dry
Occasionally, hyperalgesic skin regions have been ob
needling techniques.
served (Travell, 1981).
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Nonradicular Pain: Spondylogenic and Myofasaal Pain Syndromes
path of movement. Remember that a reflexly contracted
The Postural Pseudoradicular
pectoralis major muscle can easily mimic the substernal or
Syndrome
parasternal pain caused by organic heart disease (Fig. 6.6).
Brugger (1962,1977) coined the term pseudoradicular syn
Brugger considers the "effort syndrome" as indicative of
drome to differentiate it from the neurologically based
the sternal syndrome, representing an abnormal head
radicular syndrome. The pseudoradicular syndrome is ex
forward posture.
plained on the basis of the reflex interactions between the
In the cervical spine, the reflexly hypertonic neck
various joint structures and the muscles. Of particular in
muscles may cause a secondary spondylogenic cervical syn
terest is the potential interaction of some of the somato
drome. Abnormal sternocostal and sternoclavicular stimu
motor nociceptors that apparently come into play when
lation can also "spread" further to reflexly involve some arm
the soft tissues are irritated or become painful, such as the
muscles, which may eventually result in myotendinosis. The
joint capsule or the tendon attachments (Brugger, 1977).
reflexogenic changes in the muscles and tendons (myoten
Brugger believes that the painful reflex nociceptive re
dinosis) can be demonstrated by having the patient assume
sponses can affect not only the associated muscles and
the upright, erect posture position and then the abnormal
their corresponding tendons but the skin as well. The re
slouched position. The patient may spontaneously report
gion where the muscle-tendon junction has become pain
that the slouched posture (that is,the patient's stereotypical posture) is more comfortable than assuming the normal
ful is referred to as a "myotendinosis." Myotendinosis is described as a reflex change in or
upright position. This can be explained by the mechanisms
alteration of muscle and tendon function in response to
of involving the mechanoreceptor and nociceptor reflexes
pain. These reflex reactions can be initiated by nociceptor
as described by Wyke (1979b).
stimulation following: (1) abnormal posture: (2) muscle
When the acromioclavicular joints are involved, reflex
(3) direct or
myotendinoses have been characteristically noted in the
(4) a combination of these.
serratus anterior muscle, the trapezius muscle, the biceps
and tendon overuse and strain syndromes: indirect soft tissue injury: or
Brugger (1977) divides the various pseudoradicular syn
brachii muscle, the coracobrachialis muscle, and the exten
dromes according to body regions. Upper body involve
sors of the wrist and fingers (Brugger,1977).
ment includes the sternal syndrome and the thoracic spine
It should be noted that the sternal syndrome does not
syndromes. Lower body involvement is comprised of the
only affect the musculature of the shoulder, neck, chest,
lumbar syndrome and the symphyseal syndrome. They are
and arm but may also present with paresthesias and tro
described in greater detail below.
phic skin changes. Furthermore, and equally important, Brugger (1977) emphasized that any primary brachial syn drome, including the carpal tunnel syndrome and the var
The Sternal Syndrome
ious upper limb overuse syndromes, can all lead to a sec ondary sternal syndrome on a reflex basis (Brugger, 1977:
The sternal syndrome is usually the result of a slouched,
Gerstenbrand et aI., 1979).
trunk-forward-bent posture that is maintained over a pe riod of time. Due to abnormal mechanical loading condi tions, the sternocostal and sternoclavicular articulations are continuously subjected to ever increasing stress and strain (Fig. 6.5), in particular when abnormal loading forces are introduced to the thoracic spine and the ribs along with their connections to the sternum. As a result of these abnormal loading conditions at the sternocostal and sternoclavicular joints, the muscles in this region are increasingly called into action. This can ulti mately lead to reflex muscular contraction in many re gional muscles including the intercostal, pectoralis major and minor,sternocleidomastoid, scalene, and the posterior neck muscles. The involvement of any of these muscles can relatively easily be assessed by careful palpation. Starting with the patient in the seated or "normal" up right position and requesting him or her to adopt a slouched
b
a
posture will provide valuable feedback to the examiner
Fig. 6.5
about which muscles are engaged at what point in the
tion. (After Brugger,
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a
Slouched trunk position. b Erect (straight) thorax posi-
1977.)
The Postural Pseudoradicular Syndrome
c
Fig.6.6a-d Overview of pain radiation patterns when the sternoclavicular joints
(a,
b, c,
d)
and different sternocostal joints (c, d) are
stimulated through puncture (after Brugger, 1962).
and their related myotendinous junctions, particularly in
Reflex Syndromes Associated with the Trunk
the pelvis, the abdomen, and the lower limbs. Based on
and the Viscera
reports by Fassbender and Wegner (1973) and Fassbender (1980), Brugger further believes that some of the lumbo
Functional disturbances of the trunk and disorders of the
pelvic dysfunctions can ultimately precipitate new reactive
viscera can both result in myotendinoses and articular
inflammatory changes and swelling at the tendinous in
somatic dysfunction syndromes via somatosomatic and
sertions to bone, the tendon sheaths, and the interstitial
viscerosomatic reflex interactions. respectively (Brugger,
muscle tissue.
1965).
Thus, the confluence of the many somatic sources and
It is known that a primary segmental dysfunction aris
their secondary reflex interactions at the spinal cord level.
ing from somatic structures can cause pain referral to the
at least as seen with the various nociceptive reflex pain
inner organs (Schwarz, 1974), that is, via the somatovisceral
patterns, and possibly even at the brain level, may reduce
reflex path. The reverse is also well described, that is.
the individual's overall functional capacity, by diminishing
diseases of inner organs can reflexly induce myotendinotic
the performance of the entire musculoskeletal system in
changes via the viscerosomatic reflex (Korr, 1975; Beal and
general and the other interrelated systems. This, in turn, may explain the variability of the many pain syndromes
Dvorak. 1984). Proficiency in palpation of the muscles, the fasciae, ligaments and tendons. and, where possible, the nerves,
when they involve the back, the lower limbs. and the pelvis (e. g., shortening of the iliopsoas muscle).
requires solid knowledge of and experience in the func
Subcutaneous inflammatory processes, hemorrhages,
tional. three-dimensional anatomy. A detailed structural
and scars can also cause pain that involves the various
functional analysis of body posture and movement patterns
articular,
along with appropriate application of local infiltration of
1981). In clinical practice it is often difficult to differentiate
anesthetics in the incriminated spinal joints (apophyseal or
between the secondary reflex changes and a presumed
muscular,
and
fascial
structures.
(Reynolds,
facetjoints) or the costovertebral joints can help distinguish
primary musculoskeletal disorder. A detailed and function
whether the pain arises from a particular musculoskeletal
ally oriented structural examination is therefore often a
structure or from a visceral source (Wyke, 1979a, b).
logical place to start in order to assess the current states of the different structures, at the time of presentation in the office. The assessment should include a detailed evaluation
Syndromes of the lower Body
of the incriminated muscles, the tendons. ligaments, fas ciae. and joint capsules.
According to Brugger (1965). the functional unit of the
Stimulation or irritation of the apophyseal joints in the
lower body consists of the thoracolumbar spine, the pelvis,
thoracolumbar and the lumbosacral junctions can cause
and the lower limbs and the corresponding regional back
particular myotendinotic pain patterns in the muscles
muscles and the abdominal muscles.
and tendons associated with the spine, the abdomen, and
Abnormal mechanical stress to the lumbosacral junc
the lower limbs (Fig. 6.7).
tion. for instance, may preferentially affect certain muscles
123
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Nonradlwlar Poln: Spondylogenlc and Myofascial Pain Syndromes
,:. "
'
•
. ...:. . .: '. . .' . .... : " " 00'
"I
•
•
•
. :I
"
:..
"
"I
::
.,'•.
. ·
'
:
.
r';;,t . :
..
.
·
· · .
'
. . .
"
I , I I I I
l
Fig.6.7 Pain radiation pattern when different apophyseal joints are stimulated through puncture. (After Brugger,
Symphyseal Syndrome
1962.)
femoris muscle, sartorius muscle, tensor fasciae latae muscle) (Brugger,
1962, 1977) (Fig. 6.8).
In the slouched sternosymphyseal posture as described by Brugger (Fig.
6.9), the synergism between the paraspinal
extensors and the abdominal wall muscles is displaced in favor of the abdominal muscles, which in turn may further exacerbate the already present irritation at the symphysis. It is often impossible to distinguish on clinical grounds only a primary symphyseal disturbance from the many possible painful secondary and adaptive reflex changes invoked
by
the
various
ligaments
and
the
tendon
periosteum interface at the symphysis, when the cause may be due to disturbances in the thoracic spine, for in stance.
Fig.6.8
Pain radiation when the symphysis pubis is stimulated
through puncture. (After Brugger,
1962.)
To recognize a true radicular syndrome and to be able to differentiate it from other sources that can' mimic it, the clinician should at least be aware of that articular or so
It has been reported that the infiltration of the symphysis
matic dysfunctions, e, g., in symphysis pubis, can lead to
pubis with local anesthetics can lead to the immediate
pain due to reflex myotendinotic reactions. Thus, even a
disappearance of symptomatic pain in the pelvis or the
"simple" slouched posture may precipitate an adaptive or
legs. This would indicate that both the symphysis and the
compensatory "downward spiral" cascade that may cause
pelvis are potential pain generators. Dysfunctions involving
pain easily mimicking a true radiculopathy (Fig. 6.10),
the symphysis pubis or the entire pelvis may ultimately
When involved in the symphyseal syndrome, the por
lead to painful myotendinotic reactions in the lumbar para
tion of the longissimus thoracis muscle that spans between
vertebral muscles ("symphyseal lumbago"), in the muscles
the sacrum and the mid-thoracic spine may become painful
of the pelvis and the abdomen (symphyseal abdominal wall
and refer pain not only to the spine itself but also to the
pain), or in the muscles of the lower limb (e. g., quadriceps
interscapular region due to the reduced tone ("hypotoni
124
Copyrighted Material
The Postural Pseudoradicular Syndrome
city") and the subsequent associated myotendinotic reac tions. To counteract the backward tilt, the iliopsoas muscle must be recruited and may then be continuously con tracted. The tensor fasciae latae, sartorius, and rectus femoris muscles act synergistically. The hamstring, calf muscles, and the fibular (peroneal) muscles may become painfully hypotonic, or reflexly weak. It is therefore not surprising that a myotendinotic pain syndrome that devel ops in this fashion can easily be mistaken for a lumbar radiculopathy. The palpatory and functional examination of the various muscle groups should be performed with the patient as suming a slouched posture and in the upright-erect posture as well as the supine position. Interestingly, some of the myotendinotic reactions often seem to disappear when the patient assumes an upright posture, especially when the examiner supports such a posture by broad hand place
a
b
ment on the patient's posterior trunk for stability. However, as mentioned, a number of patients may find the erect
Fig.6.9
posture as less comfortable.
patient is in the slouched sternosymphyseal position.
Figure 6.11 provides an overview of some of the possible nonradicular pain radiation patterns encountered with ir
a
A torque acting in the posterior direction when the
b Disappearance of the torque in the pelvic region when the patient is sitting erect. (After Brugger, 1962.)
ritation of various joint capsules.
a
Fig.6.10 Muscles that are involved in extension of the trunk (red) and muscles involved in the slouched position (blue). (After BrLigger, 1962.) a
SloLiched, sternosymphyseal position.
b
Erect position.
_
Muscles responsible for trunk extension.
_
Muscles participating in perpetuating the sternosymphyseal slouched position.
125
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Nonradicular Pain: Spondylogenic and Myofascial Pain Syndromes
Fig.6.11 Pain radiation pat tern when different joint cap sules are stimulated by way of puncture. (After Brugger, 1962.)
The goal of the practitioner is to detect abnormal joint
Somatic Dysfunction and Tender Points
function with regard to asymmetry in range of motion,
In the osteopathic manual medicine literature and practice,
and tissue alterations such as "bogginess" (thickness, in-
the central consideration for diagnosis and treatment of the
creased consistency), heat, and perspiration, among others.
usually that of hypomobility rather than of hypermobility,
nonradicular pain syndromes of spondylogenic and myo-
Although these findings are typically associated with local-
tendinotic origin is the somatic dysfunction (Korr, 1975;
ized tenderness or palpatory pain, pain itself is not the
Mitchell et aI., 1979; Jones, 1981; Greenman, 1996).
"sine qua non" in the osteopathic understanding of the
Somatic dysfunction is defined as impaired or altered
somatic dysfunction.
physiological function of related components within the
The diagnosis of a segmental vertebral dysfunction or
somatic (body framework) system including the skeletal.
somatic dysfunction is based on a targeted structural and
arthrodial, and myofascial structures, and the related vas-
functional musculoskeletal examination that expands upon
cular, lymphatic, and neural elements. This definition,
the standard neuro-orthopedic examination. The structural
which replaces the antiquated term "osteopathic lesion,"
and functional examination, in essence, represents a thor-
was registered with the International Classification of Dis-
ough and at the same time refined assessment of the
eases under the number 739.
various components of the axial and peripheral articular
126
Copyrighted Material
The Spondy/ogenic Reflex Syndrome
system, looking for relevant asymmetries in form and func
they may be compared to the latent phase of the interver
tion, which may be amenable to manual medicine treat
tebral insufficiency, as described by Schmorl and Jung
ment procedures or specific rehabilitative exercise rou
hanns
(1968).
tines. The goal of the structural-functional examination is
The results of the positional examination dictate the
to arrive at a germane segmental diagnosis that is of suffi
direction of the manual therapeutic approach for the ten
cient clinical significance within the entire clinical presen
der points. After careful localization of a particular tender
tation to be treated in one form or another. While many
point, the patient's limb, or head, neck, trunk, or pelvis is
practitioners may base their findings on the presence of
positioned such that the initially reported tenderness is
localized pain, such as that associated with a tender point
significantly reduced in a specific position (at least
(described below), the convention in osteopathic practice is
intensity reduction), The examiner may find that in re
to determine motion restrictions and soft-tissue abnormal
sponse to proper treatment the initially palpated soft
70%
ities first and to treat those without "chasing the pain"
tissue "tension" is also reduced accordingly, and the tender
1983), A second, but
points should no longer be painful or be only minimally
equally important, diagnostic goal is to determine the po
painful to the patient. Again, there are a number of sim
(Greenman, personal communication
tential relationships of various findings in different spinal
ilarities with the definition of the tender points and the
regions and the limb joints and muscles, and if possible to
entity called the "irritation zone."
ascribe the findings to adaptive or compensatory mecha nisms.
The growing understanding of the somatic dysfunction complex as such and the particular attention paid to the
One of the neurophysiologic postulates about the occur
detailed soft-tissue examination using refined palpatory
rence of segmental motion restriction with soft-tissue
techniques, for instance, prompted the introduction of a
changes is that of the "facilitated segment." which is
number of new treatment concepts in osteopathic medi
thought to explain some of the chronic changes noted in
cine, such as the "muscle energy technique" (MET) (Mit
the affected spinal section and at the segmental level (Korr,
chell et aI.,
1975),
(jones,
One of the possible, but not universally required, clinical manifestations of a somatic dysfunction is the presence of what Jones
(1964, 1981), and before him Kellgren (1938),
refers to as the tender point. Such tender points can provide
1979), the "strain and counterstrain" technique
1964, 1981), and the myofascial release technique
(Ward and Clippinger,
1987). Similar to, yet different from,
these techniques are the muscle facilitation and inhibition techniques introduced by Lewit
(1981). While the "cranio
sacral" techniques have been described in early osteopathic
clinically relevant information for the diagnosis of abnor
literature, and despite their ever-increasing popularity,
mal joint function arising from either the apophyseal or the
they remain controversial, even within the circles of man
peripheraljoints and can guide the palpatory evaluation of
ual medicine practitioners (Greenman,
1996).
the associated reflex changes in the incriminated soft tis sues. The tender points described here, and which are to be
The Spondylogenic Reflex Syndrome
differentiated from tender points associated with fibro myalgia syndrome, are usually painful upon palpatory
Numerous empirical reports in the literature give an ac
pressure, The patient may characterize the pain upon pal
count of apparent relationships between the axial skeleton
pation as a stabbing type of pain, Typically, and unlike a
and the peripheral soft tissues that are difficult to explain
myofascial trigger point, these tender points do not refer
solely on the basis of neural or radicular, vascular, or en
pain spontaneously, They can be palpated as enlarged or
docrine mechanisms.
"boggy" tissue changes. The points, while typically located
Following
his
clinical
observations,
Sutter
(1975)
at specific regions that have been found to correspond to
presented a concept he termed "the spondylogenic reflex
specific articular levels, are usually in close proximity to the
syndrome" (Greek, spondylos
affected joint. They are mostly to be found in the deeper
genic reflex syndrome (SRS) is thought to arise from an
=
vertebra). The spondylo
muscle layers, and their size does not normally exceed 1 cm
articular dysfunction involving either the facet joint (apo
in diameter.
physeal joint) or a peripheral joint when it affects a limb.
With spondylogenic dysfunction, they often appear
Due to the associated motion restriction, e. g" hypomobility
multiply, primarily in the paravertebral region, often at
or abnormal functional position or dysfunction of the facet
the same level as the related articular processes. They are
(apophyseal or zygapophyseal)joint, certain reflex changes
also found on the anterior side of the trunk (Fig. 6.12).
can be invoked that may eventually lead to anatomically
Tender points have been described for a number of joint
localizable, noninflammatory changes in the soft tissues
dysfunctions. Even with subclinical disturbances, they have
associated with the incriminated joint. The articular dys
been reported to be detectable by careful palpation, Thus
function is thus believed to be a disturbance at the "internal
127
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Nonradicular Pain: Spondylogenic and Myofasdal Pain Syndromes
5
b
a
Fig.6.12 Localization of selected posterior tender points (exam
Note: There are cu rrently over 200 such points considered as
ples). (After Jones, 1981.)
tender points (after Jones).
a
b Anterior.
Posterior. 1
(1
1
Acromioclavicular joint
2 3 4
T2
2 3 4
(7
5
Tl-Tl2 L1- L3
6
T3 Ribs
functional" level of the vertebral spinal unit of the affected
Sternoclavicular joint Tl-T6
perpetuating the controversy about its very existence.
facet joint. The vertebral spinal unit, also Imown as the
Again, the articular or somatic dysfunction should be
spinal motion unit, consists of the two vertebral joint part
viewed as the expression of a reversible motion restriction
ners and their joints with the intervening intervertebral
with possible soft-tissue changes in the incriminated spinal
disk. In the articular dysfunction, there is a disturbance of
segment or spinal region, the objective clinical detection of
both the static and the dynamic balance between the in
which is accomplished through the process of specific
dividual bony parts that make up the axial skeleton such as
static tissue and dynamic motion palpation.
the skull, the vertebrae, and the pelvis, and the related
The primary afferent sources of the SRS are the inter
muscle-tendon system. Maigne (1970) refers to these dis
vertebral or facet joints (apophyseal or zygapophyseal
turbances as "derangements intervertebrales mineurs."
joints). When the joint-associated mechanoreceptors and
The osteopathic literature refers to similar entities as the
nociceptors in the joint capsule, ligaments, and muscles are stimulated above their normal threshold for a prolonged
somatic dysfunction complex. As the individual motion restriction may be rather
period, the invoked reflex pathways (CNS) will bring about
small, but nonetheless potentially clinically relevant, the
valuable soft-tissue changes that can be clinically observed
"faulty vertebral position" associated with a particular ar
and correlated within the particular clinical presentation
ticular
dysfunction
cannot usually be identified or detected
(Waller, 1975; Wyke, 1979b).
on adjunctive diagnostic studies such as standard radiog
One of the first demonstrable clinical manifestation of
raphy or MRI. This is in stark contrast to the easily recog
the spondylogenic reflex syndrome is the so-called irrita
nizable structural changes seen with even very minimal
tion zone (Caviezel, 1976). Other authors have referred to
The
similar changes as the segmental points (Sell, 1969), para
difficulty of demonstrating an articular dysfunction on
vertebral points (Maigne, 1970), or the previously men
radiographs, for instance, may partly have contributed to
tioned tender points Uones, 1981).
scoliosis
or anterior-posterior spinal deformities.
128
Copyrighted Material
The Spondy/ogenic Reflex Syndrome
may mean many things to different people, including the
Irritation Zone
description of tightness, hypertonicity, and even normal,
The irritation zone represents small. painful soft-tissue
albeit increased, muscle tone. Within the context of this
changes that, when palpated, can be quite tender even
text, the description by Rachlin (1994) is adopted to de
when the applied pressure is minimal. It averages between
scribe myospasm: myospasm is a clinical description of
0.5 and 1 cm in size. The irritation zones are located in
increased tone affecting an entire muscle that has become
topographically well-defined areas or regions at the level
painful due to an involuntary contraction. In addition to the
of the muscular and fascial tissues. The main characteristic
pain, the myospasm usually causes the muscle to be short
is the direct relationship between the temporal and qual
ened, limiting the associated range of motion. In the Ger
itative response of the irritation zone and the severity of
man literature this phenomenon is described as "myosis"
the associated articular dysfunction. That is, as long as the
(Myose), but there is no equivalent term in the English
articular dysfunction is not eliminated or effectively cor
literature. The muscle that is affected by myospasm is
rected, there will be a clinically identifiable irritation zone.
palpated perpendicularly at its belly, whereas it is palpated
However, once the disturbance has been corrected, the
longitudinally at its origin and insertion.
irritation zone disappears quite promptly. This is of clinical
A generalized increase in muscle tone in the absence of
significance, in particular in the patient management pro
muscle pain (either spontaneous or upon palpation) is
cess while monitoring patient response.
known in the German literature as Hartspann, which trans
Again we emphasize that when we speak of an irritation
lates as "hard tension." Thus, we may use the term muscle
zone we refer to a clinical entity on the palpatory expres
tension (or increased muscle tone or hypertonicity) simply
sion of joint function through the various soft tissues. To
as a description of a change in muscle tone while the
date, no anatomic or histologic substrate has been identi
muscle is contracted, while not necessarily being painful.
fied that would be pathognomonic for the irritation zone.
A relaxed healthy muscle, when palpated, displays a
Among the most important causes of an articular dys
characteristic firmness, consistency, and plasticity. The in
function are previous trauma, muscular imbalance and
dividual muscle bundles usually cannot be differentiated
uncoordinated or inappropriate movement patterns, acute
from each other by palpation except than when separated
and chronic mechanical overload of the vertebrae, and
by the various fascial septa. When the muscle is affected
osteoligamentous insufficiency. Secondary articular dys
and shows signs of prolonged increased tone, it is often
functions in response to inflammatory or degenerative
said to be "in spasm." When "in spasm," that is, it is con
joint disorders, including microfractures, or those associ
tracted for some period of time, the muscle reveals in
ated with space-occupying lesions, should routinely be
creased "bogginess" (thickness,
considered in the comprehensive management of the var
often associated with increased resistance to allow stretch,
ious painful syndromes (Northup, 1966).
and diminished plasticity. Either the entire muscle or only a
increased consistency)
Thus, in the authors' view, the term articular or somatic
few muscle bundles in the longitudinal direction can be
dysfunction may represent a more specific and potentially
affected. On palpation perpendicularly to the muscle fibers
clinically more relevant diagnosis than the current usage of
with average pressure, the myospasm may become painful
"sprains and strains" so commonly "diagnosed" in conjunc
and can be relatively easily differentiated from the sur
tion with the various spinal pain syndromes.
rounding area of the same muscle portions that are not
Noteworthy sequelae associated with the various artic
directly affected. A myospasm can be followed with palpa
ular or somatic dysfunctions arising from reduced facet
tion from the origin to the insertion of the involved muscle
mobility are the noninflammatory "tendinoses" and the
in a longitudinal manner. "Nervous misinformation" from
"myotendinoses," which, in our understanding, represent
the involved muscle bundles (Fassbender, 1980) has been
abnormal soft-tissue changes of the tendons and muscles
proposed as the mechanism underlying the reflex path
respectively. They are identified by specific and carefully
ways responsible for the origin of the involuntary isometric
performed palpation.
increase in muscle bundle tone (Fig. 6.13).
Myotendinosis and Myotenone
Myospasm and Myotendinosis
When there is continued increased muscle tone in the form of long-standing myospasm, the involved muscle-tendon
Myospasm
unit can undergo myotendinotic changes. The myotendi
While commonly used in clinical practice, the term "muscle
notic changes affecting the muscle and/or tendinous inser
spasm" or "myospasm" has not been specifically defined as
tions can be caused by uncorrected segmental dysfunc
to underlying pathophysiologic changes. As used, the term
tions. In the field of rheumatology this has often been
129
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Nonradicular Pain: Spondylogenic and Myofascial Pain Syndromes
referred to as noninflammatory soft-tissue rheumatism Segmental dysfunction
(Fig. 6.14).
l
Again, myospasm is a clinical term used to describe a state of painfully increased tone in muscle that can be elicited by palpatory pressure or that may appear sponta
Stimulation of mechanoreceptors
neously. Painful myospasm is principally found in the
and nociceptors
muscle belly, while the associated changes can involve
l
the entire length of muscle
Reflexes via eNS
"Misinformation"
-
or
where the muscle fibers
change their direction. They are also found at the free muscle borders such as the trapezius muscle, and pectoralis
l
major muscle, for instance. With continued, nonphysiologic
Myotendinosis
creased tone, it is plausible to assume that the muscles
excitatory impulses and in response to a continuously in compensate as long as possible, to the point of overcom
Fig.6.13 Development of increased muscle tone (hypertoniCity). (AFter Fassbender,
1980.)
pensation until the inherent adaptive mechanisms fail and the muscle actually starts to decompensate (Fassbender and Wegner, 1973; Fassbender, 1980). The decompensation then ultimately leads to muscle tears and overt rupture,
L
=-
====--==
potentially resulting also in significant damage to the af fected myofascial components associated with the partic
1
ular muscle (Fig. 6.15).
Attachment tendinoses represent localized swelling of
a
tendons at the respective origin and insertion. They can
.. t ...."";: ' 1 :=:'::-- ' 1 -1' _ 'l :':.'--=-:::: : :ti",==-- ........--
; ;,
-")l·-'; .::
' :':':: T
___
'.
b
sure. The hallmark is their mirror-image appearance: that is, presence at both the muscle's origin and its insertion. In addition to the characteristic points at the respective at tachment, the tendinoses can also be found at the muscle
Fig.6.14
tendon junction of the incriminated muscle.
Schematic representation of a normal muscle.
a
be extremely painful upon even minimal palpatory pres
b Muscle that has become painful with increased tone (myo spasm).
Morphologic studies have revealed that due to the pre sumed relative hypoxia in the involved muscle there is anomalous development of the mesenchymal connective tissue cells (Fassbender, 1980; Fassbender and Wegner,
L
P ermanently increase tonus
+ 0, req ui e
r m ent
1973) (Fig. 6.15).
Myotendinosis
Tendinoses and painful myospasm as a rule do not occur
in the muscle
unexpectedly as they take quite some time to develop enough to be noted clinically. One mechanism is thought
but
normal 0, supply
J
to be the result of various reflex interactions. Correspond
Overload at the tendons
ingly, once the causative disturbance has been eliminated, the tendinoses and myospasm are expected to disappear
Relative hypoxia
Degenerative fiber damage
a
] [ I
after a certain latency period (referred to as "latent zones" Localized lack of 0,
by Sutter). This helps in differential diagnosis to set it apart from the presence of the irritation zone. Also, clinically, they must be differentiated from other secondary trau
Progressively degenerative tendon changes
b
Fig.6.15 Pathogenesis of noninFlammatory soft- tissue rheuma tism. (After Fassbender and Wegner a
Myospasm.
b Tendinosis (tendonopathy).
1973.)
matic myospasms and myotendinoses. Each muscle or muscle part can independently undergo myotendinotic changes. Such a clinical muscle-unit with the corresponding tendons is referred to as myotenone. Slender muscles represent a single myotenone. Broad, flat, and fan-shaped muscles comprise several myotenones (Fig. 6.16). Clinical experience has shown that certain axial skeletal components
130
Copyrighted Material
are correlated
with specific myotenones.
The Spondy/ogenic Reflex Syndrome
L3 Rectus capitis
O bliq u us
posterio r
capitis
minor
superior Gluteus medius
(1 --'-<E:
___
(2
IE'--- 0 bliquus c a pi t is inferior
TlO
b
a
Fig.6.16 a
Individual myotenones.
b Myotenones in a fan-shaped muscle.
which can be objectively verified by palpation. A functional disturbance in one vertebral unit usually brings about myo
The Postural Spondylogenic Reflex Syndrome:
tendinotic changes in the empirically correlated myo
Clinical Correlation with Reflexes linked to
tenones. Since the spondylogenic-reflexogenic myotendi
Nociceptors and Mechanoreceptors
noses can be routinely identified. they are collectively termed systematic myotendinosis (Sutter and Frohlich.
The clinical symptom of pain in muscles and other soft
1981; Travell and Rinzler. 1952). The primary articular or
tissues. be it spontaneous pain or pain elicited with palpa
segmental (somatic) dysfunction of a vertebral segment.
tory pressure. has been termed the spondylogenic reflex
when followed by myotendinotic changes. represents the
syndrome by Sutter (1974.1975). Likewise the authors have
primary SRS.
been able to observe the various systematic myotendinoses
Under certain circumstances additional secondary. ter
in response to an articular/somatic dysfunction involving
tiary. and other SRSs can develop in a chain-reaction se
the individual apophyseal. occipito-atlanto-axial. and sa
quence. Thus. many factors can play a crucial role in the
croiliac joints. We have observed that many systematic
development of the spondylogenic reflex system. These
myotendinoses improve during the course of therapeutic
include spinal deformities. abnormal or stereotypic motion
intervention in the individual patients. It was therefore
patterns. muscle and proprioceptive imbalance. loss of
assumed that. in addition to other helpful physical and
muscle strength. and inherent articular dysfunction. In
therapeutic procedures. the mechanical and functional cor
clinical practice. many of these factors may be in play
rection of the spinal motion unit according to Schmorl and
together and in simultaneous combination represent a
Junghanns (1968) can play a significant role. if not the most
rather complex clinical picture.
crucial role in treatment.
Therefore. and almost routinely. it is not possible to
Wyke's observations (Wyke. 1979a. b) and research in
determine the causative primary SRS. especially in patients
the new field of articular neurology have brought signifi
with chronic conditions. The primary SRS may actually
cant insight into some of the principles underlying the
have "resolved" only to give way to the secondary SRSs.
diagnostic and therapeutic approaches in the field of man
which should then be considered the new primary syn
ual medicine. In a clinical study of adolescents. we found
dromes (Travell. 1981). The characteristic features of the
that the absence of pain does not automatically mean lack
irritation zone are listed and compared with the spondylo
of soft-tissue findings. It is well known that localized pal
genic myotendinosis in Table 6.1. Careful examination tech
pable muscle bands or systematic myotendinoses can be
niques and precise anatomic knowledge are necessary for
elicited upon careful palpation in many individuals who
establishing the correct diagnosis and initiating the appro
have no subjective pain complaints. According to the au
priate therapy.
thors' understanding. this situation is to be considered as pathologic and correlates with the latent state of interver
131
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Nonrodicular Pain: Spondylogenic and Myofascial Pain Syndromes
Table 6.1 Important characteristics for the zone of irritation and spondylogenic myotendinosis in the context of the spondylogenic refiex syndrome Irritation Zone Changes
III]Jltt.'j[tIlh
Skin, subcutaneous tissues, tendons,
t}{:,IllfIUII
Muscles, ligaments
muscles, joint capsule Localization
In area of the disturbed spinal segment,
Muscles. ligaments (referred pain?)
topographically defined in region around spinous or articular processes Time course (latency)
Immediate reaction to a segmental
Apparent after a certain latent period
dysfunction Qualitative palpatory findings
Decreased ease of skin displacement,
Increased resistance, less resiliency.
increased tissue tension, localized pain
tender upon pressure with radiation (trigger?)
Quantitative palpatory findings
Related to the degree of abnormal
Dependent on the duration of seg
segmental function
mental dysfunc tion
Changes observed with successful
Immediate decrease in quality and
May disappear after a certain latency
treatment
quantity
period (possibly reflexively)
tebral insufficiency according to Schmorl and Junghanns
receptors. This may occur by release of endorphins from
(1968). Applying the work of Wyke for comparison, this
cells in the gelatinous substance of the dorsal horns.
could be explained on the basis of the tonic reflexogenic
In our assessment. then. it would plausible to propose
influence of the type I mechanoreceptors upon the motor
that these and probably other related neurophysiologic
neurons of the axial or peripheral musculature. It has been
mechanisms may play at least as important a role in the
shown that pain-inducing nociceptors have significantly
manual therapeutic treatment as the pure "mechanical"
higher thresholds than pain-inhibiting mechanoreceptors.
correction of one or several segmental dysfunctions. Fig
This may explain the delay with which the individual may
ures 6.17 and 6.18 attempt to present this model schemati
perceive his or her pain. Again. the nociceptive stimulation
cally. Figure 6.19 represents the major tendinoses and irri
can be inhibited presynaptically when there is sufficient
tation zones in the lumbar spine and the pelvis.
stimulation of the mechanoreceptors. mainly the type II
132
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The Spondylogenic Ref/ex Syndrome
Fig.6.17 Model for the re Correct anatomical
Normal physiological pressure
position of vertebra(e)
and tension on fibrous
ceptor activity in the normal, nondysfunctional state (no abnormal vertebral position
joint ca psule
or particular hypomobility or hypermobility).
Resting muscle tone; equilibrium between synergists and antagonists
Abnormal position
Irritation of fibrous joint
Stimulation of mechanoreceptors
of vertebrate) Segmental dysfunction
capsule
of type I
Tonic- reflexogenic influence on motor neurons of neck, limb, jaw, eye muscles (myotendinose s)
Additional impulses (mechanical, chemical)
___
Stimulation of nociceptors
Pain perception
Manipulation
Correction of segmental
or mobilization
dysfunction
Stimulation of mechanoreceptors type II; inhibition of afferent fibers; release of enkephalins
Less pain, normalization of receptor activity Change toward normal muscle tone
Fig 6.18 Model for receptor activity as a result of vertebral se g me n tal dysfunction (abnormal vertebral position and/or somatic dysfunction with pain, hypomobility, etc.).
133
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Nonradlcular Pain: Spondylogen/c and Myofascial Pain Syndromes
ToT9. T10
)
I
TOT5.T6
1
Inferolateral quadrant of the transverse process and inferior margin of the rib from the tubercle to the angle
Part of the long issimus thoracis
JjfJ'it....--..../
Part of the longissimus lumborum
Origin tendinoses at the inner lip of the iliac crest
ToT7.T8
Iliolumbar ligament to costal process of L4 Origin tendinoses of the gluteus medius
_
Tip of the spinous process of 51
Anterior inferior iliac spine
Zone of irritation of 51 and 52 Posterior sacroiliac ligaments (short)
rrs'1J�\�\\��&<\\\\\�I��0L
Iliac tuberosity Interosseus sacroiliac ligament Auricular surface of sacrum Common insertion of the thoracolumbar and gluteal fasciae
��\« �W\\\I!!I� \\�
':ftl
7: i
Posterior superior iliac spine Origin tendinoses of the gluteus maximus (tibial portion) Posterior inferior iliac spine Iliotibial tract
Sacral cornu Sacrospinous ligament
Transitional tendomyoses of the gluteus maximus (tibial portion) Trochanter major
Insertion tendinoses of the gluteus maxim us (femoral portion)
Zones of irritation of the sacroiliac joint and vertebra L5 Origin tendinoses of the gluteus maximus (femoral portion)
Fig.6.19 Overview of the major tendinoses and irritation zones in the lumbar and pelvic region (after Sutter).
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7
The Structural and Functional Neuro- Musculoskeletal
Examination
Introduction
- Static palpation: the patient is not moving while the tissues are palpatorily evaluated by the operator
The neuro-musculoskeletal (NMSK) examination assesses
(various techniques). -
both the structure and function of the spine and the ex
Dynamic palpation: motion of a region or specific
tremities. The comprehensive examination has evolved
spinal segment is introduced (which can be active or
into a vital component in the evaluation and treatment of
passive) to assess specific motion restriction in three
a patient when in pain or suffering from loss of function.
dimensional space and the various tissue-reactions
The structural and functional NMSK evaluation, however, is
associated with that motion. The dynamic palpatory
not an isolated or stand-alone examination approach to the
examination is also known as motion palpation and
many painful syndromes. Instead, it can easily be inte
is addressed specifically below.
grated into the other existing examination routines used in such fields as neurology, orthopedics, rheumatology,
Motion Testing
physiatry, sports medicine and others (Fig. 7.1). In short,
•
this examination has also been referred to as the structural examination of the musculoskeletal system with the fol
Active and passive motion testing is used to determine regional and segmental dysfunctions.
•
In addition to the standard quantitative assessment of range of motion, the quality of movement, specific mo
lowing goals:
tion restrictions, and the particular end-feel are eval 1. To arrive at a structurally and functionally sound diag
uated.
nosis. 2. To determine the most appropriate treatment interven
Functional Muscle and Myofascial Assessment
tion according to the specific objectively verifiable
•
Assessment of muscle length and strength.
findings and particular functional needs of the individ
•
Assessment of the various myofascial structures as to their pliability, stiffness, resistance to active and passive
ual patient, for both short- and long-term management.
motion, abnormal "firing patterns," and other deviations As stated earlier, the structural musculoskeletal examina
from normal.
tion is not a "stand-alone" procedure but rather proceeds
•
Assessment of "tender points" in fibromyalgia.
within the clinical context of the individual patient. It
•
Assessment for myofascial trigger points.
typically follows the standard neurologic and orthopedic
•
Assessment for spontaneous non-fibromyalgia "tender points" (according to the "strain-counterstrain" system
examination. The six principal categories are as follows:
described originally by Jones [1981 and 1995]). 1. Observation ("look"). 2. Palpation ("feel").
Specific P rovocative Tests
3. Motion testing ("move").
•
Provocation testing may aid in the determination of
4. Functional muscle evaluation.
which technique or direction of treatment may be in
S. Provocative testing.
dicated or is most suitable.
6. Adjunct diagnostic studies.
Rational Selection of the Relevant Adjunct Diagnostic and/or A similar approach ("Iook"-"feel"-"move") was recently
Laboratory Studies
presented by the Association of American Medical Colleges
•
The timing and choice of the particular individual study are based on the specific objective and functionally
(2005).
meaningful findings obtained in the patient-centered history and the detailed examination routine, including Observation
findings from the structural and functional examination routine. These components will be reviewed in some'
Palpation •
The various musculoskeletal structural components are
detail be.low.
palpated in two ways:
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The Structural and Functional Neuro- Musculoskeletal Examination
Patient's Chief Complaint •
Detailed pain history
•
Relevantfunktional and medical social family history
•
Patient and physician goals
...... ......-
.., ... Standard Neuro-Orthopedic Physical Examination
1) Inspection/gait/posture/proprioception ("Look") 2) Gross range of motion testing
3) Sensory-motor-examination 4) Limb girth measurements 5) Check for sinister pathology ("red flags")
a
,.. ,..
.., T
o
:e
STRUCTURAL-FUNCTIOI\IAL MSK EXAMINATION
l::. ,..
1) Palpation-static and dynamic palpation ("Feel")
o
2) Motion testing-quantitative and qualitative ("Move")
3) Funktional muscle and myofascial assessment a.
Length and strength-fiber types
b. Myofascial structures-palpation etc. c.
Examination of different "points"
d.
Muscle imbalance
o
a
4) Specific provocative tests 5) Adjunct studies-rational selektion GOAL: SEGMENT-SPECIFIC DIAGNOSIS
• Diagnosis-Assessment -Impression 1) Structural level-"organic"
2) 3)
Funktionallevel-"dysfunktion" Pain perceptionlevel-pain and behavior
•
Treatment-Management Planning
Gli """"1 I
1) Comprehensive planning
2) 3) Fig.7.1
Functional and meaningful goals Periodic re-evaluation of appropriate parameters to monitor progress or lack thereof
The structural-functional musculoskeletal examination sequence for the integrated manual medicine approach.
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Peri odic reassess mentto monitor progress
According to Greenman (1996), palpatory skill affects
Observation ("LOOK'"
the following five key components of palpation in the assessment of the musculoskeletal system:
Observation occurs at two general levels. in form of a: (1) generalized or gross observation: and (2) the regional and
1. The ability to detect tissue texture abnormality.
localized (e. g. segmental. facet-level) observation. The gen
2. The ability to detect asymmetry of position. both visual
eralized observation, which may already have been done during the initial neurologic or orthopedic examination,
and tactile. 3. The ability to detect differences of movement in total
checks for gross postural abnormalities such as scoliosis,
range, quality of movement during the range. and
uneven shoulder or pelvis levels. head-forward carriage
quality of sensation at the end of range of movement.
and obvious signs of trauma. prior surgery or applications of orthoses or prosthetics.
4. The ability to sense position in space of both the patient and examiner.
The regional or segmental observation takes into ac count observable regional or segmentally related skin
5. The ability to detect change in palpatory findings, both improvement and worsening over time.
changes. swelling. signs of trauma. or other visible changes that deviate from the "normaL"
To be able to accurately assess and interpret the relevant palpatory finding. Greenman (1996) finds it essential that the physician fully concentrate on the act of palpation. the
Palpation ("FEELtt,
tissues that are being palpated. and the response of the palpating fingers and hands. Probably the most common
The palpatory assessment of the various joint and osseous
mistake in palpation is the lack of concentration by the
structures. including the overlying skin and associated fas
examiner.
ciae. muscles. tendons. and ligaments. plays a central role
Usually. palpation is started in the general area that is
in the integrated structural and functional NMSK assess
indicated by the patient as the most painful. However. if the
ment routine. Numerous palpatory approaches have been
area is exquisitely tender. the examiner may start in an
described in the field of manual medicine. The aim is to
adjacent area or the corresponding area on the other side of
obtain additional information not immediately recogniz
the body so as to obtain an initial impression of the tissues.
able by the naked eye or by particular laboratory or other diagnostic studies.
Comparison of symmetrical skeletal parts may be help ful but can also be misleading at times: disturbances may actually occur symmetrically. limiting the value of such a comparison. Thus. it is recommended to compare similar
Definitions; Required Skills; Applications
tissues or structures on the same side as that of the func tional abnormality, or. if appropriate. to compare with
According to De Gowin and De Gowin (1981). the usual
locations with a similar anatomic arrangement on the un
definition of palpation is the act of feeling by the sense of
affected side.
touch. The same authors elaborate on the art of palpation by stating that:
When changes are present in neighboring or analogous structures. the palpatory assessment is an important part of
"As in inspection. all normal persons possess these senses
the examination in differentiating the offending source(s)
tactile, temperature and kinesthetic positional and vibra
from those structures that are secondarily affected.
tional senses - but practice and special intellectual back
When searching for painful or abnormal tissue changes.
ground in medicine enable the physician to extract meaning
the palpating finger or fingers should remain at the same
that escape the layperson. If the reader doubts the influence
tissue level: that is. there should be no "deep probing" but.
of practice on palpation, let him observe a blind person read
rather. the palpation should proceed carefully from layer to
ing a book printed in Braille. then close his eyes and attempt
layer. This is referred to as nat palpation. Pain may be
to distinguish between two Braille letters by touching them."
present at rest or may only become apparent with move
Isaacs and Bookhout (2002) emphasize the need to de
ment. induced either by the patient or the examiner. The
velop adequate palpatory skills through repeated practice:
patient is often able to localize the pain to one specific
"One of the difficulties people Iwve in understanding and
point or some general area when a particular, isolated
applying techniques of manual medicine is that both diag
structure is involved. The patient may also spontaneously
nosis and treatment require a degree of palpatory skill that is
point to a contracted muscle band. which may be tender
different from, and in some ways greater than, that used in
either at rest or upon introduction of movement. However.
other branches of medicine."
the pain may be diffuse and not well localized in other situations. in particular with chronic pain. where. over
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The Structural and Functional Neuro-Musculoskeletal Examination
time. a number of adaptive and compensatory changes may
(c) Individual muscles may be identified and distin guished from each other by palpating along their
have altered the initial pain presentation.
septal divisions.
I\IMSK Structures Examined by Palpation
5. Myotendinous junction. (a) An area that is particularly vulnerable to injury and tears in response to abnormal loading/me chanical stress situations.
While general palpation can be applied to every part of the
(b) When injured. this area may appear as "rough" in
body accessible to the examining fingers or hand. including solid abdominal viscera and solid contents of hollow vis cera (De Gowin and De Gowin.
1981).
the musculoskeletal
palpatory assessment discerns information about the skin and hair. bones. joints. fascial and tendon sheaths. liga ments. superficial arteries and veins. as well as superficial
comparison with the surrounding muscle tissue
6.
and can also be exquisitely tender. Tendon and tendon sheaths.
7. Ligaments (example: transverse carpal ligament).
8.
Joint capsule.
nerves. accumulation of body fluids. joint swelling. tender
(a) Palpable joint capsules are present in patholog
ness. and heat. and also assists in localizing particularly
ical joints and are not usually found in somatic
painful or tender structures.
dysfunctions. (b) According to Greenman
The following are assessed through the practice of layer palpation (Greenman.
1.
1996):
(1996) direct-action
thrust treatment (high-velocity. low-amplitude thrust. for instance) should not be performed
Skin (thickness. moisture. temperature. smoothness).
2. Subcutaneous tissues (thickness. ease of displacement
9.
when the joint capsule is actually palpable. Bone.
and compressibility).
(a) Bone is not palpated directly. Its surface and structures are "inferred" by palpating through
(a) Note. this layer may reflect best or directly the tissue texture abnormalities associated with so
the overlying soft tissues. Some areas are natu
matic dysfunction (abnormal segmental motion
rally more easily accessible to palpatory assess
with tissue changes).
ment than others.
(b) Within the subcutaneous fascial layer are found
(b) In the spine the "feel" of bone is akin to that when palpating the radial head in the elbow from a
the vessels. arteries. and veins.
3. Deep fascia (smoothness. firmness. continuity of fascial
ventral direction. What one feels is resistance to movement more than the bone itself.
sheaths). (a) In particular the muscle septa separating the various muscle bundles of one group from an other can be palpated. (b) Palpatory assessment can distinguish between the various muscle groups; moving "between" the various muscles. one can then advance to the
-
L
--::=::::
.
--==--
--.,
deeper structures.
4. Evaluation of muscle, muscle tone, and muscle fiber direction.
(a) Determination whether there is "normal" muscle tone versus increased muscle tone from muscle
1
. ")j;:>:..\ \t ..'t--==s....
:5$.! _ ...,
"spasms" (physiologically "normal") to spasticity;
- ====
t----= 1 -1' --. ..-r=---2-+
=--=
,
- .L
-
_
_
=---
----;:-,.
___'
---=
2
-;.
'vC :l "'0-
--
: J:\
"vI----=
-t-
assessment of hypotonic muscles (denervation. atrophy. etc.). (b) The muscle itself is palpated either along its longitudinal axis. in particular toward its inser tions. or perpendicular to its length. especially at
Fig.7.2 Schematic representation of a typical manual muscle ex
the level of the muscle belly (Fig. 7.2). A muscle
amination. When there is increased muscle tone and pain ("myo
spasm reveals increased "tension" and dimin
spasm" or pain associated with hypertonic muscle). as in the
ished plasticity. and is usually tender upon pal pation.
bottom diagram. the arrows indicate the direction of palpation. At the insertions (1. 2) the muscle and tendons are palpated parallel along the muscle fiber direction. whereas at the muscle belly the palpatory direction is best perpendicular to the muscle fiber direc tion.
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Palpation (MFEEL"J
The facet joints themselves cannot be palpated directly due
definition or guidance in diagnosis (Ward and Sprafka,
to the overlying myofascial tissues and the skin. However,
1981 ).
their motion behavior can be assessed via palpation of their
There are two basic variations of the skin examination,
transverse and spinous processes. Carefully introduced
the one-handed skin stroke test and the two-handed skin
motion can then be followed by the examiner, who com
rolling test or Kibler skin fold test.
pares the movement behavior of the transverse processes in relation to each other (e. g., left vs. right), either by
In the
sl
the examiner produces a skin
bulge in front of the palpating fingers by gently pressing
comparing the corresponding processes of the same verte
the index and middle fingers against the skin (Fig. 7.3).
bra or, for example, by comparing those above or below the
With the patient in a prone position, and while applying
incriminated spinal segment.
a constant downward pressure toward the spine, the two
When examining a peripheral joint or the facet joints in
fingers push along with the bulge in front, from inferior to
the spine, the palpating finger(s) should make as close a
superior on either side of the spine (Fig. 7.3). This palpatory
contact with the particular joint as possible, while care is
maneuver assesses the ease of skin displacement or skin
taken not to compress the surrounding soft tissues. The
resiliency, presence and variation of moisture in the various
process of palpation should not be painful to the patient in
spinal regions, and pain that might be reported by the
general.
patient. A distinct difference in skin thickness may some
In the spine, a carefully performed palpatory assessment
times be palpated. Findings consistent with a segmental or
of the soft tissues proceeds from the superficial skin to the
regional (somatic) dysfunction include increased resistance
subcutaneous, fascial. and muscular structures overlying
to displacement or decreased laxity, increased moisture
the particular facet joint(s) in a particular vertebral spinal
production, and localizabl.e skin tenderness or pain. Re
segment until abnormal soft-tissue changes are elicited
peating this test two or three times in a patient with a
that would indicate a somatic dysfunction. Once an in
segmental dysfunction may actually produce erythematous
criminated area of tissue has been identified, the final
reactions of the skin in the area of segmental dysfunction
step of the examination is the evaluation of segmental
due to autonomic reactions. The skin
motion (motion palpation). The finding of a painful, localizable area, such as a par
rolling test usually follows the skin stroke test.
The skin rolling test is also known as the Kibler skin fold
ticular irritation zone in the spine, is used to help localize a
test. It has also been called the pincer palpation test. In this
specific dysfunction.
palpatory maneuver, a skin fold is formed between the
Palpation can be viewed as being either subjective or objective:
thumb and index finger of each hand just lateral to the side of the midline of the spine (Figs. 7.4 and 7.5). Starting from a caudad position and following the course of the
•
•
Subjective palpation: sensation perceived by the pa
spine, this fold is rolled in the direction of the head. The
tient while being palpated.
ease of fold displacement, skin thickness, and pain provo
Objective palpation:
cation are also of interest here. This test may actually aid in
findings observed (palpated) by
the examiner. Objective palpation is guided by sound
the final localization of a specific segmental or regional
anatomic knowledge with case-specific palpatory pres
dysfunction and thus may actually be part of the last or
sure dictated by the area, force, and direction of re
third step of the examination sequence, namely the seg
strictive changes.
Palpatory Assessment of the Skin Overlying the Spine Examination of the skin and fascia overlying the spinal column is helpful in the clinical assessment, since tissue changes in the skin and subcutaneous tissues may typically be altered in a particular location and thus may point in the direction of a dysfunctional spinal area. The examination of the skin is part of the
scan,
which is an intermediate
(second), but more detailed examination of specific body regions that have been identified by findings elicited in the initial screen (initial general musculoskeletal overview ex amination). The scan focuses on segmental areas for further
Fig.7.3 Palpation of the skin using the skin-stroke test.
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The Structural and Functional Neuro-Musculoskeletal Examination
to the task at hand. and. practice again if the skills are ultimately to become clinically meaningful.
Palpatory Assessment of Muscle Muscle palpation typically proceeds. wherever possible. in a longitudinal manner following the particular muscle from its origin to its insertion. Thus. at its attachment the indi vidual muscle-tendon structures are palpated following the direction of the insertion to bone. At the muscle belly. however. and naturally only where accessible. the muscle is examined by moving the palpating finger or fingers across Fig. 7.4 Palpation of the skin using either the Kibler-fold (skin
the belly in a direction perpendicular to the muscle's direc
stroke) or the skin-rolling test. In the latter. a skin fold is formed
tion (Fig. 7.5). With these principles in mind. the practi
between the index fingers and thumb and is then "rolled" up or
tioner should be able to differentiate by palpation healthy
down along the spine.
muscle tissue from painful. pathological muscle changes. such as found with a hard. palpable band when there is a myofascial trigger point. In the latter case. palpation can utilize either the skin stroke test (Oat palpation) or the pincer palpation (skin fold test applied to detect a myofas cial trigger point). It is the task of the practitioner of musculoskeletal med icine. and manual medicine in particular. to localize. eval uate. and correlate the painful manifestations as distinctly as possible with an anatomic structure and differentiate the incriminated tissue changes from the surrounding healthy tissues. Again. a thorough three-dimensional anatomic understanding of the various bony and soft-tissue struc tures and their relationships is crucial. Localization of particular bony landmarks and the vari
Fig. 7.5 Palpation of the skin by rolling the skin fold along the spine
ous painful irritation zones will be described in the related
using the Kibler- fold or skin-rolling test.
examination sections of this book. Palpatory assessment of the landmarks on the living human body may prove to be quite different from that learned in gross anatomy labora
mental examination (with the screening and scanning ex
tory sessions. Again. patience and continued practice will
amination being the first and second phases of the exami
be the two most important ingredients in the process of
nation. respectively). Thus. the skin-rolling test may pro
acquiring new or refining previously learned skills in order
vide information both during the intermediate level of the
to perform a good structural and functional assessment of
examination (scan) and the final segmental examination.
the neuro-musculoskeletal system.
Evaluation of broad fascial structures may utilize palpa tion using the entire palm rather than one or two fingers. This form of palpation. when used appropriately and in a skilled manner. will not only provide additional and "gross" information of one body or spinal region but may reveal functional information between neighboring or distant re gions.
especially
when coupled
with
patient-induced
movements such as during the respiratory effort. in activa
Motion Testing ("MOVE") Range of Motion Assessment Quantity of Range of Motion
tion of specific muscle groups. or by specific provocation
The range of motion (ROM) in a peripheral or spinal joint is
testing. such as introducing a myofascial pull over the
principally assessed in three ways: active. passive. and
sacrum and detecting the associated changes in the cervi
assisted motion testing.
cothoracic junction. In our experience. these palpatory ma
In the active range of motion assessment. the examiner
neuvers require repetition and practice. operator attention
requests the patient to move a specific body region or joint
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in a particular plane through the full possible range of motion (Fried and Fried, 2000). Passive range of motion is assessed by the examiner moving the particular joint through the greatest tolerable range of motion without the patient's assistance (Green berger and Hinthorn, 1993). Active assisted range of motion testing is in essence a combination of the active and passive assessments. It is assessed as the examiner assists the patient in performing a tolerable range of motion (Fried and Fried, 2000).
Documentation of Range of Motion Measurements The range of motion measurements in a jOint or spinal region about the particular primary axis should be docu
Fig. 7.6 Range of motion evaluation using the CA- 6000 motion
mented in an objectively verifiable manner. Ryf and Wey
analyzer for (a) the cervical spine and
(b) the lumbar spine.
mann (1999) present a useful, well-organized and compre hensive arrangement for the appropriate documentation of all major joints of the human body, which is more com
Axial Rotation
monly used in Europe. Whereas in daily clinical practice the angles of joint motion are often estimated by visual inspec tion and expressed as a percentage of "normal" motion for
Left
the particular joint or spinal region, the use of a goniometer has been recommended as the standard approach, in par ticular when dealing with legal issues or in disability as
Right
80
1
/LfLA . ; +-_...L_. -+--. ·
40
.
--""?... .
sessments (Andersson and Cocchiarella, 2000).
Side-bending
Computer-assisted measurements help to further objec tively document movements in the various spinal regions. Such systems as the Spine Motion Analyzer CA-6000 (Figs. 7.6 and 7.7) are able to provide information not only about motion in one plane but also about the presence and extent of coupled motions. Computer-assisted documenta tion may be particularly useful in setting specific initial target goals based on the measured motion restrictions, and in monitoring an individual patient's progress or lack thereof over time (continued monitoring or follow-along).
Fig. 7.7 Examination findings plotted for axial rotation as the major motion tested and for coupled motion (side- bending) to either side.
While Quantitative ROM measurements have been rou tinely used as one of the major descriptors for "disability," espeCially in the area of workers' compensation and dis
used can be reliably implemented for in-vivo studies of
ability, the reproducibility and actual usefulness of such
the sagittal profile and range of motion of the spine, though
ROM measurements in determining functional abilities
with a lesser degree of certainty for the small ranges of
has been Questioned by various authors (Lea and Gerhardt,
motion during flexion, for instance. Despite the shortcom
1995; Mayer et ai., 1997).
ings of their newly introduced device, it may still be of
As described in Chapter 2, Mannion et al. (2004) utilized
some use in providing clinically interesting data on seg
a new skin-surface device for measuring the curvature and
mental motion when examining groups of individuals with
global and segmental ranges of motion of the spine to study
a given spinal pathology or undergoing some type of inter
the reliability of regional and segmental vertebral range of
vention (Mannion et ai., 2004).
motion measurements and compared the findings with data reviewed from the literature. They also point out that there is an increasing awareness of the risks and
Quality of Range of Motion
dangers of exposure to radiation associated with repeated
The assessment of the "quality" of motion is, from a man
radiographic assessment of spinal curvature and spinal
ual medicine perspective, as important in the structural
movements. Their work suggests that the device they
NMSK assessment as is the standard measurement of a
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The Structural and Functional Neuro-Musculoskeletal Examination
joint's quantitative ROM. The aim of assessment of quality of movement is to determine the potential presence of any resistance that would interfere with the natural movement
Functional Examination of the Muscles and Myofascial Structures
in a spinal or peripheral joint. The examiner evaluates the joint's motion characteristics through its entire arc. from
Human skeletal muscle. from a functional standpoint. can
onset to the end point by evaluating the ease and effi
be divided into to two broad functional categories: the
ciency of the particular movement. The qualitative assess
postural and the phasic muscles. The postural muscles. as
ment a motion at the end of range has been termed the
the name implies. are primarily responsible for maintain
"end-feel."
ing posture. whereas the phasic muscles are responsible for quick locomotion or short bursts of activity. The individual histologic predominant composition of a particular muscle
End-Feel
determines the overall "type" of the muscle.
The importance of the end-feel is that it provides some
The postural muscles are composed of the so-called
indication of what is likely to be the most efficient and
slow-twitch fibers or type I fibers. whereas the phasic
2002). If the end
muscles are primarily composed of the fast-twitch fibers
feel is soft and elastic at the end of the extreme of motion,
or type II fibers. There is. however a range of intermediate
the limit is most likely due to muscular, ligamentous or
fibers that make up an individual muscle. so that a partic
effective treatment (Isaacs and Bookhout.
tendinous influences rather than bone/articular interfer
ular muscle is on a spectrum between these two funda
ence with motion. In the latter, the end-feel would be
mental types rather than being composed solely of either
hard rather than soft.
fiber type alone. Clinically. according to Janda
Factors that Influence the Range of Motion A number of factors impact upon the range of motion
(1979). the difference in
muscle fiber composition can be observed when there is a dysfunction that involves a particular muscle:
"The postural
muscles tend to shorten in response to a dysfunction whereas
characteristics of the various joints. Age. sex. previous
the phasic muscles tend to become reflexly weak." For exam
trauma, coexisting co-morbidities, joint and muscle dis
ple. when a painful knee is immobilized. the vastus muscles
ease. the patient's expectations. cooperation and motiva
quickly become weak. whereas the rectus femoris muscle
tion. and pain can all influence the range of motion exami
would be more likely to shorten. which may ultimately
nation either directly or indirectly, It is therefore important
result in a flexion restriction or even contracture.
to note in the medical record whether any of these factors
Thus. the functional examination of the various muscles
is present and may impact positively or negatively upon
will need to take into account whether a particular muscle
the ROM examination.
has shortened in response to a dysfunction. reducing range of motion and thus reducing functional ability overall. On the other hand, a phasic muscle may become weak rela-
Pain and Range of Motion Testing
tively quickly in response to dysfunction (e. g.. the vastus medialis in response to a meniscal tear and associated pain)
Pain that is present immediately upon or shortly after the
and thus shift the overall muscle balance away from the
initiation of movement may be associated with inflamma
normal towards a compensatory pattern, A sacral dysfunc
tory joint disease or advanced degenerative changes. Pain
tions, for instance. may be accompanied by reflexly inhib
toward the end of movement may represent early degen
ited gluteal muscles, which then may set up a vicious cycle
erative changes or the presence of a clinically relevant
of weak muscles leading to further dysfunction. and to a
segmental or regional motion restriction (e. g.. segmental
shortening of phasic muscles. and so forth.
somatic dysfunction).
The functional examination of the muscles therefore
Pain throughout the entire movement my present as a
does not concentrate only on muscle strength testing but
clinical challenge since the examination may be so severely
also includes a detailed evaluation for muscle length and,
limited that no final or relevant conclusions can be drawn
indirectly. for associated joint motion restriction, This is
about an underlying anatomically identifiable source of the
important when determining a patient's eligibility for an
pain. At the same time. and depending on the individual
active rehabilitation program. The patient should always be
clinical situation. it may be very difficult to differentiate
evaluated specifically for the presence and perpetuation of
between "organic disease" and possible secondary gain
any muscle imbalance between muscle length and strength.
issues. which may be related to issues of feigning. symptom
An inappropriately tailored program would in all likelihood
embellishment, and malingering.
worsen the imbalance rather than restore it. preventing the patient's return to maximal functional independence.
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Functional Examination of the Muscles and Myofascial Structures
Evaluation for Myofascial Trigger Points
least
11 of 18 tender points (nine homologous points on
each side of the body) as the essential criteria has been The myofascial pain syndrome, which is essentially defined by the presence of the
myoJascial trigger point, is frequently
encountered in clinical practice. The myofascial trigger
widely used and accepted. Nonetheless. The tender points, when present, should be elicited upon the introduction of a palpatory force not exceeding 4 kg.
point is defined as a hyperirritable locus within a taut band of skeletal muscle, in close association with motor end plates of nerves, that produces pain in a characteristic referral pattern distant from the site (Travel I and Simons
Other Tender Points: Osteopathic "Counter
1992). The "twitch response" is the hallmark of the trigger
strain" System- Related "Tender Points" and
point and represents a rapid contraction elicited by snap
"Chapman's Points"
ping palpation or upon the introduction of a needle into the taut band of muscle. The involved muscle can often be
According to the osteopathic physician L. H. Jones and his
readily identified by the characteristic pain referral pattern
colleagues Uones.
and specific functional changes the patient has noted. The
small. hypersensitive points in the myofascial tissues of the
1981 and 1995). the tender points are
muscle is palpated using either flat palpation or a pincer
body that can be elicited upon palpatory examination. They
palpation. In the tlat palpation procedure, the fingertip
typically do
moves the skin and subcutaneous tissues above the in
"respond" to operator-induced positioning of a particular
not refer pain distant to their location but
criminated muscle that harbors the myofascial trigger
joint or body region. Jones believed that the myofascial
point until the underlying cordlike texture of the taut
tender point represented a manifestation of a somatic dys
band is identified as such. This form of palpation is partic
function found elsewhere and was the result of some
ularly useful for muscles that are accessible only from one
"strain" induced into muscular tissues. Placing the tissues
direction, such as the infraspinatus muscle (Travell and
surrounding the identified tender point in a position of
Simons,
"ease" away from the restrictive tissue barrier would then
1992).
The pincer palpation for determination of a myofascial
be thought to bring about the therapeutic effect (poten
trigger point in a taut muscle band is essentially identical to
tially "countering" the initial "strain" of the muscle); thus
the Kibler skin fold test. Here, the muscle is picked up
the term "strain counterstrain" has made its entry into the
between the thumb and index (or middle finger), and the
literature. From a historical vantage pOint. it is interesting
fold is "rolled" until the taut band can be felt between the
to note that both Janet Travell and Larry Jones reportedly
two fingers. Muscles that are suited for such examination
used the term "trigger point" initially. Later Jones opted for
include the sternocleidomastoid, pectoralis major, and la
the name "tender point" as he believed that it is a conse
tissimus dorsi muscles. among others (Travell and Simons.
quence of a somatic dysfunction elsewhere and did not
1992). A detailed examination of the various muscles is
consider the appearance of a tender point to result from
included in Chapter
involvement of muscle as the offending structure alone
17.
(Glover and Yates.
1997). More than 200 such tender points
have been identified, and "new" ones are being "discov
Tender Points and the Fibromyalgia Syndrome
ered" continually.
The multiple tender points found in patients diagnosed
has been described and referred to as Chapman's points or
with fibromyalgia syndrome. an often debated chronic
Chapman's reflex points by the osteopathic physicians Ada
Based on empirical observations. another set of points
musculoskeletal pain syndrome in the form of nonarticular
Hinckley Chapman. Frank Chapman. and Charles Owens. It
rheumatism. are different from a myofascial trigger points.
is hypothesized that these "points" are the fascial tissue
Tender points associated with fibromyalgia typically do not
expression of associated visceral dysfunction. According to
spontaneously refer pain in a characteristic pattern. which
the foreword by Fred Mitchell, Sr.. D.O to Owens and Chap
is the case with myofascial trigger points. Nine pairs of
man's text
specific tender points associated with fibromyalgia syn
the body surface in the deep fascia as "gangliform contrac
drome have been defined by the American College of Rheu
tions" in predictable locations and in association with spe
(1999). the Chapman's points can be found on
1990). While there remains
cific organs. While the application of these "points" as
ongoing controversy in the literature as to the usefulness
diagnostic and therapeutic tool has been empirical. there
matology (ACR) (Wolfe et al..
and reliability of merely "counting" the number of specific
exist. to date. no specific pathologic correlations with bi
site-related tender points. the ACR definition of fibromyal
opsy samples (DiGiovanna.
2001).
gia using widespread pain for at least 3 months and of at
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The StnJcturol and Functional Neuro- Musculoskeletal Examination
Provocative Tests The aim of introducing provocative tests is to safely repro
Rational Selection of the Appropriate Laboratory and Adjunctive Diagnostic Studies
duce the patient's reported symptoms within a controlled setting. Usually the individual test is a pain provocation
The optimal imaging and/or laboratory study to be ordered
test. In addition to the commonly used provocative maneu
and its interpretation must be correlated with the patient's
vers in the orthopedic examination (e.g., Spurling's ma
history, physical examination, response to previous or spe
neuver, foraminal compression test), the field of manual
cific provocation treatment, and other ancillary tests. This
medicine utilizes additional provocation tests for the eval
approach improves diagnostic specificity and selection of
uation of segmental vertebral motion that have been de
the most appropriate conservative, interventional or surgi
veloped over years of practice. For instance, if the patient's
cal pain management approaches (Cole et aI., 2003). The
pain in the sacroiliac and buttock area can be consistently
manual medicine history and examination findings may
reproduced with anterior pressure upon the sacrum, then
help further guide the decision which would be the most
this may assist in the localization of the source of the pain
appropriate studies for the particular presentation at a
to the sacral structures as one of the sources of the patient's
particular time.
pain. Guiding the joint or spinal region into a position that
In summary, the structural and functional NMSK ex
is more painful to the patient is described as a direct
amination, also known simply as the structural examina
approach, as the structures are usually guided toward
tion, builds upon the findings elicited in the standard
their respective (painful) barriers.
neuro-orthopedic examination by using specific manual
The converse is also used in practice. Carefully guiding
medicine approaches and by:
the patient's incriminated spinal region or extremity joint into a position that is less painful is a helpful finding that might guide the appropriate direction of treatment. The pain-free direction is known as indirect treatment, as the treatment is usually away from the motion or structural
1. Paying particular attention to findings of asymmetry in
posture, regional and segmental areas. 2. Determining degree and quality of motion abnormal ities/restrictions. 3. Eliciting abnormal soft-tissue findings in muscle and
tissue barrier. Irritation zones in the spine can also be exacerbated or alleviated by introducing specific, albeit very localized, movements in certain directions, which may help in the further delineation of a mechanical back pain diagnosis, for instance.
fascial structures. 4. Eliciting specific findings through controlled provoca
tive tests. 5. Helping select the appropriate additional diagnostic
studies as indicated by the individual patient's presen
Provocation tests also include tests that help differen
tation and defined patient and physician goals.
tiate between or induce specific autonomic symptoms or signs reported by the patient such as nonsystematic ver tigo, headache, and other disorders. Since nystagmus can be elicited by the introduction of certain neck movements, these movements are also considered to be provocation tests.
144
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8
Rational Selection of Appropriate Low- Risk
Treatment Interventions
Introduction
2. Subsequently the particular signs and symptoms are:
(a) Evaluated as to their relevance and significance. The etiology of many musculoskeletal disorders is much
(b) Correlated with any objectively verifiable data
more often multi'factorial than the result of a single cause.
points (adjunct diagnostic studies or laboratory
This is particularly true when a patient presents with low
values, provocation testing, etc.).
back or neck pain. Despite tremendous international re
(c) Integrated within the greater clinical context so
search efforts, there are but a few scientifically tenable
as to arrive at a tenable clinical diagnosis (as
studies to date that have successfully identified the low
sessment, clinical impression) that tal<es into
risk treatment intervention(s) that would be the most ap
account the following:
propriate for a particular clinical presentation. Perhaps this
(i)
Structural abnormalities.
is because of the complex nature of the topic itself. Certainly
(ii)
Functional deficits.
the many obvious and not so obvious interrelationships
(iii) Patient pain perception.
spanning the entire bio-psycho-socio-emotional spectrum require the individual study methodologies to be "as clean as
To remain mindful of the various factors at play in any
possible." Especially when it is impossible to come to a clear-
given clinical situation we have found it helpful to structure
cut anatomic or pathologic structural diagnosis, one would
our thinking according to three major levels or domains,
be safest to assume that it would be easier to conduct a useful
which in turn, are further divided into to specific subcate
study on what is thought to be a "simple" or "straightfor-
gories or areas. The three main levels or domains are:
ward" clinical disorder than a more complex one. For example, compare the diagnosis of an anterior cru-
1. The structural level ("structure" domain).
ciate ligament tear with that of pain in an elderly patient
2. The functional level ("function" domain).
who has been shown to have lumbar spinal stenosis sec-
3. The pain perception level ("pain" domain).
ondary to degenerative changes and a preexisting scoliosis.
It would seem easier to elaborate specific diagnostic crite-
Recent years have witnessed a plethora of "alternati
ria, therapeutic approaches, and quality control data for a
ve"-often proprietary-treatment techniques that claim
torn ligament than for such diagnosis as spinal stenosis.
to be "holistic" and all-encompassing in the treatment of
Treatment, and in particular rehabilitative efforts, for
the various musculoskeletal disorders. Many
a
"new" tech-
many musculoskeletal disorders often present as a diag-
nique often appears to be championed by one particular
nostic and therapeutic challenge. While it is typically pain
practitioner or school of thought. In isolated cases such a
and the associated loss of function that prompts a patient
technique may have indeed provided some reported bene-
to seek medical help, the physician's job is to "start from
fit, and the temptation is to "generalize" the success to
the bottom up," that is, searching for structural and objec-
other clinical situations as well, without appreciating the
tively verifiable findings first, before looking for any func-
individual patient's entire bio-psycho-social situation. By
tionaI issues that may then have led to the patient's pain
add ressing usually only one I.evel, and making claims that
perception. This seems to be particularly true when trying
in the final analysis are clinically or scientifically unsub
to get a handle on the chronic or "overuse" conditions.
stantiated, many of these "healing cures" fail to adequately
Based on clinical experience across various specialties,
work up and treat the patient's condition within the nec
the authors of this text have found it useful to approach
essary medical as well as individual bio-psycho-social con-
an apparently complex clinical presentation in an organ-
text.
ized manner, using a rational step-by-step approach: 1. First, as many as possible relevant clinical parameters or
data points (objectively verifiable findings) are gathered and identified that pertain to a particular clinical situa tion. These objective findings are based on: (a) Thorough history. (b) A detailed physical examination.
145
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Rational Selection of Appropriate Low-Risk Treatment Interventions
The Structural Level
with those arising from the functional level. If there are known structural deficits, the functional program must al
The structural level concerns itself with the organic, mostly
ways take them into account and the program should be
the organic diagnoses that are typically based on objec
modified accordingly. When choosing the individual pa
tively verifiable findings, such as disk herniation, osteopo
tient's treatment intelventions, the benefits and potential
rosis, spondylosis, spinal stenosis, spondylolisthesis, and
therapeutic risks as well as contraindications should al
others. The structural level has been the domain of ortho
ways be weighed.
dox or "Western school" medicine (Fig.
8.1).
The functional level is similar to the WHO's definition of
The structural level corresponds roughly to the World
"disability," which entails a description of the limitation of
Health Organization (WHO) definition of an "impairment,"
normal everyday activities such as dressing oneself. The
which is defined as an abnormality of anatomical or phys
functional level also includes the WHO definition of
ical structure. However, the WHO definition also includes
"handicap." A handicap is a limitation on full participation
psychological and cognitive impairments. Examples of im
in the community because of disability or impairment, such
pairments are hemiplegia, amputation, decreased range
as driving to one's usual workplace. Both terms concern
of-motion, dysarthria, depressed mood, and aphasia. The construction of the appropriate treatment plan is
themselves with the functional limitation that arises from a fundamental structural impairment.
determined by the individual patient's clinical diagnosis, which in turn is based on specific meaningful structural and objective signs, known risk factors, indications, and
The Pain Perception level
contra indica tions. In virtually all of the musculoskeletal disorders, the pain perception level takes on a key role if not the key role. Even
The Functional level
though the patient may have had significant functional deficits over a prolonged period, it is often the patient's
The functional level concerns itself with those components
reported pain that prompts the medical visit. From a long
of the musculoskeletal system that impact upon the indi
term view, the resolution or diminution of the patient's
vidual patient's overall physical performance. Once a de
pain can only occur when there is demonstrated improve
tailed structural and functional examination has been per
ment on both the functional level and the pain perception
formed, which includes specific provocation and manual
level.
medicine evaluation maneuvers, the treatment approach is
In any event, the selection of the appropriate therapeu
constructed. The treatments that specifically address issues
tic interventions should follow a logical progression. The
associated with the functional level include manual med
indications and contraindications for one form of treatment
icine treatment, training therapy, trigger point treatment,
versus another are determined by the findings from the
reconditioning programs, and other related restorative
structural level. The goals for manual therapy and a recon
therapeutic interventions.
ditioning program are based on the findings arising from
Treatment outcome is maximized when the therapy
the functional level (Table
concepts suggested by the structural level are coordinated
146
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8.1).
Introduction
Fig.8.1 The structural, func tional. and pain perception levels and their components as related to disorders of the musculoskeletal system.
Neurophysiology
Biomechanics
STRuauRE
Table 8.1 Medical dimensions of manual medicine and its role in the management of musculoskeletal disorders ,
..
.
.
Psychology
Principal Treatment I ntervention
••
Pain Perception Level
Modification of or assistance through other treat
Social Work
ment interventions and approaches such as:
Psychiatry
•
Manual Medicine
functional Level
Rehabilitation Interventions
t Orthodox/Westem medicine
Structural Level
Surgery
•
Manual medicine treatment
•
Psychotherapy and/or counseling
•
Pharmacotherapy
Selection of: •
The most appropriate manual medicine treatment
•
A training therapy/exercise program
•
Reconditioning therapy
•
Physical therapy
technique(s)
From a manual medicine standpOint, the goal here is to determine any of the following possible points:
t
•
Structural diagnosis
•
The risk-benefit ratio
•
Potential contraindications of the intended treat ment
•
The patient's candidacy for pharmacotherapy or surgery, or other standard/orthodox medical treatment for the determined structural diagnosis
147
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Rational Selection of Appropriate Low-Risk Treatment Interventions
Examination Levels in Relation to the
On the other hand, in some clinical situations, one may
Diagnosis and Treatment of Musculo skeletal Disorders
with good conscience suggest a "wait-and-see approach," in which the individual patient's course is monitored clin
Once the various findings from the structural, functional,
self-limiting disorders (Fig. 8.2).
ically over a certain period (follow-along). This should be particularly useful when dealing with a "case" of known
and pain perception levels have been collected and ana-
If the clinical findings established for one level are
Iyzed within the context of the entire clinical situation, the
strongly suggestive of a particular structural diagnosis,
appropriate therapeutic modality or modalities are chosen.
then the appropriate diagnostic and therapeutic manage-
As with any other form of medical intervention, the pri
ment plan is directed to address these findings as specifi
mary goal is to maximize the beneficial treatment outcome
cally as possible. This may require that the patient be
while minimizing the potential risks.
referred to the appropriate medical specialist or for specific
The following schematic presentations are intended to
diagnostic studies.
provide a rational basis for the selection of an appropriate management approach. The findings determined on the three different levels are correlated with the patient's pain score, and a "therapeutic window" is opened for the appropriate therapy. If the patient has findings on all three levels, then therapies should be chosen that are recom mended in the different "therapeutic windows." The ther apeutic window is reduced if additional adjunctive studies, such as the various imaging or laboratory studies, narrow the differential diagnosis.
Fig. 8.2 Correlation of pain inten
ftnc1ln9(slgn) -xY"ln relatron to reported pain level
t
II
III
(II
(III
sity (I-III) and objective examina tion findings (signs) (A-C).
(
z ..,
Therapeutic window
§. .., z
o 2
BII
B
All
A
....
;5
Z ::J u Unre markable
F
,,(I;
o
2
3
r••
7
PAIN INT£NSITY
148
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8
9
10
..
Correlation of the Various Clinical Parameters
would be most appropriate to treat the child with mobi
Correlation of the Various
lization with impulse techniques, for instance. It would also
Clinical Parameters
be appropriate to enroll the child in an individually tailored home exercise program and/or reconditioning program if
Pain History and Pain Intensity (Fig. 8.3)
indicated.
Pain alone that occurs in the absence of any objectively
Case B
verifiable clinical findings and that cannot be attributed to
If in another child with a similar pain history there are no
either the structural or the functional level is not by itself
meaningful findings elicited in the history and a sufficiently
sufficient for the initiation any manual medicine interven
detailed physical examination, the child's psychosocial sit
tion, physical or training therapy, or a reconditioning pro
uation both at home and in school should be evaluated.
gram (Fig. 8.3).
Treatment using manual medicine techniques is clearly not indicated in this situation
Example When a patient presents with an extensive history of
Palpatory Evaluation and Potential Pain
chronic unresolved pain, despite rational previous man-
Provocation
agement, the entire bio-psycho-social situation should be taken into account before another isolated intervention is
Well-localized pain that is reported by the patient upon
introduced.
induced palpatory pressure near or at an irritation zone (or
Case A
tion for the use of manual intervention, such as mobiliza
other similar localizable regions or "points") is one indica Manual medicine examination of a child with a so-called
tion-with-impulse techniques (the classic "thrust" techni
"school headache" reveals the presence of a painful, seg
ques, for instance) or the nonimpulse technique, depen
mental somatic dysfunction in the cervical spine, a finding
ding on the clinical situation. Pain in a characteristic
that correlates with the functional level. In this situation, it
pattern of distribution may be an indication for myofascial
Fig.8.3 Correlation of pain inten sity and reported pain history.
Pain history and reported pain level
II
III
c
B
A
o
2
3
7
4
8
9
10
PAIN ImEN lTV
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Rational Selection of Appropriate Low-Risk Treatment Interventions
trigger point treatment. in particular when the snapping
In the authors' experience. a reported pain score of 7/10
type of palpation is able to reproduce the patient's de
(10 being the "worst pain ever") or higher upon palpatory
scribed pain (e. g.. manual evocation of a myofascial trigger
examination of an area is not uncommon for acute condi
point). A rather diffuse nonlocalized pain that is elicited
tions. but has been found to be relatively rare in chronic
even with the most gentle palpatory pressure on the skin
situations. Conversely. if there is an ongoing. unresolved
and soft tissues typically requires a closer look at the pa
chronic situation (especially one that has been treated in
tient's pain perception level in order to determine whether
the past) and the patient reports a 10/10 pain score during
there are any neuropathic. sympathetic reflex dystrophic.
the palpatory assessment. one should search for findings
or psychosomatic contributions to the patient's pain
on the structural level first. in order to exclude potential
(Fig. 8.4).
underlying joint or disk degeneration or space-occupying lesions or other potentially sinister pathology. [f the re ported pain has been present over years but anatomically
Example
identifiable lesions have been unequivocally ruled out
Pain elicited upon palpatory pressure over the irritation
through proper studies. yet the palpation elicits inordinate
zone at C6. for instance. may indicate a facet or segmental
amount of pain. the practitioner again should address the
motion dysfunction at that particular level. However. the
patient's overall bio-psycho-social situation rather than
overall clinical situation must be considered. On the one
one component at the structural level alone. Even in these
hand. the localized
situations
finding may represent secondary
changes in response to an underlying spondylotic degen
where there are positive manual
medicine
findings that indicate an underlying somatic dysfunction.
erative process (structural level). On the other hand. it may
which would generally be an indication for manual medi
represent only one of numerous findings in a patient who
cine treatment. the findings should not be overinterpreted.
has a radiculopathy attributable to the same level. Thus. the
If it has not already been done. it may be a good idea to
practitioner must always consider 01/ of the possible noci
refer the patient for further evaluation. to include a
ceptive reactions associated with the various musculoske
pain-behavior specialist. psychiatrist. neuropsychologist.
letal disorders.
social worker. and possibly others.
Fig.8.4 Correlation of pain inten· sity and palpatory examination
PaIn upon palpatIon.- reported pain level
II
findings.
III
c
B
A
q, eF"
"
o
2
3
•
.
7
PAIN INTENSITV
750
Copyrighted Material
8
9
10
Correlation of the Various Clinical Parameters
Segmental Hypomobility and Pain Intensity
between the ear lobe and the acromion is not more than
A segmental hypomobility (localized motion restriction or
a young person performing the side-bending motion may
3 Col. A finding of a hard end-feel at the extreme of motion in somatic dysfunction) may be the result of factors associ
represent a localized segmental dysfunction and/or a struc
ated with the structural level (degenerative changes, due to
tural pathology that requires further assistance. In a per
skeletal, arthrodial, and myofascial structures and their
son's midd Ie years, side-bending motion in the cervical
associated vascular, neural, and lymphatic interactions,
spine continues to decrease as the result of the ever-present
for instance).
degenerative changes (lateral spondylosis or uncarthrosis).
Segmental hypomobility also represents one of the major
By age 50 years, the mobility will have fallen to 600 for
findings of functional disorders of the spine. Treatment of
side-bending motion and the end-feel at the barrier is now
the segmental hypomobility is accomplished through mo
usually hard. Neither the decreased range of motion in the
bilization with or without impulse techniques. The findings
cervical spine nor the change of the end-feel at the barrier
of a segmental dysfunction alone usually does not explain a
should be interpreted as an indication for further treatment
very high pain score in the fields (-I, (-II, and (-III. and
unless other findings can be demonstrated on the other
would thus require further diagnostic work-up (Fig. 8.5).
levels. If the end-feel at the extreme of motion is soft in a middIe-aged person, one should consider the cause possi bly to be shortened muscles, in particular a shortened
Example
trapezius muscle. This would require treatment even if
A finding of a segmental vertebral motion restriction in the
only in the form of a well-designed home exercise program
absence of any additiona.1 findings associated with the
or personalized stretching program.
structural, functional, or pain perception levels should be
With advancing age, the range of side-bending motion
considered as part of the normal aging process and not as a
in the cervical spine will have decreased to 20-300, with
pathologic process per se. Both the range of motion and the
the major mobility taking place at the levels of (O-(l,
end-feel in the cervical spine have been shown to decrease
(1-(2, and (2-(3 (Dvorak et aI., 1992b). It is paramount
with advancing age.
that especially in the elderly person all of the various com
Side-bending range of motion in the cervical spine of an
ponents from the three levels are competently addressed
adolescent is approximately 80-900, that is, the distance
and any contraindications are excluded before considera-
Fig.8.5 Correlation of pain inten
Segmental hypomobi llty and reported pain level
II
sity and segmental hypomobility (motion restriction).
III
t
c
B
I
A Absent -
o
2
3
7
4
8
9
10
PAIN INTENSITY
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Rational Selection of Appropriate Low-Risk Treatment Interventions
tion is given to manual medicine intervention, whether
nerve root compression, manipulative techniques are rela
techniques that utilize the mobilization impulse techniques
tively contraindicated.
or not. Because any of the techniques can induce pain when
Deficits that progress significantly over a short period of
performed upon the elderly, in particular in the presence of
time, prominent neurologic deficits that interfere with the
spondylotic changes affecting the spine, it goes without
patient's activities of daily living, or reports of bowel or
saying that the execution of any technique must be done
bladder changes (i. e., incontinence) may herald a neuro
with caution and with as little force as possible.
logic emergency with the need for immediate diagnostic studies such as CT or MRI scans and a greater likelihood of the need for surgical intervention, depending on the clin
Neurologic Deficits and Pain Intensity
ical scenario (Fig. 8.6).
Neurologic symptoms reported in the patient's history or
include a spinal surgeon right from the start (an orthopedic
neurologic signs that are elicited in the physical exami
or neurologic surgeon with specialized training in spine
From the authors' experience, it has proven beneficial to
nation should not be ignored. They always require a ra
surgery), as the appropriate adjunctive diagnostic studies
tional diagnostic work-up. The neglect of even an isolated
and the type of treatment can be more easily and rationally
neurologic sign may become problematic when, after in-
coordinated.
appropriate treatment-i. e., mobilization-with-impulse-
Nonetheless, a "wait-and-see" approach has been found
the symptoms and signs become exacerbated. The most
appropriate for a number of patients who do have a dis-
frequent causes of neck or low back pain are cervical and
crete nerve lesion or have neurologic deficits. The reason is
lumbar disk herniation (protrusions) and prolapse, with or
that the success rate of surgery is not as high as previously
without accompanying space-occupying involvement such
assumed Uunge et aI., 1995, prospective studies: Dvorak et
as central spinal stenosis or foraminal stenosis. Symptoms
aI., 1988b, retrospective study). In a 2-year follow-up study,
or signs that progress over time certainly require ongoing
only 50% of the operated patients had complete pain relief,
clinical monitoring by the treating physician but they may
whereas 25% obtained only moderate relief, and the re-
also need referral to the appropriate specialist, often sooner
maining 25 % showed no improvement or actually reported
rather than later. In the presence of a clear diagnosis of
a worsening of their clinical situation.
Fig.8.6 Correlation of pain intensity and neurologic deficits.
Neurologic deficits and reported pain level
III
\I
c
B
A
"e
'<
·;..O
o
2
3
4
7
PAIN II\ITfNc;rrV
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8
9
10
Correlation of the Various Clinical Parameters
The previous enthusiasm for a surgical approach as the
an adjunctive or temporary treatment. Treatments should
treatment of choice is somewhat dampened by these meth
be employed only once the contraindication and indications
odologically sound studies. Not only the costs directly re
have been properly weighed as to risk and benefit.
lated to treatment should be taken into account, but also those secondary costs such as loss of productivity, future potential disability payments, early retirement, etc. When
Physical Functioning and Pain Intensity
there are subjective and objective radicular findings, it is wise to proceed with a thorough diagnostic work-up and
A reduction in physical fitness or functional capacity ("de-
meaningful observation (follow-up) in order to determine a
conditioning") usually does not in and of itself cause pain. If
patient's ultimate surgical candidacy.
a patient who is clearly deconditioned reports moderate or
Neurologic deficits in the absence of frank disk hernia-
severe pain, the cause of the pain should be investigated by
tion require a detailed and rational work-Up for such pos
searching for factors that might be attributable to the
sibilities as space-occupying lesions (benign or malignant),
structural and functional levels.
dynamic instability (spondylolysis and/or spondylolisthe-
Neither manual medicine approaches nor training or
sis), inflammatory processes, spontaneous fractures, and
reconditioning therapy are indicated for a pain patient
others. Note that spinal tumors can present identically to
who is deconditioned in the absence of any objectively
frank disk herniations.
demonstrated structural or functional factors (Fig. 8.7).
I n any event, as long as the cause of the neurologic deficit has not been adequately investigated, manual medicine techniques should never be considered as the primary ap
Example
proach to the patient's treatment. This holds true even if the
In the "fitness world" there exists a general tendency to
pain that prompted the patient to come for the medical
treat spinal disorders primarily with strengthening techni
consultation initially is reported as high and unbearable.
ques only (e. g., for the abdominal, spinal. and trunk
This is particularly true when the practitioner localizes
muscles), rather than providing the patient with the ap
"clear-cut" somatic dysfunction that might otherwise be
propriate balance of all of the components of a compre
amenable to manual medicine treatment. The treatment of
hensive program. For example, it is well known that a good
the somatic dysfunction should then be considered only as
cardiopulmonary program can reduce the risk of coronary
Fig. 8.7 Correlation of pain inten sity and physical fitness.
Physical fitness and reported pain level
II
III
t
c
B
A
I o
2
3
4 PAIN I
7
�.,..
8
9
ENSITV
10
•
153
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Rational Selection of Appropriate Low- Risk Treatment Interventions
infarctions and other cardiovascular disorders. A compre
indicated as has been initially surmised (Junge. Ahrens.
hensive program consists of stretching. strengthening. pro-
Dvorak. 1995). It is not rare for patients who have been
prioceptive retraining. and cardiovascul.ar as well as mus
suffering from pain for a long time to develop interpersonal
cular endurance training.
problems with family. friends. and peers. In addition. they may encounter difficulties and display a host of potential secondary psychosocial disorders.
Psychosocial Factors and Pain Intensity
The opposite may be true as well. Patients may have had psychosocial problems prior to undergoing lumbar spine
Psychosocial and behavioral factors play a crucial role in
surgery. which in turn might have fed a vicious cycle if the
both the development of pain and its course over time.
pain had not been eliminated. Thus. and this is the authors'
Psychosocial factors can overshadow problems arising
experience. it may ultimately become impossible to deter
from the structural and/or functional levels. When contem
mine which came first. the "chicken or the egg." In such a
plating surgical intervention. for instance. it is prudent to
clinically
address the many possible psychosocial ramifications and
individual patient's problems requires the art of medicine
to determine any contraindication to a surgical approach.
in deciding which of the three planes - the structural. the
challenging
situation.
management
of
the
Chronic pain situations that are correlated with the plane
functional. or the pain perception plane - should be ad
C-II and C-III suggest that overall management should avail
dressed first.
itself of the expertise of a pain behavioral specialist such as
Thus. once significant psychosocial behavioral issues
a psychiatrist. neuropsychologist. social worker. or others
have entered the clinical picture. the approach to an indi
(Fig. 8.8).
vidual patient's issues should not only include a complex comprehensive evaluation but may also require significant additional resources. This point seems to elude even the
Example
best-intentioned of the health insurance carriers.
The high incidence of apparent psychosocial and behavio ral issues after spine surgery should support the recent notion that spinal surgery is not always the "final answer" to unresolved back pain. and may not be as frequently
Fig.8.8 Correlation of pain intensity and psychosocial factors.
Psychosocial factors and reported pain level
II
III
c
B
A
Unre markable
vq rz," '.,lrz,.:J;
o
2
3
4
W'
"
7
PAIN INT£NSITY
154
Copyrighted Material
8
9
10
Correlation of the Various Clinical Parameters
Muscle Imbalance and Pain Intensity
The appropriate training therapy and the associated reconditioning program for a decompensated posture in
Muscular imbalance is typically associated with changes on
clude two major components:
the structural level as well. In and of itself, muscular im balance usually causes little or no pain. If the pain reported
1. Stretching the shortened tonic muscles.
by the patient is significant (see fields (-III, B-III, A-III), then
2. Improving the maximal force and endurance of the
one should direct investigate the possible pain source
weak phasic muscles.
("pain generator") on the structural and/or pain perception levels. If all three levels are involved, the muscular imbal
However, before such a program can be initiated, the first
ance is usually secondary in nature (Fig. 8.9).
goal of treatment is to reduce or resolve the patient's pain as otherwise the "protective" action of the incriminated muscles may perpetuate or worsen the pain (see discussion
Example
above). Thus the rational use of an appropriate course of
A thoracic wedge fracture seconda ry to osteoporotic
physical therapy with few passive modalities, an active,
changes may lead to kyphosis in the thoracic spine, which
hands-on approach, and/or a short-term medication trial
in turn can increase the lumbar lordotic curvature. A newly
may be indicated.
diagnosed fracture due to osteoporosis can be painful up to
3 months. The associated pain (nociceptive reactions) may lead to secondary muscle changes leading to a prominent
Instability and Pain Intensity
muscle imbalance with the erector spinae, the iliopsoas psoas, and the descending portion of the trapezius muscle
Instability is not to be confused with segmental or joint
are often found to be typically shortened. This may be
hypermobility. From a biomechanical perspective, joint in
accompanied by weak medial shoulder blade fixating
stability is associated with an enlargement of the neutral
muscles (e. g., the rhomboid muscles) as well as weak
zone (Panjabi 1992a; Grob et aI., 1993). Instability is often
abdominal muscles. The combination of shortening and
associated with segmentally related pain.
weakening leads to postural decompensation.
Fig.8.9 Correlation of pain intensity and muscular imbalance.
Muscle Imbalance and reported pilln level
II
III
c
B
A
o
2
3
4
7
,
8
9
10
PAIN INTENSITY
155
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Rational Selection of Appropriate Low-Risk Treatment Interventions
Instability is a factor typically correlated with the func tional level. Instability can be associated with pathology on
Example
L4-LS intervertebral disk and degener
the structural level in the form of either hypermobility or
Desiccation of the
hypomobility.
ation of the apophyseal joints result in a decreased ability
For the (-II area, the treatment intervention comprises mobilization-without-impulse
techniques
and
training
of the
L4-LS disk to withstand stress or loading without
pathologic deformation. This inability to "handle the stress"
therapy with a reconditioning program. If need be, this is
may lead to signs of instability when the joint's neutral
coordinated with the appropriate trigger point therapy
zone has become enlarged (Panjabi et aI.,
(myofascial trigger points).
1994).
Degenerative changes involving the intervertebral disk
For the (-Ill and 8-111 fields, the indications for surgical
routinely reduce mobility of the involved segment. Exami
stabilization must be established by an experienced team, if
nation findings and signs that indicate instability take
possible an interdisciplinary or multidisciplinary team. The
priority over the clinicaJly determined segmental hypomo
ideal team has broad expertise ranging from the surgical
bility and should be addressed appropriately.
approaches to manual medicine approaches to the medical
Myofascial trigger points should be treated according to
reconditioning/rehabilitation program. Unless there are
their clinical relevance, and nociceptive reactions should be
clear indications for emergent or urgent surgical interven
reduced as much as possible by the initiation of an indi
tion, the patient may first benefit from an appropriate trial
vidualized tailored training and reconditioning therapy
of nonsurgical, hands-on treatment through the most ap
program.
propriate conservative treatment interventions (Fig. 8.10).
Mobilization-with
or
mobilization-without-impulse
In recent years, physical therapeutic intervention has
techniques should be introduced only after a carefully per
shifted away from a purely modality-based approach to a
formed trial treatment, which might exacerbate the already
patient-centered active (e. g., exercise) approach that uti
painful clinical situation. One hypothesis is that this occurs
lizes passive modalities for preparation or specific support/
by precipitating arthritic degenerative change. Another hy
intervention.
pothesis suggests that degenerative change may actually result from an increase in the neutral zone. This could arise from too frequent application, or poor technique with in appropriately introduced manipulative forces.
Fig. 8.10 Correlation of pain in tensity and segmental instability.
Instability and reported paIn level
II
III
t
c
> I::
....
iii
B
A
}}. e "e",.,s>C'
o
2
3
4
'
:'
7
PAIN INTENSITY
156
Copyrighted Material
8
9
10
Correlation of the Various Clinical Parameters
Segmental Hypermobility and Pain Intensity
painful. and rather impressive decompensated clinical presentation. Hypermobility in patients with rheumatoid arthritis or
Mobilization-with-impulse techniques are contraindicated
patients who have sustained significant cervical spine
for a hypermobile segment. Surgery is indicated in the area (-III only when there are no known psychosocial or behavioral issues (major depres sion. axis II personality disorders. for instance).
trauma always requires a thorough
clinical
work-up.
When a patient with known and Clinically relevant hyper mobility reports an increase in or significant new pain, it
If there is little pain. despite significant hypermobility as
may reflect a progression of the previously known insta
in the field (-I. surgical intervention is usually not indicated.
bility. It is therefore of great importance to serially follow
However in the B-1I1 area. trigger point therapy and other
the patient over the entire course of his or her disease.
appropriate interventions for pain control should be applied
When attempting to treat the patient by means of
with the caveat that the chosen interventions must be se
mobilization. it is paramount to first use a carefully dosed
lected rationally from those therapies that are expected to
trial
reduce the nociceptive reactions. Lastly. a good home exer
mobilization-without-impulse techniques may reflexly in
cise and aerobic conditioning program should become part
hibit the usual nociceptive-associated impulses. It must
of the comprehensive management approach (Fig. 8.11).
treatment.
Most
mobilization-with-impulse
and
always be remembered, however, that mobilization into the plastic zone can lead to an increase of the neutral zone, thereby worsening the already existing instability.
Example Instability may develop in the cervical spine as the result of
"Clinical Pearl"
rheumatoid arthritic changes affecting the intervertebral
The presence of hypermobility or instability may be sus
disk and the apophyseal (facet) joints. In the authors' ex
pected clinically when the following is observed:
periences. a number of patients may have an underlying. clinically silent segmental hypermobility for many years.
•
Initial pain reduction, in response to mobilization-with impulse or mobilization-without-impulse techniques.
often with little or no pain whatsoever.
A "simple" mechanical overload situation or a flare-up
•
of the rheumatoid arthritis may then lead to a sudden.
Return of the original pain one to three days after the manual medicine treatment intervention.
Fig.8.11 Correlation of pain in tensity and segmental hypermo
Segmental hypennobility on radiographs and reported pain level
bility.
III
II
Surgical
c
intervention
B
I
Diagnostic worl(-up Absent
e .F. <. "e ".$
0
2
3
4 PAl
.',
7
8
9
10
INTENSITY
157
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Rational SelectIon of Appropriate Low- Risk Treatment Interventions
•
Additional treatments bring about only brief relief: the improvement lasts only a few hours and not more than
•
Example
half a day.
Degenerative changes in the cervical spine may progress
This is soon followed by yet another recurrent episode
over years without ever causing any pain. However, should the patient then be subjected even to what would be
of the original pain.
considered "minor trauma" he or she could then "all of a Again, this clinical course should alert the treating physi
sudden" develop significant pain. If conservative treatment
cian to suspect the possibility of an underlying segmental
fails, one might consider intra-articular injection using lo
hypermobility and instability.
cal anesthetics and
high-density
steroid preparations.
This clinical progression is explained as follows. The
Again, this should be done within the context of the entire
mobilization procedures were able to initially reduce the
clinical situation, with clear anticipated improvements in
reflexive nociceptive impulses but, on further and contin
mind as well as projected specific functional goals based on
ued treatment (and in particular if treatment was rather
objectively verifiable information.
forcefully introduced), the plastic zone was entered during the treatment. This increases the neutral zone, exacerbat ing the already existing instability. This example under
Muscle Strength. Endurance.
scores the necessity of performing appropriately dosed trial
and Pain Intensity
treatments with competent clinical observation. Reduction in strength and muscular endurance is typically due to lack of sufficient exercise ("disuse") and/or to neuro
Degenerative Changes and Pain Intensity
logic causes adversely affecting muscle function, including those related to chronic nociceptive inhibition (Fig. 8.13).
A
patient may present with prominent degenerative
The field (-I indicates that there may be reduction in
changes (hyperostotic facet spondylosis, for instance) that
muscular endurance and/or strength while the patient may
have built up over years without ever causing any pain. It
actually be pain-free or experience little pain. In this case,
might intuitively be even more surprising that a patient's
the patient would ultimately benefit from starting a train
normal motion may have been maintained although there
ing program in order to address the various factors affect
are prominent degenerative changes noted on radiographs.
ing overall physical fitness. While a medically based phys
If the facet joints become increasingly irritated or subject to
ical therapeutic program is typically not necessary (e. g., in
an inflammatory process, segmental pain or nociceptive
the absence of any medical co-morbidities), the patient
reactions can follow. Degenerative changes with the pa
would probably benefit from enrolling in a program that,
tient's pain being rather low (0-1/10) in the field A-I. B-1,
initially at least, may be supervised by a physical therapist,
and (-I do not require treatment unless there are also
a qualified athletic trainer. or an experienced personal fit
prominent deficits elicited on the functional level.
ness trainer. However, the patient should be able to grad
Massive structural changes in the (-III field, such as disk herniation, stenotic spinal canal, spondylolisthesis, and un abating pain, despite best efforts to improve on the func tional level, may ultimately require surgical intervention. Unimpressive radiographic findings may be overinter
uate to an independent home exercise or gym program relatively quickly, within a few supervised sessions. If the patient complains about moderate pain and over all reduced muscular endurance is apparent (demonstrated in (-Ill), it may be appropriate to have the patient enroLl in
preted, especially when they are the only factor used to
a specific supervised training or reconditioning program.
explain the patient's pain. Thus, the treating physician
However, if the patient's pain is such that it is beyond a pain
should correlate as well as possible the radiographic find
score of 6/10, then the practitioner should search for other
ings with the individual patient's clinical presentation. The
findings associated with other fields in the functional level,
ideal is for the treating physician to review the radiographs
or specific findings from within the structural and pain
on her or his own patients in addition to the official readings.
perception levels.
Manual therapeutic and reconditioning programs are
If the patient has significant pain yet has a compara
not indicated when there is inordinate pain in the A-III
tively high level of muscular endurance, as demonstrated
field while no deficits can be determined on the functional
in the field A-III, further diagnostic consideration should be
l evel. Overly prolonged adherence to manual therapeutic
given to possible abnormalities associated with the other
interventions despite the lack of objective findings can lead
levels such as the structural and pain perception levels, all
to a patient's dependence on this form of treatment, and
the while being mindful of important influences from the
can thus be counterproductive in the patient management
functional level.
process (Fig. 8.12).
158
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Correlation of the Various Clinical Parameters
Fig.8.12 Correlation of pain in tensity and degenerative joint
Degenerative changes on radiographs and reported pain level
changes
(e. g., spondylosis).
III
II
Surgical intervention
c
B
I
Diagnostic
A
work·up Absent
x. ,,'I, ,,'I, ,,::i ,,'I, 0\>1;: ..,.s
0
2
3
4
5
\.
7
8
9
10
NSITV
PAl
Fig.8.13 Correlation of pain in tensity and muscular endurance.
Endurance and reported pain level
III
II
c
B
A
o
2
3
4
:"
7
8
9
10
159
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9
Indications and Contraindications for Conditions with Potentially Increased Risk of Treatment
This chapter provides an overview of the indications and
for a given diagnosis. As always, the selection of the most
contraindications based on the various primary diagnoses
meaningful treatment(s) of choice should be based on
related to spinal pain or disorders associated with the
multifactorial considerations, including objectively verifi
spine.
able findings, rational, realistic, and time-contingent treat
It is assumed that the appropriate diagnostic work-up,
ment goals with specific medical end points in mind, pa
medically and surgically, has been performed, and the in
tient response to previous similar or different treatment,
dividual patient's clinical situation has been evaluated as to
patient and physician expectations, and pote ntial barriers
candidacy for the specific manual medicine treatment.
to successful treatment, among others.
The following listings are meant to be general guides rather than specific prescriptions for a particular treatment
Diagnosis: Lumbar Disk Herniation Mobilization-with Impulse (Thrust) Almost always this tech
Mobilization-without
This technique is
Appropriate stretch
nique is contraindicated
impulse may be at
often not indicated as'
ing of the incrimi
often the only mao
for an acute lumbar disk
tempted when:
it may exacerbate the
nated shortened
nipulative treat
herniation; if this tech
•
This technique is
Relatively pain- free
patient's pain.
tonic muscles has
ment possible in
pOSitioning is possible.
Optimal isometric
been found to be
the acute state.
The mobilization ma
contraction beyond
quite beneficial.
Exact localization
neuver does not exac
the pathologic barrier
Muscle stretch
and careful fixation
following criteria should
erbate the patient's
is often impossible
should be done
(stabilization) are of
be fulfilled:
symptoms.
secondary to pain in
carefully. however.
utmost impor
hibition.
so as to avoid any
tance.
nique is nevertheless considered by the indi vidual practitioner. the
It
•
should be possible
•
potential mechani
to position the patient so that the pain is
cally induced stretch
reduced to a mini
at the nerve root
mum.
Prior trial treatment
•
using mobilization
without-impulse has
been successful.
Other treatment mo
•
dalities have thus far
been unsuccessful.
The patient has been
•
informed about the
potential risks of this
therapeutic proce
dure.
Rather than manipulative treatment alone, the initial man
elude interventional spine care with epidural steroid in
agement of choice for the acute or subacute lumbar disk
jections, for instance (B ush and Hillier,
herniation should be based on a rationally chosen conser
the standard texts and the latest literature with regard to
1991).
We refer to
vative approach, including medications and the appropri
the indications for surgery or other interventional spine
ate physical therapeutic regimens. Treatment may also in-
care.
160
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Diagnosis: Cervical Disk Hemiation
Diagnosis: Lumbar Spinal Stenosis (Central and lor Foraminal Stenosis) Mobilization-with
Mobilizatlon-without
Impulse (Thrust)
Impulse
NMT Type 1
NMT 2 techniques
Mobilization techniques are not able to correct/reverse
the permanent structural changes associated with a
may be particularly
have limited lasting influence. if any. on long-term
ment of associated
tion.
changes associated
address associated secondary segmental or regional
stenosis. The goal
useful for the treat
stenotic process. and they are therefore expected to
secondary muscular
improvement of the associated neurogenic claudica
with the spinal
Both of these techniques. however. can be used to
here would be to
dysfunctions and soft tissue changes.
improve overall pos
As always. the indications and contraindications must
be weighed against each other. particularly when there
ture and/or to reduce
bony abnormalities.
lumbar lordosis.
is evidence for or suspicion of osteoporosis or other
abnormal (excessive)
Treatment of spinal stenosis in a patient with known neurogenic claudication is typically conservative or
interventional. including epidural steroid injections. etc. If clinically indicated. and in particular when the
stenosis is advanced. surgical decompression (e. g
.•
foraminotomy) may be the treatment of choice.
Diagnosis: Cervical Disk Herniation Mobilization-with Impulse (Thrust)
Mobilization-without
In the presence of a
Contraindicated in the
niation. this technique
chronic state treatment
known acute disk her
is contraindicated in the
cervical spine; there is a
cervical spine. In the
may be attempted if: •
Patient positioning
•
The mobilization
reduces the pain.
potential risk of spinal
cord compression sec
ondary to the possibility
of a disk prolapse (es pecially if there is
NMT Type 1
Impulse
technique does not exacerbate pain.
Stretching of the
This may be the only
particular the suboc
ment procedure ap
motion barrier is
prove to be of some
state.
significant pain in
Muscle stretch should
careful localization
Often not useful
because optimal
isometric contrac
tion beyond the
impossible due to
hibition.
shortened muscles. in cipital muscles. may benefit.
be done carefully so
as to avoid any pull at
the nerve root.
underlying disk disease or an existing disk her
manipulative treat
plicable In the acute Exact fixation and
and optimal isometric
contractions are of paramount impor tance.
This technique ad
niation that has not
dresses the paraverte
been asymptomatic or
bral muscle ·spasms."
one that has not been
demonstrated thus far).
Rather than manipulative treatment, the initial manage-
techniques, when considered, should be applied extremely
ment of choice for the acute cervical disk herniation should
carefully and gently without much force. Regarding the
be based on a rationally chosen conservative approach,
indications for surgery and/or interventional spine care,
including pharmacologic and appropriate phYSical thera-
we again refer to the standard texts or the most recent
peutic regimens. In general, treatment can be initiated with
evidence-based literature.
the NMT type 3 techniques. Mobilization-without-impulse
,
Copyrighted Material
161
Indications and Contraindications for Conditions with Potentially Increased Risk of Treatment
Diagnosis: Cervical Spinal Stenosis Cervical spinal stenosis, when severe enough, may result in
NMT type 3 technique or manual cervical traction may be
myelopathy and thus may present in the medical office
indicated as long as both are done very carefully and after
with signs and symptoms characteristic of such changes.
the indications and contraindications have been weighed
The stenosis may be the result of congenital malformations
in the individual'S presentation. If such manual treatment
or of progressive spondylotic changes. Due to the pre
were to be undertaken it would only be done to address the
sumed risk of spinal cord injury, mobilization techniques
secondary changes such as associated "muscle spasms."
would be contraindicated. Possibly the application of the
Diagnosis: Acute Soft- Tissue Injury to the Cervical Spine The techniques outlined may be utilized assuming there
•
No radiologic signs of instability.
exist:
•
No objective neurologic deficit(s).
Mobilization- with Impulse
(Thrust)
Mobilization- without
NMT Type 1
Impulse
Mobilization procedures are typically not the tech
After the acute phase
In the acute phase,
NMT type 3 proce
nique of choice in the first 4-6 weeks follOWing an
(i. e., after 4-6
NMT type 2 treat
dure can be utilized
accident that involves major mechanical trauma.
weeks), the NMT type
ment is typically con
soon after the trau
1 technique may be
traindicated.
ma as long as local
well indicated for
However, in practice,
ization and fixation
soft- tissue treatment
the NMT type 2
are performed care
of the cervical spine
technique may be
fully.
as long as a detailed
applied by an experi
structural examina
ence practitioner
tion reveals that:
while assuring opti
•
•
There is no seg
mal fixation (stabili
mental instability,
zation) to the
and
incriminated spinal
No exacerbations
region.
occur within hours of the provided treatment.
Rest and medical and phar macologic treatment with ap
in the first 2-6 weeks in trauma-induced cen;ical spine
propriately dosed and carefully applied passive physical
injuries, and as long as there are no objective neurologic
therapy are the initial treatment interventions of choice
and/or radiographic findings.
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Diagnosis: Cervicogenic Vertigo (Including Cervical Migraine)
Diagnosis: Chronic Phase of Soft- Tissue Injury to the Cervical Spine The techniques outlined may be utilized assuming there
•
No radiographic signs of instability.
exist:
•
No objective neurologic deficit(s).
Mobilization-with
Mobilization
Impulse (Thrust)
without-Impulse
NMT Type 1
Mobilization techniques may prove to be benefi
This technique may
The NMT type 2 pro
May be only neces
cial. if:
serve as a good pre
cedure may be one of
sary for acute exac
• A prior trial treatment with NMT type 1 was
paratory technique for
the treatments of
erbations during the
the mobilization tech
choice in cases where
chronic phase.
successful. • The findings are clearly limited to a specific segmental or particular region (I). • Patient positioning can be accomplished with out difficulty.
niques with and with
there is significant
out impulse as well as
muscular imbalance.
for an individually tail ored home training or exercise program.
Instability may be present if the patient continues to report
matism" may develop with various diagnostic entities de
symptoms, especially if there has been an initial trial treat
scribed in the literature ranging from regional myofascial
ment using manual medicine procedures tailored to the
pain syndromes to cervical "sprain/strain syndromes,"
patient's individual clinical situation. It should be recalled
among many others. While some of the manual medicine
that standard radiographs often may not be able to detect
techniques may be distinctly helpful in the treatment of the
pathologic motion barriers or restrictions that are due to
various tissue injuries, one should be very careful about
muscle dysfunction, for instance. They may therefore be
their long-term use or potentially open-ended manage
interpreted as "normal," clouding the clinical picture, po
ment using manipulative techniques. There always exists
tentially leading to the false interpretation that there is no
the risk of psycho-social-emotional problems including the
instability.
patient's potentially becoming dependent on manipulative
In response to a soft-tissue injury to the cervical spine a number of signs and symptoms typical of "soft-tissue rheu
procedures, for instance, or other possible psychological changes.
Diagnosis: Cervicogenic Vertigo (Including Cervical Migraine) Mobilization- with
Mobilization
Impulse (Thrust)
without-Impulse
NMT Type 2
Mobilization procedures with and without im
This is a well-suited
This may be a very
pulse are indicated. as long as:
technique for pre
useful technique es
used in situations in
• The dysfunction is unequivocally segmental or
liminary treatment
pecially in chronic
which vertigo is exacer
regional. • Neurologic signs do not become apparent upon provocative testing (positioning. palpa
This technique may be
and for teaching a
situations in which
bated by different posi
home exercise pro
there is demonstrated
tioning. The reciprocal
gram.
pronounced muscle
inhibition may be of
im balance.
tory pressure). • Trial treatment using NMT type 1 was suc
benefit but exact local ization and fixation are
cessful.
to be performed with utmost care.
Evaluation of vertigo often proves to be rather difficult. It
Mobilization techniques and NMT type 1 and type 2
may be necessary to consult a specialist who is familiar
techniques are contraindicated when the vertiginous epi
with functional disorders of the cervical spine as well as
sodes are due to blood flow abnormalities in the vertebro
neurologic and otologic disorders.
basilar area.
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Indications and Controindicatlons for Conditions with Potentially Increased Risk of Treatment
Diagnosis: Spondylolisthesis with Spondylolysis in the Lumbar Spine Mobillzation- with
Mobilization-without
Impulse (Thrust)
Impulse
NMT Type 3 I
Mobilization to the incriminated spinal segment is
This is often of bene
Muscle stretch tech
contraindicated. Neighboring segments and/or the
fit for the neighbor
niques can be of
be helpful in the
adjoining sacroiliac joints. however. may benefit
ing spinal segments.
some use when
acute phase so long
from treatment using mobilization techniques.
as well as the sacroil
treating patients with
as motion testing
depending on the individual presentation and
iac joint. Exact local
diagnosed spondylo
reveals a soft end
ization and fixation of
listhesis.
feel.
specific structural examination findings.
This technique may
the restricted joint partners are neces sary.
Manipulative therapy concentrates primarily on the seg
ments may include orthotics or stabilizing surgery, when
ments neighboring those involved in the spondylolisthesis
indicated. We refer to the standard texts of the orthopedic
and is more of a supplement to other treatment procedures
literature.
than the primary management choice. Additional treat
Diagnosis: Bony Malformations of the Vertebral Column, Malformations of the Spinal Cord A thorough orthopedic and neurologic knowledge is nec
pathologic findings, one is then able to determine whether
essary to diagnose malformations in the spinal cord or the
and which manipulative techniques are indicated or con-
vertebral
traindicated in the individual case.
column.
With this together with
functional
Diagnosis: Osteoporosis (in the Presence of Pathologic Vertebral Fractures) Mobilization-with-Impulse
Mobilization
(Thrust)
without-Impulse
NMT Type 1
NMT Type2
Both techniques are contraindicated until medical
This technique is
Stretching of the
Often the only
treatment has restored an acceptable level of mineral
contraindicated in
shortened tonic
technique possible
content of the bones.
the acute phase.
muscles is often nec
in the presence of
It may be of benefit
essary for postural
acute fractures in
as trial treatment
physical therapy
the affected verte
before mobiliza
training and exercises
bral area.
tion-without
to be successful.
Mobllization-wlth- impulse may be applicable. as long as: •
The mineral content of the bone is adequate.
•
Mobilization-without
impulse.
impulse has been per formed successfully. •
The patient is informed about the increased risk including that of possible rib or vertebral fractures.
Medical and pharmacologic (pain) treatment is the major
be complemented by postural physical therapy training
treatment approach in addition to well-delineated passive
exercises. For advanced osteoporosis without pathologic
physical therapy and orthotics at least in the acute fracture
fractures, the same considerations apply.
situation. In a chronic state, manipulative therapy should
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Diagnosis: Ankylosing Spondylitis (Bechterew Disease) without Clinical Signs of Acute Inflammation
Diagnosis: Ankylosing Spondylitis (Bechterew Disease): Acute Inflammatory Changes Mobilization-with
Mobilization-without
Impulse (Thrust)
Impulse
NMT Type 1
This is a technique
This technique is abso
Mobilization-without-impulse and NMT type 1
Muscular imbalance
lutely contraindicated
procedures can be utilized to improve localized or
should be treated
well suited for re
in the following spinal
regional motion, but only if it is possible to guide
with the NMT type 2
laxing the patient
areas:
that takes advant
the patient to a relatively pain-free position, and if
procedure even in
•
Sacroiliac joint
mobilization does not lead to immediate or longer
the acute inflamma
age of reciprocal
•
Thorax, especially
lasting exacerbations of the pain.
tory state in order to
inhibition.
prevent further dete
during acute exacer bation of inflamma
rioration of postural
tion.
imbalance. The func tional pathologic findings, however, must be clearly iden tified.
Manipulative therapy should be applied very ca ut iou s ly
procedures, especially when tr ea ting patients with known
wben dealing with inflammatory processes affecting the
rheumatoid arthritis.
cervical spine. Segmental and regional instability in the
Similar considerations apply to the various seronegative
atlanto- OCCipital joint must always be considered and
spondyloarthropathies including psoriatic arthritis, ulcer-
clinically excluded if one is to apply manual medicine
ative colitis, and Crohn disease, among others.
Diagnosis: Ankylosing Spondylitis (Bechterew Disease) without Clinical Signs of Acute Inflammation Mob ilization- with
Mobilization-without
Impulse (Thrust)
Impulse
NMT Type 1
This technique is of
Mobilization-with
Successful trial treat
This technique can be
This technique is of
impulse should only
ment utilizing NMT
very effective and
great benefit when
rather limited bene
be applied if the trial
type 1 is a good tech
specific, especially as
dealing with muscular
fit, if any, in the
treatment utilizing
nique employed before
introduction to an
imbalances of the
treatment of anky
mobilization-without
mobilization-without
indiVidually tailored
tonic cervical spine
losing spondylitis.
impulse was unequivo
impulse is initiated.
home exercise/train
muscles, muscles in
ing program.
the shoulder girdle,
cally successful.
and especially in cases in which there is pro gressive loss of flexi bility of the thorax,
These techniques are absolutely contraindicated for those
occurred. This is also true for hyperostotic spondylosis as
spinal areas and the sacroiliac joint where bony growth has
well as spondylopathy in association with psoriasis.
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Indications and Contraindications for Conditions with Potentially Increased Risk of Treatment
Diagnosis: Inflammation of the Vertebral Column in Association with Chronic Rheumatoid Arthritis If the cervical spine is affected, mobilizing techniques
equivocal clinical or radiologic examination findings, ma-
should be applied only in the rarest of instances and then
nipulative treatment to this region should be considered as
only with the greatest caution. If there is atlantoaxial in-
absolutely contraindicated.
stability suspected or demonstrated objectively by un-
Diagnosis: Abnormal Segmental or Regional Spinal Hypermobility (Congenital or Acquired) Mobilization- with Impulse (Thrust) Mobilization techniques and NMT type 1 techniques are contraindicated.
NMT type 2 techni
NMT type 3 utilizing
Occasionally, mobilization techniques may be of benefit when there is acute
ques are often the
reCiprocal inhibition
segmental or regional motion restriction, especially in the presence of a
treatment of choice
is well suited for
demonstrated soft end-feel. In these situations, however. the mobilizing force,
to address any mus
regional therapy to
as well as the total number of treatments ("dosage") should be chosen very
cular imbalance or
limber up or to "re
carefully.
before stabilizing ex
lax" the muscles.
ercise training pro
These techniques
grams can be started.
should be supple mented by appro priate stabiliZing exercises and a well-deSigned training program. however.
Diagnosis: Patient on Anticoagulation Medication Mobilization with-Impulse (Thrust) This technique is contraindi
Mobilization can be per
These techniques are relatively safe to apply to treat the
cated for the spine due to the
formed as long as the forces
segmental or regional functional disturbances in patients who are on anticoagulants.
potential risk of epidural or
that are being introduced
subdural hematoma. espe
are relatively small and
cially when the patient is on
carefully chosen (appropri
anticoagulation therapy.
ate dosage. appropriate di rection of force introduction).
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10
Evidence Base in Manual Medicine for the Treatment of Back Pain Syndromes: Background, Status, and Practice
Brief Historical Background
Zurich can matriculate in a course on manual medicine diagnosis and interest is high. In the same year, the medical
The use of the hands as a diagnostic and therapeutic too.1
faculty of Otago in Christchurch, New Zealand, started a
has a long history in the treatment of disorders affecting
program that leads to a diploma in manual medicine. A
the spine and the limb joints. Ever since the introduction of
similar course of education was created in 1993 in Aus
osteopathic and chiropractic medicine in the late 19th
tralia. In a number of European countries, the medical
century. the use of the hands as a major component in
student of the classical medical curriculum is exposed to
patient management was considered as an "outside"
manual medicine (in the Czech Republic, Austria, France,
method, one that would not be acceptable to the allopathic
and Germany, for instance).
medical profession for most of the 20th centul)' as well.
According to our own survey, 640 000 manual medicine
Manual medicine, even when practiced by medical doctors,
procedures are performed annually by physicians in Swit
was routinely labeled as unscientific. In the past, the dis
zerland, approximately 5 million manipulations in Ger
course between medical doctors (M.O.s), chiropractors
many, and 340 000 in Austria. According to the survey,
(O.Cs) and osteopathic physicians (O.O.s) may often have
manual medicine treatment for low back pain is applied
been based on personal and emotional exchanges and
805 times per year, and 3 50 times per year for treatment of
preconceived notions "along professional lines," rather
cervical spine syndromes (unpublished data from Swiss
than engaging each other in constructive discussions that
Medical Association of Manual Medicine SAMM). Depend
would help establish a common language and understand
ing on the medical specialty, manual medicine treatment
ing.
comprises between 20-50% of all medical treatment. The
In the 1960s and 1970s, however, the interest in and
number of treatments applied for each patient depends not
study of manipulative procedures as one of the ways to
only on the medical specialty but also on the clinical sit
address pain syndromes grew steadily among allopathic
uation overall. Whereas the general practitioner applies
physicians, both in Europe and the United States and in
manual medicine techniques in 1.4 treatments per patient,
other parts of the world. While there may be several rea
the specialist may treat the patient between four and five
sons for such a development, three major factors seem
times. One explanation for the greater utilization of manual
stand out: (1) an ever-increasing body of "successful" cases
medicine by specialists is that often the patient has a
that had previously been recalcitrant to other forms of
chronic situation whereas the primal)' care physician may
treatment;
treat primarily acute presentations or exacerbations.
(2) the growing interest among patients to be
treated within an individualized and hands-on "holistic" approach: and (3) the growing realization that surgical intervention (introduced by Mixter and Barr in 1934) for
Effectiveness and Cost Considerations:
painful back disorders has limited success and application.
Evidence and Recommendations
[n 1958 the Swiss rheumatologist John-Claude Terrier, M.D. founded the International Federation of Manual Med
A growing number of published reports have investigated
icine (F[MM, Federation Internationale des Medecins Man
the effectiveness and cost considerations of spinal manip
uels), which has grown since to a physicians' organization
ulative procedures either alone or in comparison with
of more than 6 000 members and representing 29 coun
other treatment interventions (Fig. 10.1 ). Most of the studies have concentrated on studying the high-velocity!
tries. During the past 30 years, there has also been a signifi
low-amplitude (HVLA) thrusting maneuvers ("spinal ma
cant growth in the numbers of graduates from osteopathic,
nipulation," or simply "manipulation," or "thrust," or also
chiropractic, and physical therapy institutions in the United
mobilization-with impulse-techniques: see Chapter
States.
definitions).
Since the mid-1 980s, there has been less resistance by
These studies typically
do
not
2 for
make
a
distinction between the thrusting maneuvers and the
the orthodox branch of medicine to manual medicine ap
low-velocity mobilization techniques (www.backpaineu
proaches. Since 1992 students at the medical school in
rope.org). The entire manual medicine armamentarium,
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Evidence Base in Manual Medicine for the Treatment of Back PaIn Syndromes
which includes the thrusting as well as the non-thrusting
Number of studies
soft-tissue (or other) techniques. has been referred to as a • Orthoses
• Acupuncture
single "spinal manipulation package" (Harvey et aI., 2003). Two UK BEAM (Back pain Exercise and Manipulation)
D Behavioral therapy • Traction • TENS o EMG/biofeedback
trials published in 2004 and one major review (ECRDG. 2005) provide a detailed basis for our current understand
• Back school
ing of manipulation within the context of the effectiveness
D Bed rest
of the treatment and the associated cost-effectiveness.
• Exercise
The UK BEAM trials studied 1287 participants (from 1334 recruited) in 181 practices around 14 centers across the United Kingdom (Brealey et aI., 2004a), The goals of these two studies were to estimate the effect and cost effectiveness of treating low back pain patients by adding
Acute
Chronic
exercise classes. spinal manipulation offered by the Na
Fig. 10.1 Schematic representation of the number of different
tional Health Service (NHS) or private practitioners. or
interventions included in the systematic review by van Tulder et
manipulation followed by exercise to "best care" in general
al. (1997). The authors reviewed 150 articles, of which 81 dealt
practice. The UK BEAM trial (2004b) addressed specifically
with chronic pain, 63 with acute pain, and one article with both. The specific distribution was as follows: Interventions for acute pain
Number of studies
other trial (Brealey et al.. 2004a) studied the cost-effective ness of delivering manipulation with and without exercise,
Pharmacologic intervention: NSAIDs
19
Muscle relaxants
14
Analgesics
the effectiveness of physical treatments for back pain in primary care. including exercise and manipulation. and the
left- hand column:
The results and the authors' conclusions regarding the effectiveness of manipulation and exercise are as follows
6
(UK BEAM Trial. 2004b):
ESI Nonpharmacologic intervention (physical and cognitive/behavioral therapies): Manipulation
16
Exercise
10
Bed rest
6
Back school
4
TENS
3
Traction
2
•
by a smaller but still statistically significant margin at 1 year, irrespective of location (and irrespective of treat ment - whether manipulation took place in a private practice or NHS.
Behavioral therapy
•
The exercise program improves back function by a small
•
Manipulation followed by exercise improves back
Right- hand column: Interventions for chronic pain
NSAIDs
but significant margin at 3 months but not at 1 year.
Number of studies
Pharmacologic interventions:
The spinal manipulation "package" improves back function by a small to moderate margin at 3 months and
function by a moderate margin at 3 months and by a
6
smaller but still significant margin at 1 year.
Muscle relaxants Analgesics
1
ESI
6
Antidepressants
4
Nonpharmacologic intervention
The authors of the effectiveness study (UK BEAM trial team 2004b) conclude that combined treatment (manipulation
(physical and cognitive/behavioral therapies):
and exercise) improves back function by a moderate mar
Manipulation
9
gin at 3 months and a small but significant margin at 12
Exercise
16
Bed rest
0
months. Generally this combined treatment achieves little
Back school
10
EMG/biofeedback
5
TENS
3
Traction Behavioral therapy Acupuncture
more than manipulation, except for increased understand ing of back pain and fear avoidance. The results and the authors' conclusions regarding the cost-effectiveness of manipulation and exercise are as fol
11
lows (Brealey et al.. 2004a):
6
Orthoses
•
Spinal manipulation. exercise classes. and manipulation
NSAIDs: nonsteroidal anti- inflammatory drugs
followed by exercise all increased the participants'
ESI: epidural steroid injections
quality of life
TENS: transcutaneous electrical nerve stimulation
"best care" in general practice.
EMG: electromyography
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(QOL) over
12 months by more than did
Effectiveness and Cost Considerations: Evidence and Recommendations
•
Adding spinal manipulation to best care in general
definitions of chronic low back pain patients were in
practice is effective and cost-effective for patients in the United Kingdom. •
consistent across reviews. 2. In many of the randomized controlled trials (RCTs) upon
If the NHS can afford at least approx. US $ 20 000 for
which the conclusions of the Cochrane review (Assen
each quality-adjusted life year (QALY) yielded by phys
delft et al.. 2004) were based. the study sample included
ical treatments. manipulation alone can probably offer
mixed populations of patients with subacute and
better value for money than manipulation followed by
chronic neck. thoracic. and low back pain. Although this
exercise.
was not necessarily compatible with their own general criteria for these recommendations. it was difficult to
These conclusions are maintained even if the NHS has to
extract those studies that only deal with chronic low back pain and therefore probably reflect the treatments
pay for spinal manipulation from the private sector. One of the three established working groups (Working Group 2 - Chronic Low Back Pain) of the European Com mission Research Directorate General (ECRDG. 2005) sys
given in the offices of chiropractors and manual thera pists. 3. The best systematic reviews stated that the general
tematically reviewed the literature. including prior reviews
quality of RCTs on spinal manipulation is low. making
and meta-analyses dealing with spinal manipulation/mo
it difficult to draw proper conclusions. although recent
bilization using established evidence-based guidelines.
additional trials appear to be of higher quality. 4. Most of the manipulation/mobilization treatments were
Their summary of the evidence is as follows:
administered by personnel who were considered •
•
•
•
•
There is moderate evidence that manipulation is supe
"qualified" within their own medical specialties (oste
rior to sham manipulation for improving short-term
opathy. chiropractic. manual medicine. and physiother
pain and function in chronic low back pain (level B).
apy). although the qualification requirements differ
There is strong evidence that manipulation and G.P.
markedly among these professions. The study that
(general practitioner) care/analgesics are similarly ef
showed no difference between manipulation and sham
fective in the treatment of chronic low back pain (level
manipulation was carried out by third-year and fourth
A).
year medical students in the process of completing an
There is moderate evidence that spinal manipulation in
additional year of training devoted to osteopathic
addition to G.P. care is more effective than the G.P. care
theory and practice (Licciardone et al .. 2003). The au
alone in the treatment of chronic low back pain (level B).
thors of the study conceded that "it was possible that
There is moderate evidence that spinal manipulation is
the predoctoral fellows may not have had sufficient
no less and no more effective than physiotherapy/exer
practical experience to provide the treatment with the
cise therapy in the treatment of chronic low back pain
same efficacy as more seasoned practitioners or to
(level B).
provide nontherapeutic sham manipulation." However.
There is moderate evidence that spinal manipulation is
the failure to identify any difference between sham and
no less and no more effective than back-schools in the
real manipulation may also have arisen as a result of the
treatment of chronic low back pain (level B).
small. size of the control and sham groups. Further. the study had a relatively high drop-out rate. especially in
The same working group makes the following recommen dation:
the manipulation group. In general. it would seem pru dent to recommend that the treatment only be carried out by suitably qualified/trained practitioners within
•
Consider a short course of spinal manipulation/mobili
the given medical specialty.
zation as a treatment option for chronic low back pain.
5. The manipulative/mobilization treatments used in the
Perhaps as important as their conclusions and recommen
per week (range one to seven times per week). and most
dations are this working group's comments. paraphrased
commonly for a period of two to three weeks (range two
RCTs to date were most commonly administered twice
here. which are based on the detailed analysis not only of
to nine weeks). There is no evidence to suggest that
the randomized trials but also of the published results from
long-term manipulative treatment contributes any ad ditional benefit.
various meta-analyses:
6. Most of the systematic reviews on effectiveness in 1. The studies considered in the various systematic re
cluded RCTs on spinal manipulation and spinal mobili
views included patients with and without referred
zation. and in fact considered both as the same treat
pain. All studies considered included a substantial pro
ment. As such. it is impossible to determine the relative
portion of "chronic" low back pain patients. although
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Evidence Base in Manual Medicine (or the Treatment of Back Pain Syndromes
effectiveness of spinal manipulation or mobilization. Nonetheless, in practice, they are usually used together as part of a treatment package (Harvey et aI., 2003). 7. One recent study sought to examine whether a mobi
Requirements for Successful Manual Medicine Management: The Individual Practitioner
lization technique selected by the treating physio therapist is more effective in relieving low back pain
First and foremost, the individual practitioner of manual
than a randomly selected mobilization technique. There
medicine must be familiar with the appropriate indications
was no suggestion that this was the case (Chiradejnant
and contraindications of the proposed approach or partic
et aI., 2003).
ular technique(s). The physiCian who utilizes manual medicine in the
A recent systematic review and meta-analysis of random
management of acute or chronic pain syndromes should
ized osteopathic manipulative trials (Licciardone et aI.,
also be familiar with the limitations associated with this
2005) concluded that osteopathic manipulative therapy
form of treatment. Thus, it serves well if the medical record
(OMT) significantly reduces low back pain. The level of
clearly states the physician's projected goals of anticipated
pain reduction is greater than expected from placebo ef
outcomes over a well-prescribed timeframe, taking into
fects alone and persists for at least 3 months. The same
consideration patient expectation, structural and func
authors, not surprisingly, sum up the status of OMT re
tional diagnoses, existing co-morbidities, and previous suc
search by stating that additional research is warranted to
cess of treatment or lack thereof.
show mechanistically how OMT exerts its effects, to deter
Just as does any surgical procedure, manual medicine
mine whether OMT benefits are long-lasting, and to assess
maneuvers require a high level of skill of the practitioner.
the cost-effectiveness of OMT as a complementary treat
Thus, continued updates on techniques and actually seeing
ment for low back pain.
patients is very important to keeping one's skills main
Further research in the field of manual medicine is ex
tained at the highest level. Manual medicine examination and treatment proce
pected to continue along three lines:
dures are best employed when rationally integrated into 1. Outcome studies.
the overall diagnostic and treatment management. Undis
2. Mechanisms of action (e. g. physiologic and biomechanic
ciplined treatment (open-ended, indiscriminate treatment
phenomena).
based on symptoms alone, for instance) that does not
3. Approach to the patient.
reflect appropriate monitoring against expected outcomes and does not take the above factors into account will most
There is currently a paucity of literature that has looked
likely lead to greater healthcare costs, increased risk to the
into the "approach to the patient" component. The under
patient, and unnecessary procedures. This not only in
lying question here is whether the additional information
creases the risk of greater patient dissatisfaction but also
that the practitioner of manual medicine obtains through
gives this form of medicine a bad name. Monitoring of
his or her hands in the patient examination and treatment
outcomes in the individual treatment should include fac
process is able to provide a basis (albeit yet "uncharted" as
tors such as medication use (e,g., reduction in medication
to specifics) for more effective, more efficient, and thus
dosing), increases in vocational and nonvocational abilities,
more successful patient management (Greenman, personal
and improvement of function, while always monitoring the
communication, 2005, as quoted in www.com.msu.edu/
patient's pain perception.
communique/Summer98/Greenman.html).
Like virtually every research article that has been pub lished about this topic, this chapter closes with the obser vation that more research is needed because the important questions answers.
170
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already asked are awaiting some insightful
11
Informed Consent, Complication Assessment, Quality Control, and Documentation
Informed Consent within Patient Care
•
A working or presumed diagnosis.
•
Differential diagnoses.
Obtaining informed consent from the patient is an impor
•
Th.e purpose and risks of any planned tests.
tant process within the patient-doctor relationship. The
•
Options to treatment recommendations.
goal of the informed consent is to educate the patient about
•
Prognosis.
potential complications or side-effects. Informed consent is
•
An estimate of the current level of severity of the
necessary in situations where a reasonable patient would
patient's condition,
not be aware of the potential consequences of a given tr'eatment decision without obtaining specific information
In order to fulfill the above obligations, one of the points in
from the treating physician (Mock, 2003).
the discussion of providing informed consent is the ques
The requirement that physicians obtain informed con
tion of what is "sufficient" or what is "going overboard."
sent from their patients before treatment codifies a belief
While in theory many of these considerations can be im
predominant in Western culture that people have a basic
plemented, in the end-and in the "real world"-it is prac
right to control their own lives and bodies (Howard, 2005).
ticality and the availability of time that may be the overall
However, there are distinctions between countries with a
deciding factors.
legal tradition based upon civil law ("Roman" law) and
Howard (2005) provides a rationale for full and com
those with common law ("English"). What follows is dis
plete disclosure, a disclosure that informs the patient of
cussion based upon a common law perspective.
"everything." This recommendation is based first on the
The requirement for informed consent not only varies
premise that patient autonomy "means that the values that
from state to state but is also inherently dependent on the
lead to the patient's decision must be respected." He states
nature of the work the physician performs. Furthermore,
secondly that in preparing a comprehensive list only the
not every patient assesses the risks and potential out
most obscure possibilities are excluded. "A conscientiously
comes, including the disastrous ones, in the same manner.
prepared list excludes only a few risks that are highly unlikely
Some patients may find any risk whatsoever unacceptable
and occur in fewer than 1 per 100 000 cases. Therefore, the
and will not proceed with having the procedure or treat
chances of such an event both occurring and being absent
ment performed. Another patient may feel. in his or her
from the list is much less than 1 per 100 000 cases". Docu
assessment of the overall possibilities, that the risks should
mentation of the informed consent is more than crucial.
be taken as a matter of "trust," no matter what could
The ideal is for the physiCian herself/himself to obtain the
happen.
informed consent, review it with the patient, and docu
In order to obtain informed consent that is acceptable to
ment any questions the patient has and how comfortable
the courts and that meets the ethical obligations, the fol
the patient felt signing the consent form. The best docu
lowing information must be provided (AMA, 1998):
mentation is that provided to the patient and reviewed with the patient, with documentation that the review ac
•
The nature of the disease and the proposed treatment or
tually took place and what steps were taken to make cer
surgery.
tain that the patient indeed felt fully informed.
•
The chances of success based on medical knowledge.
•
The risks of the proposed treatment.
•
Adverse effects of the proposed treatment or procedure.
•
Reasonable alternatives and their chances of success, risks, and adverse effects.
In the field of manual medicine, similarly to other medical
•
The consequences of deciding not to proceed with the
specialties, the provision of informed consent varies not
recommended course of treatment.
only from state to state or from country to country but also
Complication Assessment
from profession to profession. While, generally speaking, The process of informed consent requires that ultimately
the side-effects of manual medicine procedures are rather
the patient be provided with the following (Howard,
minimal and typically transient, they can in rare situations
2005):
be quite disastrous and life-threatening and may poten tially reduce a patient's function to a state of complete
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Informed Consent. Complication Assessment. Quality Control. and Documentation
dependency. The potential major complications include the
complex and very careful review is indicated in such an
following entities:
unfortunate event.
1. Spontaneous dissection of the vertebral artery.
According to the literature review by Ernst (2002) with
2. Disk herniation.
regard to adverse events after cervical spine manipulation,
3. Phrenic nerve paresis/palsy.
large and rigorous prospective studies of cervical spine manipulation are needed to accurately define the true
These complications are often cited in the literature by
risks, and the incidence of these events is unknown.
various medical professionals, who seem to come into contact with the patient only
after
the patient has experi-
Disk Herniation
enced an adverse event. This in itself may raise the possi-
Based on today's scientific knowledge, there is no indica
bility of an inherent "post hoc ergo propter hoc" fallacy.
tion that a correctly performed manual medicine proce-
In 2003, a symposium in Frankfurt, Germany, consid
dure would cause a disk herniation. It should be noted that
ered quality control in manual medicine and the above
a manipulative procedure in the presence of an already
clinical entities. The representatives and speakers came
damaged but asymptomatic disk may bring about a new
from varied specialties such as orthopedics, neurology,
set of radicular symptoms. There is no indication from the
anatomy, family practice, physical medicine and rehabili
literature that would substantiate claims made by various
tation, occupational medicine, and legal medicine. The con-
people that their "disk" was caused by manipulation. Cor
c1usions were as follows, based on current knowledge then
rect execution requires that the slack in the joint neighbor-
available.
ing the incriminated joint be positioned in the correct
Spontaneous Dissection of the Vertebral Artery
while the entire body should be relaxed.
barrier position, from which manipulation can proceed, There is no indication that an appropriately applied and executed manual medicine procedure would cause a pri-
Phrenic Nerve Paresis/Palsy
mary dissection in a healthy, nonpredisposed artery system.
Again, if the execution of the technique was within the
Spontaneous dissection of the vertebral artery is espe
standards set by the various manual medicine societies,
cially important to consider in patients who report a par-
there is no indication in the literature that manual medi
ticular set of symptoms. A manipulative procedure applied
cine procedures lead to phrenic nerve paresis or paralysis.
to a patient who has recently had a spontaneous dissection can indeed be very dangerous. The etiology is essentially unknown. Clinically, it should be noted that the patient typically is not the older person but rather the healthy
Quality Control in Manual Medicine; Continuing Education
appearing 35-year-old executive. It has been documented that approximately 20% of patients who have had a stroke
In addition to the recommendations made for manual
experience a spontaneous dissection under subsequent
medicine procedures at the Bingen Conference (Graf
manual medicine treatment. In such cases, the internal
Baumann and Ringelstein, 2005), the following summary
carotid artery is affected 75% of the time and the vertebral
in regard to quality control can be provided:
artery 25% of the time. It is important to remember that a dissection may be the
1. The application of manual medicine approaches and
manifestation of a constitutional disorder. Here, the follow
techniques using sound principles requires cognitive
ing two conclusions can be drawn:
education and skill development that is in addition to
1. A detailed patient history is very important so as to
art of such practice requires ongoing clinical activities as
the standard allopathic medical school curriculum. The construct a valid differential diagnosis that includes the possibility of constitutional dissection. Thus the physician should investigate whether there is dizziness,
well as continued (typically postgraduate) medical education. 2. It is important when there is sufficient suspicion or
vertigo, or significant change in the patient's headache
supportive information that the treating physician
quality and intensity (e. g., sudden appearance of uni
should query the patient with regard to a known past
lateral "shooting type" pain to the right posterior parietal-occipital region).
medical and/or family history. 3. Better understanding of spontaneous dissection and
2. A dissection may have a temporal correlation with a manipulative procedure but should not necessarily be causally associated with it. Again, the issue is very
early recognition of warning signs is required. 4. Treatment should be performed only on the relaxed patient.
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Documentation Requirements
5. Thorough medical documentation is an important component of the patient-physician encounter.
1. Treatment must be considered within accepted standards in current medical practice, with measures as specific and effective as possible.
2. Procedures that require the performance or supervision
Documentation Requirements
of the physician and that are considered reasonable or necessary.
It cannot be overemphasized how important it is to main-
3. The treatment provided must not be palliative or of
tain a record that can be read by anyone. Initial consent
maintenance type unless specific functional parame-
should be obtained and this should be reflected in the
ters are being addressed and reviewed or monitored on
record. The consent should state that the patient has
a timely basis, so as to maintain the highest level of
been informed about the potential side-effects, risks, and
functioning. An example of this would be the reduction
outcomes of treatment. Again the goal of the informed
of medication use, a decrease in emergency visits, or the
consent is to appropriately assure and inform the patient,
reduction from two personal assistants to one, when a
and not to exacerbate any preexisting anxiety.
patient receives appropriate manual medicine man-
Furthermore, in today's "litigious society," it is important to maintain the patient's records in as impeccable an order with as much relevant clinical/management informa-
agement at an acceptable level of frequency. This must be clearly documented.
4. There should be a reasonable expectation that the pa-
tion content as possible. This is becoming a balancing act as
tient's condition will improve significantly over a certain
the goals of communication and good record-keeping
projected period.
should be just that: documentation should not be undertaken for documentation's sake nor should one try on
5. The plan of care or treatment must contain reasonable goals to be achieved over a specified period.
principle to include as much information as possible-one Naturally, these can only be broad recommendations or
risks "losing sight of the forest for the trees." A necessary component in the medical chart or elec-
guideline suggestions, as each profession and locale will
t\'onic record IS the information that determines the overall
determine the individual applications of the law according
relevance of the individual findings, their apparent se-
to the specific statutes and the "standard" practice for
verity, and further treatment considerations:
locally.
173
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12
Patient Outcome and Follow- Along Measures
Introduction
The purposes of Rasch analysis are to maximize the homogeneity of the trait and to allow greater reduction
Neck and back pain are common disorders around the
of redundancy with no sacrifice of information by decreas
globe. According to the National Health Information Survey
ing items and/or rating levels to yield a more valid and
of 2002 in the United States, over a 3-month period prior to
simple measure.
a survey, 26% of surveyed individuals experienced lower
To develop a scale to measure the performance of a
back pain and 14% experienced neck pain (Lethbridge
particular task, we need to break down the task into its
t;:ejku et aI., 2004). Some 5-6% of patients with back pain
principal components. Successful completion of a task de
develop chronic disability. These patients consume 80% of
pends on two factors: the person's ability and the difficulty
health care resources spent on treating back pain (Hashemi
of the task. If the person's ability exceeds the difficulty of
et aI., 1998). The need to develop effective treatment op
the task, then the person will successfully accomplish the
tions for patients with chronic pain conditions is a major
activity. In order for an observation to have contextual
challenge for health care professionals involved in muscu
meaning, the concepts of a person's ability and the diffi
loskeletal/pain management. Good and accurate outcome
cUlty of the task must each have independent directions;
measures are critical for evaluation of treatments for neck
otherwise, an observation is devoid of meaning. It is within
and back pain.
the context of direction that ability and difficulty become
Chronic neck and back pain results in multidimensional dysfunction
relevant.
involving physical function, affective and
Having independent directions of the two factors per
mood state, activities of daily living, patients' satisfaction
mits quantification and comparison with other independ
with life in general, quality and quantity of pain, and sleep
ent observations. Criteria may be established to determine
and fatigue. These result in significant decrement in a
whether there is sameness
patient's quality of life (QOL). The outcome measure should
difference, in what direction along a latent variable or how
be able to evaluate all these aspects of a patient's function
much distance along that direction.
or
difference; and if there is
ing. In addition, the measure should be able to track these
Only after replication of observations of people with
over time. Tracking allows comparison of how treatment or
different abilities doing tasks of different difficulties can
life events impact a patient's function and quality of life.
the variables of ability and difficulty be used to calibrate a yardstick related to performance of a particular task. Both can be measured along the same hierarchy. This is known
SM The lIFEware System
as conjoint additivity.
The main purpose of the LlFEwarSM system (Granger et aI.,
tions-expressed as Bn
1995; Baker et al., 1996) is to measure QOL in patients from
logarithm of the probability (log odds). Rasch measure
teenage through adult life. The domains measured in the
ment is based on probability rather than certainty. In other
The only tool for achieving conjoint additivity specifica -
OJ (ability minus difficulty)-is the
example that follows are physical function, mood and af
words, a person-rating can be achieved in a number of
fective state, and pain. The measures were developed using
different ways. However, depending on the item of hier
Rasch analysis (Wright and Stone, 2004). To understand the
archy, only one-way is expected. Rasch analysis measures
LlFEware measures, it is important to review key concepts
the degree of expectedness.
of Rasch analysis.
Rasch analysis proposes a model for measurement. Data collected are tested against that model to determine whether the data fit the model. If the data are judged to
Rasch Analysis
fit the model then the data form a measure.
Usually items are rated with numbers to indicate more or
based on a latent trait and accomplishes stochastic (prob
less of the trait that is presumed to be homogeneous. Rasch
abilistic) conjoint additivity (measurement of the item dif
analysis permits the rating of a limited set of attributes that
ficulty and the person ability on the same metric).
In summary, Rasch analysis is a mathematical model
are representative of the underlying trait. Whether ob
Rasch analysis transforms ordinal scales into equal-inter
served or self-reported, the sum rating of the attributes
val measures that may be used in parametric statistical ana
represents how much of the trait has been mastered.
lyses. Those measures are one-dimensional and have pre
174
Copyrighted Material
LlFEware System Domains
dictable hierarchies of item calibrations that span the range
measure. Effort is an ordinal scale that asks the respond
of difficulty within a domain of assessment. Patient meas
ents to rate the most strenuous activity they can perform
ures and calibration of individual item values are meas
for at least 2 minutes. Effort is measured with a 6-point
ured on the same metric and are locally independent
scale. Effort is also transformed into an equal-interval
(Wright and Stone. 2004).
measure using Rasch analysis. The converted measure
The Rasch modeling provides a philosophical and mathematical foundation for the theory of objective meas
also ranges from a to 100. where 100 represents the upper limit of effort.
urement. It is operationalized by the WINSTEPS software (Linacre and Wright. 2000).
Mood and Affective State
LlFEware System Measures
Mood and affective state are measured using the Placid measure and a satisfaction with life question. Respondents
The L1FEware measures for musculoskeletal conditions
rate if they feel lonesomeness or isolated; pessimistic about
were tested as the Medical Rehabilitation Follow Along
the future; uptight. tensed. stressed; are having panic at
(MRFA) (Granger et al., 1995; Baker et al.. 1996). The reli
tacks; are easily irritated or annoyed; have morbid or
ability of MRFA was established in a study of 47 patients.
gloomy thoughts; or have self-blaming/guilty feelings.
The patients completed the musculoskeletal form of the
The respondents rate their feelings on a 5-point ordinal
MRFA instrument on two occasions separated by an inter
scale. The raw data is transformed to a a-lOa-point scale
val of 1 -7 days. Responses were examined using the intra
using Rasch analysiS. with 100 representing absence of
class correlation coefficient (ICC) and kappa. ICC values for
listed mood disturbance. The satisfaction with life question
the sections of the MRFA instrument examining quality of
asks the respondents to report how satisfied they are with
daily living and physical functioning ranged from 0.74 to
life in general on a 4 -point scale. The responses are trans
0.97. ICC values for items assessing pain and feeling of well
formed into a lOa-point scale variable using Rasch analysis.
being were more variable. ranging from 0.36 to 0.93. The
with 100 representing being very satisfied with life in
kappa values displayed a similar pattern. The reliability of
general.
the MRFA instrument was found to be adequate for gather ing screening information in outpatient settings. The va lidity of the measure was confirmed by comparing it to the
Pain
SF-36 (Ware, 1993). comparing pre- and post-treatment ratings and comparing the scale ratings with therapists'
There are two pain measures: Painfree and the L1FEware
ratings of improvement. The scale includes within it ele
Visual Analog Scale (LVAS). The Painfree is a lO-item meas
ments of the Functional Assessment Screening Question
ure used to assess the qualitative dimension of pain. It is
naire (Granger and Wright. 1993). Oswestry Scale (Fairbank
derived from the McGill Pain Questionnaire (Melzack
et al.. 1980). short form McGill Pain Questionnaire (Mel
1987). Respondents rate their pain using pain descriptors:
zack. 1987), and Brief Symptom Inventory (Derogatis and
throbbing. sharp. aching, tender. tiring and exhausting. hot burning, fearful. splitting pain. punishing cruel pain. and
Melisarotos. 1983).
cramping. Each item is measured on a four-pOint ordinal scale. The last four items are not included in the measure as
LlFEware System Domains
they do not fit the expected hierarchy. These items are tracked as they are of clinical interest. The raw rating is
Physical Function
transformed into a 0-100 point rating through Rasch anal ysis. where 100 represents no pain with these character
Physical function is measured using the Body Movement
istics. The LVAS measures the perceived quantity of pain. It
and Control (BMC) measure and the Effort measure. BMC is
ranges from a to 100. with a representing the worst imag
a lO-item measure that asks patient to rate difficulty in
inable pain and 100 representing no pain.
performing: personal care. lifting. walking distance. travel ing duration, rising from a low seat. climbing stairs, ex tended sitting. extended standing. reaching and grasping at eye level. and bending or kneeling to the floor. Each item is rated on an ordinal scale. The BMC is transformed into an equal-interval measure using Rasch analysis. It ranges from a to 100. with 100 representing the upper limit of the
175
Copyrighted Material
Patient Outcome and Follow-Along Measures
Other Dimensions
Reports
Other dimensions of function measured by the L1FEware
The L1FEware system is Internet-driven. Subscribers can
system are satisfaction with adequacy and quality of sleep;
enter the data directly on-line or can fax questionnaire
primary and secondary roles in life and satisfaction with
responses
level of accomplishment of each (expressed in percentage);
Rehabilitation (UDSMR) for immediate analysis. (UDSMR,
physical and cognitive fatigue; and impact of dysfunction
a division of UB Foundation Activities, Inc., is located in
on occupational, vocational, and social role participation.
to
the
Uniform
Data
System for
Medical
Amherst, New York.) Subscribers can further analyze their own data by downloading converted data from their as sessment forms into computer spreadsheet software and
Administration
can also e-mail information from L1FEware directly to physicians and referral sources.
Data are collected through a self-administered question naire and clinician interview completed in 10-20 minutes.
Case Profile Report
The same questionnaire is used for initial and follow-up
In this summary report (see Fig. 12.2), measures are shown
visits. If the patient is incapable of completing the ques
graphically. The
tionnaire, the clinician may query the patient.
specified threshold of clinical significance. It is different
expected
value
represents
the
pre
for each measure and for each item within a measure.
Assessment Forms
Case History Report This report (see Fig. 12.3) tracks a patient's function over and response
multiple assessments. Higher is better. Green bars indicate
choices. The respondents have to mark the appropriate
that the measure is greater than the pre-specified thres
choice as they would in a multiple choice examination.
hold of clinical significance.
The forms pose questions,
statements,
Patients can fill out the forms on-line or on paper. The musculoskeletal assessment form is shown in Figure
Patient- Specific Report
12.1 a-d. Supplementary measures are available with this
This narrative report (see Fig.12.4) provides a detailed
form for assessing the shoulder, knee, ankle, hand, and
description of each item within a selected measure. It
temporomandibular joints. Other forms have been devel
uses Rasch analysis to determine whether the respondent
oped specific to neurological, cardiopulmonary, and cogni
is doing better or worse than the expected value for each
tive disorders.
item. It can help identify specific problems that need to be addressed. For example, if the respondent with back pain is having difficulty getting up from a sitting position, that might be a specific area that can be addressed during therapies.
176
Copyrighted Material
UFEware System Domains
LlFEWARE® MUSCULOSKELETAL ASSESSMENT FORM 23700
I
Drnitial Ornterim DDischarge o Follow-up
Patient:
I#
The following is to be completed by clinical staff only
# of proc's:
of visits:
Subscriber
Patient
Assessment Date
Problem Onset
Code
Identification #
(mm/dd/yyyy)
(mm/dd/yyyy)
[IJI [IJI I I I I I
OIJ-[IJ-I I I I I
LI I I I I
0 000 1 000 2 000 3 000 4 000 5 000 6 000 7 000 8 000 9 000
0 0000 1 0000 2 0000 3 0000 4 0000 5 0000 6 0000 7 0000 8 0000 9 0000
00 00 00 00 00 00 00 00 00 00
0 00 1 00 2 00 3 00 4 00 5 00 6 00 7 00 8 00 9 00
0000 0000 0000 0000 0000 0000 0000 0000 0000 0000
0000 0000 0000 0000 0000 0000 0000 0000 0000 0000
00 00 00 00 00 00 00 00 00 00
[IJ/[IJ/I I I I I 0 00 1 00 2 00 3 00 4 00 5 00 6 00 7 00 8 00 9 00
00 00 00 00 00 00 00 00 00 00
0000 0000 0000 0000 0000 0000 0000 0000 0000 0000
C/O
[IJ 0 00 1 00 2 00 3 00 4 00 5 00 6 00 7 00 8 00 9 00
The following questions on this and remaining pages are to be answered by the patient What category best describes your current problem (fill in only one):
o Pain in low back
o Pain in neck
o Shoulder related
o Elbow related
o Hip related
o Knee related
o Foot/ankle related
0 Other
o Hand/wrist related
What is your marital status (fill in only one):
o Married
o Cohabitating
0 Separated
0 Divorced
o Other
o Single
0 Widowed
Who lives with you and where do you live (fill in only one):
o Live alone
o Live with family
0 Live with friends
0 Live in an assissted living environment
What is your current employment status (fill in only one):
o Employed
o Homebound employment
o Homemaker
o Sheltered
o Volunteer
o Cannot find work
o Student
o Worker's Compensation
o Unemployed
o Retired (age 60+)
o Retired (age <60)
o Disabled (age <60)
What is your primarv role (main responsibility) or activity (fill in only one):
o Work
o School/education
o Homemaking (cooking, shopping)
o Household tasks (lawn, home repair)
o Recreation/hobbies/sports
o Home activities (TV, music, kids) o Other
Rate your current primarv role activity level, assuming a desired level of
o 10
o 20
o 30
o 40
o 50
o
o
60
70
o 80
o
o
90
100
If your current primary role a ctivity level is less than
o Physical limitations
0 Pain
0 Emotional distress
1000 /0,
100%
o Volunteer (fill in only one):
e select main reason why (fill in only one):
0 Loss of vocation
0 Cognitive impairment
Fig.12.1a LlFEWARE musculoskeletal assessment form (i).
Copy rig ht 1999-Uniform Data System for Medical Rehabilitation, a divi si on of UB Foundation Ac t ivi ties Inc., All Rights Reserved ,
177
Copyrighted Material
Patient Outcome and Follow-Along Measures
LlFEWARE® MUSCULOSKELETAL ASSESSMENT FORM 23700 What is your secondary role or activity (fill in only one):
o School/education
o Work
o Homemaking (cooking, shopping)
o Household tasks (lawn, home repair)
o Recreation/hobbies/sports
o Home activities (TV, music, kids) o Other
Rate your current secondary role activity level, assuming a desired level of
0\0 \(YO
o 10
o 20
o 30
o 40
o 50
o 60
o 70
o
o
80
90
If your current secondary role activity level is less than
o Physical limitations
0
Pain
0
Emotional distress
o 100 100%,
0
©
100%
o Volunteer (fill in only one):
v
select main reason why (fill in only one):
Loss of vocation
0
Cognitive impairment
How well can you perform personal care including washing, dressing, etc. (fill in only one):
o I can look after myself normally without having extra discomfort o I can look after myself normally but have extra discomfort o It is uncomfortable to look after myself and I am slow and careful o I need some help but I manage most of my personal care o I need help everyday in most aspects of self care o I do not get dressed, I wash with difficulty and I stay in bed How well can you lift (fill in only one):
o I can lift heavy weights without having extra discomfort o I can lift heavy weights but I get extra discomfort o I can lift heavy weights only if they are conveniently positioned o I can only lift light to medium weights if they are conveniently positioned o I can only lift very light weights o I cannot lift or carry anything at all How well can you walk (fill in only one):
o I am able to walk any distance o Discomfort prevents me from walking more than 1 mile o Discomfort prevents me from walking more than 1/2 mile o Discomfort prevents me from walking more than 1/4 mile o I walk only a limited distance or I use a cane, crutches or walker o I am in bed most of the time or use a wheelchair How well can you travel (fill in only one):
o I can travel anywhere without extra discomfort o I can travel anywhere but I get extra discomfort o I manage trips over 2 hours but with some discomfort o My discomfort limits me to trips of less than 1 hour duration o My discomfort limits me to short necessary trips under 30 minutes o My discomfort prevents me from traveling except to the doctor or hospital
Fig. 12.1 b LlFEWARE mu sculoskeletal assessment form (ii). Copyright
1999-Uniform Data System for Medical Rehabilitation, a division of UB Foundation Ac tivities, In(., All Rights Reserved
178
Copyrighted Material
LlFEware System Domains
LlFEWARE® MUSCULOSKELETAL ASSESSMENT FORM 23700 For each of the following activities, please fill in one response indicating your level of difficulty: No difficulty (and you can easily perform the activity)
I I
Some difficulty (but you can still perform the activity well enough) A lot of difficulty (but you can still do the activity)
I
Unable (you cannot do this activity or someone else helps you with it)
I
Not applicable (you choose not to do this activity)
0
0
0
0
Getting up from a low seat like a sofa
0
0
0
0
Climbing a flight of stairs
0
0
0
0
Sitting a long time, like for
30
minutes
30
0
0
0
0
Standing a long time, like for
minutes
0
0
0
0
Reaching and grasping something off a shelf at eye level
0
0
0
0
Kneeling or bending down to the floor
0
0
0
0
Driving an automobile
0
What is the most strenuous level of activity that you can do for at least
2
minutes (fill in only one):
o
Very heavy activity
o
Heavy activity
o
Moderate activity
o
Light activity
o
Very light activity
o
Extremely light to no activity
For each of the following areas, please fill in one response indicating your type and level of pain in the last
3
days: No pain
No pain Mild pain
Mild pain
I
Moderate pain Severe pain
Moderate pain Severe pain
0
0
0
0
Throbbing pain
0
0
0
0
Tiring-exhausting pain
0
0
0
0
Sharp pain
0
0
0
0
Fearful pain
0
0
0
0
Aching pain
0
0
0
0
Punishing-cruel pain
0
0
0
0
Cramping pain
0
0
0
0
Hot-burning pain
0
0
0
0
Tender pain
0
0
0
0
Splitting pain
Imagine that the line below forms a scale. Fill in one of the circles to indicate the corresponding intensity of your pain: No pain
©
0
o
o
o
o
o
o
o
o
o
o
®
Worst pain you can imagine
------
Rate your current social activity level, assuming a desired level of
o
o
o
o
o
o
o
o
o
o
10
20
30
40
50
60
70
80
90
100
100%
(fill in only one):
©.
v
How satisifed are you with life in general (fill in only one)?
o
Very well satisfied
o
Fairly well satisifed
o
More satisfied than not satisfied
Fig. 12.1 c Ll FEWA RE musculoskeletal assessment form (iii). Copyright 1999-Uniform Data Syste m for Medical Rehabilitation, a division of UB Found a tio n
o
Not satisfied
Activities, Inc., All
Rights Reserved
179
Copyrighted Material
Patient Outcome and Follow-Along Measures
rn
LIFEWARE® MUSCULOSKELETAL ASSESSMENT FORM
23700 For each of the following feelings or moods, please fill in one response indicating how much you have been bothered or worried during the last
Not bothered or worried
Not bothered or worried
Mildly
0
0
0
Extremely
0
Are you
Moderately
feeling...
QUite a bit
I
Mildly
Are you
Moderately
I
7 days:
I
feeling...
Quite a bit
I
Extremely I
0
Lonesome or isolated
0
0
0
0
o
Easily irritated or annoyed
0
0
0
0
o
Morbid or gloomy thoughts
0
0
0
0
o
Blaming yourself or guilt
0
0
0
0
0
Pessismistic about future
0
0
0
0
0
Uptight, tense or stressed
0
0
0
0
0
Panic attacks
o
How much are you limited in each of the following areas:
Complete
o
Do not complete
No limitation
No limitation None to mild limitation
None to mild limitation
Mild limitation
Mild limitation
Mild to moderate limitation
Mild to moderate limitation
Moderate limitation
Moderate limitation Moderate to severe limitation
Moderate to severe limitation
Severe limitation
Severe limitation
0
0
0
0
0
0
0
Right upper limb
0
0
0
0
0
0
0
Bowel continence
0
0
0
0
0
0
0
Left upper limb
0
0
0
0
0
0
0
Bladder continence
0
0
0
0
0
0
0
Fatigability
0
0
0
0
0
0
0
Vision
©
Completely satisfied
©
Completely satisfied
©
Completely satisfied
©
Completely satisfied
©..
Completely satisfied
0
0
0
0
0
0
0
Right lower limb
0
0
0
0
0
0
0
Left lower limb
•
Please fill in at time of discharge or if instructed to do so.
How satisfied are you with the overall process of treatment:
Not satisfied at all
®
0
0
0
0
0
0
0
0
o
o
o
o
10
20
30
40
50
60
70
80
90
100
How satisfied are you with respect to plans for finishing treatment:
Not satisfied at all
®
0
0
0
0
0
0
0
0
0
o
10
20
30
40
50
60
70
80
90
100
How satisfied are you with respect to the time waiting for treatment:
Not satisfied at all
®
0
0
0
0
0
0
0
0
0
o
10
20
30
40
50
60
70
80
90
100
How satisfied are you with your participation in treatment decisions:
Not satisfied at all
®
0
0
0
0
0
0
0
0
0
o
10
20
30
40
50
60
70
80
90
100
How satisfied are you with your ability to function and the comfort achieved:
Not satisfied at all
\OJ
0
0
0
0
0
0
0
0
0
0
0
0
10
20
30
40
50
60
70
80
90
100
Fig. 12.1 d LlFEWARE musculoskeletal assessment form (iv). Copyright 1999-Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc., All Rights Reserved
180
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LlFEware System Domains
LlFEWARE ASSESSMENT SUMMARY REPORT FOR JT ON 3117/1999 CONDITION:
MUSCULOSKELETAL
Patient code:
PROBLEM:
PAIN
Gender:
Male
Birth:
IN LOW BACK 11""
Lxxxx
Marital:
Cohabiting
Onset:
Em ployment:
Emplo"",
Living with:
live with family
Clinicians:
Prl. role:
Y\'ork
Pri. level:
Sec. role:
Homo aCliyilies
Sec. level:
Treatm ent Sallgfaclion:
60
Referral
N/A
-
Pri. reason:
Category:
ao
Wailing:
Physical
N/A Participation:
90
_49
Physical Functioning
Physical Activity
1012/1997 N/A
Case close:
Sec, reason: Pain
NJA
SfC:
ao
Finishing:
Body Movement and Control BMC
3030
Case open:
NJA
Subscriber:
Social level: Functioning:
17
0
30 30
EFFORT - Physical Functioning
I
UFEware Visual Analog Scale VAS - Pain Expenence
17
Absence of Pain PAI NFR EE - Pain Experience
_ 63
Absence of Distress PLACID - Affective Well-being Satisfaction with Ufe
0 176
SATISFACT - Affeclive Well-being o
I-
10
20
30
40
_
Below Expected
50
60
70
Above Expected
80
90
100
Expected Score
Raw Scores ( ' indicates a secondary item not included in the rating summation) BMC (Body Movement and Control)
PLACID (cant.)
PAINFREE (cant.)
Walking
3- Under 1/4 mi
Splitting
Traveling
2- Under
Tiring
3-Mild 2 - Moderate 3- Mild' 2 - Moderate
Getting up
2
Fearful
3 - Mild'
Stairs
3 - Some difficulty
Punishing
3 - Mildly'
Sitting
2 - Lot of difficulty
Cramping
2- Moderate'
Standing
2- Lot of difficulty
Burning
2- Moderate
Reaching
3 - Some difficulty
Kneeling
2- Lot of difficulty
Personal care
5- Normal/discomfort
Aching
Lifting
3- LighUmedium
Tender
-
30 min
Lot of difficUlty
Effort
3 - Light
VAS (LiFEware Visual Analog Scale) Pain
40 - 6 on
scale 10
4 - Mildy
Life satisfaction
1 - Not satisfied
PLACtD (Absence of Distress) Lonesome
EFFORT (Physical Activity)
Blame
SATtSFACT (Satisfaction with Life)
4 - Mildly
Pessimistic
2 - Quite a bit
Uptight
3- Moderately
Panic
4 - Mildly
Irritated
2- Quite a bit
Morbid
3-
Moderately
PAINFREE (Absence of Pain) Throbbing Sharp
2- Moderate 3- Mild
Fig. 12.2 LlFEWARE assessment summary report. Copyright 1999-Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc, All Rights Reserved
181
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Patient Outcome and Follow-Along Measures
UFEWARE CASE HISTORY REPORT FOR JT MUSCULOSKELETAL
CONDlllON: P.tlent code:
PROBLEM:
PAIN IN LOW BACK
Gendar.
Male
Birth:
Cne open:
Marital:
Cohabiting
Onset:
living with:
Live with famity
Clinicians:
Worl<
Pri. le"el :
90
Pd. reason:
Recreational
Sec.le"el:
80
SIIC. reason: Physical
NJA
Referral Src:
NJA
Category:
Subscriber: Employment
Employed
prj. role:
S.c. role: Treatment:
NIA
Case close:
10/211997 N/A
Physical
NIA
Sociallell'el:
80
76 BMC (Body Movement and Control) Physical Functioning
55
EFFORT (Phyaical Activity) Physical Functioning
VAS (LiFEware Visual Analog Scal.) Pain Experience
PAINFREE (Abs.nc. of Pain) Pain Experience
PLACID (Abs.nc. of Dist .. ) Affective Well-being
SATISFACT (Satisfaction wi...) Affeclive Well-being
3/17/1999 ----
Fig.12.3 LlFEWARE
Expected (absolute)
6/25/1999
_ Below Expected
_ Above Expected
case history report.
Copyright 1999-Uniform Data System for
Medical Rehabilitation, a division of UB Foundation Activities, Inc., All Rights Reserved
182
Copyrighted Material
LlFEware System Domains
LlFEWARE CASE ASSESSMENT NARRATIVE REPORT FOR JT CONDITION:
MUSCULOSKELE TAL
Pallent code: S ubscriber.
Employed
PR O BLE M:
PAIN IN LOW BACK
Gender:
Male
Birth:
Case open:
Marital:
LIVe with fnends
Onset:
Case close:
Employment:
Work
Livi ng with:
70
Cli n lc:t a ns:
N/A
Prl. rola:
Home actJvities
P rl . lo vo l:
20
P rl. reason:
N/A
Sec. role:
NlA
Sec, level:
N/A
Sec. reason: N/A
Treatment:
NlA
Referral Src;
Satlsfacllon:
N/A
NJA
-21 (49)
06125199 6 Chtlr.:lClenslically
(76)
lor:
Low back pain· Sitting IBnd Standing ore lower IhEm ,.acltlng. Lower body dysfundion lower
Lhan sitting and
NIA
N/A Fu nc t i oning:
Participation:
Assessment 03117/1999
BMC
Below Expected
"Body Movement and Contro'"
03/17199
50 Social level:
Category:
Waiting:
Finishing:
•
Standing
Is
reaching,
Neck pam I Upper limb dysfunclion .
Asses5ment 0612511999
Above Expected
-44 (30)
SITTING
-'11
LOWSEAT
-35 (35)
STANDING
-28 (35)
WAlKING
10(80)
KNEELING
-25 (35)
LIFTI NG
12 (65)
WAlKING
-20 (50)
REACHING
- 10 (70)
LIFTING
-3(5 0)
(35)
-10 (70)
LOWSEAT
0(70)
TRAVELING
-9 (SS)
STANDING
7 (70)
SITTING
-6 (70)
KNEELING
10(70)
PERSCARE
0(80)
REACHING
STAIRS
0 (70)
--
I
Assessment 03/1711999 Below Expected
"Absence of Pain"
.:20
(50)
I
TRAVELING
PAINFREE
06125199 15 (85)
Above Ellpecte d
Below Expected
Reactlllog Is lower than sitling and staMing.
03/17199
1012/1999
PERSCARE
20(100)
STAIRS
30(100)
Assessment 06/2511999
Above Expected
Above Expected
Below Expected
eURNING
-'12(40)
SHARP
3 (70)
CRAMPING
-12 (70)
PUNISHING
CRAMPING
-42 (40)
ACHING
15(70)
THROBBING
-3 (70)
FEARFUL
12 (100)
THROBBING
-33 (40)
TIRING
-3 (70)
AOjING
15(70)
12 (100)
TIRING
-33 (40)
SPUn! G
15(100)
TENDER
-27 (40)
eURNIN
18 (100)
FEARFUL
-18 (70)
SHARP
33 (100)
PUNISHING
-18 (70)
TENDER
33(100)
SPLITTING
·15 (70)
I Assessment 03117/1999
PLACID
Below Expected
"Absence of Oistress"
I Assessment 0612511999
Above Expected
Below Expected
Above Expected
9( 1 00)
03117199 -23 (53)
PESSIMIST
-'10(30)
PANIC
06125/99 24
MORBID
-35 (SO)
MORB ID
15 (100)
IRRITATED
-32 (30)
BLAME
15 (100)
PANIC
-21(70)
LONESOME
20 (100)
BLAME
-15(70)
PESSIMIST
30(100)
LONESOME
-10(70)
IRRITATED
38 (100)
uPTIGHT
-10(50)
UPTIGHT
40(100)
(100)
I Copyright 2005
-
t
Uniform Data System for Medical Rehabililation, a division of UB Foundation Activities Inc., All Rights Reserved
Fig. 12.4 LlFEWARE case assessment narrative report. Copyright 1999-Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activities, Inc.. All Rights Reserved
183
Copyrighted Material
Patient Outcome and Follow-Along Measures
Chronic low back pain is commonly associated with
Case Study
multidimensional dysfunctions producing decrements in quality of daily living. Thus, patient-reported measures
The following case study illustrates how the L1FEware sys
from the L1FEware system were used to address physical
tem can be used to assess and track a patient's function and
functioning. experience with pain, affective/mood state,
QOL. This shows the outcome for a patient J.T. after prolo
socialization, role/activity participation, and satisfaction
therapy treatment for chronic low back pain. Note that the
with the results of treatment. Data were recorded for dates
examples of the various reports (Figs.12.2-12.4) reflect
17 March 1999 (before treatment) and 25 June 1999 (6
data collected and analyzed on this patient.
weeks after completion of treatment). The range of ratings is from a to 100, where a higher value indicates a better
A 55-year-old construction manager was seen on 17 March 1999 for persistent low back pain secondary to a
state, meaning more physical function, less pain, less emo
motor vehicle accident about 2 years previously. He never
tional stress, and higher satisfaction.
manifested sensory or motor deficits. An MRI was reported
Comparison of functional assessment total-rating values
as showing mild disk protrusion and degeneration at
before and after prolotherapy treatments for chronic low
L4-L5. He had responded minimally to conservative man
back pain are shown in Table 12.1, range 0-100, a higher
agement, including medication, physical therapy, exercises,
rating indicating a better state. He identified his work role
and chiropractic treatment. Physical examination demon
as primary; initially his home activities role was secondary,
strated tenderness of the left sacroiliac joint, joint dysfunc
but 3 months later he identified his recreational activities
tion, and inconstant inequality in lower limb length. It was
role as secondary. A change of five or more points is con
decided to treat him for sacroiliac joint dysfunction asso
sidered to be clinically significant, see Table 12.1.
ciated with ligamentous instability.
Single-item scales and multi-item measures are used to
He received prolotherapy injections consisting of 25%
evaluate quality of daily living. The behavior of the indi
dextrose solution to strengthen ligaments on two occa
vidual items within measures should be noted in order to
sions, 24 March 1999 and 10 May 1999. Locations of in
appreciate the complexities that underlie any total rating
jections were interspinous ligaments from L2 to 51, bilat
and to provide an opportunity for addressing needs that are
eral facet joints from L3 to 51, bilateral iliolumbar liga
evident from single-item values. In order to identify the
ments, and bilateral sacroiliac joints. On 25 June 1999 he
behavior of items within measures, the values of items are
reported 80% satisfaction with the results, in terms of
compared
comfort and function achieved.
specified thresholds of clinical importance. Expected val-
with
expected values
determined
Table 12.1 Com parison of item ratings' and role participation percentages before and after prolotherapy treatments
Item Physical func tioning Pain inten sity
=---=="""'=
.:.-= =-- ---==- - :-:-:"
Pain quali ty
BMCb
..
LVAS<
49 ----------
..."
- =-==-==-=
Painfree ---------
Physical and pain
--
-
-
50 - - -
-=-=-=-- :.==
Work role
...,
==--=�-
-
.. .
Social %
--=--:-- -=-=--=-=---=
Work %
-=
85 73
--
53
Satisfaction
Social int erac tions
-
-
Placid
-
80
_.
-------
Ufe in general
76
:....
47 -
-
Affective state/ mood
40
---
Back ill -
-
100
=.=--.=..=.::-:-
Not
Very - ---
-
30%
80%
30%
90%
Home activities
Home %
30%
N /Ad
Recreation activities
Recreation %
N /Ad
80%
'Ratings range
0-100
points: a change of
5
or more points is clinically significant: percentages.
b
Body Movement and Control.
cLiFEware Visual Analog Scale. d
Not applicable (patient changed roles)
184
Copyrighted Material
0-100.
as
pre
Conclusion
Table 12.2 Comparison of item ratings, before and a fter prolotherapy treatment. O nly item values below expected are shown. Minus signs indicate the number of points values
BMC measure
are
below the expected value
Items
17 March 1999
25 June 1999
Traveling
-44
-9
Sit ting
-41
-6
Arise low seat
35
Above expected
Standing
-26
Above expected
Kneeling
-25
Above expected
Walking
-20
Above expected
Reaching
-10
-10
Lifting
-3
Above expected
BMC total Painfree measure
76
49
Burning
-42
Above expected
Cramping
-42
-12
Ti r ing
-33
3
Pa in free total
50
85
6 , reaching - 1 0 ) and for Painfree (cramping -12,
ues for items are derived from Rasch analyses of thousands
sitting
of assessments in the database. Items that were rated
tiring -3). Placid had a full rating with no items below
below expected values are shown in Table 12.2. Analysis
expected value. The patient rated his satisfaction with
-
assigned a different expected value for each item within a
function and comfort achieved as 80%; it was therefore
measure. Minus signs indicate the number of points the
deemed that no further treatment was necessary and the
rating values are below the expected value.
patient was advised to gradually resume normal activities.
Comparison of functional
assessment
item ratings
within measures before and after prolotherapy treatments for chronic low back pain are shown in Table 12.2. Only
Conclusion
item values below expected are shown. Negative values of The L1FEware system provides good and accurate outcome
lower absolute magnitude are closer to expected. Comparison of functional assessment total-rating values
measures for evaluation of treatments for back and neck
before and after prolotherapy treatments demonstrated
pain. The measures provide a multidimensional assess
improved values for the several measures of quality of daily
ment of patient function, allowing the clinician to assess
living covering physical functioning, pain experience, affec
physical function, affective and mood state, activities of
tive/mood state, social interaction, and role participation.
daily living, a patient's satisfaction with life in general,
Comparison of functional assessment item ratings within
quality and quantity of pain, sleep, and fatigue. In addition,
measures before and after prolotherapy treatments dem
the L1FEware system can track these over time.
onstrated residual problematic items for BMC (traveling -9,
185
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13
Imaging Studies of the Spine
Introductory Remarks
•
Fever, chills, night sweats.
•
Unexplained weight loss.
The ready availability of high-quality radiographs should
•
Injury or trauma that may have resulted in a fracture.
not tempt the clinician to order them for every patient who
•
presents to the office with neck or shoulder pain. Even though the exposure to roentgen rays has been signifi
•
cantly reduced in today's studies, one should also keep in
Changes in pain frequency, timing, duration or quality, intensity, and location. This should be done especially if
mind the cost-benefit ratio when ordering these studies. Previous research has shown that especially for non
History of repetitive stress loading to the spine that may have caused a stress fracture.
previous studies were performed more than 2 years ago. •
malignant low back pain, routine radiographs of the spine
Previous low back surgery-to identify and evaluate postsurgical anatomy and hardware or whether there is
are not indicated initially, that is during the first 4-6 weeks
a change in quality, intensity, duration, or type of the
of symptom presentation, especially when there is no in
perceived pain.
dication of sinister pathology or specific co-morbidities.
•
History of other diagnostic studies such as a bone scan.
•
The need to prepare for further studies, such as an
them did not provide any additional clinically useful infor
•
The patient with an unreliable history.
mation. Over half of the radiographs taken were normal;
•
Certain psychological or social circumstances.
30% were clinically questionable.
•
Scavone et al. (1981) examined the diagnostic value of 1000 lumbar spine radiographs, and showed that 75% of
epidural injection.
Liang and Komaroff(1982) investigated the cost-benefit relationship between obtaining radiographs at the initial
•
presentation and waiting 8 weeks. The study excluded patients with indications for a potential tumor, inflamma
Decisions needed regarding the patient's vocational fitness or future sports.
•
Potentially increased risk for injury during normal or
•
Specific legal considerations that need to be addressed.
tory disease, signs of disk herniation, or radiculopathy. It was concluded that the use of radiographic studies at the
History suspicious for cancer suspicion (primary or metastatic).
routine functional or sports activities.
initial office visit is not justified in the absence of signs of Based on their comprehensive review of the literature from
sinister pathology. Simmons et al. (1995) provides the following literature
1966 to 2001, Jarvik and Deyo (2002) present two major
review summary:
conclusions about the diagnostic accuracy of clinical infor
"Standard radiographic studies of the lumbar spine are not
mation and imaging for patients with low back pain in
indicated in patients who, in the absence of any signs of
primary care settings:
sinister pathology, present with low back pain that lasts less than seven weeks and who show gradual symptomatic improvement...
1. For adults younger than 50 years with no signs or symptoms of systemic disease, symptomatic therapy
However, if the pain is thought to be due to structural! congenital abnormalities, fractures, inflammation, or ma
without imaging is appropriate.
2. For patients 50 years of age and older or those whose
lignant processes, then radiographic stud ies are clearly
findings suggest systemic disease, plain radiography
indicated as the next step in the clinical work-up routine.
and simple laboratory tests can almost completely rule
The history and clinical situations that help determine
out underlying systemic diseases. Advanced imaging
the need for plain radiographs include the following data:
should be reserved for patients who are considering surgery or those in whom systemic disease is strongly
•
Patient age-new onset of unexplained low back pain in
suspected.
a person older than 65 years. •
•
High risk for osteoporosis (hormonal, corticosteroid use,
These recommendations are well founded on the current
oophorectomy history, etc.).
evidence. However, with regard to manual medicine, they
Known or suspected bladder or kidney disease.
do not take into account any specific consideration. Radio
•
Persistent neurologic sensory or motor deficits.
graphic studies in manual medicine may be indicated if
•
Progressive pain despite adequate treatment.
there are complaints of recurrent pain or if the practitioner
•
Intense pain even at rest.
is considering high-velocity low-amplitude thrust or artic
•
Night pain.
ulatory techniques. The goal of such studies would be to
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Cervical Spine
determine as early as possible any potential instability or mechanical abnormality due to space-occupying lesions, fractures, inflammatory processes, or other pathologic states that would otherwise be contraindications for ma nipulation. In general, radiographs should not be ordered indis criminately, simply as a "reflex" or as "something to do next." or purely for medicolegal concerns. Haphazard use would certainly increase the chance of false-positive and false-negative results, not to speak of the unnecessary radiation exposure. Again, in situations where there is clinical uncertainty or suspicion of sinister disease, imaging stud ies are a logical next step. Such stud ies, when based on best clinical judgment and current evidence, will help in determining the next diagnostic steps and may provide reassurance to the individual patient that an occult diag nosis has not gone undetected. Fig.13.1
Lateral view of the upper cervical spine in
a
healthy
person.
Cervical Spine Plain Radiographs
1
Dens of the axis
2
Anterior arch of the atlas
3
Posterior arch of atlas
4
Vertebral body of the axis
Standard radiographs of the cervical spine are used to determine major vertebral misalignment, segmental insta
•
Suspected congenital malformation.
bility, fractures, and dislocations, and to quantify degener
•
Chronic polyarthritis affecting the cervical spine, e. g.,
ative changes. Clues about the cervical soft tissues can also be obtained. This can be especially important in patients with rheumatoid arthritis, generalized osteoporosis, or
rheumatoid arthritis. •
History of recent injury or trauma and associated frac ture of the cervical spine.
previous surgery. The standard radiographs of the cervical spine include
The lateral view is performed at a distance of 1.5 m bet
the anterior-posterior (AP) view, lateral views, and oblique
ween the roentgen ray tube and the transverse process of
views. If specific studies of the upper cervical spine or the
the atlas (Fig. 13.1). In the AP view, it may be difficult to
craniocervical junction are indicated, they should include
visualize the upper cervical spine (CO-C1). For example, the
the AP views and the Sandberg-Gutmann views, in which
upper row of the teeth and the occipital bone may obliter
the roentgen ray tube is tilted 20°.
ate the upper cervical spine and thus render the study
It must be noted that with all of these views there is
ineffective (Fig. 13.2).
radiation exposure and concern for the thyroid gland. A
Zimmer (1937), Sandberg (1955), and Gutmann (1981)
radiation shield can be employed without disrupting the
recommend that the upper cervical spine be radiographed with the head held in approximately 20° of extension while
diagnostic information in upper cervical spine studies.
the roentgen ray beam is directed superiorly. This allows projection of the occipital shadow over the upper teeth,
Upper Cervical Spine: AP and Lateral Views
ensuring visualization of both sides of the articulations in
The following situations are indications for studies of the
the upper cervical spine. The disadvantage of this tech
upper cervical spine:
nique is the change in vertebral position in the upper cervical spine due to the head extension secondary to the
•
Functional disturbance (e. g., somatic dysfunction) in the upper cervical spine based on the clinical examination.
coupled motion patterns in the upper cervical spinal joints. According to our own studies (Reich and Dvorak,
Findings may include pain elicited with palpatory ex
1986a, b), the "standard" transbuccal view may provide
amination, the presence of hypomobility and/or hyper
the best view. The transbuccal view attempts approximate
mobility, and pain that is reproduced by introducing
the contour of the occiput and the upper row of the teeth.
rotation to the cervical spine while the head and neck
While the atlanto-occipital joint is not visualized in a de
are flexed.
tailed manner, this view reveals the dens of the axis, the
187
Copyrighted Material
ImagIng StudIes of the SpIne
Fig. 13.3 AP view of the upper cervical spine with identification of the salient structures.
1
Dens of the axis
2
Lateral mass of the atlas
3
Posterior arch of the atlas
4
Spinous process
o
Fig. 13.2 AP view of the upper cervical spine in a prepared speci men, void of soft tissues. Presentation of the atlanto-occipital joint, the atlantoaxial joint, and the spinous processes of the second and third cervical vertebrae.
/
-
Massa lateralis atlantis
Dens axis
Recess for transverse vertebral body
Fig. 13.4 Schematic representation of the bony structures used in the assessment of positional relationships between the atlas and the axis. This also allows measurement of the distance between the
Spinous process of axis
dens of the axis and the lateral mass of the atlas (A-B).
lateral mass of the atlas, and the spinous process of the axis.
mass of the axis and the posterior arch of the atlas is a
For orientation, the upper row of the teeth and the trans
valuable sign that indicates rotation. The position of the
verse process of the atlas are utilized. The focus-film dis
axis is evaluated by comparing the position of the spinous
tance is 110 em, which results in magnification by a factor
process in relationship to the midline as well as asymmetry
from 1 to 1.25 (Reich, 1985).
between the transverse process and the vertebral body
These views serve as starting point for the functional lateral radiographs of the upper cervical spine (Fig. 13.3). Various authors recommend an evaluation of atlas posi
from one side to the other (Kamieth, 1983) (Fig. 13.4). The symmetry between the body and the transverse process is a valuable criterion for axis rotation, especially since the
tion by looking for any asymmetries in the lateral mass
spinous process is typically not located right at the center
triangle (LMT) (Lewit, 1964; Jirout, 1973; I
of the vertebra.
The base of this triangle is formed by the posterior arch of the atlas. Any increase in distance is an indication of rota tion toward one side. The distance between the lateral
188
Copyrighted Material
Cervical Spine
Cervical Spine: Oblique View The oblique view is utilized in the following situations:
•
Suspected narrowing of the intervertebral foramina.
•
Evaluation of the uncinate processes.
•
Status post trauma-unilateral or bilateral subluxation
•
Fractures of the articular processes.
or overt dislocation.
•
Increase of the intervertebral foraminal space due to tumors such as neuroma or meningioma.
The patient should stand for this technique. The body is rotated 45° with respect to the plane of the film. The left oblique view demonstrates the right intervertebral fora men and the right oblique view demonstrates the left intervertebral foramen. It may be good procedure to label the side of the foramen directly on the radiograph during the procedure to minimize error (Fig. 13.5). Figure 13.6a-e demonstrates a typical left-sided fora minal stenosis due to degenerative changes affecting the cervical spine.
Mid and lower Cervical Spine: AP and lateral Views During the initial work-up of the mid-cervical and lower cervical spine, the AP and lateral views are the standard radiographic studies. The distance between the roentgen ray tube and the film is 1.5 m. The patient holds the head
Fig.13.5 Lateral view of the cervical spine of a 20-year-old woman
and neck in a neutral position, with the shoulders lowered
with a cervical rib.
maximally so that the cervicothoracic junction can be vi sualized. It is mandatory to count all the vertebral bodies to make sure that pathology is not missed (Penning, 1980),
The posture of the head and neck during the examina
because the lower cervical spine may not be entirely visi
tion can have a notable effect on the curvature and appear
ble, especially in muscular and obese patients. It may be
ance of cervical spinal lordosis. For instance, lowering of
necessary to utilize a 2-5-pound weight in each hand to
the patient's shoulders during the radiographic procedure
lower the shoulders further, or to obtain the standard
may introduce a reversal of the normal cervical lordosis
"swimmer's view."
simply due to natural adaptive postural changes. This is
Normal lateral and AP views are demonstrated in Figure
why it may not be meaningful to measure the degree of the
13.7. The lateral view allows evaluation of the diameter of
cervical lordosis or kyphosis. Furthermore, such radio
the spinal canal (Fig.13.8) as well as the width of the
graphic findings are reported as "abnormal," but the actual
retropharyngeal and retrotracheal space. The width of the
clinical relevance of such a finding has not been fully
retropharyngeal space is usually between 1 and 7 mm,
determined.
while the retrotracheal space is 14 mm (Penning, 1980) (Fig. 13.9). The width of the spinal canal is determined by measuring the distance between the articular pillars and the lamina of the vertebral arch (Fig. 13olO).
189
Copyrighted Material
Imaging Studies of the Spine
b
a
d Fig.13.6 a,
b Lateral view of a 42-year-old man with left-sided radicular symptomatology in the C6 sensory and motor distribution. There are symptoms associated with unisegmental foraminal spinal stenosis at C5-C6 due to posterior osteophyte formation and hyper trophy of the uncovertebral jOints.
c c
AP view. Note the sign of Guntz at C5-C6 left, which clearly reveals
a
new arthritic
change.
d
Comparison examination using CT.
13.6e
190
Copyrighted Material
[>
Cervical Spine
Fig. 13.6e Reconstructed (T views com paring one right and left side.
e
b
a
Fig. 13.7 Standard radiographs of the cervical spine. a
Fig. 13.8 Schematic representation of the measurements for the width of the spinal canal.
A-P view.
b Lateral view.
10mm
C2
7 7
Retrotracheal space (e s ophagu s)
Fig. 13.9 Technique for measuring the retropharyngeal and retro tracheal space according to Penning (1980).
191
Copyrighted Material
Imaging Studies of the Spine
A major contribution came from the American spinal Normal
Constitutional
Canal stenosis:
Canal stenosis:
canal
canal stenosis
Transverse
Vertebral body
pedicle
hypertrophy
surgeon JW Fielding, who introduced cineradiography to visualize normal and abnormal cervical spinal motion (Fielding, 1957). His clear depiction and graphic represen tations of the relationship between the cervical interverte bral disks and the apophyseal joints during flexion, extension, and side-bending as well as rotation have as much validity today as they did when they were initially presented (Fielding, 1957) (Fig. 13.11 ). The pioneering work by the Dutch radiologist, Lourens Penning was a major contribution to the understanding of
Fig. 13.10 Schematic view of a different presentation of spinal canal stenosis in the cervical spine as represented in the lateral view. Constitutional canal stenosis secondary to hypoplasia of the
the functional pathology of the cervical spine. His disserta tion was a treatise about the degenerative process and its etiology of the uncovertebral joints in the cervical spine
laminae is the most frequent form. Canal stenoses due to trans
(Penning, 1960). This was followed by his seminal study in
versely-oriented pedicles or due to vertebral body hypertrophy are
1963 on the normal and abnormal ranges of motion in the
relatively rare. (After Wackenheim and Dietemann, 1985a.)
cervical spine (Penning and Tondury, 1963). Technological advances have resulted in the use of CT scans and magnetic imaging to study motion of the cervical spine. In the past, technical difficulties (projections that were unable to visualize the upper cervical spinal joints) stood in the way of detailed analysis. Newer technologies have allowed further study, especially that of axial rotation (Dvorak and Panjabi, 1987b: Dvorak et aI., 1987a, c: Ono et aI., 1984: Penning and Wilmink, 1987a,b).
Functional Radiographic Diagnosis of the Cervical Spine: Flexion and Extension Based on our own studies (Dvorak et al., 1988d) and Frohlich (1988), there is a significant difference between active and passive motion at all spinal levels in flexion and extension. Fig.13.11 Motion behavior in a final segment in relation to the facet (apophyseal joint) during flexion and extension motion as well as side-bending in rotation in the mid-cervical spine (Fielding,
1957).
Passive radiographic examination provides the most relevant and reliable information. One of the limiting fac tors is the pain that would typically appear at the extreme of motion. This may be due to muscle spasm and is quite often reported in the radiological reports associated with a "straightening of the curve." However, more importantly,
Functional Radiographic Studies of the
the pain may actually be due to segmental instability. Thus
Cervical Spine
it is helpful to encourage the patient to relax as much as possible during the examination. Even with such prepara
A significant number of patients who experience neck pain
tion, the passive functional radiographic study may not
with movement, will not have objective evidence of an
provide much additional information in a patient with
underlying structural abnormality. For this reason, func
advanced degenerative changes in the presence of segmen
tional radiographic studies have been employed. The goal
tal hypomobility.
is to determine whether the patient's pain can be objec
The contraindications for passive flexion and extension
tively correlated with segmental or regional motion limi
motion studies include a history of recent cervical spine
tations (e.g., hypomobility) or excesses (hypermobility).
trauma, chronic polyarthritis, as well as suspected primary
Bakke (1931) was the first to use radiographic studies to
space-occupying lesions or metastases.
evaluate motion at the cervical spine. De Seze et al. (1951)
The study is performed with the patient standing and
and Buetti-Bauml (1954) presented the first systematic
the left side of the body placed against the film plate. The
functional radiographic results.
distance between the film and the roentgen ray tube is
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Cervical Spine
1.5 m. The focus of the beam is upon the mid cervical spine. The patient should be as relaxed as possible, with the shoulders lowered maximally. The patient is stabilized between two padded supports placed anterior to the sternum and posterior to the mid thoracic spine. This helps facilitate a neutral patient posi tion. One should be careful not to introduce rotation, in order to maintain clear visualization of the vertebral bodies. Initially, the patient is instructed to carefully nod his or her head, which introduces a nutation motion (flexion) at CO-Cl and C1-C2. From this flexed position, further flexion is introduced to the neck until the maximal allowable flexion position is reached by the patient. In this final, actively engaged position, the first radiograph is taken. For the passive examination, the radiologist wears a lead apron, lead gloves, and lead glasses. The left hand of the
Fig. 13.12 E xa m ination technique for passive flexion and extension
radiologist is placed over the posterior portion of the pa
views u sing functional radiographic diagnosis in the cervical spine
tient's head and the parietal region, while the right hand is
(Dvorak et aI., 1988d; Frohlich, 1988).
placed over the patient's chin. After introducing maximal passive inclination (flexion) at CO-C1 and C1-C2, the oper ator introduces maximal passive flexion to the remainder of the cervical spine. In this position, the second radiograph is taken. Once the flexed radiograph has been taken, the head is guided passively into maximal reclination (that is, exten sion motion) at CO-C1 and C1-C2, followed by maximal allowable extension introduced to the neck by the radi ologist's guiding hand. Every care should be taken that the hand guides the head and neck into these positions in a slow, careful, and precise manner (Fig. 13.12).
Fig. 13.13 Passive (a) flexion and (b) extension views during func
tional examination. The cervicothoracic junction should be view able, requiring that the patient lower the shoulders as much as
If pain is elicited or exacerbated during the functional
possib le .
examination, it may be necessary to reschedule the patient. In our experience, low-dose analgesic or nonsteroidal anti inflammatory may help facilitate the execution of the
spine are the graphic method and the computer-assisted
study. Again, it is emphasized that if there is pain associ
method. They are described as follows.
ated with the passive maneuver, consideration should be given to the potential presence of segmental instability. If
The Graphic Method
the patient reports the onset of dizziness, nausea, or other
This method was originally described by Penning in 1960.
autonomic symptoms, further diagnostic neurologic eval
The flexion view is projected onto the normal film of
uation may be warranted.
24
x
36 cm size and the extension view onto one of
18
x
24 cm. The radiographic film of the extension view is
Representative flexion and extension views utilizing the functional radiographic examination protocol just de
placed upon that of the flexion view while the spinous
scribed are shown in Fig. 13.13.
processes and the vertebral bodies of C7 are matched as
The original method presented by Penning (1960) has
much as possible. Subsequently, a line is drawn following
been found to be the most useful and reliable method, as
the edge of the seventh cervical vertebra in the extension
well as
the computer-assisted
method presented by
view and the flexion view. This procedure will then be
Dvorak et al. (1988d). The techniques introduced by Bakke
repeated for each vertebra superior to C7. The angle created
(1931), De Seze (1951), Buetti-Bauml (1954) have not been
between the two lines thus marked on the films in the
able to reproduce data sufficiently consistently (Frohlich,
maximal flexion and extension position will determine
1988; Dvorak et aI., 1988d).
the degree of range of motion between maximal passive
The two current procedures used to measure passive
flexion and extension.
segmental and regional range of motion in the cervical
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Imaging Studies of the Spine
Computer-assisted Method The contours of the vertebral body are outlined and the intersections of the lines are digitized for each vertebra in
II ' \ )-'(f\ \.. /"'"' \ \ /
the flexion and extension views (Fig. 1 3.14). The method is
Cl
.
I
.//' .....-/ I
/::ft:)
C2
-
! . 'V/",,,----, '" .,../
repeated four times to obtain an acceptable average value
'\'
and in order to minimize human "entry error" (Panjabi et al.,1992b).
\
A specifically designed computer program then ana
--.. @
lyzes the superimposition of the vertebral bodies and the differences with respect to extension and flexion (Yale Biomechanics Laboratory, Department of Orthopedics and Rehabilitation/Spine Unit, Schulthess-Clinic, Zurich). The geometric fundamentals used for the final calculation of the rotation and translation motions and the center of rotation are presented in Fig. 1 3.15. Normal values for flexion and extension motion are summarized in Tables 1 3.1 and 1 3.2 (Dvorak et al., 1 988d,
Fig. 1 3.14 Landmarks for the computer·assisted method used to
1991a, 1993).
determine segmental motion. The landmark of the axis is some· what difficult because the osseous structures cannot always be clearly defined.
are those that deviate by more than one or two standard
Pathological values for hypomobility and hypermobility deviations from the normal value for each segmental level. For example, as demonstrated in Figs. 1 3.16a-e, a pro nounced segmental hypomobility is demonstrated in the functional diagram and the associated radiograph films.
Y
The differences between the active and passively per
Rx
formed motions are clearly evident.
'"'
\
Fig. 1 3.15 Labeling of the different reference points used in the calculations using a computer· assisted model (CAM).
Rx
Rotation about the x-axis (flexion-extension motion)
AV, AY
Translation of the lower border or lower edge or of the point A of the above neighboring vertebrae-motion
.y
+Z
ffit
+X
from extension to nexion. CRY
X 0�
J
Translation of the upper posterior corner or the point B
BV, BY
·z
from flexion to extension. CRZ. CRY Calculation of the rotatory center in relationship to the coordinate system of the vertebrae below.
Table 13.1 Segmental range of motion for cervical spine flexion and extension
Bakke (1931)
Cl-(2
1 1 .7
C2-C3
1 2.6
C3-(4
(4-(5 (5-(6
1 5.4 1 5. 1 20.4
Oe·Seze et al. (1951)
Biietti- Bauml (1954)
1 3.0
1 1 .0
1 5.5
- .-. -
1 9.0 27.5
1 7 .0 21.0
--
1 7.0
1 7.5
-----
1 9. 0
:===-=--
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1 0.0
12.5
1 5.0
18.0 20.0 21.5
23.0
_.
(6-C7
- . ---
1 5.5
.
.
-
--
19.0 20 .0 19
--
1 1 .7
12
1 6.0
18
20.1
22
21.2
24
2 1 .0
21
Cervical Spine
Table 13.2 Segmental range of motion For cervical spine translation and notation of the rotatory centers (Dvorak 1991 a). For description of abbreviations, reFer to Figure 13.15
SO
Transl.
SO
Transl.
SO
Transl.
SO
(1-(2
-3.8
1.6
6.2
2.3
-1.4
1.4
8.1
3.0
-4.1
4.2
C2-G
2.4
0.9
1.8
0.8
6.9
1.7
3.0
1.3
4.0
3.5
(3-(4
3.2
1.0
2.3
1.0
8.5
1.8
3.6
1.2
4.3
2.7
(4-(5
3.6
1.2
2.9
0.7
10.0
1.9
4.2
1.0
6.0
2.2
(5-(6
2.9
1.1
3.2
0.8
9.8
1.9
4.3
1.0
6.4
1.8
(6-0
2.0
0.9
3.1
0.8
8.4
1.9
3.0
0.9
6.4
2.5
Active
Pa ss ive
a Hypermobile
Hypermobile
______ ________________________________
35'
c
30'
Fig. 13.16 a -e
.....
a A 5 1 - year - old woman aFter soft-tissue trauma to the cervical spine with persistent pain in the mid cervical spine. Radiographs (a, c) and Functional diagrams (b, d, e) clearly reveal the diFFer ence between active and passive motion and the presence of a hypermobility at C3-(4 (Dvorak et al" 1988d). b Extension-Flexion views of the cervical spine using Functional
20'
.
15' 10'
radiography.
c Extension and Flexion views of the cervical spine in lateral pro jection (Functional diagnosis. passive examination).
d Example of a functional diagram For Functional radiographic
.
l
t-
A· C1-(2
-k -1-
C>
1-
::::::::-I -
1: J. ...
(2-(3
Hypo C3-C4
(4-C5
L-____________________
..
.
-
Active
diagnosis for the cervical spine (active examination). Fig. 13 .16 e
l
i
,/
!
"
I
i
obile
C5-C6
(6-C7
______________
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b
d
Imaging Studies of the Spine
The measurements compare the distance between a line
35 " "------,------,------,------,------, Hypermobile
3 "
I
25"
I
.... ! ,'f>- .:...: .
through the center of the dens and either lateral mass of tile atlas (the lines should be parallel as they follow the medial aspect of the mass of the atlas). The central axis of the dens is constructed in the mid-portion of the dens perpendicular to the base of the dens (Fig. 13.17). Figure 13.18 demonstrates a typical example of side bending evaluation for a healthy adult. However, a quanti
10" I
,.
I
I
5"
tative evaluation of rotation in the lower cervical spine as
!.
coupled with side-bending could not be reliably per formed.
0"�1-----+----_4--�--� C1-C2
C2-C3
C3-C4
C4-C5
C5-C6
C6-C7
An increased sliding motion of the atlas in the same direction as that of induced side-bending may be found in patients who have atlantoaxial instability that is due to
Fig. 13.16e Example of a functional diagram for functional diag· nosis in the cervical spine (passive examination).
chronic polyarthritis and that may involve both the trans verse ligament and the alar ligaments. If there is no translatory motion of tile atlas, or if there is a paradoxical motion in which the atlas is translated in a
Cervical Spine: Side- bending Motion
direction opposite to the side-bending, one can safely as
When the usual coupled motions in the cervical spine are
sume the presence of a functional disturbance (e. g., so
absent, there should be suspicion of cervical spine insta
matic dysfunction) in the upper cervical spine (Fig. 13.19).
bility. This can be demonstrated in lateral side-bending
This may be due to a lesion involving the alar ligament. Instability in the mid cervical spine in regard to side
radiographs. The lateral spine study is performed with the patient supine. This eliminates the influence of the weight of the
bending or rotation is demonstrated by excessive diver gence of the articular processes in that region.
head. The examiner passively side-bends the cervical spine to the allowable extreme of motion (Reich, 1985a: Reich and Dvorak, 1986a,b). In order to obtain a view of the entire cervical spine, the beam is centered upon the mid cervical spine. The rotation of the atlas is determined by evaluating the
Computed Tomography Computed Tomography in the Neutral Position
lateral mass-triangle relationships. The evaluation of the
Computed tomography is particularly helpful to evaluate
axis is determined by evaluating the spinous processes as
the osseous structures in the cervical spine (Fig. 13.20), and
they should move into the direction opposite of the in
provides good information about the presence of osteo
duced spine rotation motion.
phytes and congenital or traumatic anomalies and frac-
Fig. 13.17 Positional relation·
Sidebending right
Sidebending left
ships between the atlas and axis during passively held side· bending. The atlas translates in the direction of side-bending. The distance between the lateral mass of the atlas and dens of the axis is increased on the side to ward which side-bending occurs
v;
,.., ,..,1> \0
\5=:
in relation to the opposite side. Spinous process
The axis is rotated into the ipsi lateral direction as side- bending. Note that this motion of the axis causes the spinous process to rotate in the opposite direction.
III our own studies, there was no atlas rotation noted or demon strated (Reich. 1986a; Reich and Dvorak, 1986b).
196
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Cervical Spine
Fig. 13.18 Side- bending demonstrated in a healthy patient.
Fig. 13.19 A 45-year-old woman after indirect cervical spine injury and persistent posttraumatic upper cervical spine synd rome Side .
bending of the cervical spine to the right reveals a normal gliding transition motion of the atlas in the same direction as Side- bend ing
.
However, when side-bending to the left, this norm al gliding motion is absent. This finding allows the possibility that there may be injury of the ligaments affecting the cervical spine.
tures. Furthermore. cr scans of the cervical spine are able to visualize foraminal spinal stenosis and investigate a patient's radicular symptomatology (Fig. 13.21).
Functional Computed Tomography The indication for functional computed tomography is ro
MRI is superior to computed tomography when inves
tational instability due to abnormalities of the ligaments in
tigating abnormalities of the spinal canal. especially when
the cervical spine. especially the upper cervical spine re
there is suspicion of space-occupying lesions, other neural
gion (Dvorak et al.. 1987a, d; Penning. 1987a). Functional
structures. and abnormalities of the intervertebral disks.
computed tomography may objectively demonstrate insta
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Imaging Studies of the Spine
Fig. 13.20 a, b A 53-year-old woman. CT of the upper cervical spine with significant destruction and arthrosis of the left atlantoaxial joints with hemo chromatosis.
b
a
b
a
Fig. 13.21
a,
b CT scan of the lower cervical spine demonstrating significant foraminal stenosis at C5-C6 (a) and C6-C7 (b) on the right.
This 54-year-old man presented with prominent sensory motor symptoms and clinically demonstrated weakness of the biceps brachii muscle.
bility in the mid cervical and lower cerv i cal spine when
nal occipital protuberance. the nasal septum and the indi
there is multisegmental instability.
vidual vertebrae (Fig. 13.22). The specific landmarks are
Functional computed tomography of the cervical spine
highlighted with a cursor and then analyzed using a spe
is a technically demanding study. Therefore. one should
cific software program (Dvorak and Panjabi. 1987 b; Dvorak
carefully evaluate the entire clinical situation in light of
et al.. 1987c).
the information anticipated to be obtained from the study
Table 13.3 lists the normal and abnormal values for the range of motion in the cervical spine. Both the individual
before it is actually performed.
measurement of motion at each vertebral level and also the
Evaluation of Rotation Using Computed Tomography
difference between the left and right rotation are of im portance.
A lateral scout view is initially performed in order to de
Functional computed tomography is currently the only
termine the specific focal points. The slice thickness is
examination technique that allows adequate objective
3 mm apart. The upper cervical spine should be evaluated
evaluation of rotation motion in the upper cervical spine.
all the way from (0-(1 to the third and fourth cervical
This allows evaluation for segmental atlantoaxial hypomo
level. This is repeated for passive rotation to the opposite
bility or hypermobility. Segmental hypomobility can also
side.
be demonstrated on the functional cr scan of the cervical
The entire examination including the neutral position
spine. Antinnes and colleagues (Antinnes et al.. 1994). using
and left and right rotation lasts approximately 30 minutes.
functional computed tomography. examined 423 patients
The landmarks that are utilized to measure the findings
after cervical spine injury. They found an abnormal left
in the functional cr of the cervical spine include the inter
right rotation in 36% patients at the (0-(1 level. Twice as
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Cervical Spine
Fig. 13.22 Functional CT of a healthy 24-year-old woman. For
CT allows automatic measurement of the ranges of motion. The
measurement, the nasal septum and internal occipital protuber
individual segmental motion values are noted in the individual
ance are used as landmarks. The individual vertebrae are evaluated
frames. The value for C2 summarizes the entire rotation of the
with respect to the center of the vertebral artery as bony landmark.
mid and lower cervical spine.
+ Table
13.3 Segmental rotation motion in the cervical spine as determined by measurements obtained in functional CT studies (Dvorak et
al.. 1987 a. 1988 e; Penning and Wilmink. 1987 a)
Rotation (Degrees)
Standard Deviation
Pathologic Barrier
Pathologic Side-to-side
(Degrees)
(Degrees)
Difference ( left-Right) (Degrees)
>8
>5
38-44
>54
>8
(0-(1
4.0
(1-(2
43.0
(2-(3
3.0
-2.7-8.7
>9
>6
(3-(4
6.5
1.2-11.8
>12
>6
(4-(5
6.8
1.3-12.0
>12
>6
(5-(6
6.9
1.3-12.7
>13
>6
(6-C7
5.4
0-10.8
>11
>6
C7-Tl
2.1
-2.8-7
many patients revealed an increased rotation to the left.
lia. demyelinating diseases. spondylitis, and prevertebral
which may be an indication of a lesion of the right alar
soft-tissue abnormalities such as abscesses, the MRI study
ligaments. Patients who demonstrated paradoxical rota-
is superior to conventional computed tomography.
tion exhibited a greater rotation to the contralateral side.
The MRI study allows specific measurements of the
A paradoxical rotation means that the more superior seg
width as well as the overall diameter of the cervical spinal
ments rotate less than the inferior segments. Again. this
canal. The cranial migration distance determines the dis
may be a result of loss of normal ligamentous function.
tance between the axis to the occiput, i. e., the foramen magnum (Fig. 13.23). The tip of the occiput and the clivus are connected by
Magnetic Resonance Imaging
drawing a line between these two structures. A line per
The MRI of the cervical spine is particularly well suited for
the axis. The average value of the cranial migration distance
pendicular to this line is then directed to the lower edge of evaluation of the soft tissues, the spinal cord, and nerve
(( MD) is 38.7 mm (standard deviation 2.9 mm, range
roots. This allows the evaluation of potential compression
33-46 mm) (Dvorak, 1989). A superior migration distance
due to a space-occupying lesion. Disk herniations are also
of less than 31.5 mm is indicative of cranial migration of the
usually well demonstrated with MRI. When there is suspi
axis or basilar impression.
cion of extradural or intramedullary tumors. syringomye
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Imaging Studies of the Spine
performed with the head being passively guided to max imal flexion and then extension. The extreme positions are supported with specific wedges. The extreme positions are delimited only as far as the patient allows them to be Clivus
Occiput _ _
;r
_
achieved without much pain or other symptomatology. Axial cuts for a functional MRI study are performed only
_-=-f-�2cGre
c=:::::::.
J
(1-
when there is suspected spinal cord compression as deter mined in the sagittal views. The duration of the functional
-- Redtund-Johnett <:
44 mm
extension, and the neutral position is about 30 minutes.
_.- Ranawa1 <:
--
22 mm
Dvorak-Grauer (MRI) <:
examination using magnetic resonance imaging in flexion,
32.5 mm
Similar to the examination that is done in the neutral position using computed tomography, the study using MRJ allows determination of the diameter of the spinal canal and the spinal cord at the various spinal levels. The extreme positions of flexion and extension are then
Fig. 13.23 Schematic representation of the superior migration line.
A migration distance of less than 31.5 mm would indicate a basilar impression (Dvorak, 1989).
compared to the neutral position. The cranial migration distance is also evaluated in the flexion and extension views. Based on this technique, it has been determined that there is significant spinal canal narrowing during neck flexion and an associated high risk of spinal cord
Functional Magnetic Resonance Imaging
compression in patients with chronic polyarthritis or
Indications for this study include prominent neurologic
with instability in the upper cervical
deficits such as a positive L'Hermitte sign in patients with
1989x). A typical case of compression of the spinal cord
spine (Dvorak,
motion-dependent compression of the spinal cord as a
during flexion is that resulting from a retrodental pannus
result of space-occupying lesions or significant ligamen
(Fig. 13.24).
tous instability. Patients with chronic polyarthritis or
Figure 13.25 demonstrates a massive cranial migration
movement-dependent spinal cord compression or retro
of the axis with compression of the brain stem due to the
dental inflammation may also benefit from this specific
destroyed tip of the dens and the inflamed tissue surround
study (Dvorak, 1989),
ing it. Spinal cord damage should be assumed when the
First a scout study is performed with the patient's head and neck in the neutral position, Subsequently, an MRI is
diameter of the spinal cord is less than 6 mm when the neck is flexed (Dvorak, 1989).
b
a
c
Fig. 13.24a-c Functional MRI of a 64-year-old woman. Chronic polyarthritis and retrodental pannus. This 13.7- mm soft tissue tumor caused a significant compression upon the spinal cord during cervical spine flexion.
200
Copyrighted Material
Indications for functional MRI study are given by the pa tient's history and a detailed clinical examination. Such a study should typically occur in collaboration with a neuro radiologist and, as stated above, after an initial study in the neutral position. If the neutral position study provides sufficient information to explain the current clinical situa tion, the patient should not be subjected to further studies unless they are clearly medically indicated.
Thoracic Spine Plain Radiographs
a
It is difficult, if not impossible, to demonstrate the presence of somatic dysfunction (e. g., vertebral functional motion restriction) in the thoracic spine by means of standard radiographs. However, plain radiographs are a useful ad junct in the overall clinical assessment of a patient with thoracic pain, especially when there are clinical "red flags" that would indicate a potentially sinister organic pathology, including fractures, dislocations, space-occupying lesions, and inflammatory and metabolic abnormalities. In elderly patients it is not uncommon to visualize both chronic and acute vertebral compression fractures in the thoracic spine at the same time. Usually the straight anteroposterior (AP) and lateral views will be sufficient. The AP view (Fig. 13.26a,
b
b) allows 13.25a,
b Functional MRI of a 33-year-old man with chronic
visualization of the base of the vertebral arch and the
Fig.
spinous processes, less so the articular processes or the
polyarthritis. Due to the inflammatory progression, one can note
facet joint spaces themselves. The head of the rib in its close anatomic proximity to the disk can usually be readily
complete destruction of the dens of the axis and superior migra tion of the second cervical vertebra. The cranial migration distance was measured at 16.5 mm
seen as well as the neck and the tubercle of the rib laterally.
(b) during
The costotransverse joint space may be demonstrated in
the brainstem.
(a) in the neutral position and
13.8 mm
exion. The major cause of compression is at the level of
the lower segments. In the mid thoracic spine, the tip of a spinous process, due to its oblique and inferiorly directed arrangement, is projected over the next inferior vertebral
as the intervertebral foramina, the joint space, and articular
body. Again, positional asymmetries should not be over
processes. The ribs are frequently projected over the verte bral arch and the spinous process. When counting the
interpreted. Vertebral rotation should only be suspected when posi
individual vertebral bodies, the position of the diaphragm
tional asymmetry is found along with an asymmetry in
in the anteroposterior view may be used as a guide. In
distance between the base of the arch and the outer margin
special cases, it may be necessary to place a needle bet
of the vertebral body. In this instance, the base of the arch
ween specific vertebrae for exact localization. Abnormal
appears broader on the side to which it is rotated and
posture, growth abnormalities (e. g., Scheuermann disease
narrower on the opposite side. Such isolated rotations are
or juvenile kyphosis), and degenerative disk disease can be
not rare, and in most cases rotation occurs in the same
demonstrated on the lateral views.
direction as that of a scoliotic convexity. According to Lewit
(1999),
unilateral changes noted
at the level
of the
Functional radiograph diagnosis in the thoracic spine has thus far found little application due to the rather small
intercostal space due to somatic dysfunctions associated
ranges of motion at each vertebral level and to the rare
with the costal articulations can also be detected in the
finding of instability in this region of the spine.
anteroposterior view. The lateral views (Fig. 13. 27a,
b) clearly reveal the thora
cic vertebral contours and the intervertebral disks, as well
201
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Imaging Studies of the Spine
L
3
4
"
b
a
Fig. 13.26 Thoracic spine. a Standard rad io graph ;
AP view.
b Skeletal model.
Spinous process
2
Root of the arch
3
Rib
4
Transverse process
5
Costotransverse joints
a
Fig. 13.27 Thoracic spine.
3
a Radiograph; lateral view.
4
Intervertebral foramen
b Skeletal model.
5
Vertebral arch
1
Inferior facet
6
Rib
2
Joint space
7
Transverse process
Superior facet
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Thoracic Spine
computed Tomography and MRI Computed tomography of the thoracic spine is indicated when there is suspicion of advanced arthritis/arthrosis as this affects the intervertebral joint as well as the costo transverse and costovertebral joints (Fig. 13.28). cr should be able to support one's clinical impression and possibly provide additional clinically useful information. MRI is use ful when evaluating the thoracic spine for disk herniation (Fig. 13.29), intraspinal space-occupying lesions, or verte bral body lesions.
Lumbar Spine and Pelvis
Fig. 13.28 (T of a 39-year-old woman with left-sided costotrans verse arthrosis.
Low back pain in patients will typically resolve within 6 weeks after presentation. Therefore, imaging within the first month of painful symptoms is generally not necessary. Exceptions would include patients suspected of tumor, fracture, infection, cauda equina syndrome or progressive neurological deficit. Magnetic resonance imaging (MRI) is the study of choice in suspected herniated disk. Contrast enhancement can be used to evaluate malignancy, infec tion, and postoperative changes. cr scan is indicated to study osseous structures such as vertebral body, spinal canal, and posterior elements in cases of suspected frac ture. Bone scans can also be used to evaluate fracture, but also metastatic disease. All findings should be correlated clinically because of the presence of false positives in the normal, asymptomatic population.
Plain Radiographs Initial imaging should involve plain films because they are expeditious, inexpensive, and provide reasonable diagnos
Fig. 13.29 MRI of thoracic spine disk herniation in a 40-year-old woman with clinical signs and symptoms of a thoracic myelopathy.
tic information for screening purposes. Gonadal shields can be employed to reduce radiation exposure. This is partic ularly important for young women, although shielding is
lower part of the thoracic spine because of the high inci dence of injury between the T12 and L2 levels.
more easily done with men. Some radiological standards
The AP view is useful to evaluate for tumors or spinal
also recommend that elective pelvic studies be performed 10-14 days after the last menstrual period to minimize the
misalignment, such as scoliosis or rotational injury. A nor mal spine in the AP view is indicated by smooth contours of
risk of radiation exposure.
the lateral masses and uniform disk space. The lateral view 43 cm)
is very useful to evaluate alignment, integrity of the verte bral bodies and posterior elements, the intervertebral fora
is well suited to provide an anteroposterior view of the
men, and disk heights. Slippage (spondylolisthesis) is not
For studies of the lumbar spine and the pelvis, the plate size that is commonly used for the thorax (35 cm
x
entire lumbar spine and the pelvis, which should also in
uncommonly seen at L5-S1 in the lateral views. Also on the
clude the sacroiliac joints, symphysis pubis, and femoral
lateral view, the interspinous pseudarthrosis associated
heads (Fig.13.30). This view, taken with the patient in the
with the Baastrup syndrome may be visualized. In the
standing position, provides more meaningful information than the narrow view of the spine alone or the pelvic view
processes of the lower vertebrae run into each other and by
with the patient in the supine position. When evaluating for trauma, it is also important to include imaging of the
Baastrup syndrome, with exaggerated lordosis, the spinous friction cause a false joint with marginal osteophytic changes. This is often accompanied by pain.
203
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Imaging Studies of the Spine
Fig.13.31 Spondyloarthrosis.
Fig. 13.30 Lumbar spine and pelvis in the AP projection. The facet (apophyseal joints in the L4-L5 and L5-S1 segments are aligned in the frontal plane on the right and in the sagittal plane on the left.
Oblique views can be helpful to evaluate the neural foramen and pars interarticularis. They are useful for as sessing spondyloarthropathy (Fig. 13.31) or spondylolysis/ spondylolisthesis (Fig. 13.32). Flexion-extension views are used to evaluate stability of the ligamentous and bony
Fig. 13.32 Lumbosacral radiograph demonstrating spondylolysis at L5 (left).
structures in the sagittal plane. In some cases, and with appropriate studies, the lateral views may provide infor mation about the presence of hypermobility or hypomo bility. Usually, there is greater mobility at L4 than at L5. The so-called Barsony view of the sacroiliac joint helps elucidate
whether
there
is
any
advanced
arthrosis
(Fig. 13.33) or inflammatory processes (Fig. 13.34). With all of these studies, the physician is cautioned against the temptation of overinterpretation, since minor asymmetries may simply be the result of uneven patient positioning or a sign of normal adaptation. Nevertheless, pelvic torsions that may cause a functional disturbance in the sacroiliac joint can be recognized if both hemipelves appear asymmetric on the radiograph (Fig. 13.35). In this view, the examiner evaluates whether the symphysis pubis is level (e. g., unilateral elevation of the symphysis pubis),
Fig. 13.33 Sacroiliac joint arthrosis (Barsony view).
or if there is asymmetry of the obturator foramina, and unilateral hiking of the pelvic crest with the ilium being narrower on the same side when compared to the other (Cramer, 1965).
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This initial lumbar and pelvic study also provides an initial impression of the hip joint, especially the relation ship between the femoral head and neck. Asymmetries can include sacral base unlevelness and can be the source of an otherwise unknown cause of scoliosis. Whether, and to what extent, a leg length difference causes changes in the lumbar spine is in part dependent on the position of the lumbar facet joints. The facet joints between L1 and L3, due to their sagittal plane orientation, can be seen well on the AP projection. In contrast, asymmetries of the facet joints at the L4-LS level, and in particular the LS-S1 level, are fre quent, and on radiographs these joints appear oriented more in the frontal plane unilaterally. Such changes may alter the relationship of the loading forces and movement patterns, which may contribute to asymmetric degenera tive changes. In the lumbar spine (Fig. 13.36), the shape and positional
Fig. 13.34 Inflammatory changes involving the sacroiliac joint (sac roiliacitis) (Barsony view).
relationships of the vertebral bodies, the intervertebral disks, and the base of the vertebral arch are evaluated in greater detail. The latter usually conceal the joints in the lumbar spine. The spinous processes may occasionally make contact with each other (Baastrup syndrome). The lowermost lumbar vertebra has the greatest tendency to reveal anomalies. For instance, spina bifida occulta, which represents the incomplete union of both laminae to form the spinous process, may have little clinical re.levance in low back pain syndromes unless associated with additional findings, such as fractures, dislocations, or surrounding pseudarthrosis. In contrast, radiographic findings of unilat eral junctional abnormalities of the lumbar vertebrae may be clinically relevant when the transverse processes have become inappropriately large to the extent that they make
Fig. 13.35 Pelvic torsion (patient supine). Asymmetric projection
contact with the lateral mass of the sacrum. This may lead
of the hemipelvis, the right os pubis is displaced superiorly, and
to constant irritation in this region with subsequent scle
there is asymmetry of the obturator foramen.
rosis in the adjoining bony components and a potential to form a pseudarthrosis. Of less significance for the practitioner of manual med
assessment of the involved region appears to provide more
icine than for the surgeon is the decision whether the transi
and additional information about the soft tissues and their
tional vertebra has sacralized or lumbarized. Occasionally,
response to underlying or associated segmental dysfunc
the presence of a stub rib or architectural changes involving
tions than the radiologic evaluation alone. A detailed pal
the transverse processes are helpful in this determination.
patory static and motion assessment is better able to help
These altered transverse processes reveal a very broad cos
assess whether manual medicine approaches are indicated
tal process at the L3 vertebra, while that ofL4 and LS may be
and what type of hands-on techniques may be most suited
distinguished by the extent to which they point upward in
for the individual patient.
the superior direction (LS significantly more so than L4). Again, it is important for the practitioner to remember
The lateral view (Fig. 13.37) should include the femoral heads and may reveal a pelvic torsion. [n the latter case, the
that an isolated finding of an asymmetric spinous process
pelvic crests are not congruent but rather intersect at the
should not be overinterpreted. According to Lewit (1984),
level of the facet joints (Fig. 13.38).The degree of the spinal
however, signs on the radiograph that suggest vertebral
curvatures in the sagittal plane on the lateral view (i. e.,
rotation include a broader appearing base of the arch on
exaggerated versus reversed I.ordotic curvature in the lum
the side to which the vertebra has rotated, a clearly visible
bar spine), along with variations in sacral base inclination,
joint space, and a transverse process that appears shorter
have been used to define three pelvic types: the arched
and narrower. In the clinical arena, a detailed palpatory
type (or high-assimilation pelvis), the normal pelvis ("block
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ImagIng Studies of the Spine
Fig.13.36a-c Lumbar spine.
7
Spinal canal
a, c Skeletal model with anterior (a) and posterior (b) views.
8 9
Posterior superior iliac spine (PSIS)
b
Radiograph; AP view.
1
Spinous process
10
Sacroiliac jOint Intervertebral disk
2
Superior facet
11
Transverse process
3
Vertebral arch
12
Vertebral body
4
Interarticular region
13
Vertebral arch
5
JOint space
14
Sacroiliac joint
6
Inferior facet
Inferior facet
Fig. 13.37 Lumbar spine.
3
a Radiograph; lateral view.
4
Superior facet
b Skeletal model.
5 6 7
JOint space
1
Vertebral arch
2
Interarticular region
Intervertebral foramen Transverse process
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Thoracic Spine
pelvis"), and the flat type (Gutmann, 1985). It is also possi ble to differentiate a genuine spondylolisthesis with a spondylolysis of the pars interarticularis from an anterior or posterior pseudolisthesis with spondyloarthrosis and osteochondrosis. For the manual medicine practitioner, the differentiation between instability due to spondylolis thesis/spondylolysis and osteophytic reaction is often more important than the pelvis type or configuration. According to MacNab (1977), instability can be detected on plain radiogl:aphs by the presence of what he refers to as traction marks. These bony changes occur as a result of
overstretching of the outermost fibers of the annulus fi brosus (Figs. 13.39, 13.40). These traction marks appear as ossifications that protrude horizontally from the edge of the vertebral body. They measure approximately 1 mm in length. This is in contrast to the marginal osteophytes, also known as spondylophytes. These bony outgrowths approx imate each other as they grow toward each other at the
Fig. 13.38 Lateral radiograph of the lumbosacral junction. When
level of the intervertebral disk. When sufficiently exten
the iliac crests intersect at the level of the facet joints, it may be an
sive, they can restrict movement overall, but do not typi
indication of a pelvic torsion.
cally cause a segmental dysfunction. Hypermobile spinal segments, in contrast, are frequently associated with sec ondary segmental dysfunction. Hypermobile segments re quire specific stabilization treatment and should not re ceive, in general, manipulative procedures, unless clinically indicated. Functional views of the lumbar spine in flexion and extension may occasionally reveal abnormal hyper mobility, but due to the large variation in what are consid ered normal values it is difficult to provide an absolute set of numbers (Dvorak et aI., 1991 a,
d).
In summary, the radiologic evaluation of the thoracic and lumbar spine, including the pelvis, aims to determine the presence of any static abnormalities or any recogniz able contraindications.
Functional Studies of the lumbar Spine The functional radiographic diagnosis technique has found
Fig. 13.39 Lumbar spine radiograph (lateral view) revealing trac
useful application in the lumbar spine as well, especially
tion spurs at the level of L3-L4.
when one suspects a localized segmental or regional insta bility and when there is pain associated with movement. The instability may be due to trauma or other processes leading to instability,
Table 13.4 Segmental range of motion for lumbar spine flexion! extension and side-bending
including degenerative changes
(Figs. 13.41-13.43). Radiologically demonstrated instability may be further analyzed with regard to segmental insta
Flex ion/Extension (Oegrees)
Side-Bending (Oegrees)
bility by measuring the range of motion at each segmental
11-12
11.9
10.4
level (Dvorak et aI., 1991d). In this study, functional radio
12-l3
14 5
12 . 4
l3-l4
15.3
12.4
sion as well as side-bending. Both the graphic and com
l4-l5
18.2
9.5
puter-assisted
l5-S1
17.0
5.1
graphs of the lumbar spine were taken of 41 healthy per sons measuring the range of motion in flexion and exten methods
were
utilized.
Representative
.
findings are shown in Table 13.4.
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Fig. 13.40 Vertebral instability may be suspected when there are
Fig. 13.41 Lateral lumbar radiograph of a 40-year old man after a
traction spurs. These spurs are typically horizontal and represent an
fall onto the back 3 years prior to this study. Despite treatment, he
over-stretch of the outermost annular fibers.
continues to have low back pain, which is worse with movement.
The noted spondylophytes, which "point" toward each other (at
The ventral glide of L4 with respect to LS, intervertebral narrowing,
the level of the intervertebral disk) are thought to be signs of
and presence of traction spurs suggest segmental instability.
"restabilization" secondary to osteophytic proliferation.
Fig. 13.42 Lateral lumbar radiographs of a 23-year old man after a motorcycle accident. Despite treatment, he continues to complain of back pain that is worse with movement. Flexion/extension views (left/right) reveal segmental instability at the L4-LS level.
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Thoracic Spine
Fig. 13.43 Flexion/extension views of a 59-year old man who reported chronic recurrent low back pain over decades. The study reveals significant instability at L4-L5 and traction spurs, and a resorptive osteochondrosis at L5-Sl.
RX
Extension
Flexion
\
\
\
\
\
\ \'LJL-__
Fig. 13.44 Range of motion in the lumbar spine as demonstrated in a functional radiograph using the computer-assisted method.
-L______
Fig. 13.45 Translatory motion is plotted using the computer assisted functional radiographic method.
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Imaging Studies of the Spine
The advantage of the computer-assisted measuring technique comes from its ability to measure both the rota tory range of motion (Fig. 13.44) and the translatory motion (Fig. 13.45). Independently of the etiology, the results also revealed that patients with low back pain have a general ized hypomobility in the lumbar spine, predominantly at the L4-LS spinal segment. Only in a group of elite athletes was there found any increase in the range of rotatory or translatory motion above the norm. Thus, it was concluded that the there is little application for functional radiographic studies to determine segmental motion in the lumbar spine, as they do not pro vide additional information for further differentiation of the causative pathology for patients with low back pain, espe cially in the absence of radicular signs or symptoms. The functional radiographic studies that evaluate the flexion and extension motion passively in the lumbar spine do not provide any additional indication or support for surgical fusion (Dvorak et aI., 1991 c,d). However, the func tional radiograph diagnosis may be helpful in the evalua tion and documentation of a clearly demonstrated instabil-
Fig. 13.46 MRI demonstrating a disk herniation at the L4-L5 level;
ity in patients after spondylodesis of the lumbar spine and
sagittal view.
when evaluating the patient for possible pseudarthrosis. The functional radiographic diagnosis helps determine instability due to trauma or degenerative causes as well as
computed Tomography. Magnetic Resonance
generalized constitutional hypomobility. The studies pro
Imaging. and CT Myelography
vide additional information for flexion and extension as The choice of neurodiagnostic studies, such as CT, MRI, and
well as side-bending. The technique for the lumbar spine is similar to that
myelo-Cf, to be employed for the lumbar spine follows the
described for the cervical spine. The films are obtained with
differential diagnosis and the considerations of sinister
the patient in the neutral position first, followed by max
organic pathology as specifically noted for each individual
imal passive flexion and extension positions. The vertebrae
patient. These studies are in general indicated when it
are identified and marked and then the radiographic films
appears that one is dealing with a radicular-type sympto
depicting flexion and extension, respectively, are superim
matology or symptomatic lumbar spinal stenosis, among
posed on each other. The range of motion is then individ
others.
ually measured segment by segment. The computer
MRI reveals better information when evaluating the
assisted measuring technique (Dvorak et aI., 1991 a) pro
lumbar spine for the soft tissues and the spinal cord as
vides information about the rotatory range of motion and
well as the intervertebral disks, especially when there is
the translatory range of motion. The center for rotation can
suspicion of a disk herniation or infection (Figs. 13.46 and
also be mathematically calculated.
13.47). Postoperative scarring in the lumbar spine is best
To date, however, the role of, and indications for use of,
demonstrated using MRI with contrast enhancement. The
functional radiographs in the lumbar spine in the assess
contra indications include the presence of ferromagnetic
ment of low back pain have not been identified, nor
implants, intracranial clips, a cardiac pacemaker, or patient
whether they may serve a purpose in the determination
claustrophobia.
of a lumbar spondylodesis. There may be a place for
Generally, Tl-weighted images are obtained in the sag
diagnostic functional studies of the lumbar spine in the
ittal plane and T2-weighted images in the sagittal and axial
presence of a degenerative pseudospondylolisthesis with
planes. Spin-echo is the standard weighting technique used
demonstrated instability despite otherwise appropriate
with the Tl-weighted images in order to enhance spatial
conservative treatment. The functional studies may then
resolution and contrast in the neural foramen and nerve
support the decision for spinal fusion.
roots. It can also be used to survey bone marrow signal
The values that are found for the individual patient are entered into a patient-specific diagram and then compared to the normative data from the general population.
changes to detect metastatic disease. If there is an indication that the cause of the patient's symptoms may be due to the osseous components in the
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Fig. 13.47 MRI demonstrating a disk herniation at the L4-L5 level; axial view.
Fig. l3.48 Myelography demonstrating a lumbar spinal stenosis ("sausage sign").
Fig. 13.49 Myelo-CT demonstrating lumbar spinal stenosis.
lumbar spine, such as foraminal stenosis secondary to
When combined with functional-dynamic studies of the
spondyloarthrosis, cr would be the p referred method as
lumbar spine, while assessing both flexion and extension
it can differentiate bony components better than MRI.
motions, myelography may actually provide some addi
Myelography to determine extensive spinal stenosis is
tional information that is otherwise not obtainable. Sub
still used today, albeit much less frequently given the ad
sequently, this should be followed by cr, which allows
vent of the MRI. It may be helpful in cases where MRI is
further delineation of the extent of central and/or fora
contraindicated, such as when the patient has a cardiac
minal spinal stenosis. Myelography is an invasive techni
pacemaker or is claustrophobic. Myelography allows a
que and may not detect far-lateral disk herniations due to
view of a broad area of the lumbar spine ("sausage sign
the termination of the nerve root sleeve, which inhibits the
for spinal stenosis") (Figs. 13.48 and
spread of contrast dye beyond that point.
13.49).
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Imaging Studies of the Spine
Bulging Lumbar Disks and Disk Herniations Nomenclature and Classification of Lumbar Disk Pathology The nomenclature and classification, as applied to diagnos tic studies, was reviewed and presented in a landmark article published simultaneously in two journals: Spine and the American Joumal of Neuroradiology [AJNR] in 2001 (Fardon and Milette, 2001). On that momentous occasion, each author was invited to write an editorial, one published in each journal (Fardon, 2001; Milette, 2001). Not unlike many occasions when manual medicine practitioners have convened to discuss concepts and ideas (e. g., the "Fischingen Conference" in 1984), Fardon stated almost like a universal theme - that: "When I began work on this topic . .. , I was sure that I knew what al/ these words meant and that my task was to teach
Fig. 13.50 Schematic representation of a "normal" appearing in tervertebral disk. (After Fardon and Milette, 2001.)
everybody else. I have been humbled repeatedly by my col leagues, the members of the task force, and by PierTe Milette. Knowledge of meaning is a shared concept ... To achieve a standard, we al/ must give up a little of what we think we know and accept a little of the concepts of those with whom we communicate."
The following definitions were then proposed and have facilitated a better common understanding, not only among neuroradiologists but among practitioners dealing with the spine in general (Fardon and Milette, 2001).
Bulging Disk (Figs. 13.50 and 13.51) Symmetrical presence (or apparent presence) of disk tissue "circumferentially" (involving 50-100% of the circumfer ence) beyond the edges of the ring apophyses may be described as a "bulging disk," or "bulging appearance," and is not considered a form of herniation. Furthermore, "bulging" is a descriptive term for the shape of the disk contour and not a diagnostic category.
Fig. 13.51 Schematic representation of a "disk bulge." Note that
Asymmetrical bulging of the disk margin (50-100%), such as found in severe scoliosis, is also not considered a form of herniation. Herniated disks may take the form of protrusion or extrusion, based on the shape of the displaced material.
the definition of a disk bulge is such that the disk tissue has "expanded" circumferentially (between 50% and 100%) beyond the edges of the ring apophyses. This is not a form of disk hernia tion. The disk bulge shown here is a symmetric change, mostly in the posterior direction, but can occur to either side, front, back, or a combination of these. (After Fardon and Milette, 2001.)
Focal Herniation Disk herniation involving less than 25% of the disk circum ference.
Protrusion (Fig. 13.52) Disk protrusion is present if the greatest distance, in any plane, of the edges of the disk material beyond the disk
Broad-based Herniation
space is less than the distance between the edges of the
Disk herniation involving 25-50% of the disk circumference
base in the same plane. In the craniocaudal direction, the length of the base cannot, by definition, exceed the height of the intervertebral space.
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Nuclear Medicine Studies
Extrusion (Fig. 13.53) Extrusion is present when, in at least one plane, any one distance between the edges of the disk material beyond the disk space is greater than the distance between the edges of the base, or when no continuity exists between the disk material beyond the disk space and that within the disk space (Fig. 13.S3). Sequestration is a form of extrusion in which the dis
placed material has completely lost any continuity with the parent disk.
Nuclear Medicine Studies Nuclear medicine studies (bone scans) use radioactive trac ers such as technetium phosphate or gallium citrate to obtain physiologic information regarding bone turnover. In these studies, the tracer material is incorporated into hydroxyapatite crystals in areas of new bone formation.
Fig. 13.52 Schematic representation of disk protrusion. Here the disk material can invade the space of the spinal canal. (After Fardon and Milette, 2001.)
The images are useful to evaluate infection, metastasis, tumor, and fracture. As in myelography, the addition of CT scanning (e. g., single-photon emission computed to mography, or SPECf) can enhance diagnostic information. The indication for any combination of these additional neuroradiographic studies is based upon the individual's clinical presentation, especially when surgical intervention for the lumbar spine is being contemplated.
Fig. 13.53 Schematic representation of a disk extrusion. Here the disk material is being displaced even further into the canal, either still part of the associated disk or actually separated from it (se questration). When the material is allowed to undergo migration, it denotes that there is displacement of the disk away from the site of extrusion, regardless of whether sequestrated or not. (After Fardon and Milette, 2001.)
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14
Selected Clinical Syndromes
Clinical Disorders and Syndromes of the Spine
function within the entire bio-psycho-social context. The manual medicine approach that uses an individualized treatment approach with specific hands-on maneuvers (di agnostic and therapeutic), in combination with individually
Pain and the Spine: A Brief Overview of
tailored exercise and lifestyle and activity modifications,
Approach
may be indicated to address a clinical situation in which
In 1955, Gutzeit referred to Mixter and Barr's classic article
one of the pain-generators may be in the facet-joint
in the New England Journal of Medicine (Mixter and Barr,
fascia-muscle-sympathetic nervous system complex.
there is nonradicular or pseudoradicular pain, or where
1934) as a "turning point" in spine care. Prior to this article,
As a result of their extensive palpatory experience, man
there was generally the perception, especially by osteo
ual medicine practitioners in allopathic medicine (Maigne,
pathic physicians and chiropractors, that pain of vertebral
1970), osteopathic medicine (Seal, 1984: Greenman and
origin could be positively influenced through specific man
Buerger, 1984; Jones, 1981 ; Mitchell et aI., 1979), and chi
ual treatment of the spine (think of this as "Chapter 1 ").
ropractic (Walther, 1981) have made considerable contri
Soon after the publication of Mixter and Barr's eminent
butions to the field of musculoskeletal medicine by refining
article on the surgical removal of the herniated interverte
and expanding on the structural and functional diagnosis of
bral disk it was believed that disk surgery could "cure" such
the musculoskeletal system, especially the vertebral col
entities as rheumatic ischialgia, and sciatica. Almost to the
umn and the paraspinal and other soft tissues.
exclusion of conservative treatment options, surgical spine
In the final assessment, then, the true goal of good spine
care became the accepted mainstay for years to come (this
pain care is to provide the best patient-centered manage
is "Chapter 2").
ment with the most specific treatment, as early as possible
Today, both of these "Chapters" bear great significance,
in order to maximize individual functional outcomes. Pain,
especially since "Chapter 3" is being written as we speak
especially movement-related pain, should be considered a
and draws upon both of the earlier ones. Guided by evi
complex interplay, not solely as a psychiatric or a neuro
dence-based medicine, one of today's missions in good
logic problem but rather as a problem related to the inte
spine care is to evaluate the evidence of the relevant use
gration of nervous and biomechanical mechanisms, and the
fulness of any of the various treatment options described at
various feedback mechanisms from muscles, fasciae, disks,
times up to and including today: from doing nothing ("it
and joints in relationship to their central, autonomic, and
will get better anyway"); to the conservative measures,
peripheral nervous system interactions (Holm and Indahl.
including the hands-on manual, pharmacologic, and be
2004).
havioral approaches; to interventional spine care (injec tions, nerve blocks, denervation procedures, among others)
Assessing the Patient Who Has Spine- related Pain
and finally spine surgery.
Pain and the associated functional deficits are what
Against this backdrop, and as true today as in the past,
ultimately-prompt the patient to seek medical help. A
the diagnostic work-up and management of spine-related
recent study (Vide man and Nurminen, 2004) reported
pain starts with the fundamentals of good medical care by
that the frequency of back pain had a highly significant
making sure that the patient receives a thorough medical
relationship to the occurrence of lumbar anular tears. Uti
and pain history-taking and a detailed neurological and
lizing barium sulfate discography in more than 150 speci
orthopedic examination.
mens, Videman and Nurminen conclude that anular degen
In addition to the standard medical approach, manual
eration and tears of the lumbar disks appear earlier and are
medicine examination routines provide further structural
more clearly related to back pain than previously thought.
and functional information about specific segmental spinal
While the underlying "source" may be the anular tears, it
joint dysfunctions as well as adaptive or compensatory
becomes important to address as soon as possible the
global or regional musculoskeletal changes. The goal of
adaptations and compensatory reactions not only at the
the manual medicine practitioner is to determine the rele
level of the tears (localized reactions) but also the effect
vance of such findings within the entire clinical presenta
these ultimately have on the entire body, such as postural
tion, to elicit additional information that may aid in prog
changes, muscle activities, or recruitment of "new" muscle
nosis, and to provide management options that are not
patterns, and avoidance of certain activities for fear of pain
otherwise available in order to reduce pain and improve
(generalized reactions).
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A clear-cut presentation of an acute nerve root compres
criteria for surgery appear to have been much stricter.
sion with overt objective signs and symptoms should not
Certainly. surgical technology, experience, and treatment
pose a significant diagnostic challenge to the physician in
options might not have been as advanced as they are today.
the clinical setting. In contrast. it is much more difficult to
yet it is interesting to note that residual symptoms have
develop a "correct" diagnosis. that is. a clear-cut diagnosis
been observed less frequently in those elderly patients who
based on apparent structural abnormalities. in patients
were seen by a physician at a time when practitioners were
who suffer from chronic low back pain. where a "pain
more reluctant to use surgical intervention to treat low
generator" has been elusive. In the absence of a clearly
back pain Ubrg, 1982). In this context. the conservative
verifiable "organic" diagnosis. it is even more difficult to
approach. based on functional and palpatory examination
formulate an appropriate therapeutic plan. This becomes
of patients with back pain. assumes a paramount role.
especially difficult in the many cases that present with a
If complaints continue to be reported by the patient
mixed clinical picture.
despite what would be considered successful therapy
Surgery or Not?
times raised. However. it is extremely difficult to determine
(i. e .. surgery). the question of psychologic overlay is some The indications for surgery remain a matter of ongoing
whether there had been preexisting psychologic factors
discussion. especially when considering the results from
that played into the pain situation. or whether the pain
various outcome studies. Deyo's excellent review of the
resulted in psychological changes. such as anxiety. depres
role of outcomes research points out that. for low back
sion. or behavioral changes. In some cases then. it may
disorders. traditional measures such as death. cure. and
actually be beneficial to arrange for preoperative psycho
physiologic outcomes have some. but limited. applicability
logical evaluation (i. e.. the Minnesota Multiphasic Person
(Deyo. 2004). Deyo states that in many cases. patient's
ality Inventory IMMPIJ). as the results may influence the
symptoms. function. and work status are the most impor
decision whether or not to operate (Cashion and Lynch.
tant outcomes to measure. He furthermore points out that
1979; Southwick and White. 1983; Herron and Turner.
extreme care is warranted to ensure that comparisons are
1985; Dvorak et al.. 1988c). It is still the case today that a
fair when comparing providers as to quality of care and
helpful piece of information is the location of the pain as
treatment effectiveness.
described by the patient (Yoss. 1957).
According to their prospective study of 131 patients.
To recapitulate. the key to good management is the indi
Komori et al. (2002) concluded that while the initial assess
vidual practitioner's ability to integrate the current evidence
ment and type of a herniated nucleus pulposus on MRI
for back pain (see further reading: Deyo and Weinstein
evaluation could be used as major prognostic factors. the
2001) and for neck pain (see further reading: Tsang. 2001).
conventional manner of treatment selection appears inad
While the evidence may change from time to time. it is
equate for the appropriate management of lumbar disk
the "partnership" of up-to-date knowledge with real-world
herniation.
patient experience and its application to individualized
From an international perspective. the United States
patient care that will ultimately determine outcomes. In
appears to perform roughly twice as much back surgery
addition to performing the best possible patient history
as most developed countries. and five times more back
and detailed neuromusculoskeletal examination. the judi
surgery than the United Kingdom (Cherkin et al.. 1994).
cious use of imaging techniques and appropriate referral
Large statistical analyses indicate that conservative meas
strategies is key (Findlay. 2002).
ures show satisfactory results in 80% of patients Ubrg.
The remainder of this chapter will attempt to provide a
1982). In former West Germany. for instance. 20 000 pa
practical. and admittedly not an exhaustive. overview of
tients
various disorders or syndromes as they relate to pain and
underwent
lumbar
disk
surgery
in
one
year
(Schirmer. 1981). The question whether the surgical proce
the spine.
dure was indicated in all of these patients remains unan swered. In the authors' own experience. approximately one-third of patients who had undergone back surgery were later dissatisfied with the results. and between 10% and 20% of the patients were in partial or complete dis ability (Dvorak et al.. 1988c). On the other hand. one can say that surgery was able to help the majority of these back pain sufferers. and offers legitimate if not total curative potential. These statistics and clinical experiences should be thought-provoking, because only a few decades ago the
Further Reading Deyo RA. Weinstein IN. Low back pain. N Engl J Med. 2001; 3 44(5):363-370. Hazard RG. Failed back surgery syndrome: surgical and non surgical approaches. (lin Orthop Relat Res. 2006;443: 228-232. Henry SM, Hitt JR, Jones SL, Bunn JY. Decreased limits of stabil ity in response to postural perturbations in subjects with low back pain. (I.in Biomech (Bristol. Avon). 2006;21(9): 881-892.
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JarvikJG. Deyo RA .. Diagnostic evaluation of low back pain with emphasis on imaging. Ann
Intern Med.
Speed
2002;137(7):
586-597.
C.
ABC
of
rheumatology.
Low
bac k
pain.
BMJ
2004;328:1119-1121. Speed CA. Crisp AJ. Referrals to hospita l based rh e umatolo gy -
Manek NJ. MacGregor AJ. Epidemiology of back disorders:
and orthopaedic services: seeking direction. Rheumatology.
prevalence. risk factors. and prognosis. Curr Opin Rheuma
2005;44( 4):469-471.
Tsang I. Rheumatology: 12. Pain in the neck. CMAj. 2001;
tol. 2005;17(2):134-140. Pahl MA. Brislin B. Boden S. et al. The impact of four common lumbar spine diagnoses upon overall health status. Spine J.
164(8):1182-1187. Wasan AD. Kaptchuk TJ. Davar G. Jamison RN. The association
2006;6(2):125-130.
between p sychopathology and placebo analgesia in patien ts
Silleets RJ. Wade D. Hidding A. et al.The association of physica l
with discogenic low back pain. Pain Med. 2006;7(3):
deconditio ning and chr o nic low back pain: a hypothesis
217-228.
oriented systematic review. Disabil Rehabil. 2006;28(11): 673-693.
Nerve Roots and Nerve Root Pain Anatomy of the Spinal Nerves
2 3 Cervical nerves
i
All but three of the 31 pairs of the peripheral nerve roots
4
exit the spinal column through intervertebral foramina.
5
The first cervical root exits between the occiput and the
6
atlas. and the last sacral and the only coccygeal nerve exit
7
via the sacral hiatus (Fig. 14.1).
8 1
The faster growth rate of the vertebral column results in a heigh t difference between the spinal cord level and the
2 3 4 5
Thoracic nerves
3 4 5
7
6
8
7
10 11 12
the lumbar and sacral region run laterally and almost ver tically to their point of exit in the intervertebral foramen. This is in contrast to the cervical roots. which are near ly
6
9
vertebral level. Due to this displacement. the nerVe roots in
8
aligned with the horizontal plane. The length of the roots
Fig.1 4 . 1 Relationships between the individual nerve roots. spinal nerves. and vertebral levels. (After Borovansky. 1967 a).
Anatomic relationships between spinal nerve and vertebra: •
In the cervical spine. the same-named spinal nerve leaves the
cord above its respective vertebra (e. g .. C1 spinal nerve leaves above C1 vertebra. C2 spinal nerve above C2 vertebra. until C8 spinal nerve. which leaves above Tl vertebra). •
Starting from the Tl vertebral level. the spinal nerve related to
the particular vertebral level leaves the cord inferio r to its respec tive vertebra (e. g. . Tl spinal nerve leaves inferior to Tl vertebra. T2
2
Lumbar nerves
3
spinal nerve inferior to T2 vertebra. and so forth all the way inferior down to •
The lumbar spine (e. g. . L5 spinal nerve and ultimately the S5
spinal nerve. which leaves inferior to the S5 "vertebra" (fused here).
Disk herniation level and spinal nerve root involvement 4
•
Nerve root compreSSion follows the same "rule." even though
the rationale is different for the various spinal regions: in general. it can be said that at any spinal unit with intervening disk (e. g . .
5
Sacral nerves Coccygeal nerve
H
C5-C6 disk) will impinge on the spinal nerve that is named accord ing to the lower partner (in this example. the C6 spinal nerve). •
In the cervical spine. if the C3-C4 disk is involved. one would
expect the C4 spinal nerve root to be impinged. •
In the lumbar spine. a disk herniation between L5 and Sl (one of
the most common areas of lumbar disk herniation) would impinge on the Sl nerve root (also see Fig. 14.3). Note that C1 nerve root leaves the cord above C1 (atlas). and the C8 nerve root above Tl.
216
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Nerve Roots and Nerve Root Pain
Dorsal root
--
Posterior primary ramus
Anterior primary ramus Ventral root -------"
Meningeal branch --------'
Gray communicating branch White communicating branch
Ganglion of the sympathetic trunk ------"
c:=:J ..
Efferent (motor) nbers
..
Afferent (sensory) fibers
Preganglionic sympathetic fibers Postganglion ic sympathetic fibers
Fig. 14.2 Schematic representation of the nerve nbers of one individual spinal nerve. Note the pre- and post-ganglionic sympathetic connections.
increases from a few millimeters to about 25 em (Mu
It is important for practical purposes to appreciate the
menthaler and Sehliack, 1977). The spinal cord inferior to L2 contains nerve roots only, and is referred to as the cauda
topographic relationship of the nerve root to two spinal "tunnels," namely: (1) the spinal canal, and (2) the interver
equina.
tebral foramina. The vertebral bodies, the vertebral arches,
intradurally. The pia mater covers the initial portions, and
and the articular processes form the bony limitations, whereas the joint capsule and the intervertebral disk re
the arachnoid runs along the roots, terminating at the root
present the soft-tissue borders. Fat tissue (which is easily
The spinal nerve roots are positioned for the most part
pockets formed by the dura. Both the anterior and the
noted in a CT or MRI scan) and the venous plexuses actually
posterior roots exit through separate openings in the
cushion the spinal nerve against the wall. It is of clinical
dura before they unite to form the spinal nerves. After leaving the intervertebral foramen, the spinal nerve divides
significance that the diameter of the intervertebral foramina decreases from L 1 to L5, whereas the circumference of the
into four typical rami (Fig.14.2).
nerve roots increases severalfold from superior to inferior.
The meningeal nerve contains both sensory and auto nomic fibers and returns to the spinal cord. The white
In addition to radicular pain that is caused by compres sion upon the nerve itself, any of the surrounding osseous
communicating branches of the sympathetic fibers are di
and soft-tissue structures may serve as a source of pain
rected to the corresponding ganglion of the sympathetic
(Wyke, 1967). The joint capsule of the small apophyseal
trunk in the paravertebral region. A section of the post
joints seems to play a special role in the character of non
ganglionic, less-myelinated sympathetic fibers returns to
radicular pain, sometimes termed referred pain or pseu
the nerve roots via the gray communicating branches. The
doradicular pain (Brugger, 1977; Feinstein et aI., 1954;
remaining fibers continue to the visceral organs. The rami
Hockaday and Whitty, 1967; Kellgren, 1938; Korr, 1975; Reynolds, 1981; Sutter, 1975; Wyke, 1967, 1979).
communicantes contain sensory fibers in addition to auto nomic fibers that pass through the ganglion and terminate
In a more recent study of the cervical spine, Slipman and
at the visceral organs. Further, each spinal nerve root di
colleagues determined that the areas of symptom provo
vides into a dorsal ramus and a ventral ramus. With the
cation of f1uoroscopcially guided cervical nerve roots is
exception of the first and second dorsal rami of the cervical
similar to but not identical with the "old" dermatomal
spinal nerve (the suboccipital nerve and greater occipital
maps of spinal nerve distribution. These symptom
nerve, respectively), the ventral rami are substantially
provoked maps are termed "dynatomes" by these authors
thicker than the dorsal rami.
and are represented in Figs. 14.3a-d. (Slipman et aI., 1998). 217
Copyrighted Material
Selected Clinical Syndromes
o 1-10 11-19 20-29 30-39 40-49 50-59. 60-69. 70-79. 80-89. 90-100.
o 1-10 11-19 20-29 30-39 40-49. 50-59. 60-69. 70-79. 80-89 . 90-100.
-
-j \
-j \ b
a
o
o
1-10 11-19 20-29 30-39 40-49. 50-59. 60-69. 70-79. 80-89. 90-100.
1-10 11-19 20-29 30-39 40-49. 50-59. 60-69. 70-79. 80-89. 90-100.
c
d
Fig. 14.3a-d Dynatomes of the (4, (5, (6, and o levels (5lipman et aI., 1998). Representation of the various dynatomes: the area of symptom provocation of fluoroscopically guided cervical nerve roots.
a (4 nerve root.
b (5 nerve root. (6 nerve root. d (7 nerve root.
e
218
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Nerve Roots and Nerve Root Pain
Important Radicular Syndromes The topographic relationship between the nerve roots and the intervertebral canal and the disk, as well as the differ ing loads on the individual spinal segments (also known as vertebral units), is primarily responsible for disk protrusion (or prolapse) that occurs most frequently at the lower
L5
------H"',.
L5
------;.. \\
51
-----'''.---t--.../
lumbar and first sacral root levels. The relationship between the diameter of the nerve root and the intervertebral canal is distinctly unfavorable in the lumbosacral junction in comparison to other segments of the spinal cord. Apart from the limited spatial arrangement, the vertical course of the nerve roots at the lumbosacral junction can cause the next root to come into contract with the inter vertebral disk as well.
51
-
--
-
__
-
The posterolaterally herniated disk at L4-L5 primarily compresses the fifth lumbar nerve, whereas the disk of L5-S1 compresses the first sacral nerve. The nerve root leaving the intervertebral foramen in this vertebral unit
Fig. 14.4 Schematic representation of a large lateral lumbosacral
can exit without compression. When the disk herniation
disk hemiation between L5 and 51, which compresses not only the
is substantial, the L4-L5 and L5-S1 disk or a radicular
first sacral root (51, which would be expected) but also the fifth
syndrome can arise (Fig. 14.4). The incidence of the radicular syndrome from involve ment of the cervical nerve roots is about one percent of that encountered in the lumbar region. The root of C6 is in volved most frequently, which may be due to the compa ratively large mobility of the segment C5-C6.
lumbar root (L5) (after Dubs, 1950). Typically, the L5 nerve root should have lef t the canal above the L5-S1 disk level (in other words, L5 spinal nerve leaves "below" the L5 v e r te bra ). However. if the disk is sufficiently large, it can extend and compress the L5 root by pushing "up" on the nerve root from below. The 51 nerve root at
that level is s till mostly in the spinal canal on its nearly vertical
course to leave the canal just under the 51 vertebral l evel.
Thoracic root syndromes are extremely rare. The clinical presentation of a herniated disk in the mid-thoracic spine can be very dramatic, however, since the diameter of the canal of the spinal column between T4 and T9 is very small
Further Reading
and the vascular supply is markedly decreased in compar
Cyteval C, Fescquet N. Thomas E, et al. Predi cti v e factors of
ison to the remaining segments of the spinal cord (White
efficacy of p erirad icu l ar corticosteroid injections for lumbar
and Panjabi. 1978 ). These two factors can increase the like lihood of injury as the consequence of a "contrecoup" mechanism involving the spinal cord and the nerve roots
radicul opathy. AmJ Neuroradiol. 2006 Ma y;27 (5) :978-992 . Dvorak J, Grob D. E pidural injections. What is certain? Or thopade.2004;33(5):591-593. Hirayama J, Yamagata M. Ogata S, et al. Relationship between low-back pain, muscle spasm and pressure pain thresholds
(Fig. 14.5).
in patients with lumbar disk herniation. Eur Spine J. 2006;15(1 ):41-47. Kendall R, Werner RA. Interrater reliability of the needle ex
Symptomatology of Nerve Root Syndromes
amination in lumbosacral radiculopathy. Muscle Nerve. 2006; 34(2):238-24l.
Compression of the individual nerve roots is typically ac companied by the following signs and symptoms (Table 14.1 ):
Rothman SM, Kreider RA. Winkelstein BA. Spina l neuropeptide responses in persistent and transient pain following cervical nerve root injury. Spine. 2005 Nov 15;30(22):2491-2496. Waggershauser T. Sc hwa r z kop f S, Reiser M. Facet blockade, peridural and periradicular pain therapy [in GermanI Radi
•
Pain following the dermatomal region supplied by the
010ge.2006;46(6):520-526.
incriminated nerve root(s). •
Radicular loss of sensitivity along a dermatomal distri bution.
•
Motor loss of the muscles innervated by the corre sponding roots.
•
Abnormal (reduced or absent) muscle stretch changes.
219
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Selected Cllnkol Syndromes
Relative AP canal diameter Relative blood supply
I J
The
Thoracic disk herniations
T4
critical zone
T9
Fig. 14.5 Schematic cross-section of the spinal cord at different
felt to be responsible for the potentially disastrous outcomes when
levels and the blood supply in the various spinal regions. Demon
the mid-thoracic spine is injured. With permission from White and
stration of the contrecoup phenomenon seen with thoracic disk
Panjabi, Clinical Biomechanics of the Spine, Lippincott Williams &
herniations. The small spinal cord cross-sectional area in the thora
Wilkins, 1990.
cic spine, coupled with the smallest blood supply in this region, is
220
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Nerve Roots and Nerve Root Pain
Table 14.1 Overview of the major cervical and lumber nerve root syndroms (after M umen thaler and Schliack, 1991). Sensory Deficits
Motor Deficits
Pain Distribution Cervical nerve root syndromes C3-C4
Pain (or hypoalgesia)
Partial or total paresis/pa-
in shoulder region
ralysis of diaphragm
No detectable changes
Partial diaphragmatic paresis/ paralysis. 0 more ventral and
C4 more dorsal CS
Pain (or hypoalgesia)
Disturbance of innervation
Diminished or absent
Typically. the biceps reflex is
over lateral aspect of
of deltoid and biceps bra-
biceps reflex
thought of as a "CS reflex"
shoulder. covering
chii muscles
Typically. the brachioradialis
deltoid area
C6
C7
C8
T1
Dennatome on outer
Paresis/paralysis of biceps
Diminished or absent
aspect of ann and
brachii. brachioradialis
biceps reflex. brachiora-
reflex is thought of as a ·C6
foreann as far as the
muscles. and the wrist
dialis reflex
reflex"
thumb
extensors
Dermatome lateral
Paresis/paralysis of triceps
Diminished or absent
Differential diagnosis of carpal
and dorsal to C6
brachii. pronator teres and
triceps reflex
tunnel syndrome: note the
dennatome. includ-
occasionally finger flexors:
ing index finger to
often visible atrophy of
ring finger
the thenar eminence
triceps reflex
Dermatome to C7.
Small muscles of hand.
Diminished triceps re-
Differential diagnosis of ulnar
extending to include
visible atrophy especially
flex
nerve palsy: note the triceps
little finger
of hypothenar eminence
reflex
Dennatome to T1.
Small muscles of the hand.
No detectable reflex
extending along me-
paresis of little finger ab-
changes
dial forearm
duction.
Lumbar nerve root syndromes L2
Dermatome proximal
Paresis/paralysis of the
to greater trochanter
iliopsoas muscle. hip ad-
extending anterior
ductors. and quadriceps
over to medial sur-
femoris muscle
No detectable changes
face of groin/thigh
L3
Dermatome extend-
Paresis/paralysis of quad-
Diminished or absent
Differential diagnosis of fem-
ing from greater tro-
riceps femoriS muscle
quadriceps reflex (di-
oral nerve palsy: area of sa-
chanter over the
minished/absent "knee
phenous nerve innervation
extensor surface to
jerk")
remains intact
the medial side of the thigh and knee
L4
Dermatome extend-
Paresis/paralysis quadri-
Diminished or absent
Differential diagnosis of fem-
ing from lateral sur-
ceps femoris and tibialis
quadriceps reflex ("knee
oral nerve palsy: involvement
jerk")
of tibialis anterior muscle.
face of thigh across
anterior with reduction or
the knee to the an-
loss of ipsilateral dorsi-
Patient may report "foot-
terior and medial
fleXion.
slap" in the history. or this
quadrant of the leg.
Functional testing: Patient
may be apparent when pa-
including the medial
has difficulty walking on
tient walks into the examina-
part of the sole
heel (if unilateral) or heels
tion room
(if bilateral)
221
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Selected Clinical Syndromes
Table 14.1 (cont.)
Sensory Deficits Pain Distribution L5
Comments
Dermatome extend-
Paresis/paralysis and atro-
Absent tibialis posterior
L5- nerve root innervation is
ing from above the
phy of extensor hallucis
reflex, only useful if the
best evaluated by checking
lateral condyle of the
longus, and/or posterior
opposite reflex can be
sensory loss over the great
femur, over the an-
tibialis muscle
clearly elicited.
toe and motor deficit of the
Note: there is really no
extensor hallucis longus
terior and outer
S1
quadrant of the leg
"clear-cut" reflex station
muscle (best performed with
as far as the great toe
as there is for the L4 and
patient either supine or sit-
S1 roots
ting) (Marciniak et aI., 2005a) (Marciniak et aI., 2005)
Dermatome extend-
Paresis/paralysis of fibula-
Absent triceps surae
ing from flexor sur-
ris muscles. and gastro-
"Achilles'" reflex ("ankle
face of thigh to the
cnemius; often also
jerk")
outer and posterior
disturbed innervation of
quadrant of the leg,
gastrocnemius/soleus
and over the lateral
muscle.
malleolus to the little
Functional testing: Patient
toe
has difficulty coming up onto or walking on toes
Combined
L4 and L5 derma-
All extensor muscles of
Diminished quadriceps
Differential diagnosis of fibu-
L4/5
tomes
ankle; also disturbance of
reflex. Absent tibialis
lar nerve palsy: fibularis
innervation of quadriceps
posterior reflex
muscles escape. Note knee
femoris muscle
jerk and tibialis posterior
Combined
L5 and S 1 derma-
Extensors of toes, fibularis
Absent tibialis posterior
L5/S1
tomes
muscles, occasionally also
and triceps surae reflex
electrodiagnostic studies to
disturbances of innerva-
(Sl )
differentiate a root-level
It may be necessary to utilize
compression (e. g., secondary
tion of triceps surae muscles.
to disk herniation) from fibu-
Func tional testing: Patient
lar neuropathy (Marciniak
has difficulty walking on
et aI., 2005)
heels and toes
Neurologic Disorders Associated with Back Pain
sion of the spinal cord by the tumor or. as in an acute situation, occlusion of the anterior spinal artery. Schwannomas may grow along the nerve root and ex
An excellent review of the literature was presented by
tend inferiorly beyond the intervertebral foramen, thereby
Mattie (1986). The following descriptions are based on
enlarging it at the same time. This can be demonstrated on
and expand this review.
oblique radiographs, and better yet on axial IT scans or MRI.
Extramedullary, Intraspinal Tumors
Intramedullary Space-Occupying lesions
In the presence of prolonged and prominent radicular
and Syringomyelia
symptoms, differentiation must be made between a cer vical herniated disk and an extramedullary. intraspinal
It can be weeks to months before neurological deficits
tumor.
Schwannomas (neurilemmomas) are the most
associated with intramedullary space-occupying lesions
frequently encountered tumors (Burger and Vogel, 1982).
become clinically noticeable. The presentation may be
These tumors are benign. When they are found during the
neck pain or back p ain or both. There is usually segmental,
course of the clinical work-up in a patient with radicular
radiating pain corresponding to the level of tumor involve
,
symptoms, surgical interventions are associated with good
ment, as well as distal paresthesias and peripheral paresis
outcomes (Fig. 14.6). However, the prognosis is worse in a
or overt paralysis. Segmental muscle weakness and atrophy
patient with a transection-type of injury to the spinal cord.
or fasciculations are sometimes seen on physical examina
Causes of such an injury may include prolonged compres
tion. Below the level of involvement, a central palsy and
222
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Neurologic Disorders Associated with Back Pain
Fig. 14.6 Demonstration of a neurinoma in the left intervertebral
Fig. 14.7 Syringomyelia in the upper cervical spine as demon
foramen at C5-C6 (oblique view).
strated via MRI in this 52-year-old man. Probably due to bony abnormality in the upper cervical spine.
dissociated sensory changes can occur (loss of pain and
Whenever a patient presents with "obvious" spinal pain.
temperature sensation with preserved proprioceptive and
e. g.. pain that would point to degenerative disk or joint
touch modalities). Frequent causes of space-occupying le
disease. the entire clinical situation should be taken into
sions include
astrocytomas and ependymomas. If the
symptoms have
extended
over
years.
and especially
account. including the patient's age. trauma. and the potential for any underlying and yet-to-be-recognized
when the patient has not had a prior neurologic work-up
sinister pathology. A recent case underscores the medical
(e. g.. the patient has not seen a physician). a syringomyelia
necessity for being "on the alert." as here the patient pre
should be suspected. The causes of syringomyelia may
sented with upper thoracic pain of prolonged duration only
include malformations such as basilar impression or Klip
to reveal metastasis of poorly differentiated carcinoma
pel-Feil or Arnold-Chiari syndromes. The diagnosis is
(Stoll et al.. 2005).
made either by CT or by MRI (Fig.14.7).
Neurogenic Amyotrophy, I\leuritis,
Metastatic Bone Disease
and Polyradiculitis Diffuse pain that develops over a relatively short period of time and that can be localized to a particular spinal region
Neurogenic shoulder amyotrophy is primarily a lower mo
or specific vertebrae with possible dermatomal radiation
tor neuron disorder with pain. It is characterized by initial
may be due to metastatic carcinoma of the bone (Harner
constant. severe pain or sharp. throbbing. stabbing pain.
and Wiernir. 1982).
The pain may be exacerbated by shoulder motion. and the
The spine is recognized as one of the most common
pain may actually wake the patient from sleep. Frequently.
sites. if not the most common site. for bony metastases in
it is not until the original sharp pain has subsided that the
patients with systemic malignancy (Ecker et al.. 2005).
patient realizes the presence of weakness. atrophy. or even
Patients with metastatic spinal tumors may present with
paralysis in the upper arm (Fig.14.8). Tsairis et al. (1972)
pain. neurologic deficit. or both. while it should be remem
report that in approximately half of the patients investi
bered that some tumors can be entirely asymptomatic
gated the weakness was confined to the shoulder region.
(Ecker et al.. 2005). metastases usually reach the spinal
with the majority of the deficits suggestive of multiple
cord anteriorly. therefore causing more destruction on
nerve lesions (90% vs. 10% suggestive of individual nerves;
the anterior components of the cord than the posterior
e. g.. radial. long thoracic. or suprascapular nerve). Sensory
ones. Clinically. there may be paraparesis with loss of
changes may be present. especially in the region over the
pain and temperature sensation. whereas touch and posi
deltoid muscle and the lateral side of the forearm. By
tional sensation are usually preserved. Conventional radio
definition. if the patient's presentation can be attributed
graphs. in particular the anteroposterior view. may reveal
to one or several nerve roots or extrinsic cord compression.
bony changes. and particular attention should be paid to
it is not neuralgic amyotrophy.
the arches of the roots.
223
Copyrighted Material
Selected aln/col Syndromes
infection, for instance, but who has not progressed beyond the prodromal period, until the vesicles actually appear (Mumenthaler, 1985). A recent article investigating potential differences in pain pathways associated with either radicular pain or neuropathic/neurogenic pain reports that while the two models of persistent pain may produce similar allodynic outcomes, there is a difference in gene expression (Lacroix Fralish et ai., 2006). According to their pain models, these authors suggest that diverging mechanisms may lead to a common behavioral outcome.
Circulatory Changes Affecting the Spinal Cord The vessel most frequently involved is the anterior spinal artery. Occlusion of this artery may lead to a central mo noparesis with contralateral dissociated sensory disturban ces, that is, the Brown-Sequard syndrome (Aminoff, 1996) (Figs. 14.9a,
b). These neurological deficits are often accom
panied by acute back pain which radiates segmentally. There is flaccid paresis in the segmentally related muscles in the presence of circulation abnormalities. According to Kelley (1991), transient occlusion of the anterior spinal artery due to aortic thrombosis may cause paraplegia and may also progress to renal failure, bowel infarction, and limb loss if left untreated. Abdominal aortic thrombosis should be considered in a patient who presents Fig. 14.8 Neuralgic shoulder amyotrophy visible in this 60-year-old man. Note the prominent atrophy of the right shoulder blade muscles.
with an anterior spinal artery syndrome, which, if present, must be treated as rapidly as possible to preserve motor and sensory fu nction.
The polyradiculopathy in Guillain-Barre syndrome usu ally progresses without much pain except for initial pares thesias at the onset (Loffel et ai., 1977; Guillain et ai., 1916).
Spontaneous Spinal Epidural Hematoma
It has occasionally been observed that a patient complains
(SSEH)
of nonspecific lumbago-like, nonspecific low back pain for days to weeks preceding the muscle weakness. A polyradiculitis caused by spirochetes (Lyme disease;
The occurrence of a spontaneous spinal epidural hematoma is rare (Foo and Rossier, 1981). Immediate diagnosis of this
Borrelia burgdorferi infection, borreliosis) is usually charac
disorder and prompt laminectomy will prevent the patient
terized by monosegmental or plurisegmental pain and may
from becoming permanently disabled (Mattie et ai., 1987).
reveal severe, pronounced peripheral muscle weakness
The first clinical symptoms the patient complains about are
(Pacher and Steere, 1985 ; Schmitt et ai., 1985; Steer et ai.,
usually severe neck pain or back pain, or both, soon fol
1983). Asking specifically whether the patient has been
lowed by pain radiating along the distribution of the in
bitten by a tick or has traveled to tick-infested areas may
criminated nerve root. Within minutes to hours, or perhaps
help in specifying this diagnosis, especially when the ex
days, the patient may develop a transection type of cord
posure is followed by skin changes consistent with eryth
injury with paraplegia. The possibility of a spontaneous
ema chronicum migrans ("target lesion" or "bull's eye le
spinal epidural hematoma should always be considered
sion"). Laboratory examination of the spinal fluid of the
when there is acute pain, especially when the patient is
patient infected with spirochetes usually reveals an in
on anticoagulation medication. The diagnosis is confirmed
creased cell count. Confirmation of a diagnosis of spiro
by CT or MRI, replacing the formerly "standard" myelo
chete infection requires serological testing.
gram.
It is difficult to differentiate dermatomal pain from
Favorable surgical outcomes of SSEH include an incom
other causes in a patient who suffers from a herpes zoster
plete neurological injury at the time of the preoperative
224
Copyrighted Material
Neurologic Disorders Associated with Back Poin
b
a
Fig. 14.9a,b The original presentation of the Brown-Sequard syndrome.
status (vs. complete neurological injury) and a short oper ative time interval (Shin et al., 2006).
A recent case report of a 44-year-old man who devel oped paraplegia due to a paraspinal and epidural abscess after reported spinal manipulative intervention (with a reported delay in diagnosis) highlights once more the
Spinal Epidural Abscess
need for comprehensive clinical vigilance in order to ini tiate the appropriate diagnostic work-up promptly when
Extremely severe and well-localizable pain in patients with
the situation dictates, and especially when there is well
signs of a systemic infection and fever may be due to an
localizable back pain (Wang et al., 2006).
epidural abscess. In most cases Staphylococcus is the of fending organism (Kaufmann et aI., 1980; Baker et aI., 1975). The abscess causes the dura to bulge into the spinal
lumbar Spinal Stenosis
cord, whereby it applies mechanical pressure on the cord, which in turn can impair normal spinal circulation. The
Lumbar spinal stenosis should be suspected especially in
ensuing paraplegia may progress quite rapidly Today the
the elderly patient who presents complaining of chronic
diagnosis is made by MRI, whereas in the past myelograms
back pain with radicular symptoms and with intermittent
were required (An and Seldomridge, 2006; Stabler and
neurogenic claudication (Blau and Loque, 1978; Benini,
Reiser, 2001 ).
1981; Hohmann et aI., 1984). The patient's history usually
Therapeutic intervention includes surgical decompres
reveals the need for frequent rest periods after walking a
sion by drainage, possible laminectomy and appropriate
short distance. Furthermore, a change in posture, such as
intravenous antibiotic coverage.
leaning forward (e. g., supporting oneself over the cart
225
Copyrighted Material
Selected Clinical Syndromes
Fig. 14.10 Central canal spinal stenosis as demonstrated in a con
complete interruption of flow of the contrast material at the L4-L5
ventional myelogram (a) and with myelo-CT (b) in a 74 year old
level, where there is also noted a pseudospondylolisthesis.
-
-
man who had presented with neurogenic claudication. Note the
when shopping) or assuming a sitting position. is necessary
Cervicogenic Vertigo and Headache
to bring about some relief. To demonstrate possible deep tendon reflex changes. alteration in sensation. as well as
Some authors (e. g.. Hulse.
muscle weakness. it is often necessary to have the patient
icine treatment is indicated in those cases where the pre-
1 98 1 ) suggest that manual med
move until the state of claudication is reproduced. Electro
senting cervical vertigo or reported perception of imbal
diagnostic studies may provide additional information. es
ance is felt to be the result of relevant structural and func
pecially when the presentation is relatively "classic" but
tional disturbances (i. e., somatic dysfunction) in the upper
the neurologic examination is rather unremarkable. MRI or
cervical spine. This is true particularly when it would ap
cr have become the mainstay tools in the diagnostic work-
pear that the facet joints in the upper cervical spine (CO-Cl
uP. in addition to a thorough history and physical exami
and
nation (Fig. 1 4.10).
genic vertigo must always be clearly differentiated from
C1-C2 articulations) are involved. However. cervico
other causes of vertigo, especially those not amenable to or even contraindicated for manual therapy.
Further Reading Atlas SJ. Delitto A. Spinal stenosis: surgical versus nonsurgical treatment. Clin Orthop Relat Res. 2006 Feb;443:198-207. de Graaf I. Prak A, Bierma-Zeinstra S. et al. Diagnosis of lumbar spinal stenosis: a systematic review of the accuracy of diag
Sensation of Imbalance (Disequilibrium): Dizziness, a Cardinal Symptom
nostic tests. Spine. 2006 May 1;31(10):1168-1176. Huntoon MA. Anatomy of the cervical intervertebral foramina: vulnerable arteries and ischemic neurologic injuries after transforaminal epidural injections. Pain. 2005 Sep; 117 (1 -2):104-111. Kluner C. Kivelitz D. Rogalla P, et al.. Percutaneous discography:
In
1 9 1 3 Oppenheim described vertigo as an unpleasant
sensation resulting from a disturbance in perception of the body in relation to its surroundings and position in space.
comparison of low-dose CT, fluoroscopy and MRI in the
To maintain equilibrium. or in other words to assure an
diagnosis of lumbar disk disruption. Eur Spine J. 2006
intact awareness of the body in space. three sources of
May; 15(5):620-626.
afferent impulses from different systems are required:
Vogt MT. Cawthon PM. Kang JD. et al. Prevalence of symptoms of cervical and lumbar stenosis among participants in the osteoporotic fractures in men study. Spine. 2006 Jun
1 ;31
(13):1445-1451. Yamashita K, Ollzono I<. Hiroshima K. Five-year outcomes of surgical treatment for degenerative lumbar spinal stenosis: a p rospective observational study of symptom severity at standard intervals after surgery. Spine. 2006 Jun 1 ;31(13): 1484-1490.
the optic. vestibular, and proprioceptive systems. In addi tion, according to studies by Hulse Wyke (personal communication.
( 1 98 1 , 1 982.1 983) and
1 983). the receptors of the
facet (apophyseal) joints in the cervical spine assume an important role in the maintenance of equilibrium. A dis turbance or irritation of the receptors in the cervical spine may lead to vertigo and cervical nystagmus. Hulse (1981 , 1 983) describes cervical nystagmus as a sine
qua 11011 condition in patients with complaints of dizziness
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Cervicogenic Vertigo and Headache
and findings of functional disturbances in the cervical spine
disturbance in the somatosensory proprioceptors located
(i. e .. somatic dysfunction).
in the CO-Cl or upper cervical spinal joints.
In their experimental studies. Hikosaka and Maeda
A detailed structural and functional examination of the
(1973) suggest that a connection exists between the facet
cervical spine is particularly indicated in patients who
joints and the abducens nuclei. It has been shown that
present with vertigo that is thought to be related to cervical
impulses originating from joint receptors are transmitted
joint receptor irritation. This evaluation should include a
to the vestibular nuclei (Fredrikson et al.. 1965; Maeda.
careful search for particular irritation zones as well as
1979). These two connections may help explain the exis
localized muscle changes (i. e.. palpable bands) associated
tence of cervicogenic vertigo. At the same time. it may be
with potential myofascial trigger points.
difficult to differentiate between cervical vertigo and that
Radiographic evaluation includes the conventional an
caused by vascular abnormalities or changes in the vestib
teroposterior and lateral views of the cervical spine. In the presence of segmental or regional joint dysfunctions. addi
ular apparatus.
tional views should be utilized. such as the functional
Differential Diagnosis of Vertigo
lateral and transbuccal anteroposterior views. It has been
Various authors (e. g.. Hi.ilse. 1981) suggest that manipula
suggested that atlantoaxial instability may be demon
tive therapy is indicated in those cases where the cervical
strated on functional transbuccal views.
vertigo or perception of unbalance is caused by functional
Otoneurologic studies. including electronystagmogra
disturbances (i. e.. somatic dysfunction) in the upper cer
phy. aid in the differentiation between peripheral and cen
vical spine. including the CO-CJ. C1-C2 facet joints. How
tral abnormalities of the vestibular apparatus. Based on
ever. this form of vertigo must always be clearly differ
studies by Hi.ilse (1983). electronystagmography is also
entiated from other causes of vertigo. especially those not
very helpful in distinguishing between vascular and cervi
amenable to or even contraindicated for manual therapeu
cal nystagmus or vertigo.
CT and MRI scans of the head and cervical spine have
tic maneuvers.
become very useful in the diagnostic work-up. especially
Examination of the Patient with Vertigo
when a tumor (intracranial or extracranial) is suspected.
A carefully performed case history is of utmost importance. One of the main tasks for the examiner is to pay particular
Important Disorders Associated with Vertigo
attention to those reported symptoms that assist in the
•
differentiation between the so-called systematic and non
Meniere disease: labyrinthine disease characterized by whirling or rotational vertigo. tinnitus. unilateral deaf
systematic types of vertigo.
ness. autonomic changes (nausea. vomiting); nystagmus is present during the acute attack.
The systematic form of vertigo is most often being en countered when the patient complains about such sensa
•
Vestibular neuronitis (neuropathy): disturbance in ves
tions as head and body rotation or whirling (known in the
tibular function (mostly unilateral vestibular paresis)
European literature as "rotary vertigo"). nonrotatory sway
characterized by suboccipital headaches, rotatory ver
ing or to-and-fro movements ("sway vertigo"). or up-and
tigo (hours. days, weeks). autonomic symptoms (nau
down movement ("lift vertigo"). This form of vertigo is
sea. vomiting). and the feeling of unsteady gait ("off
usually due to a disturbance in the vestibular system. In
balance"); tinnitus and deafness are usually absent.
contrast. nonsystematic vertigo is associated with such
•
Oculomotor disorders: diplopia. possible brief sensation
complaints as unsteadiness. lightheadedness. and general
of vertigo accompanied by mild nausea; may be seen in
unpleasant feeling of discomfort.
persons with error of refraction (astigmatism. myopia.
During the neurological examination. particular atten tion should be paid to the sensory branch of the trigeminal
hyperopia). •
Tumors in posterior cranial fossa: including meningi
•
Acoustic neuroma: loss of hearing, tinnitus. vertigo
oma. ependymoma.
nerve and the other more inferior cranial nerves. The pa tient should also be evaluated for the presence of nystag mus. including spontaneous nystagmus (Pfaltz. 1983). ves
(usually of the nonsystematic type and rarely observed
tibular nystagmus by use of provocative testing. as well as
as initial symptom). ipsilateral ataxia of limbs, nystag
postural nystagmus. and the nystagmus elicited with head
mus. involvement of the trigeminal nerve (corneal re
positioning or induced movement (using fitted Frenzel
flex). increased intracranial pressure.
spectacles; Hess. 1983). However. it must be emphasized. that. in association with head rotation. it is easy to mistak
•
Ischemia (labyrinthine apoplexy): basilar insufficiency. orthostatic vertigo. usually a single precipitous attack
enly diagnose a postural nystagmus that in reality is a
with nausea and vomiting but without tinnitus or
cervical nystagmus (Hi.ilse. 1983). Kornhuber (1974) rejects
hearing loss.
the idea that a postural nystagmus can be caused by a
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Selected Clinical Syndromes
•
Multiple sclerosis: when localized to the bulbopontine
same monograph, compared to a placebo control, manip
region, vertigo is usually of the nonsystematic type.
ulation resulted in immediate improvement when used to
•
Epilepsy due to abnormalities in the temporal cortex.
treat a single episode of headache with posterior cervical
•
Trauma: traumatic brain injury, cervical spine trauma,
discomfort in one trial (Hoyt et al.. 1979). It is further
including hyperextension/hyperflexion injuries to the
reported that when compared to soft-tissue therapy (e. g..
•
cervical spine due to deceleration accidents.
deep friction massage). a course of manipulation treatment
Craniocervical malformations: basilar impressions, as
resulted in sustained improvement in headache frequency
similation of the atlas.
and severity in patients with cervicgogenic headache (Nils
•
Neurotic or psychogenic abnormalities.
son et a\., 1997).
•
Cervical vertigo.
Differentiation between the proprioceptive and vascular
Anatomy
types of cervical nystagmus is significant inasmuch as ma
Virtually any structure in the upper cervical spine has been
nipulative therapy is contraindicated in the vascular type
incriminated at some time as a potential source of head
due to potential complications associated with the proce
ache. Neurophysiologic experiments (Kerr, 1961) have
dure. According to Hulse (1983), proprioceptive nystagmus
shown that stimulation of nerve roots. ligaments. perios
occurs immediately upon turning the head (i. e., there is no
teum, apophyseal joints, and paravertebral muscles can
latent period). In contrast, the vascular type of nystagmus is
project pain into areas that topographically separate from
usually not evident until the patient's neck is turned to the
a particular nerve's innervation. By injecting hypertonic
extreme position, in which case it takes from seconds up to
salt solution into the joint capsules of the upper cervical
3 minutes to become apparent. Thus, a certain latent period
spine, Cyriax (1938) and Kellgren ( 1939) were able to show
is more characteristic of the vascular type of nystagmus.
that pain may be provoked in a specific region. Dwyer et al.
An additional differentiating quality is the clearly decre
(1990) produced pain by injection of contrast material into
scendo character of the nystagmus seen with the proprio
the intra-articular space. Bogduk and Marsland (1986) used
ceptive type, in contrast to the crescendo character of the
specific nerve blocks to investigate whether the source of
nystagmus observed with the vascular type.
the cervical headache could be attributed to the C2-C3 apophyseal joint, for instance when affected by osteoar thritis. They found that in seven out of ten consecutive
Further Reading
patients with suspected cervical headache the pain origi
Ernst A, Basta D, Seidl RO, et al. Management of posttraumatic vertigo.
Otolaryngol
Head
Neck
Surg.
2005:132(4):
554-558.
nating from the C2-C3 joints was mediated by the third occipital nerve.
Peripheral Anatomy The structures that may cause cervicogenic headaches are
Cervicogenic Headache
typically supplied by the dorsal rami of the celvical spinal
Cervicogenic and tension headache are frequent reasons
imity to the cervical plexus and the areas supplied by the
nerves. In the lateral portion of the neck they are in prox for medical visits, particularly to manual medicine practi
ventral rami. In the head they are in proximity to the
tioners. Tension-type headache and cervicogenic headache
trigeminal region.
are two of the most common nonmigraine headaches
The receptive field is associated with the uppermost
(McCrory et aI., 2001). This report, which was produced
three spinal nerves and their associated joints, the liga
by the Duke University Evidence-Based Practice Center
ments, and the vertebral motion segment as well as the
(EPC), concludes that with regard to cervicogenic headache
anterior and posterior neck muscles, the sternocleidomas
manipulation is effective, while with regard to tension
toid, and the trapezius muscles. Also, the dura of the pos
type headache manipulation is unproven (based on the
terior fossa and the intracranial portion of the vertebral
studies available and their methodological shortcomings,
artery may be part of the receptive field.
among other reasons). The same report further reports that the various behavioral therapies have modest efficacy for
Central Anatomy
tension-type headache.
The spinal tract descending from the medulla oblongata
Cervical spinal manipulation was associated with sig
reaches the spinal medulla at the level C2 to C4. Fibers
nificant improvements in headache outcomes in trials in
arising from the spinal tract terminate in the inferior por
volving patients with neck pain and/or neck dysfunction
tion of the fifth spinal nucleus in the upper three segments
and headache (McCrory et a\., 2001). As reported in the
of the spinal medulla. In the spinal medulla, the terminal
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Cervicogenic Vertigo and Headache
projections of the fibers of the spinal tract overlap those
uncovertebral joints in the lower cervical spine have been
from the afferent fibers of the upper three cervical spinal
thought to be one of the causes of the pain due to the
nerves. Therefore, they form an overlapping region in
potential irritation of the neighboring vertebral nerves
which the individual contributions cannot be separately
(Barre and Lieou, 1928).
distinctly. This region in the gray substance of the spinal
In 1949, Bartschi published a text entitled "Cervical
cord is thus described as the trigeminal-cervical nucleus in
Migraine, the Encephalic Syndrome after Cervical Spine
(Neuhuber et aI., 1990). The trigeminal-cervical nucleus
Trauma") (Bartschi, 1949). He described a situation in
may be viewed as the nociceptive nucleus of the head
which the patient presented with headache that was sim
and the upper cervical spine according to Bogduk (1992).
ilar to the classical presentation of migraine while demon strating features that were quite different from those asso ciated with migraine.
Hypotheses for Cervical Headache
Heyck (1982) devised four categories according to the
The Swiss physician, Otto Nageli (1843-1922) was one of
potential source of the cervical headache in an attempt to
the first physicians in Europe to treat headache by using
provide an overview of the rather complex symptomatol
specific hand applications or manipulative procedures to
ogy . As with any category, there are often rather blurred
the cervical spine. In his text "Therapy of Neuralgia and
borders rather than distinct groupings (Table 14.2).
Neurosis by Hand Application" (1894), Nageli presented his
Sjaastad et al. (1983), who coined the term "cervicogenic
theoretical construct concerning the development of head
headache," made the attempt to differentiate between the
ache in an attempt to explain the therapeutic success of his
presentation of classic migraine or paroxysmal hemicrania
various manipulative techniques (Biedermann, 1954).
on the one hand and other types of headache. The term
At about the same time, various osteopathic physicians
"cervicogenic" was specifically chosen to indicate a possible
and chiropractors in the United States were also trying to
relationship between the cervical spine and the headaches.
treat headache using spinal manipulations and other
While initially there was lack of a potential physiologic
hands-on techniques applied to the cervical spine.
correlation between headaches and an abnormality or dys
Some of the osteopathic and chiropractic techniques
function in the cervical spine, more recently Bogduk in his
developed in the United States were imported into Europe
own anatomic studies concluded that a dysfunction affect
where they were adopted by physicians and integrated into
ing the spinal segment at C2-C3 may lead to irritation of the
their medical armamentarium. This would later lead to the
third occipital nerve and thus may be one of the major
formation of the field of manual medicine (Cramer et aI.,
causes of cervical headache (Bogduk and Marsland, 1986).
1990).
One currently proposed explanation for cervical head
In reviewing the osteopathic and chiropractic literature,
ache is the convergence of incoming information at the
it is readily apparent that the upper cervical spine, and in
spinal and trigeminal levels (medulla level) that is being
particular the various somatic dysfunctions related to it,
transmitted centripetally from the periphery due to inflam
have always been considered to be one of the clinically
matory reactions or other injury-related processes.
important regions that may lead to headache. In 1928,j. A. Barre and his student, Y. A. Lieou, coined the term "sympathetic posterior cervical syndrome." They de scribed a clinical presentation the symptoms of which in
Clinical Presentation of Headache Associated with Cervical Syndrome
clude neck pain, dizziness, vertigo, and latent headache.
In 1983, Sjaastad and colleagues presented a clinical syn
They thought that the symptoms were due to irritation of
drome they termed "cervicogenic headache." This presen
the vertebral nerves. Degenerative changes that involve the
tation is defined as the paroxysmal occurrence of unilateral
Table 14.2 Factors in the formation of cervical headache (after Heyck, 1982)
1 2
Myogenic pain due to involvement of the suboccipital muscles Neurogenic pain due to nerve root irritation of (2 and C3 Greater occipital nerve--C2 nerve root lesser oc cipital nerve--C2 and C3 nerve roots
F
3
Greater auricular nerve--C3 nerve root
iiiiiii
PrOjected pain due to initation of the periarterial sympathetic nerve plexus of the vertebral artery and the vertebral nerve
4
Venous congestion in the cervical canal
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Selected Clinical Syndromes
Table 14.3 Criteria for cervicogenic headache based on the Headache Classification Committee of the International Headache Society (Cephalgia. 2004;24[supplement 1 J:115-116) F
A
Pain referred from a source in the neck, and perceived in regions of the head or face
B
Clinical, laboratory, and/or imaging evidence of a disorder within the cervical spine or soft tissues of the neck generally accepted to be a valid cause of headache Fractures, infections, tumors, rheumatoid arthritis, or other distinct and objectively verifiable pathology (not cervical spondylosis or osteochondritis)
C
Evidence that the pain can be attributable to the neck disorder based on one of the following:
•
Demonstration of clinical signs which implicate a source of pain in the neck
•
Abolition of headache following diagnostic blockade of a cervical structure or its nerve supply using placebo or other controls - Neck pain, focal tenderness, history of trauma, mechanical exacerbation of pain, reduced range of motion, nuchal onset, nausea, vomiting, photophobia are suggestive of but do not define cervicogenic headache
D
Pain resolves within 3 months after successful treatment of the causative disorder
Table 14.4 Headache characteristics (after Mumenthaler and Regli, 1990) Pain localized to the neck and/or occipital region
II
2
I
3 4
----
Seconda ry pain may be referred to the frontal region Characteristics of
(1) and (2) above, except that the pain is unilateral
Recurrences, with each the episode lasting for quite some
5
Pain may be precipitated or aggravated by abnormal loading to the cervical spine secondary to postural or motion abnormalities
6
Either associated with or noted in the history:
•
•
Cervical spine pathology, such as torticollis, cervico- brachialgia, etc. Cervical spine lesion (dislocation, fracture, ligamentous tears) due to trauma or extension/flexion injury, etc. --
7
A detailed physical examination reveals the following:
•
Motion restriction in the cervical spine (hypomobility), or abnormally large motion (hypermobility)
•
Pain elicited with palpation in the cervical musculature
•
Congenital or acquired anomalies: trauma, bony, degenerative, functional, etc.
•
Radiologic findings
8
Other causes of occipital headache have been ruled out
9
Specific treatment is successful
-----
headaches with associated symptoms that are similar to
cervical origin. These include characteristics of pain loca
those typically associated with migraine. The headaches
tion, temporal profile, provocative factors, associated signs
are often precipitated or aggravated by certain neck move
and symptoms, as well as objective findings of motion
ments and in particular seem to become more prominent
restriction (hypomobility) or situations of ligamentous in
after trauma (Sjaastad et aI., 1983. Sjaastad. 1992).
sufficiency (after trauma, massive degenerative processes,
In 1988. the Headaches Classification Committee of the
for instance) that result in hypermobility (Table 14.5).
International Headache Society determined criteria for cer
Treatment of cervicogenic headaches. while apparently
vicogenic headaches. The criteria were recently revised in
amenable to manual medicine intervention, may require a
2004 (Table 14.3). The pain is typically referred from a
multi modal approach when refractory to hands-on treat
source in the neck, and perceived in regions of the head
ment. This multimodal or multidisciplinary approach may
or face.
utilize the spectrum of pharmacological interventions (e. g.,
Mumenthaler and Regli presented their criteria for
NSAlDs, analgesics, tricyclic antidepressants, antiepileptics,
spondylogenic headache in their text "The Headache" (Mu
and muscle relaxants, with awareness of their potential
menthaler, 1990) (Table 14.4).
side-effects), and nonpharmacologic interventions such as
Thus. over time a number of clinical characteristics have been gathered that are commensurate with headache of
appropriately
dosed
physical
therapeutic intervention
(preferably active-exercise-based therapy), transcutaneous
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Degenerative Disorders of the Spine
Table 14.5 Summary of different characteristics of cervicogenic headache
Pain location
Occi pital Frontal
Temporal and/or facial 2
Temporal profile
Episodic With/witho ut each episode lasting for a prolonged period (constant pain of long duration)
3
Pain provocation
Movement of the head or the neck
4
Associated signs/symptoms
Autonomic chang es
5
Examination finding s
Motion restriction determined by a functional-structural manual medicine examination Increased muscle tone
electrical nerve stimulation ("TENS"; there may be benefit from an initial trial course), or biofeedback and other ther
Degenerative Disorders of the Spine
apeutic behavioral treatments. If all of this fails, or concur rently, one may consider interventional care including
The neuromusculoskeletal evaluation and treatment of the
anesthetic block, trigger point injections (this especially
patient presenting with spine-related pain, and in partic
may be done concurrently with manual medicine proce
ular when there are degenerative changes, should always
dures), botulinum toxin injections, or neurolytic interven
be tailored to the individual presentation and particular
tions. The patient may be a candidate for surgical interven
patient needs. The approach takes into account all of the
tions in sufficiently severe cases.
objectively verifiable and functionally meaningful para meters that can be determined in detailed history and a thorough physical examination that is then expanded by a
Further Reading
targeted structural-functional examination (manual med
Antonaci F, Bono G, Chimento P. Diagnosing cervicogenic head ache. J Headache Pain. 2006 7(3): 148-148. Biondi OM. Cervicogenic headache: a review of diagnostic and treatment strategies. J Am Osteopath Assoc. 2005;105 (4 Suppl 2):165-225. Biondi OM. Noninvasive treatments for headache. Expert Rev Neurother. 2005 ;5( 3): 355-362. Bogduk N. Headache and the neck In: Goadsby PJ, Silberstein SO, eds. Headache. Boston, MA: Butterworth-Heinemann; 1997. Fernandez-de-Ias-Penas C. Alonso-Blanco C, San-Roman J, Mi angolarra-Page Jc. Methodological quality of randomized controlled trials of sp inal manipulation and mobilization in tension-type headache, migraine, and cervicogenic head ache J Orthop Sports Phys Ther. 2006;36(3):160-169. Frese A, Schilgen M, Edvinsson L, Frandsen E, Evers S. Calcitonin gene-related peptide in cervicogenic headache. Cephalalgia. 2005;25(9):700-703. Hulse M, Seifert K. Cervicogenic head and neck pain lin Ger mani. HNO. 2005;53(9):804-809. McCrory DC, Penzien DB, Hasselblad V, Gray RN. Evidence report: behavioral and physical treatments for tension type and cervicogenic headache. Des Moines (IA): Founda tion for Chiropractic Education and Research; 2001. Prod uct No. 2085. Zito G, Jull G, Story I. Clinical tests of musculoskeletal dysfunc tion in the d iagnosis of cervicogenic headache. Man Ther. 2006;11 (2): 118-129. .
icine assessment). For instance, the examination of an adolescent spine directs the history and the examination in one clinical direction (e. g., scoliosis), while that of an octogenarian spine would emphasize different directions (e. g., degener ative changes, spinal stenosis, metabolic disorders, space occupying lesions). Standard radiographic studies have some, albeit limited, usefulness. It is well known that radiographic findings, as well as CT and MRI findings, often do not correlate well with a patient's painful presentation. Severe degenerative changes may be noted in diagnostic studies in a patient who has virtually no pain, and vice versa. The literature has thus far not been able to explain this common phenom enon satisfactorily. The manual medicine approach to a patient with known spondylotic changes follows a rational sequence of first eliminating any sinister pathology ("red flags"), while the management addresses structural and functional changes as elicited in the detailed work-up. The goal of the manual medicine assessment and treatment is not to "correct" a single "lesion" or "joint blockage," rather it wants to deter mine the relevance of the various motion and tissue re strictions within the entire clinical presentation. The eval uation of fascial restrictions and of the different muscles as being short (e. g., tonic muscles, type I muscles) or being
231
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Selected Clinical Syndromes
weak (e. g., phasic muscles, type II muscles) takes on an
fracture), and the vertebrae, especially in the thoracic
important role. Furthermore, while localized findings in
spine.
one particular region may be quite prominent, the detailed
The etiology is known to be multifactorial, but the out
manual medicine assessment investigates the influence of
standing feature is an imbalance between bone formation
such local findings on other regions, as one can rather
and resorption, in favor of the latter. Thus new bone is not
quickly observe adaptive and compensatory changes in
formed to the same extent as in the normal, healthy sit
regions quite distant from the original area of dysfunction
uation, resulting in a decrease in bone mass secondary to
(e.g., neck pain resulting from lumbosacral or pelvic aber
bone loss.
rations).
Causative factors implicated in osteoporosis are immo
With respect to manual medicine maneuvers performed
bilization, estrogen reduction as occurs during menopause,
on patients with spondylotic changes, the distinction must
hyperparathyroidism, calcium deficiency, and corticoste
be made between performing high-velocity/low-amplitude
roid use.
or manipulation-with
Pain is typically not one of the presenting signs for a
impulse maneuvers) and the non-thrusting techniques
patient with osteoporosis until a fracture has occurred.
(mobilization-without-impulse techniques, e.g., soft-tissue
Conversely, it should be remembered that vertebral com
thrusting
maneuvers ("thrust."
techniques, among others). The manipulative techniques
pression fractures may have actually been present for quite
that involve high-velocity/low-amplitude thrusting (re
some time before they become symptomatic.
ferred to by some authors as "spi nal manipulative therapy,"
Prolonged periods of immobilization quite readily lead
or SMT) have been subject to considerable intra- and in
to substantial loss of bone mass. This should always be kept
terprofessional discussions and varied interpretations and
in mind when dealing with forced immobilization after the
2002; Malone et aI., 2002);
patient has had a stroke, spinal cord injury, or fracture, for
more studies, especially large population-based studies are
instance. During the immobilization period, dramatically
needed to comprehensively address the multifactorial in
more bone is being resorbed than is being produced. Up to
fluences involved in the topic.
40% of the initial bone mass can be lost when a person is
conclusions (Haldeman et al .
.
immobilized for 6 months. This, therefore, leads to greater risk of spontaneous fractures. After about 6 months, how
Further Reading
ever, it seems that a new homeostatic balance is reached.
Daffner SO, Hilibrand AS, Hanscom BS, et al. Impact of neck and arm pain on overall health status. Spine.
2003;28(17):
2030-2035. Ratliff JI<, Cooper PRo Cervical laminoplasty: a critical review. J Neurosurg.
2003;98(3 Suppl): 230-238.
Roh JS, Teng AL. Voo JU, et al. Degenerative disorders of the lumbar and cervical spine. Orthop Clin North Am.
2005;
36(3):255-262.
Clinical Examples An elderly patient may lose as much bone mass within one month of immobilization as the typical bone loss that occurs over one year in an otherwise healthy person. If a patient has been subjected to a prolonged period of immobilization, they may have lost an amount of bone mass that could not be restored to the pre-injury level
Metabolic and Rheumatologic Disor ders Affecting the Spine
even if mobility were to be fully restored. The major crite rion for reversibility is the degree to which the trabeculae have been destroyed. In younger patients, osteoporosis may be reversible as long as the trabeculae have not been
Four major metabolic subsets involving the spine include
entirely resorbed.
osteoporosis, osteomalacia, Paget disease, and proximal
Presenting Signs and Symptoms
motor neuropathy.
In general, osteoporosis is not painful; it is the occurrence of a fracture or several fractures that presents with notable
Osteoporosis
pain. In a patient with progressive osteoporosis. only a small amount of trauma is necessary to cause a fracture.
Osteoporosis may be best defined as normally calcified but
It is known that once a fracture has occurred, there is a
quantitatively deficient bone that has resulted in clinical
greater chance of additional fractures in other vertebrae. A
disability. The generalized loss of bone mass is typically
stable vertebral fracture in the absence of nerve root com
asymptomatic. However, when sufficiently severe, it often
pression typically heals within 3 months.
results in painful fractures that draw attention to the
From a manua.1 medicine perspective, one would want
underlying problem. The most common areas of increased
to know whether a vertebral fracture due to osteoporosis is
risk for fracture include the hip, the distal radius (Colles'
a stable or an unstable fracture. Additionally, one should
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Metabolic and Rheumatologic Disorders Affecting the Spine
remain vigilant for occult fractures and should not assume
tenderness and the patient may present with a readily
that every vertebral fracture in the presence of osteopenia
recognizable waddling gait. Laboratory studies reveal ele
is due only to osteoporosis. These points can be evaluated
vated alkaline phosphatase in the majority of patients.
with good radiographic studies. Frequently they can only
Nearly half of the patients have hypocalcemia and hypo
be resolved by the use of CT or MRI. Indications for CT
phosphatemia. Treatment involves the use of vitamin D
include the presence or suspicion of vertebral cord com
supplements.
pression or pain of unknown source, especially when there has been what would be considered adequate therapy,
Differential diagnosis includes osteoporosis and tumors including multiple myeloma.
which might include the use of the a three-point corset and appropriate analgesics. Indications for MRI include suspicion of occult fracture due to malignancy, spinal
Paget Disease
cord myelopathy, or radicular nerve root compression. Again, it is emphasized that a patient who is known to
Another metabolic bone disorders Paget disease, also
have an osteoporotic process may have an increased risk of
known as ostitis deformans, is characterized by abnormally
further bone mass loss due to immobilization. This may
high bone resorption while at the same time the bone
require the utilization of calcitonin or bisphosphonates,
formation is disorganized. Even though the bone is en
whose action if thought to be as bone resorption blockers. DEXA (dual-energy roentgen ray absorptiometry) is a
larged in the individual with Paget disease, it is functionally weak. The bone is prominently vascularized.
useful study for determination of the patient's osteoporotic
Paget disease increases with age. Men are involved twice as frequently as women. Approximately 3% of men
status. Cummings (Cummings et aI., 1993) demonstrated that
over the age of 50 are reported to have Paget disease, and
individuals who are between 20 and 40 years old, and
its incidence triples to 10% in the cohort of men older than
whose bone density value is one standard deviation below
80 years of age.
the average value for their age group, are at two to three times the risk of sustaining a fracture. The same study also
The distribution of the various skeletal regions is as follows:
observed a direct correlation between bone density and the •
Sacrum 56%
From a manual medicine perspective, it is important to
•
Spine 50%
ability to withstand mechanical stress. recall that when pain is elicited over the spinous process
•
Femur 46%
with palpatory percussion, one's suspicion should be raised
•
Skull 28%
for the presence of osteoporotic vertebral fracture, As long
•
Sternum 23%
as the provocation pain upon percussion remains over the
•
spinous process of a vertebra that has sustained a fracture,
•
Clavicle 13%
one may assume that the vertebral fracture has not com
•
Ribs 7%
Pelvis 22%
pletely healed. In particular, mobilization techniques with impulse (thrusting or high-velocity, low-amplitude im
There is typically multilocation involvement of different
pulse) to the site of vertebral fracture involvement are
bones in the Paget disease patient.
contraindicated unless there are other intervening factors
The patient with Paget disease is usually asymptomatic.
that enter the overall clinical situation. These should be
However, when presenting to the office with pain, the
clearly documented.
patient as a rule reports it as a deep, aching type of pain that is constant rather than fluctuating. Back pain is present in about 10-30% of patients. There are often associated
Osteomalacia
deformities including an enlarged skull, bowing of the legs, and spinal abnormality due to weakening of the
Osteomalacia is a disorder of bone metabolism character
bone itself. While spinal cord compression has been re
ized by a faulty process of mineralization of the organic
ported to occur, especially in the hypertrophic form, it is
matrix.
relatively rare.
Associated etiologies include malabsorption-related vi
The most critical region is the thoracic region where the
tamin D deficiency, renal and hepatic disease, and abnor
spatial spinal canal-spinal cord relationships are tightest.
malities in calcium and phosphorous mineralization.
The enlargement of the vertebral bodies, especially the
In contrast to osteoporosis, nearly 90% of patients with
vertebral arch and the articular facets, may lead to inter
osteomalacia experience back pain, along with pain in the
vertebral foraminal narrowing and nerve root compression
long bones of the legs and the ribs. There is palpatory
that may present as a neurogenic claudication.
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Selected Clinical Syndromes
Typically, as stated above, Paget disease is rarely asso ciated with spinal pain except when associated with sec ondary osteoarthritic changes involving the facet joints and in the presence of a narrow spinal canal. Often the spinous process, the sacrum, or the sternum is tender to percussion and palpation.
Rheumatologic Disorders Seronegative Spondyloarthropathy The seronegative spondyloarthropathies (SNSAs), repres ent a group of arthritides that, while lacking the antibodies
It should be noted that secondary osteoarthritic changes
for rheumatoid arthritis in the serum (hence "seronega
of the facet joints may cause articular pain that is resistant
tive"), are inflammatory in nature. Representatives include
to treatment due to the plastic deformation of the bone.
such entities as ankylosing spondylitis (Bechterew disease),
Often the pain is exacerbated when the patient performs
psoriatic spondyloarthropathy, and Reiter syndrome. The
simultaneous extension and rotation movements. In addi
involvement is typically that of the spine (hence "spon
tion to carefully applied manual medicine treatment, med
dylo-"), the sacroiliac joint, and other bones, The pain at the
ical treatment including the use of bisphosphonates and/or
long bone is typically due to an inflammatory response at
calcitonin should be utilized.
the attachment of muscle to bone, the region of the en thesis. Thus, enthesitis is not uncommon in this group of disorders. Although the HLA-B27 antigen (see below) has
Proximal Motor Neuropathy
been used as the mainstay of laboratory examination, con ventional radiographs of the lumbosacral spine have re
Proximal motor neuropathy due to diabetic polyradiculop
mained the imaging investigation of choice. However, it has
athy or diabetic amyotrophy is another metabolic disorder
recently been reported that standard radiographs are un
that may be seen in a spine clinic. This typically occurs in
able to detect early inflammatory changes of sacroiliitis,
patients older than 50 years and is associated with a recent
potentially delaying the establishment of the appropriate
onset of type II diabetes. As with Paget disease, men seem
diagnosis, which may therefore require employment of
to be more commonly affected.
additional radiographic modalities (MRI) as early as possi
The hallmark of presentation for a patient with proximal
ble (Grigoryan et aI., 2004).
motor neuropathy is that of bilateral or unilateral lower
The only laboratory marker is the presence of the HLA
limb pain that may actually resemble or mimic that of
B27 gene, There is strong correlation of the laboratory
sciatica. The pain is usually worse at night. The patient
finding of the HLA-B27 gene marker with the various
may report spontaneously that she or he has difficulty
spondyloarthropathies, Currently, there are seven subtypes
climbing and managing stairs. Upon examination there is
known of the HLA-B27 gene. However, the gene marker is
notable proximal upper muscle weakness and muscle
not required for diagnosis.
wasting may be noted during the examination. The primary goal of treatment is to address the under
Typically, the seronegative spondyloarthropathies are diseases of the young person as the initial presentation is often between the 25 th and 40th year of life. The patient
lying disorder of glucose metabolism.
typically reports early morning pain in the sacroiliac joint region associated with morning stiffness of the spine. The
Further Reading
diagnosis is primarily clinical, with appropriate laboratory
Argoff CE, Backonja MM, Belgrade MJ, et al. Consensus guide lines: treatment planning and options. Diabetic peripheral neuropathic pain. 1 : Mayo Clin Proc. 2006 Apr;81(4 Suppl): 512-25. [Erratum: Mayo Clin Proc. 2006 Jun;81(6): 8541.
studies to exclude other rheumatologic or autoimmune diseases. The work-up may additionally require the appro priate use of radiographs, cr scan, and other diagnostic
Hosking D. Pharmacological therapy of Paget's and other met
imaging studies, especially when the diagnosis is uncertain
abolic bone diseases. Bone. 2006 Feb;38(2 Suppl 2):53-7.
(Grigoryan et aI., 2004). The standard radiographs include
I Epub ahead of print 2006 Jan 10].
films of the sacroiliac joint as well as of the lumbar spine
Lespessailles E, Prouteau S.ls there a synergy between physical exercise and drug therapies for osteoporosis? Clin Exp Rheumatol. 2006 Mar-Apr;24(2):191-195.
(Fig. 14.11 ). The clinical presentation of the seronegative spondy
Licata AA. Discovery, clinical development, and therapeutic
loarthropathies is characterized by low back pain and
uses of bisphosphonates. Ann Pharmacother. 2005 Apr; 39
morning stiffness. The average age of the initial manifes
( 4):668-677.
tation of the disease is 26 years. Men are affected by SNSA
Sambrool< P, Cooper C. Osteoporosis. Lancet. 2006 Jun 17;367 (9527):2010-2018. Seeman E, Delmas PD. Bone quality-the material and struc
three times more often as women (Table 14.6). The physical examination concentrates on the mobility
tural basis of bone strength and fragility. N Engl J Med. 2006
of the spine in general and the segmental or vertebral
May 25;354(21):2250-2261.
mobility, and includes the measurement of thoracic cage excursion. If the thoracic excursion is less than 3 cm be
234
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Metabolic and Rheumato/ogic Disorders Affecting the Spine
b
a
Fig. 14.11 a, b CT of the sacroiliac joint revealing degenerative changes and "bridge-formation."
tween the extremes of inhalation and exhalation, this may be an indication for further work-up with regard to SNSA. Acute sacroiliac joint arthritis or acute spondylodiscitis is often associated with prominent percLission pain over the incriminated sacroiliac joint or the incriminated verte
Table 14.6 Seronegative spondyloarthropathy involvement of the spine and other regions (after Kahn, 1994)
Skeletal Involvement
Spine •
Sacroiliac joint involvement/spondylitis (90%)
Arthritis of the joints
brae. Complications of SNSA include spinal fracture and/or
•
Shoulder girdle and pelvic girdle (25%)
dislocation, cauda equina syndrome, or osseous ankylosis
•
Peripheral joints-rare
•
Enthesopathy
of the spine resulting in an abnormal posture. While manual medicine treatment is not expected to alter the underlying pathophysiology in the SNSA patient, careful application of hands-on techniques should address the
associated
secondary
adaptive
or
compensatory
Nonskeletal structures •
Acute anterior uveitis (25%)
•
Cardiac involvem e nt (1-4%)
•
Pulmonary Involvement (le ss than 1 %)
•
Amyloidosis (less than 1 %)
changes locally and distally. The goal of the manual med icine treatment is that of restoring as much mobility as possible while designing an individually tailored exercise program for the patient to encourage their own active
diminished glucose tolerance test (17-60% of all patients
program.
with DISH syndrome) but also with adiposity. However, it appears that the glucose tolerance and adiposity are inde
Disseminated Idiopathic Skeletal Hyperostosis (DISH; Forestier Disease)
pendent factors in relationship to the DISH syndrome. A clear correlation between the severity and duration of hyperglycemia and radiologic findings has not been dem
Disseminated idiopathic skeletal hyperostosis (DISH), also
onstrated. Also, there is no correlation between juvenile
known as Forestier disease, is considered a variant of osteo
diabetes and the DISH syndrome.
arthritis or osteoarthrosis. The hallmark is the presence of
The DISH syndrome is not associated with the HLA-8 27
significant ossification of the spinal ligaments while there
antigen, but the advanced stage of the DISH patient is
is surprisingly little pain.
closely resembles that of the patient with ankylosing spon
This is a chronic disorder of the connective tissue of the
dylitis.
body in the musculoskeletal apparatus, affecting up to 10%
From a manual medicine standpoint, it is not expected
of men and 8% of women over the age of 65 years. The
that hands-on application would alter the underlying path
ossification of the ligaments in the spine and the joints
ophysiology directly. NonetheJess, the manual medicine
results in prominent stiffening of the spine with notable
evaluation and treatment should conCentrate on both the
reduction in mobility. While stiffness is prominent feature
primary as well as the secondary changes and adaptive
in both the seronegative spondyloarthropathies and the
compensatory alterations in the regions directly involved
DISH syndrome, pain is relatively uncommon in the DISH
or distant so as to minimize energy expenditure due to the
population. The DISH syndrome correlates well with a
higher demand secondary to the compensatory changes.
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Selected ainical Syndromes
be helpful. A hands-on approach is not expected to alter the
Polymyalgia Rheumatica
underlying etiology but may be able to address early any
Polymyalgia rheumatica is a is a relatively common disease
potential compensatory or adaptive movement patterns or
in middle-aged and older persons that generally runs a
abnormalities associated with the patient's use of alterna
self-limited course (Chuang et ai., 1982).
tive muscle groups for moving about, as when getting up
The initial presenting symptoms include proximal
from a chair or ambulating.
shoulder and hip girdle pain that is typically associated with stiffness. According to Bird et al. (1979) the seven most valuable criteria for differentiation were bilateral shoulder pain or stiffness, onset of illness of less than 2
Rheumatoid Arthritis Rheumatoid arthritis may be difficult to diagnose in the
weeks' duration, initial ESR greater than 40 mm/h, duration
spine especially in the early stages. A detailed review of the
of morning stiffness exceeding 1 hour, age 65 years or
differential diagnostic approach to a patient with rheuma
more, depression and/or weight loss, and bilateral tender
toid arthritis would be beyond the scope of this text, but a
ness in the upper arms. The diagnosis is made upon con
specific review in relation to manual medicine approaches
firmation by a significant elevation of the sedimentation
is indicated. The use of manual medicine techniques in a
rate. The disorder is responsive to low-dose prednisone.
patient with rheumatoid arthritis affecting the spine re
A recent review comparing the sensitivity of the various
quires particular attention and care.
parameters (Bird et aI., 2005) suggests that criteria pro
Juvenile chronic arthritis rarely starts with an initial
posed by Bird et al. (1979) or Hunder and Bunch (1982)
presentation involving the cervical spine. However, this
should be used whenever possible.
changes drastically as the disease progresses, and as soon
Women are affected more frequently than men. Various
as 5 years after the onset of the disease, 40% of children
etiologies have been proposed, but no specific etiologic
with juvenile chronic arthritis show involvement of the
factor has been identified.
cervical spine (Ansell, 1980).
The patient complains typically of pain affecting the
The different forms and degrees of subluxation, trans
shoulder and neck, upper and lower back, and buttocks.
lation, and overt dislocation in the cervical spine, including
There may be a report of thigh pain and particularly morn
basilar compression, account for the many different neuro
ing stiffness is often pronounced. Tenderness is typically
logic presentations. In a meta-analysis of 1749 patients,
elicited in the soft tissues upon palpation. Potential com
Casey (1995) reports that 32% of patients with rheumatoid
plications include giant-cell arteritis (temporal arteritis),
arthritis have demonstrated atlantoaxial instability; 17% of
especially if untreated. A detailed history may reveal recent
the study population presented with neurologic deficits (Fig. 14.12). In association with the findings of localized
headaches or visual disturbances. From a manual medicine standpoint it is important to
instability, there is development of significant arthritic de
proceed carefully in the diagnostic palpatory assessment as
generation noted in the involved region of the cervical
patients frequently report pain upon palpation. Thus a
spine, which in and of itself may then lead to significant
thorough explanation of the examination procedure may
pain. (Fig. 14.13).
Fig.14.12 Lateral radiograph demonstrating numerous manifesta
onstrates a significant atlantoaxial arthrosis in this 65-year-old man
tions of rheumatoid arthritis in the cervical spine.
with known history of chronic polyarthritis.
Fig. 14.13 Lateral radiograph of the upper cervical spine that dem
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Metabolic and Rheumatologic Disorders Affecting the Spine
From a manual medicine perspective, it is important
Fibromyalgia is defined as a chronic, difficult-to-treat,
first to determine whether there is a finding of any insta
and often therapy-resistant generalized musculoskeletal
bility and second whether there are any signs that would
pain syndrome with pain throughout the body. There is
indicate spinal cord compression in the cervical spine.
often associated fatigue, muscle and joint stiffness, and
Therefore, for further work-up the radiographic study of
reports of paresthesias as well as the patient's perception
choice would be a radiograph in the lateral view with
of swelling, and reproducible tender points on physical
maximal flexion. Atlantoaxial instability is present when
examination.
the flexion view reveals a dens-axis and atlas distance that
According to the late Allen Barbour, it is useful to have a
is greater than 4 mm or when there is noted a translatory
name for every functional syndrome, for communicating
dislocation of the vertebral body that is greater than 3 mm.
both with patients and with other doctors. He believed
Further studies such as cr scan or MRI may be necessary.
"fibromyalgia" to be a good name for the kind of diffuse
Early diagnosis of a mechanically related myelopathy may
pain associated with it (Barbour, 1995). However, in the
be substantiated by the use of motor or sensory evoked
naming of a syndrome, no matter how organically focused
potentials (Dvorak and Herdmann, 1990).
and even if the name might imply a certain pathophysio
The indication for spondylodesis is the presence of cer
logic insight (Hadler, 1986), the name itself (in this case
vical myelopathy. Conclusive demonstration of a cervical
fibromyalgia), should not serve as a substitute for trying to
myelopathic process may require the use of evoked poten
understand the person with a functional disorder (Barbour,
tials as this may currently be the only way to demonstrate
1995 ).
the neurologic involvement early. Clinical signs of myelop
The diagnosis of fibromyalgia often depends on the
athy such as atrophy of the intrinsic muscles may be diffi
point of entry of the patient into the medical system. For
cult to assess, especially in the patient with rheumatoid
instance, if the patient is seen by a rheumatologist, the
arthritis who may already have the associated degenerative
initial diagnosis may be just that of fibromyalgia. If the
changes involving the joints and muscles secondary to the
patient enters the system through psychiatry, the patient
polyarthritis.
may be diagnosed with a chronic sleep disorder or chronic
An important sign for myelopathy is tile L'hermitte sign.
fatigue syndrome with a pain component. Thus, the treat
Sudden "electric" pain with jerky motions that involve the
ment of patients who have widespread total body pain can
entire the body should be considered a sign of compression
be challenging, both in the diagnostic and therapeutic are
myelopathy. The Hoffman test may also be useful.
nas.
Patients who suffer from rheumatoid arthritis typically
For the manual medicine practitioner, this becomes im
develop osteoporosis concurrently. This may be due to
portant as he or she is often consulted as a matter of "last
non-use atrophy associated with prolonged bed rest or
resort" after many and various other specialties have been
secondary to long-term corticosteroid use.
visited and revisited and multiple diagnostic tests have
Manipulation with impulse in particular should not be
already been performed, typically without specific findings
employed in a patient with demonstrated rheumatoid ar
that would be able to explain or "prove" the patient's
thritis in the cervical spine because of the potential risks of
generalized pain. The pain symptoms might have started
injury. Each treatment should be individualized, especially
in one location, especially in the cervical spine and
those consisting of soft-tissue techniques, and the patient
shoulder region, and then may develop to a diffuse pain
should be examined neurologically prior to such applica
syndrome involving the entire body (Goldenberg, 1987). Patients typically report continued fatigue even if they
tion.
have received what appears to be a sufficient amount of sleep of as much as 8-10 hours per night.
Fibromyalgia
More than 50% of fibromyalgia patients complain of
Fibromyalgia (FM) evokes rather controversial opinions.
headaches.
There are essentially two major camps with a considerable
Clinical examination comes up with very few systemic
spectrum spanning between these two opposing views.
findings or abnormalities and patients may have had a
One group affirms its belief that such an entity as FM
number of advance studies including very rarely utilized
does indeed exist, while the other group does not believe
laboratory studies in the futile hope of determining one
in this diagnosis at all. Despite these varying opinions, and
"pain-generating" entity.
following best current evidence, it is recommended to
One finding that has been utilized as a standardized
apply a stepwise approach that consists of education, cer
type of approach is the evaluation for so-called fibromyal
tain medications, appropriately dosed exercise, and cogni
gia tender points. If 11 of 18 circumscribed points are
tive therapy, or a combination of these (Goldenberg et aI.,
present, the patient can be diagnosed with fibromyalgia
2004).
(Wolfe et aI., 1990). The examination should be performed
237
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Selected Clinical Syndromes
Table 14.7 Fibromyalgi a palpato r y findings as defi ned by the
There has been correlation with psychosomatic disorder in up to 25-60% of patients. but it is not clear what is "the
American Colleg e of Rheumatology
Note: There are 18 points of which the following 9 are
chicken or the egg."
symmetrical points. Typically the diagnosis is made on the basis of 11 findings out of the 18 points •
O cciput: Bilateral at the insertion of the suboccipital muscles
l ower cervical spine: Bilateral at the anterior margin of
•
Further Reading Arnold LM. Lu Y, Crofford LJ. et al. A double-blind, multicenter trial comparing duloxetine with placebo in the treatment of
the transverse process between (5 and C7 •
tibromyalgia patients with or without major depressive
Trapezius: Bilateral at the mid portion of the muscle at the upper margin Supraspinatus muscle: Bilateral at the origin at the
•
disorder. Arthritis Rheum. 2004;50:2974. Bennett RM. Kamin M, Karim R. Rosenthal N. Tramadol and acetaminophen combination tablets in the treatment of
scapula (or close to the medial angle) • •
lateral epicondyle: Bilateral. 2 em distal to the epicon dyle
•
fibromyalgia pain: a double-blind, randomized. placebo
Second rib: Bilateral at the costochondral junction
controlled study. Am J Med. 2003;114:537. Braun J. Baraliakos X. Godolias G. Bohm H. Therapy of anl
Gluteal muscle: Bilateral at the upper outer quadrant of
treatment and surgical therapy. Scand J Rheumatol. 2005:
the buttock •
Greater trochanter: Bilateral posterior to the trochanter minor
•
Knee: Bilateral in the region of the medial subcutaneous fat pad approximately one hand-width proximal to the
34(2):97-108. Fitzcharles MA. Esdaile JM. The overdiagnosis of tibromyalgia syndrome. Am J Med. 1997;103(1 ):44-50. Frank AD, De Souza LH. Frank CA. Neck pain and disability: a cross-sectional survey of the demographic and clinical char
medial joint space
acteristics of neck pain seen in a rheumatology clinic. Int J Clin Practice. 2005;59(2):17 3-182. Hakkinen A, Neva MH. Kauppi M. et al. Decreased muscle strength and mobility of the neck in patients with rheuma toid arthritis and atlantoaxial disorders. Arch Phys Med
with the thumb and no more than 4 kilograms (8.8 pounds) of pressure (Table 14.7).
Rehabil. 2005;86(8):1603-1608. Holden W, Orchard T. Wordsworth P. Enteropathic arthritis.
There has been significant controversy in the literature and practice of pain management. A concise history of
Rheum Dis Clin North Am. 2003:29(3):513-530. Keitel W. Backache from the interna.1 medicine-rheumatologic viewpoint [In GermanI. Z Arztl iche Fortbildung Uena). 1997;
fibromyalgia is presented by inanici and Yunus (2004). They point out that the original term fibrositis was coined by the British neurologist Gowers over a hundred years ago
90(8):67 1 -676. Nash P. Mease PJ. Braun J. van der Heijde D. Seronegative spondyloarthropathies: to lump or split? Ann Rheum Dis.
(Gowers, 1904). and was changed to the descriptive term "fibromyalgia" in the 1970s. whereby Smythe (1972) is
2005;64(SuppI2):ii9-13. Smythe HA. Rheumatologists and neck pain. Scand J Rheuma tol. 2000:29(1 ):8-12.
identified as the "grandfather of modern fibromyalgia syn drome (FMS) (Inanici and Yunus. 2004). However, it is important for the manual medicine prac titioner that while the etiology and pathophysiology of the fibromyalgia may remain unclear. there may be concurrent findings of somatic dysfunction and/or myofascial pain
Organ- related Pain and Pseudo Spine Pain
syndrome in the form of a regional pain syndrome super imposed on the fibromyalgia. Careful examination is indi
Organic pain is pain that arises from the viscera or other
cated to determine the extent and relevance of such find
hollow or solid body structures and that may cause either
ings.
diffuse or speCific pain, and pain of varying characteristic
Differential diagnostic evaluations would include the following:
presentations from "colicky" to "lancinating." Within the sequence of a detailed work-up of a patient presenting with the pain initially, these organic sources should be sought in
•
Polymyalgia rheumatica.
order to rule out any "red flags" as the goal is to diagnose
•
Myositis.
sinister pathology as early as possible.
•
Hypothyroid disease.
•
Neuropathies.
ways. but using an organ systems classification is relatively
•
Systemic lupus erythematosus.
straightforward way to approach a patient whose presen
•
Rheumatoid arthritis.
tation points into the realm of organic disease.
The pain presentation can be categorized in a number of
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Organ-related Pain and Pseudo Spine Pain
Table 14.8 Su m m ary of org an- related and pseudo-spinal pain Organ System
t
'
.
•
Cancer and entire body
Pain that is related to different types of cancer
system
(% indicates the percentage presentation of
for various types of cancer, but note that nearly
pain for the particular type of cancer.
half of the cancer patients do have pain.
Example: 85% of patients who have bone
Patients with lymphoma and leukemia, how
cancer report pain)
ever, have statistically a lower incidence of pain
•
Bone (ca. 85%)
•
Oral cavity (ca. 80%)
•
Cardiovascular system
There is a rather wide range of pain incidence
(Foley, 1985)
Genitourinary (ca. 78% female and 75%
Bone involvement is almost always painful and
male)
is responsible for most presentations to pain clinics (Kelly and Payne, 1995)
•
Breast (ca. 50%)
•
Lung (ca. 45%)
•
Gastrointestinal ( 40%)
•
Lymphoma (20%)
•
Leukemia (5%)
•
Abdominal aneurysm
Abdominal oneurysm:
•
Angina
•
•
Aortic aneurysm
•
Myocardial infarction obliterating arterio
•
sclerosis
Gastrointestinal system
Abdominal pain which may range from asymptomatic to the ·worst ever" 10% of patients with abdominal aneurysm have low back pain
•
Cholecystitis
Penetrating or perforating ulcer.
•
Duodenal ulcer
•
May mimic acute pancreatitis
•
Irritable bowel syndrome
•
Is associated with back pain
•
Pancreatitis
Pancreatitis is associated with: • •
Acute mid-epigastric abdominal pain Radiating through to the back in up to 90% of patients
Genitourinary system
•
Cystitis
Bacterial prostatits:
•
Nephrolithiasis
•
•
Prostatitis
•
Associated with fevers Associated with low back pain and/or perineal pain
Nephrolithiasis: •
Gynecologic system
Flank pain
•
Endometriosis
Endometriosis:
•
Pelvic inflammatory disease
•
•
Ectopic pregnancy
One- fourth to one- third of patients have back pain
EctopiC pregnancy: •
Abdominal pain; may mimic upper lumbar radiculopathy with radiation to the thighs
Respiratory system
•
Pulmonary embolism
•
Pneumonia
When the patient describes back and/or leg pain as the presenting symptom of an underlying systemic disease, it is often referred to as pseudo spine pain (Mazanec, 2003).
Further Reading Heary RF, Bono CM. Metastatic spinal tumors. Neurosurg Focus. 2001 ;1l(6):e1.
The same author reminds us that the recognition of con
Hosono N, U eda T, Tamura 0, et al. Prognostic relevance of
ditions associated with pseudo spine requires an appreci
clinical symptoms in patients w ith spinal metastases. Clin
ation of key extraspinal diagnostic clues in the appropriate demographic setting. A summary overview is presented in Table 14.8, adapted from Mazanec (2003).
Orthop Relat Res. 2005;(436):196-201. Lu C, Gonzalez RG, Jolesz FA, et al. Suspected spinal cord com pression in cancer patients: a multidisciplinary risk assess ment. J Supportive Oncol. 2005;3(4):305-312. Ross MD, Bayer E. Cancer as a cause of low back pain in a patient seen in a direct access physical therapy setting. J Orthop Sports Phys Ther. 2005;35(10):651-658.
239
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Selected Clinical Syndromes
Widening of the spinal canal in the cervical spine in the
Orthopedic Spinal Disorders
craniocervical junction may require further work-up due to
Congenital Malformations of the Spine:
the potential presence of an Arnold-Chiari deformation in this region (Fig. 14.14a.
Spinal Oysraphism
b).
Incidental findings of an abnormal spinal curvature in the lumbar spine and thoracic spine may reveal a hemi
b).
It should be remembered that spinal malformations do not
vertebra (Fig. 14.15a.
necessarily present with pain. For instance. a block vertebra
initially. but with advancing age the patient may report
These findings often are pain-free
in the cervical spine associated with a Klippel-Feil malfor
radicular type of pain. especially in the presence of a devel
mation may present with no symptoms at all (Patel et al..
oping scoliosis in the spine and especially when there is
1995) and is often found as an incidental finding during
radicular symptomatology. If there is a significant functional finding. espeCially in a
radiologic studies. Congenital deformities of the spine due to spinal dysra
young person. further radiographic studies are indicated to
phism (from Greek meaning defective fusion of a raphe. in
rule out malformations or space-occupying lesions. In par
particular the neural folds) and are associated with neural
ticular when there is unresolved pain. progressive neuro
tube defects represent a group of congenital spinal anoma
logic symptoms, and overt signs. one should strive to cor
lies that result from failure of fusion of the neural tube early
relate these with additional diagnostic findings.
in fetal life. The anomalies in this group include such enti ties as meningocele. myelomeningocele. myelocele. spina bifida cystica and occulta. tethered cord. diastematomyelia. diplomyelia. and others. As in spina bifida. the malforma tions may range from minor abnormalities (e. g.. spinal bifida occulta) to lesions that are incompatible with sur vival. Most cases of spina bifida occulta (as the name im plies) are not detected until they are recognized serendip itously on routine radiographic examination.
Further Reading Herman MJ. Pizzutillo PD. Cervical spine disorders in children. Orthop Clin North Am.
1999;30(3):457-466. ix.
Kaplan KM. Spivak JM. Bendo JA. Embryology of the s pi ne and associated congenital abnormalities. Sp ine
J. 2005;5(5): 564-576. Mitchell LE. Adzick NS. Me\chionne J. et al. S pina bifida. Lancet. 2004;364(9448):1885-1895.
Fig. 14.14 Arnold-Chiari malformation Coronal view. b Axial view.
a
240
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Spondylosis, Spondylolysis. Spondylolisthesis. and Spinal Stenosis
Fig. 14.1Sa Hemivertebra at L3 in this 6 yea r old girl who pre
b Radiographic follow-up study in the same patient 3 years after
sented with a progressive lumbar scoliosis.
surgical decompression and spondylodesis.
-
-
Fig.14.16 Spondyloptosis in a 14-year-old girl. il
Preoperative study.
b Six months after surgical correction and spondylodesis.
Spondylosis, Spondylolysis, Spondylo listhesis, and Spinal Stenosis
The gradation according to Meyerding has been a useful tool for baseline assessment and time-based follow-along! monitoring:
Spondylos (Greek) refers to the spinal vertebrae. Spondy lolysis refers to the degenerative process in the spinal
•
Grade 1: 0-25%
structures (lysis; Greek "loosening") refers to a disruption
•
Grade 2: 25-50%
or dissociation of a bony part (e. g., spondylolysis). Listhesis
•
Grade 3: 50-75%
(also Greek) means slippage or sliding. Thus, spondylolysis
•
Grade 4: 75-100%
refers to a fracture or disruption of the pars interarticularis; spondylolisthesis refers to the displacement of one verte
Spondylolisthesis in the child or young adult is typically
bra with respect to another, usually described in the ante
due to bilateral or unilateral spondylolysis affecting the
rior direction. Spondyloptosis (ptosis "dropping"; adjectival
pars interarticularis. This spondylolysis is best visualized
form: ptotic) is the "end-result" of spondylolisthesis, where
in standard radiographs (Figs. 14.17, 14 18) The spondylol
there is complete slippage of the fifth lumbar vertebra with
ysis may or may not be associated with a slippage itself. It
.
.
respect to the first sacral segment. Spondyloptosis is asso
should be noted that an incidental finding of a spondylol
ciated
deformity
ysis does not automatically mean a recent injury or frac
(Figs.14.16a. b) and may be associated with neurologic
ture, nor can such a finding be ascribed to recent trauma
with
severe
spinal
and
postural
deficits.
241
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Selected Clinical Syndromes
(e.g., in a motor vehicle accident) if there are no other signs of forceful trauma, for instance (Table 14.9). The congenital or early-acquired spondylolysis-spon dylolisthesis may be amenable to manual therapeutic approaches; that is, these diagnoses are not absolutely contraindications for manipulative approaches. However, a clear diagnosis must be established prior to the applica tion of a hands-on approach, especially when considering thrusting or high-velocity, low-amplitude thrusting tech niques. The first description is vertebral gliding in the absence of significant lesion in the pars interarticularis as presented by Junghans (1931), which he describes as pseudospondy Fig. 14.17 Spondylolysis at L5 in a 20-year-old man; observe the typical "Scottie dog" formation in the L4 vertebra, where there is
lolisthesis. Newman (1965) describes this situation as a degenerative lumbar spondylolisthesis due to degenerative
"no collar". As the pars interarticularis is disrupted in the L5 ver
changes, especially in the presence of arthrosis of the in
tebra, the Scottie dog is "wearing a collar" (disr u ption of the bony
tervertebral joints.
component with greater radiolucency).
If the Iisthesis is progressive, which is found more fre quently after the 5 th decade of life, especially in women, the extent can be sufficient to cause a spinal stenosis. The stenosis may be central or foraminal or both. The incidence is known to increase several-fold with advancing age. The greatest incidence of pseudospondylolisthesis is at the L4-L5 and L3-L4 levels (Fig. 14.19). The fact that the inter vertebral joints bear up to a 30% of the axial load may be one explanation for the rather early degenerative changes involving these joints (Nachemson, 1960). The orientation of the facets in the apophyseal joints, especially when aligned in the coronal plane, may also constitute a negative factor. The natural progression of this abnormality reveals that the extent of the gliding associated with the listhesis may reach up to 30% of the
Fig.14.18 Minimal gliding/translation of the fifth lumbar vertebra
vertebral body. Patients who have back pain alone in such a
in this 25-year-old male top athlete.
situation may not require surgical intervention. However,
Table 14.9 Different types of spondylolisthesis Classification of Types Isthmic
Most common type of spondylolisthesis Due to pars interarticularis lesion: •
Congenital or dysplastic Degenerative
lytic fatigu e fracture
•
Microfracture that healed with elongation
•
Acute trauma
Dysplastic facets and/or abnormal orientation Prolonged segmental instability with associated remodeling of the articular processes at the incriminated vertebrae
Traumatic
Fracture of the facet, lamina or pedicle Note: The traumatic type of spondylolisthesis refers to a fracture that involves structures
neighboring the pars interarticularis Pathologic
Bone disease: either localized or systemic/general
Examples:
242
•
Osteogenesis imperfecta
•
Paget disease
Copyrighted Material
Spinal Deformities
With regard to surgical intervention, Herkowitz
(1995)
has formulated the following indications for surgery:
•
Persistent or recurring leg pain lasting more than
3
months and refractory to appropriate conservative treatment. •
Progressive neurologic deficits where additional neu rologiC signs need to be excluded.
• •
Significant reduction of quality of life. Diagnostic SLIbstantiation using appropriate studies in cluding CT, myelo-CT, and MRI depending on the indi vidual patient and including neurodiagnostic studies if indicated.
Fig. 14.19 Degenerative pseudospondylolisthesis in a 75-year-old man with complete blockage of the contrast material in the myelo gram noted at the L3-L4 level. a
Further Reading
Myelogram in flexion.
b Myelogram in extension.
Gibson IN. Waddell G. Surgery for degenerative lumbar spon dylosis: updated Cochrane Review. Spine. 2005;30(20):
the presence of neurogenic claudication with or without radicular symptomatology may be an indication to proceed to operative decompression and/or spondylodesis. Natu rally this requires the appropriate diagnostic work-up rou tines employing the full complement of the appropriate radiographic/neurodiagnostic studies as indicated for the individual patient. It is a reasonable requirement that the
2312-2320. Logroscino G, Mazza 0, Aulisa G, et al. Spondylolysis and spon dylolisthesis in the pediatric and adolescent population. Childs Nerv Syst. 2001 ;17(11 ):644-655. Mossaad MM. Degenerative lumbar spondylolisthesis with spi nal stenosis: natural history, diagnosis, clinical presenta tion, and nonoperative treatment. In Herkowitz H, Dvorak j, Bell G, et aI., eds. The Lumbar Spine, 3 rd ed. Philadelphia: Lippincott, Wilkins W illiams; 2004:514-522.
conservative treatment should be exhausted prior to con
van Tulder MW, Assendelft Wj, Koes BW, Bouter LM. Spinal
sideration of surgical intervention unless the clinical situa
radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine. 1997;
tion dictates otherwise. The conservative treatment should include an individu
22( 4 ):427-434.
ally tailored manual therapeutic approach (mobilization/ soft-tissue techniques rather than manipulative thrusting techniques) with an appropriate and well-dosed muscular
Spinal Deformities
exercise program to stretch the shortened postural muscles and strengthen the paravertebral musculature (e. g., isomet
The spine can be distorted in any one plane or in all
ric techniques). As with other disorders, one of the goals of
directions or (Fig. 14.20). While there is almost always a
the manual medicine practitioner is to determine relevant
rotatory component in the horizontal plane that accompa
adaptive, compensatory, and overcompensatory changes.
nies the spinal distortions, the most common spinal
Once there is muscular insufficiency (e. g., decompensation
deformities occur in the coronal and the sagittal planes.
due to fatigue, structural damage of the stabilizing struc
Abnormalities in the coronal plane are associated with
tures, for instance) and other failure to provide sufficient
scoliosis. Changes in the sagittal plane involve the spine's
stability, then manipulative techniques are indicated.
anterior and posterior relationships.
According to the review by Mossaad (2004) radicular
When sufficiently pronounced, the spinal deformities
pain due to spondylolisthesis or spinal stenosis is much less
can be recognized easily by the naked eye, as is the case
amenable to the same nonoperative management strat
in thoracic kyphosis, for instance, where a curve of approx
egies that are applicable when radiculopathy is related to
imately
a herniated disk. Speaking in general terms, Mossaad notes
spinal contour changes, especially in the coronal plane,
30° is easily discernible. Minor and even moderate
that when there is predominantly leg pain, the course of
may not be readily apparent upon visual inspection alone
nonoperative care may require a prolonged period of time
and therefore routinely require radiologic assessment.
to determine if it is efficacious or not. For some patients
Recent studies (Huysmans et aI.,
with leg pain the administration of epidural steroids (ESI,
it may be possible to replace radiographs by surface meas
epidural steroid injection) may provide an appropriate
urements in order to measure position and orientation of
2005) have reported that
temporizing measure.
243
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Selected Cllnlcol Syndromes
Adolescent Idiopathic Scoliosis Retrospective review of one scoliosis database showed that
Planes of involvement in spinal deformities
while adolescent idiopathic scoliosis is the most common it also felt to represent the least significant variety of spinal deformity (Goldberg et a/., 2002a,b) (Fig. 14.21).
Horizontal plane
In their study of 112 girls (Goldberg et a/., 2002a,b), it
Rotarycurves
was shown that the date of menarche is an important factor in the natural history. Furthermore, they noted that braces were prescribed early but were gradually aban doned, and did not increase the study's surgical rate. Pro
Scoliosis
gression of the curve was reported to depend on the age and maturity of the patient as well as the initially present ing Cobb angle. One-quarter to one-third of the patients
Fig. 14.20 Spinal deformities.
studied were recommended to undergo surgery. (Goldberg
the pelvis. These authors conclude that using certain ana tomic landmarks of the back it may be possible to reduce the number of radiographs otherwise employed to meas ure the position of the pelvis in a scoliotic deformity. Any and all of the tissues and structures that aid in axial stability can be affected, including the nervous system, muscles, bones, ligaments, cartilage, and other connective tissues. This explains the varied factors that may underlie the various etiologies. In the pages that follow adolescent kyphosis, often re ferred to as Scheuermann disease, will be discussed in more detail. Both are very commonly represented. As the name implies, the disease progression occurs most signifi cantly during adolescence until the final stage is reached around the time of maturity. Adolescent idiopathic scoliosis affects girls much more commonly than boys and is rela tively asymptomatic. In contradistinction, juvenile idio pathic kyphosis affects boys more commonly and it is often pain that brings the patient to the medical office.
et a/., 2002a,b). Adolescent idiopathic scoliosis becomes apparent in early adolescence, and is often detected through various screening examination routines in the community. Pain is typically not one of the presenting or early complaints. Another common presentation comes with the young pa tient or the family seeking medical advice when a very minor lateral curvature is noted.
Etiology As the name implies, the etiology is unknown, although various factors have been incriminated, including genetic, hormonal, neurogenic and myogenic causes. Certainly there exist non-genetic influences, while at the same there are clear genetic components with a sex-linked trait given the prominent female predominance (five to seven times more frequent than boys), or the familial involvement (be tween 10 to 20 times greater chance of intra-familial in volvement),
Biomechanical Considerations
Changes in the Coronar Plane: Scoliosis
In a scoliotic curvature, the incriminated structures a.ll have a "domino" eFfect upon each other. Taking the thoracic spine as an example, the character
Distortions of more than 10° in the coronal plane result in a
istic changes shown in Table 14.10 take place. In contrast to
deformity known as scoliosis. Scoliosis is the appearance of
the postural scoliotic curve, the noted deformity has a
aberrant lateral curves in the otherwise "straight" spine.
rather limited involvement, since it usually affects no
The most common etiology of scoliosis is idiopathic, with a
more than seven to eight vertebrae.
number of other etiologies forming a rather large spectrum of possibilities. The classification of scoliosis (Fig. 14.21 )
Muscle Fiber Changes
distinguishes between nonstructural and structural scoli
In unbraced patients, a shift in the fiber distribution (from
otic distortions and the various subsets. Nonstructural sco
"slow twitch" fibers to "fast twitch" fibers) was observed
liosis is reversible, while structural scoliosis is not reversi
exclusively at the concave side of the apex. This shift was
ble. The appearance of a nonstructural scoliosis is in re
paralleled by an increased percentage of the intermediate
sponse to postural or other neuromusculoskeletal changes.
type IIC fibers, which would be indicative of fiber trans
The structural scoliotic abnormalities are grouped accord
formation (Meier et a/., 1997). In the same study, and in
ing to more than 10 subsets. The idiopathic adolescent form
contrast, patients wearing a corset revealed muscle fiber
of structural scoliosis is found more frequently than any of
transformation at difFerent levels along the scoliosis, sup
the other entities.
porting the notion that those muscular changes noted in
244
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Spinol Deformities
Fig, 14,21 Classification of
I I
I
II
Classification of scoliosis
J-
Idiopathic scoliosis
I
I
Structural scoliosis
·
Infantile
·
Juvenile
·
Adolescent -
•
scoliosis,
Nonstructural scoliosis
I
Postural scoliosis
most common ·
Compensatory due to leg length inequality
·
I
l-
Congenital scoliosis
Failure of
·
formation ·
Hlp flexion contracture
Failure of
·
Radiculopathy
segmentation · ·
Posterior
Functional adaptive changes
defect: spina bifida
I
I
I l I
l-
Neuromuscular
with tumors
I
I
Metabolic bone disease
I Neurofibromatosis
I
Cerebral palsy
·
Muscular
·
Spinocerebellar
dystrophy
I
Scoliosis associated
·
disorder
Rickets I
I
Trauma
Table 14,10 Characteristic scoliotic changes seen in the thoracic spine Convexity to the Right Vertebral rotation
Vertebrae are rotated to the right (in •
Vertebrae are rotated to the left (in direction of the convexity):
direction of the convexity): Transverse processes rotate toward
•
prominent) •
Transverse processes rotate toward convexity (left transverse process is prominent)
convexity (right transverse process is •
Spinous processes rotate in direction of concavity
Spinous processes rotate in direction of concavity
Intercostal space
Widened on side of convexity (right)
Widened on side of convexity (left)
Bulging of ribs pos
Side of convexity (right)
Side of convexity (left)
Thoracic kyphosis
Reduced
Reduced
Shoulder level
Elevated on convex side (right)
Elevated on convex side (left)
teriorly ( rib hump)
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Selected Clinical Syndromes
Table 14.11 King classification of scoliotic curvatures
King I type
Double major curve •
King II type
the thoracic curv e
Thora ci c curve is more pronounced than the lumbar curve Thoracic curve
is the
major deformity while the lumbar curve does not cross the midline
Right thoracolumbar curve •
King V type
more pronounced than
Right thoracic curve •
King IV type
is
Right thoracic and compensatory left curve •
King III type
Lumbar curve
Major curve that ·sw eeps· from thoracic to lumbar region
Double thoracic curve •
Essentially no involvement of
the
the apical regions are secondary, rather than being due to
lumbar spine but
double
c urve s in
the thoracic spi ne
Clinical Examination
specific muscular disorders restricted to the area of the
The detailed history is followed by a thorough examination
apex. (Meier et aI., 1997).
that relies on the typical components of inspection, a struc tural and postural evaluation of the entire musculoskeletal
Types of Scoliosis Curves
apparatus, assessment of leg length, and a thorough neuro
The King classification is one of the more common systems
logic examination. Gait is evaluated in sufficient detail.
for categorizing scoliosis. Any cl assification is often an
Recently, Kramers-de Quervain et al. (2004) measured the abnormal gait patterns in their patients with adolescent
approximation rather than a rigid representation, given the large variability of the presentations (Table 14.11).
idiopathic scoliosis (left lumbar and right thoracic curve
More recently Lenke et al. (2001) introduced a new
pattern). While the timing of the individual gait phases and
three-component classification system based on the eval
the hip, knee, and ankle motion were all normal with
uation of standing coronal and lateral radiographs as well
respect to the sagittal plane, it was found that there was
as supine side-bending views. The three-component crite
significant asymmetry in trunk rotation within the trans
ria include a description of the curve type, a lumbar spine
verse plane with respect to a symmetric motion of the
modifier, and a sagittal thoracic modifier. According to
pelvis. These authors describe this as torsional offset to
these investigators, this new classification was found to
the line of progression. The magnitude of offset during the gait cycle correlated directly with the severity of the
be more reliable than the King classification, but they also noted that further studies are needed to determine the new
thoracic deformity and with the standing posture. It was
classification's accuracy, reliability, and versatility. The sys
noted, however, that the range of rotational motion was
tem by Lenke et al. appears to underscore the complexity
not affected by the severity of the deformity.
and variability of the different vertebral deformities, with their individual presentations, biomechanical challenges,
The forward-bending test of the trunk is one of the hallmark tests for scoliosis as it is very sensitive. landmark
and different opinions about surgical approach.
comparisons are equally useful, especially in order to ob tain a general overview and for follow-along recordings. Currently the best tool to determine the presence and
Clinical Assessment of Scoliosis
magnitude of the disease is the standard posterior-anterior
Clinical Presentation
radiograph.
lateral idiopathic scoliotic deformities in the coronal plane can occur at any age (infantile and juvenile forms), but the
Inspection
most common presentation is the spinal deformity that
If sufficiently progressed, a noticeable vertebral rotation or
presents in the younger adolescent girl, at approximately
torsion about the longitudinal axis in the horizontal plane
10 to 16 years of age. Typically the deformity is the reason
is usually seen with scoliosis. The involved vertebral units
for the visit, which is often noted in a routine screening
typically rotate in the direction of the convexity and con
examination. When pain is the presenting reason in the
tribute to the visible prominence of a rib-hump on the
young child, one should be sure to rule out any sinister
same side as the convexity. For instance, with a scoliosis
pathology.
that has a right-sided convexity, the vertebrae are rotated toward the right. where the right rib and right transverse
Copyrighted Material
Spinal Deformities
processes are more prominent than on the left. Conversely,
prominent vertebra. However, this may be confirmed by
the spinous processes move in direction of the concavity. In
specific segmental motion testing because the first thoracic
our example, the motion direction would be to the left side.
vertebra can be the most prominent.
In clinical practice, however, it should be remembered that
Studies by Huysmans et al.
(2005) assist in the objective
the observation of motion behavior of the spinous proc
verification of observable changes. The future usefulness of
esses is relatively unreliable and underestimates the de-
routine clinical practice is yet to be determined.
gree of rotation, because the vertebral body and transverse
Radiographic Evaluation
processes undergo significantly greater rotation. Further inspection of the involved spinal region may
Standard radiographs consisting of both the postero
reveal a less accentuated thoracic kyphosis with an ele
anterior (PA)
vated shoulder on the ipsilateral side to the convexity.
which should include the cervicothoracic junction and
The patient's overall flexibility is evaluated by determin
(13 in.
x
36 in.
cassette) and lateral views,
the lumbosacral junction, and should be done with the
ing the ranges of motion in the cervical, thoracic, and
patient standing. Care must be taken to minimize radiation
lumbar regions, including flexion/extension, side-bending,
exposure to the gonads and the breasts. It may sometimes be helpful to obtain views while the patient side-bends in
and rotation. A focused neurologic examination, including a detailed
order to determine the rigidity of the thoracolumbar spine.
motor-sensory assessment, should be performed, not only
Based on the radiographic study, one is able to deter
in the initial examination but also routinely in periodic
mine the Cobb angle (Fig. 14.22). This angle is measured by
check-ups.
the intersection of two lines, upon which perpendicular
Again, it is emphasized that the typical presentation of
lines are constructed:
(1)
one line follows the superior
adolescent idiopathic scoliosis is not associated with pain.
end plate of the uppermost involved vertebra of the sco
If considerable pain is reported spontaneously or is the
liosis; and (2) the other line follows the inferior end plate of
precipitating reason for the medical visit, the history and
the most inferior involved vertebra.
examination should be careful in ruling out the possibilities
The Cobb angle is then recorded and used as baseline for
of space-occupying lesions, inflammatory or auto-immune
any future follow-up studies to determine the progression
disorders, a tethered spinal cord, or other sinister pathol
of the curve.
ogy.
Treatment of Scoliosis
Motion Testing; Trunk Forward- Bending Test The patient is requested to stand with the medial malleoli
Treatment for scoliosis is principally divided into nonoper
touching each other and the knees extended. With the
ative and operative care. In nonoperative approaches, the
hands together in front, both palms and fingers touching
mainstay components are a "wait-and-see" observation
each other, the patient is then requested to bend forward
period, the application of orthoses or braces, and exercise.
from the waist. The scoliotic curve becomes most prom
Despite various empirical claims, manual medicine techni
inent when the patient bends forward. This maneuver is
ques or approaches have not been shown to halt or even
known as the forward-bending test of the trunk. The test is
reverse the progression of a structural scoliosis. When they
quite sensitive test and thus clinically very useful.
are applied, the major goal is to address the regional spe cific segmental changes that have adapted or compensated
landmark Measurements
in response to the associated scoliosis. This may include the
A scoliometer can be utilized to measure the extent of the
region neighboring directly above or below the scoliosis, as
rib hump that is tested during the motion testing in the
well as regions quite distant from it. Another goal is to
forward-bending test of the trunk.
address the associated muscular changes, in an attempt
The levels of the trochanteric heights in comparison to
to normalize the balance between the tight or shortened
the levels at the iliac crest, the lower costal margin, and the
primarily tonic muscles and strengthen the weakened, pri
shoulders are valuable landmarks for recording postural
marily phasic muscles.
abnormalities. There may also be a functional or structural leg length
Nonoperative Treatment
discrepancy, which should be noted during structural
Nonoperative treatment consists of the following three
functional examination.
mainstays of treatment:
The spatial relationships between trunk and pelvis are best visualized by comparing the body posture against the plumb line, which is aligned with the seventh cervical vertebra, which in typical situations should be the most
1. 2. 3.
Wait-and-see observation. Orthotic management-bracing. Exercise.
247
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Selected Oinical Syndromes
Wait-and-See Observation •
20-25° -follow with serial radiographs every 6-12
•
If the curve changes by more than 5 ° (initial curve is 20°
months (skeletally immature patient). or greater), this should be followed up by spine surgeon.
Orthotic Management: Bracing The use of different orthoses to correct spinal deformities in one way or another has been an accepted practice in the standard orthopedic armamentarium. Howard et al. (1998) in their retrospective cohort study of 170 patients who had been fitted with different braces found the thoracolumbo sacral (TLS) orthosis to be superior in preventing curve progression in adolescent idiopathic scoliosis to the Mil waukee or Charleston braces. More recently, the effectiveness of braces has been questioned. Goldberg et al. ( 2002a,b) conclude that if brac ing does not improve prognosis significantly, its efficacy cannot be accepted. In a study of 136 patients (Ugwonali et aI., 2004), it was shown that brace wearing did not decrease the quality of life of adolescents compared with their ob served counterparts who had not been fitted with braces. A recent study (O'Neill et aI., 2005) suggests that over weight patients with adolescent idiopathic scoliosis will have greater curve progression and less successful results following orthotic treatment than those who are not over weight. The same autllOrs conclude that the ability of an orthosis to transmit corrective forces to the spine through the ribs and soft tissues may be compromised in over weight patients. This factor should be taken into consider ation when making treatment decisions. Additional study is warranted to determine a threshold effect.
Fig.
14.22 Measurements used in the evaluation of idiopathic sco·
liosis, employing the angle method of Cobb. The angle is measured as follows:
1. Draw a line along the superior surface of the uppermost in Exercise
volved vertebra.
Exercise is used as an adjunct to minimize potential com pensatory changes, regionally or globally, by trying to keep the spine as flexible and strong ("stable") as possible. Exercises have not been shown to prevent the progres sion of an already existing
or newly developing curve.
2. Draw a line along the inferior surface of the lowermost involved vertebra.
3. Construct perpendicular lines onto the lines constructed in steps (1) and (2). 4. Measure the angle with respect to the horizontal. Note: The rotation of the vertebrae can actually "move" beyond the involved region.
Electrical Stimulation While historically a number of smaller-sized studies have supported
well
that the classifications and treatments of pediatric spinal
designed study found no statistical difference in outcome
the
use
of
electrical
stimulation,
a
deformities have evolved since the distraction instrumen
between patients in the electrical stimulation treatment
tation introduced by Harrington. Surgical approaches rang
group and those who had
ing from anterior-spine instrumentation systems and seg
110
treatment at all (O'Donnell et
al.,1988).
mental fixation to the recently introduced the pedicle
Surgery
lution. According to these authors, the pedicle-augmented
screw-augmented fixation approach demonstrate the evo Once surgery is indicated, there are many surgical techni
fixation approach promises to shift, once more, the stand
ques, approaches, and hardware options available with
ard of surgical therapy.
encouraging innovations. Wiggins et al. (2003) point out
248
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Spinal Deformities
Winter and Lonstein (2003) conclude from their retro spective case report after a 63-year follow-up that true outcome studies cannot be ascertained at 2-year follow up or even at a 10-year follow-up. The primary goals of treatment are as follows (An, 1998):
Table 14.12 Spinal deformities in the sagittal plane (e. g., exagger ated or diminished kyphosis or lordosis)
Postural Scheuermann disease Congenital
1. Prevention of curve progression. 2. Maintenance of balance: if the patient is to undergo surgery, spine and pelvic balance are more important than curve correction.
•
Defect of formation
•
Defect of segmentation
•
Mixed
•
Congenital (present at
Neuromuscular Myelomeningocele
birth)
3. Maintenance of respiratory function.
•
5. Cosmesis.
Developmental
(late pa ralyti c )
4. Reduction of pain and preservation of neurologic status. Traumatic
Natural History of Scoliosis: Factors Contributing to Curve Progression A number of variables have been incriminated in contribu ting to the progression of the scoliotic curve. There is an
•
Po stirradi atio n
•
Neuroblastoma
•
Wilms tumors
Metabolic
increased risk associated with sex, as females are affected more frequently. There is clearly a greater risk of progression in curves of
Postlaminectomy
Postsurgical
•
Osteoporosis
•
Osteomalacia
•
Osteogenesis imperfecta
Skeletal dysplasia
greater magnitude at time of first presentation. For in
Collagen disorders
stance, a 20' curve is at lesser risk of progress than a 45'
Tumors
Marie - Strumpell dise ase
curve. Skeletal maturity as correlated with the patient's age is a significant contributing factor: that is, the younger the patient the greater the risk of curve progression. what otherwise would be considered a normal kyphosis in
Progression
the thoracic spine, or lordosis in the cervical and lumbar
Studies of the natural history of adolescent idiopathic sco
spine (Table 14.12).
liosis reveal that a number of factors are of predictive va lue
When standing erect, the sagittal plumb line should
in assigning risk for progressive curvature and subsequent
ideally cross the individual's cervicothoracic (C7-Tl) and
deformity and/or morbidity (Gunnoe, 1990). These include
thoracolumbar junctions (T12-L1). Thus, when viewed
the age at the time the diagnosis is first made, the stage of
from the side, the anterior convex curve (lordosis) in the
skeletal maturity, and magnitude and pattern of curvature
cervical and lumber spine may become more pronounced
(Cobb angle). A recent study confirmed these prior notions,
or more flattened. In the thoracic spine, the posterior con
supported by the specific findings in a subgroup that had
vex curve, the kyphosis, can become prominently accen
actually discontinued bracing (Goldberg et aI., 2002a,b).
tuated or reversed. Senile kyphosis, adolescent postural
The goal in scoliosis surgery is to reduce curvature and
round back, and Scheuermann disease are examples of an
to create a stable framework on which vertebral fusion can
abnormally increased thoracic kyphosis. Exaggerated ky
occur so as to reduce curve progression and to minimize or
phosis may be smooth and continuously rounded, as is
prevent secondary changes such as respiratory complica
typically seen when several adjoining vertebrae are in
tions.
volved. An angular formation, described as a gibbus (Latin "hump") deformity, is more typical of vertebral collapse due to osteoporosis and associated fracture, neoplasm, or
Changes in the Sagittal Plane:
infection.
Kyphosis and Lordosis Spinal deformities in the sagittal plane result from distor tions of the normal anterior-posterior relationships of the
Scheuermann Disease: Juvenile Scoliosis This disease represents an accentuation of the normal
spinal curve. Any direction can therefore become exagger
thoracic kyphosis with adaptive changes in the cervical
ated, resulting in either an exacerbation or flattening of
and lumbar spine secondary to anterior wedging of the
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Selected Clinical Syndromes
vertebrae in the adolescent. It is a growth disorder that
is more typical for patients who have lumbar spine involve
involves several vertebrae and leads to an overall loss of
ment. Again, this is different from the adolescent idiopathic
flexibility in the involved spine secondary to developmen
scoliosis, which typically does not present with initial pain
tal abnormalities in the cartilaginous end plate. InScheuer
unless there is a concomitant co-morbidity or sinister path
mann disease there are abnormal vertebral pressure rela
ology present.
(1) abnormal compressive loading abnor
There may be a history where the deformity had been
malities anteriorly disrupting end plate function and thus
noted for some time and had not responded to a self
stunting normal growth; and (2) increased posterior ten
initiated exercise program. One of the frequent parental
sion stress leading to hypertrophy. Thus a vicious cycle is
complaints is that their child is unable to stand up straight,
being set up. In addition to changes seen in the cartilagi
unable to assume a good "military position."
tionships with:
nous
vertebral
end
plate,
such as irregularities and
Schmorl's nodes, and compression of the vertebral body,
Examination
there is later disk prolapse, all of which again contributes to
The patient's thoracic kyphosis is exaggerated. Normal
the anterior wedging of the vertebrae.
thoracic kyphosis ranges between 20° and 45°.
Etiology
of the lumbar spine.
There may be adaptive or compensatory hyperlordosis Although the etiology remains unknown, various factors have
been
incriminated
including
endocrine
factors
(growth disturbance during puberty), familial and congen ital factors (assumed),
nutritional factors
Neurologic examination is usually unremarkable unless severe progression or significant pain is reported, requiring further work-up in some cases.
(nontropical
No special tests are necessary.
sprue), and postural abnormalities associated with me chanical abnormalities. The latter, however, are probably
Radiographic Examination
the consequence of the vertebral changes rather than bei ng
The lateral radiograph and the postero-anterior view of the
a causative factor.
entire thoracic spine together provide the diagnostic clues to substantiate the diagnosis:
Pathogenesis The underlying pathology is thought to involve develop
1. Exaggerated thoracic kyphosis measuring more than 45° (using Cobb angle measurement techniques) with
mental abnormalities of the cartilaginous end plate. With disruption of the end plate, there is stunted vertebral
noticeable anterior wedging of at least three adjacent
growth and a shift in load sharing with wedge-shaped
apical thoracic and/or lumbar vertebrae. The wedging should measure at least 50 or more.
abnormalities. The shape changes associated with continued abnormal load is summarized by the Hueter-Volkmann law of phys
2. Irregular appearance of the vertebral end plate.
3. Schmorl's nodes.
eal growth. With a narrowed intervertebral disk, there is increased anterior loading. Also observed is a thickened
Differential Diagnosis
and tightened anterior longitudinal ligament. Disruption
•
Ankylosing spondylitis.
of the intervertebral disk and vertebral end plates may
•
Fixed kyphotic deformity due to paralysis.
result in penetration of the vertebral body by disk material.
•
Inflammatory changes affecting the spine.
This is thought to lead to the formation ofSchmorl's nodes,
•
Neurofibromatosis.
a phenomenon readily visible on radiographs. Continued
•
abnormal loading stress may lead to structural change of
Postural kyphosis (radiographic findings are typically minimal).
the entire vertebra, which changes shape from a rectangu
•
lar outline (lateral view) to wedge-shaped, with the ante
•
Tuberculosis of the spine (Pott disease).
rior portion significantly narrower than the posterior por
•
Vertebral fracture (trauma, metabolic disorder).
Space-occupying lesions of the spine.
tion. Thus, the formation of the kyphotic posture is due to a
Treatment
mismatch between the anteriorly narrowed and posteri
Similarly to the treatment of adolescent idiopathic scolio
orly maintained vertebral height.
sis, the conservative treatment relies on exercise and or thotic prescription/bracing while keeping a watchful eye
Clinical Presentation
on the potential progression. Especially recommended are
The adolescent presents to the office primarily for two
swimming and guided extension exercise regimens coor
(1) the noticeable deformity; and/or (2) the pres
dinated with pelvic tilt exercises and abdominal strength
ence of pain in up to half of the patients. Pain presentation
ening. Maintaining as much flexibility in the spine as pos
reasons:
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Spinal Deformities
sible. including the adjoining regions. should be a central
If the patient is skeletally immature and the curve is
goal. Also. stretching of the pectoralis muscle is indicated as
greater than 50°, treatment utilizes a Milwaukee brace
they are often shortened.
until maturity is reached (Frymoyer, 1993).
Manual medicine approaches have not been reliably
Surgical intervention is indicated when there is intoler-
shown to arrest curve progression. especially if advanced.
able pain. neurologic deficit, and/or severe deformity with
However. an individually tailored program to maintain
curves measuring more than 75°. A trial of bracing may
flexibility of the tonic. and typically shortened. muscles is
have been utilized as a "last conservative attempt" measure
of importance. Treatment should also address the compen-
prior to proceeding with surgery.
satory changes associated with the primary disorder, which
The surgery involves anterior release and spinal ar-
may be in areas quite distant from the kyphosis. e.g., upper
throdesis. or posterior arthrodesis with instrumentation
cervical spine or lower limb. especially if associated with
to accomplish permanent correction (Frymoyer, 1993).
tight hamstrings. for instance.
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Selected alnlcol
Syndromes
Clinical Disorders and Syndromes
be it in showing through gestures, writing with a pen or computer, composing on a musical instrument, or changing
of the Upper Limb
a blank canvas into a painted landscape.
General Comments
"touching someone" that the physician communicates di
It is through the use of the hand and the act of disciplined rectly and professionally with the patient, affecting changes that might not be accomplished simply through the spoken The upper limb comprises the shoulder-elbow-wrist com
word. In this sense then, the physician who uses his or her
plex, and functionally should be viewed as one mobile unit.
hands judiciously in the diagnostic and therapeutic process
Mobility is favored over stability, especially in the shoulder,
acts within the context of holistic ("whole-istic") care and
which is the most mobile of all of the joints in the human
caring and, when fortunate, even some curing. Indeed,
body (Kapandji,
"wearemoreconnectedthanwe/lOvebeenledtobelieve."
1982).
Upper limb function is viewed as a four-phase process that includes the following specific components:
Below, common disorders of the upper limb are presented as encountered in clinical practice. The goal is not to be exhaustive in all aspects for all disorders known, but
1. Reaching
rather to present a coherent overview that allows integra
This activity allows placement of the hand upon the
tion into one's management of those disorders when they
desired spatial target.
are encountered in musculoskeletal and manual medicine
2. Carrying
practice.
This activity, like reaching, allows placement of the hand upon the desired spatial target while at the same time securing transportation of an externally applied load.
The Shoulder
3. Prehension patterns This activity is a description for hand function, which
Common Shoulder Disorders
consist primarily of three components, namely, pinch ing, grasping, and hooking.
4. Releasing
The following common shoulder disorders are described in
After holding an object with one's fingers, the voluntary
this section:
release of the held object is the final action in hand function. It is accomplished by the extensor action of the
•
Disorders associated with humeroscapular periarthr opathy complex:
thumb and fingers, and little active strength is required for the release. However, if release cannot be initiated
-
actively within the desired parameters, hand function is
-
Rotator cuff tear.
severely impaired if not rendered ineffectual.
-
Calcifying tendinitis.
-
Adhesive capsulitis.
Beyond this four-phase activity, the use of the hand is what
•
Common rotator cuff tendinopathy (tendinosis).
Glenohumeral arthritis.
gives life to the majority of the expression of our cognitive
•
Arthrosis of the acromioclavicular joint.
and creative activities: the hand serves as the most versa
•
SLAP lesions.
tile "translator" of our thoughts in a most efficient manner,
•
Shoulder (glenohumeral) instability.
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Common Shoulder Disorders
Common Rotator Cuff Tendinopathy ("Tendinosis") Synonyms and Related Terms
Key Points
• • • • • • •
Common or uncomplicated humeroscapular periarthropathy. Rotator cuff impingement. Rotator cuff injury. Rotator cuff tendonitis/tendinosis. Shoulder impingement (internal) syndrome. Shoulder pain. Swimmer's shoulder.
• Degenerative changes of rotator cuff with tearing, usually due to overuse. • Frequently due to or associated with impingement syndrome, in particular with a curved acromion, and resulting from a vicious cycle of use-irritation-impingement-tear-re-use ...
• Progressive course may be demonstrated in patients as early as 30-40 years of age. • Pain typically upon movement or against resistance: possible night pain. • Painful arc-between 700 and 1200 of abduction and forward flexion. Clinical Pearls
• Remember that not all full-thickness tears are painful. • Up to one-third of patients with rotator cuff tears may have no pain. • Consider the subacromial bursa as source of pain due to the significantly higher number of nerve endings in the bursa.
• Consider the cervical spine as a source of referred pain (spondylosis, disk hemiation, spinal stenosis, muscle imbalances).
• Patients may report night pain. • Utilize the Neer and HawkinsJjobe tests. • Utilize additional manual medicine examination techniques in the parascapular region and look for compensatory body changes elsewhere.
• lidocaine injection to the subacromial bursa may give some relief (confirms impingement). • Treat the entire patient (vocational and avocational goals). Prevalence
• Peak age: 40-45 years.
Pathology/
• Degenerative tendon changes resulting from overuse or trauma • Thickened tendon narrows the otherwise free passage at the anterior acromion and
Etiology
coracoacromial ligament.
• • • •
May involve any portion of the tendon as partial or complete tears. Tendinotic changes ("tendinosis") typically in absence of signs of inflammatory reaction. Thus the preferred term is "tendinosis" rather than "tendonitis." Consider subacromial bursa involvement, especially in light of it having significantly more free nerve endings
Clinical Presentation
(10-20 times more) compared to the cuff tendon (Vangsness et aI., 1995).
• Pain is often of insidious onset, typically in absence of any identified recent trauma. • With advancing age there is significantly greater frequency and intensity of this disorder (peak age 40-45 years). • Particularly increased in athletes who use the arm overhead (baseball, tennis, swimming, weight lifting, etc.).
• Associated with repetitive strain syndromes (e. g., overhead activities). • Patient may complain about pain located in area between the acromion and the deltoid muscle insertion.
• Pain may be worse at night, and it is difficult for the patient to lie on the incriminated side. Functional Information
• Pain may be tolerated ("toughed out") by the patient until particular functional activities have clearly become affected.
• loss of ability to do usual work or avocational activities. • Difficulty donning shirt, sweater, etc., and performing other routine activities of daily living (ADls).
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Selected Clinical Syndromes
Common Rotator Cuff Tendinopathy ("Tendinosis") (cant.) Examination/
•
Neer test (modified Neer test)-positive (Fig. 14.23).
Special Tests
•
Hawkin's test-positive (Fig. 14.24).
•
Painful arc between 70° and 120°.
•
Absent interscapular pain or pain with cervical movement to differentiate from cervical spine disease. (Note: If the patient has cervical disk disease. with disk herniation to the right and associated symptoms. the patient may present with the ipsilateral arm placed over the head to reduce symptoms.)
Diagnostic Adjunctive
Plain Radiographs
Studies
•
Typically the initial imaging study of choice. when indicated.
•
May help exclude sinister pathology. overt dislocation. or trauma.
•
Usually limited information about the tendinous involvement except in chronic situation where there may be sclerosis at the greater tubercle or the undersurface of the acromion.
Ultrasound •
Imaging of bicipital. subscapularis. supraspinatus and infraspinatus tendons. subdeltoid bursa. humeral surface. and spinoglenoid notch.
•
Subacromial space not visualizable.
•
Most useful to evaluate for tendon tears. or to guide accurate needle placement for injections.
•
Sensitivity and specificity for tears are highly dependent on the sonographer' s skill level.
MRI •
Suspected rotator cuff involvement is one of the most common reasons for ordering MRI of the shoulder.
•
Tears are best visualized on coronal and sagittal views. - --
Treatment Options
..._ .. -
Conservative Approaches including Manual Medicine Approaches •
Appropriately designated physical therapeutic management with specified activity restrictions and functionally based goals.
•
Manual medicine approaches emphasizing functional return of the entire cervical spine trunk-upper limb complex.
•
Manual medicine techniques address regional deficits as well as specific dysfunctions associated with a particular articulation. including rib dysfunctions and muscle imbalances.
•
Pharmacologic supportive care (e. g
•
Steroid injection into the subacromial space.
.•
acetaminophen. NSAIDs. etc.).
Surgical Considerations
Differential Diagnosis
•
Acromioplasty (subacromial decompression).
•
Calcific tendonitis.
•
Rotator cuff tear.
•
Intratendinous cyst (typically associated with partial rotator cuff tear).
•
Myofascial pain syndrome. in particular the supraspinatus. infraspinatus. teres major and minor muscles. pectoralis minor major muscles. and the levator scapulae. among others.
•
Rib dysfunction(s) (may present with shoulder pain only. especially upper ribs).
•
Referred pain from the cervical spine (spondylosis. disk herniation. spinal stenosis).
•
Referred pain/pseudo-shoulder pain of visceral origin: - Pancoast tumor - Gallbladder (right shoulder) - Cardiac (left shoulder) - Other
Prognosis
In the uncomplicated course. improvement is usually seen in 3-6 weeks. If objective and functionally meaningful progress is not seen in a reasonable time frame. or there is continued significant pain. the goal of the reevaluation is to determine potential alternative sources of the pain and functional loss.
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Common Shoulder Disorders
Fig. 14.23 Modified Neer test, evaluating passive internal rotation.
Fig. 14.24 H awkins test: exaggeration of passive internal rotation and adduction.
- In a randomized, single-blind study of 198 patients, it
Commentary •
•
The key to successful management rests in addressing
was determined that in the treatment of shoulder
pain and functional deficits in as comprehensive a
gird Ie disorders manipulation seems to be the pre
manner as possible with realistic, patient-specific goals
ferred treatment. For synovial disorders, however,
(vocational and avocational) over a specific time frame
corticosteroid injection seems the best treatment. In
with ongoing monitoring if goals are being achieved.
the manipulative group, the duration of complaints
Remember that patient expectations and preferences
was significantly reduced after manipulation (Win
may affect outcome (van der Windt and Boulter, 2003).
ters et aI., 1997).
Manual medicine treatment may assume an important
•
While commonly encountered in daily medical practice,
role in the management of shoulder symptoms when
the clinical diagnosis is also partly dependent on the
appropriately coordinated within the entire patient
point of contact with the health care system: that is,
management:
whether the individual practitioner's or clinic's ap
- In a randomized, controlled trial of 150 patients with
proach to the various musculoskeletal syndromes is
shoulder symptoms and dysfunction of the shoulder
through a rheumatologic or physiatric practice versus
girdle, manipulative therapy for the shoulder girdle
that of an orthopedic surgical practice or a family prac
in addition to usual medical care was shown to ac
tice, for instance.
celerate recovery of shoulder symptoms compared with patients assigned to usual care alone (Bergman et aI., 2004).
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Selected Clinical Syndromes
Rotator Cuff Tear Synonyms and Related
•
Terms
•
Musculotendinous cuff rupture. Pseudoparalytic humeroscapular periarthropathy (as it may be difficult to initiate or carry out shoulder abduction due to supraspinatus involvement, for instance).
Key Points
•
Rotator cuff rupture.
•
Supraspinatus tear/rupture.
•
Chronic situation: progression of degenerated tendon (precursor: existing impingement) to the point of rotator cuff tear.
•
Acute situation: due to sudden mechanical overload/trauma.
•
Routinely noted on MRI in distal tendon or the "critical zone."
•
Rupture may be intramural ("partial") or transmural (full thickness).
•
Typically the tendon of the supraspinatus muscle is involved.
•
Rotator cuff tears become progressively more common with advancing age, to the point where most patients in their 70s and 80s have some form of rotator cuff tearing.
•
Despite the finding of tears, upper limb function may not be prominently impaired in some patients.
Clinical Pearls •
Full-thickness tears may not actually be painful.
•
Assess for rotator cuff tear by good muscle strength testing:
1. Drop arm test (lower abducted arm slowly: if unable to do so slowly, consider positive test unless other interfering factors are present). 2. In large rotator cuff tears note that there is prominent weakness in external rotation.
3. Make sure to evaluate the shoulder rotator muscles (trapezius and serratus anterior muscles; for the latter, check for presence of "winging of scapula"). 4. Special tests include drop arm test, Neer's and HawkinS-Kennedy test, as well as lobe and Blackburn tests (supraspinatus testing). • •
Up to one-third of patients with rotator cuff tears may not experience pain. Consider the subacromial bursa as a source of pain due to the significantly higher number of nerve endings in the bursa.
•
Compensatory motion in favor of scapulothoracic motion and simultaneous reduction in glenohumeral motion may lead to a further vicious cycle of "enlarging" compensatory regions to the neck, trunk, and entire body (thus: check which motion is most impaired and which one is most favored).
•
Thorough clinical evaluation and appropriate individualized goal setting for every patient is key.
•
No statistical relationship was found between the level of pain and disability and the size and location of full-thickness tears of the rotator cuff (Krief and Huguet, 2006).
Prevalence
•
More common in men, with peak age between 45 and 55 years (median age for surgical repair is
•
Incidence of full-thickness tears is 5-25% in cadaver studies.
•
Degenerative changes due to overuse with intramural and transmural tears (usually the portion
•
Usually resulting from overuse associated with glenohumeral instability or an already existing
age 55).
PathologyJ Etiology
proximal to the joint). impingement syndrome, especially with a curved acromion.
Clinical Presentation
•
May occur in collagen vascular disorders where there is tearing of other involved tendons.
•
Patient may be unable to sleep on the incriminated side.
•
Pain, similar to the rotator cuff tendinosis, is usually insidious in onset, but is more typically associated with trauma, especially in the younger patient.
•
In the elderly patient, what would otherwise be considered "trivial" trauma can lead to a spontaneous rupture.
•
Pain may involve the upper arm but typically does not "refer up· to the neck (which may be the
•
In the advanced stage, it may be difficult to clinically differentiate a rotator cuff tear from
case when there is acromioclavicular joint pathology). adhesive capsulitis or other shoulder tendinopathies, as the various forms may coexist. Functional Information
•
Reduction or loss of usual functional activities may be the actual reason why a patient decides to come to the medical office.
•
Reduction in ability or inability to perform overhead activities or usual sports activities.
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Common Shoulder Disorders
Rotator Cuff Tear (cont.) Examination/
•
Painful arc of movement between 70° and 120°.
Special Tests
•
Pain is typically worse with abduction and elevation.
•
Crepitus at the anterior edge of the acromion.
•
Possible gap of up to 1-2 cm with the arm adducted and induced humeral rotation about its longitudinal axis.
•
Positive drop arm test (arm abducted to 90° and patient is requested to lower slowly; positive if unable to do so slowly or arm "drops").
Diagnostic Adjunctive/
•
Positive Neer test/modified Neer test (for impingement).
•
Positive Hawkins-Kennedy test (impingement).
•
Positive Jobe "empty can" test (supraspinatus tear).
•
Positive Gerber lift-off test (subscapularis test).
•
Positive Speed and/or Yergason test (biceps tendon).
•
Palm up test.
•
MRI is today the study of choice (best visualized with fat-saturated fast spin-echo T2-weighted images).
Imaging Studies •
There may be fatty atrophy of the incriminated muscle (chronic stage).
•
Tears are best visualized on the coronal and sagittal views.
•
Plain-film arthrogram to demonstrate the extent of contrast fluid extravasation.
•
MRI arthrogram in specific circumstances.
•
Potential risk of ·overinterpretation" when using MRI studies; thus clinical correlation and thorough history and examination remain key components of diagnostic work-up.
Treatment Options
•
Treatment is based not only on the diagnosis itself but should consider the following factors: - Location and extent of the rotator tear. - Patient age and vocation. - Reported pain perception. - Patient expectations. - Patient preferences.
•
Except where surgery is indicated from the beginning. the course of treatment consists of individualized physical therapeutic management. Initial treatment may consist of passive modalities. However. active treatment should be initiated as soon as possible and tailored to the individual patient's needs.
Manual Medicine Treatment •
Manual medicine approaches may be of significant benefit both initially and in the subsequent course of treatment to address secondary adaptive or compensatory in the AC and SC joints as well as potential changes in the cervical spine. the trunk and/or the remainder of the upper limb.
Differential Diagnosis
Prognosis
•
Acromioclavicular arthropathy.
•
Adhesive capsulitis.
•
Impingement syndrome with partial rotator cuff tear.
•
Intratendinous cyst.
•
Myofascial pain syndrome.
•
Entrapment of the infraspinatus nerve.
•
Lesions that involve the supraspinatus tendon "only" do not carry the same prognostic significance as when either the infraspinatus and/or the subscapularis muscles are also involved.
Involvement of Infraspinatus and/or Subscapularis Muscles •
Both of these muscles. and in particular the subscapularis muscle. are very important in maintaining shoulder joint stability.
• •
When they are involved. there is prominent loss of normal shoulder function. Potential formation of painful cuff arthropathy with formation of pseudoarticulation between the head of the humerus and the acromion (thinning of acromion on plain radiographs. for instance).
•
Further Reading
Subscapularis tears require earfy intervention due to potential for irreversible retraction.
Gerdesmeyer L et al. Extracorporeal shock wave therapy for the treatment of chronic calcifying tendonitis of the rotator cuff: a randomized controlled trial. JAMA.
2003;290:2573.
Grant HJ et al. Evaluation of interventions for rotator cuff pathology: a systematic review.
J Hand Ther.
2004; 17:274. Luime JJ et al. Does this patient have an instability of the shoulder or a labrum lesion? JAMA.
2004;292:1989.
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Selected Clinical Syndromes
commentary Three major considerations influence the management of a rotator cuff tear, namely:
•
The location and extent of the ruptured tendon or ten dons.
•
The patient's age and vocational activity requirements.
•
The patient's pain and impact on overall function (ac tivities of daily living. avocational interests, personal goals. etc.).
Location and Extent of the Ruptured Tendon or Tendons Lesions that are restricted to the supraspinatus tendon only do not hold the same prognostic significance as when the infraspinatus and/or the subscapularis tendons are in volved. The infraspinatus and subscapularis muscles are very
Fig. 14.25 Rotator cuff arthropathy with pseudo-joint formation between the acromion and the humeral head. There are sclerotic changes of the adjacent osseous joint partners. Significallt thillning of the acromion.
important in securing shoulder joint stability. When the tendons of these muscles are torn. there is typically a significant loss of shoulder function. Due to the accompa nying change of position of the head of the humerus within the joint. a painful cuff arthropathy may also develop (Fig.14.2S). Rupture or complete tears of the subscapularis muscle call for early intervention as the muscle typically tends to retract immediately and may therefore be injured irrever sibly. Patient Age and Vocational Activity Even if there is extensive tearing of the rotator cuff. it is our experience that many elderly patients and patients who have stopped working prefer not to undergo a surgical procedure. as long as they feel they can "live with the pain."
Fig. 14.26 Degenerative rupture of the supraspinatus tendon with avascular margins (intraoperative findings).
However, if the pain interferes with a person's sleep, including patients older than 65 years, surgery may be indicated. In fact, sleep difficulties due to pain are one of the most frequent reasons for proceeding with surgery. Younger patients whose jobs require little physical de mand on the upper limbs may also not require surgical intervention. However. due to the natural tendency of ro tator cuff tears to enlarge over time (Figs.14.26 and 14.27). the decision to undergo surgery sooner rather than later is dependent on a number of factors. including the impact the pain has upon the patient's vocational and avocational functioning, and individual goals in regard to overall activ ity requirements. Pain, in the end, may be the deciding factor. Fig. 14.27 Massive rupture of the supraspinatus tendon with sig
Pain and Function Patients over the age of 55 years are best treated initially with appropriate medications and four to six weeks of individualized conservative care that includes well-dosed
nificant retraction of the muscle and tendon as well as of the infraspinatus tendon and proximal involvement of the subscapu laris muscle and secondary degenerative changes (intraoperative findings).
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Common Shoulder Disorders
physical therapy and/or manual medicine approaches with
ities, the ability to sleep t h roug h the night, dressing and
appropriate exercise instruction.
feeding (activities of daily living [ADLs]), and others.
If there is documented improvement in the patient's
Patients younger than 55 years of age, and whose symp
pain while the projected functional outcome has not been
toms appeared in the absence of any significant trauma,
reached despite appropriate therapy, an additional 3-6-
can be treated in a similar manner. The likelihood of spon
week course of physical therapy/manual medicine treat
taneous pain is directly related to the patient's age. That is,
ment may be indicated, as long as there is documented
in the absence of known trauma, significant pain is much
improvement. The decision to extend treatment should be
more common in the elderly patient than in the younger
based on objectively verifiable examination findings (e. g.,
patient. Furthermore, if there is clear improvement in the
improvement in range of motion measurements, improved
patient under 55 years of age, and if the vocational and
muscle tone, and fewer substituted motion patterns).
recreational activities are not particularly demanding
Equally important to the assessment of the "measured"
physically, an additional course of skilled and supervised
treatment response (e. g., range of motion), is the patient's
treatment may be indicated as long as objective and func
functional ability, such as the ability to drive, a reduction in
tional gains are occurring within the anticipated outcome
pain medication usage, the ability to maintain a certain
goals.
posture, the return to performing previously limited activ-
Calcifying Tendinitis of the Shoulder Synonyms and Related Terms
Key Points
•
Calcareous tendonitis.
•
Calcific tendinitis or tendonitis.
•
Calcific tendinopathy.
•
Calcifying supraspinatus tendonitis.
•
Hyperalgetic humeroscapular periarthropathy.
•
Tendinitis calcarea.
•
Calcific tendinitis is a clinical diagnosis more than a radiographic diagnosis (see below).
•
It is typically of sudden onset and associated with most severe pain that is neither activity- nor position dependent.
• •
This disorder may be clinically silent for years, especially if the calcified focus remains small. Pain is typically unrelated to shoulder/arm position or a particular activity within the active phase of the disease.
•
Common cause of shoulder pain especially in the younger patient, with peak incidence between the ages of
•
Calcium hydroxyapatite deposits, which become symptomatic, are typically located approximately 1-2 em
•
The cause is essentially unknown but the tendinous tissues may have undergone degenerative changes due
30 and 50 years. proximal to the tendon insertion on the greater tuberosity. to ongoing friction or due to decreased local oxygen tension. Thus the cause may be a combination of chemical, inflammatory, and mechanical factors. •
The supraspinatus tendon is most frequently involved, followed by the tendon of the infraspinatus, teres minor, and subscapularis muscles.
• •
Several tendons may be affected Simultaneously. Bilateral involvement is not uncommon (some figures are as high as nearly 50% of patients with findings of significant calcium deposits).
•
Therapeutic management takes into account the potential for spontaneous resolution of the painful episode.
•
During chronic phases of the disease symptoms of impingement are prevalent.
Clinical Pearls •
Clerical workers and housewives account for most cases.
•
Calcific deposits may occur in both shoulders in up to half of patients.
•
Trauma is not typically a major antecedent finding.
•
Usually not associated with rotator cuff tears.
•
Treatment is tailored to the individual patient'S presentation, expectations, and preference.
•
If conservative care fails to produce appropriate and realistic goals. surgery may be indicated on an individual basis. especially if activities of daily living or job performance are impaired.
Prevalence
•
Highest incidence is in persons aged 30-50 years.
•
5-18% of the general population.
•
Homemakers and clerical workers have the highest incidence.
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Calcifying Tendinitis of the Shoulder (cant.) Pathology,
•
little is known about the cause.
Etiology
•
Diminished oxygen tension has been implied.
•
InAammation may represent the response to tendon injury or may be the primary event.
•
Trauma is not typically a major antecedent finding.
•
May resolve on its own (in contrast to degenerative tendinopathy, where one rarely observes spontaneous resolution).
Clinical
History
Presentation
•
Functional
Pain may appear first in the morning upon awakening.
•
Course typically develops over 12-48 hours.
•
Pain is typically not improved with any particular positioning.
•
Symptoms of impingement in chronic (silent) course of the disease
•
Information Examination'
Acute onset of unbearable pain and associated loss of motion.
•
Patient reports significant loss in function of the involved limb with major impact on simple ADLs such as dressing, hygiene, meal preparation.
•
The patient enters the office with typical arm position close to the trunk, often supported by the noninvolved hand.
Special Tests
• The patient clearly avoids any type of movement. • Pain at the site of the calcium deposit (this is helpful in differentiating other similar diagnoses such as
impingement syndrome) (Fig. 14.28). Diagnostic
Radiographic Studies
Adjunctive'
•
Studies
Standard orthopedic radiographs reveal single or multiple calcium deposits around the greater tuberosity (Fig. 14.29).
Imaging
• MRI studies may not be as reliable in demonstrating the areas of calcification because of surrounding
edema (and therefore, may not help differentiate between a possible rotator cuff tendinopathy/tear). •
Ultrasound is more sensitive than radiography, but this is highly dependent on the skill of the sonographic operator and interpreting radiologist.
laboratory Studies •
Typically not needed in the initial work-up unless septic arthritis or bursitis are relevant components of the differential diagnoses.
Treatment
•
In general. the patient should be treated according to the clinical presentation rather than potential findings on radiographs.
Options •
"Needling" and aspiration to break up the calcium deposits may be very helpful. When the needling proves successful. the patient typically reports significant improvement in both pain and function (usually within
a
few days or a week). Thus the needling technique serves both diagnostic and therapeutic purposes: impingement syndrome and adhesive capsulitis do not respond so favorably to the needling technique. •
Extracorporeal shock wave therapy may be an effective but painful treatment option.
•
Pharmacologic approaches include acetaminophen, NSAIDs. etc.
Surgery •
Rarely needed.
•
Referral to surgeon after appropriate course of PT that has failed within a well- prescribed time period.
Manual Medicine and Rehabilitation •
Acute situation: rarely requires an extended supervised course of skilled physical therapeutic management other than learning a few compensatory strategies.
•
Short course of hands-on manual medicine treatment (e. g
.•
twice a week for 2 weeks followed by once a
week for 4-6 weeks) may be indicated based on objective findings that may include muscle imbalance and rib and thoracic or cervical spine dysfunctions. The goal is to address the already existing compensatory changes (other regions of the body), and to restore muscle balance with reduction of pain. High-velocity treatments, based on clinical experience, should be avoided and substituted by carefully applied soft-tissue or appropriate mobilization-without-impulse techniques. •
Subacute situation: careful planning of a skilled course of physical therapy is indicated with specific end points in mind. with graduation to an independent home exercise program as soon as possible.
Differential
•
Impingement syndrome (which is typically of more gradual onset, sometimes with night pain. and pain with
•
Adhesive capsulitis (which has more gradual onset-e. g weeks-with typical loss of both active and passive
Diagnosis
overhead activities. and little pain when shoulder is held stationary). .•
range of motion). Prognosis
•
Overall favorable.
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One of the major considerations whether the younger patient (less than 65 years of age) is a candidate for surgery is whether the involved muscle or muscles are expected to retract (e.g., especially the infraspinatus and subscapularis muscles), which would negatively impact upon the pa tient's ability to perform his or her usual physical job duties. Surgery typically includes the reattachment of the ten don to bone and the use of an anterior acromioplasty to enlarge the subacromial space. This may require resection of the acromioclavicular joint.
Fig. 14.28 Pronounced calcification of the supraspinatus tendon with resultant impingement symptoms.
Adhesive Capsulitis Synonyms and Related Terms Key
Points
•
Frozen shoulder.
•
Stiff shoulder syndrome.
•
"Freezing" shoulder.
•
Inflammatory changes affecting the inferior shoulder capsule resulting in loss of range of motion to the point of absence of any motion (frozen shoulder).
•
If some motion is retained. the patient's presentation may be during the disorder's evolution ("freezing" shoulder).
•
Pain is typically present at the onset of the disease process.
•
Causes may be related to micro trauma in the shoulder in general.
•
The patient may present with a typical posture where the arm is held close to the trunk, so as to minimize pain.
•
Pain is often present in the partial shoulder stiffness state but usually appears after the glenohumeral joint is completely restricted.
•
Generally, after the course of 1-2 years, there is self- resolution (restitutio ad integrum).
•
The goal of treatment is to minimize the painful period and to maximize the healing quality.
•
The term was coined in 1934 by Codman.
Clinical Pearls •
Frozen shoulder has many points in common with many other shoulder problems including calcifying tendonitis (see above), impingement syndrome (see above), rotator cuff pathology (see above), subacromial bursitis and others and can be concomittant with those.
•
Distinguish whether it is due to known trauma (check for other areas of potential involvement/ dislocation/fracture) or is insidious onset.
•
In frozen shoulder passive range of motion is prominently and painfully restricted. while with rotator cuff tear/pathology the range is typically preserved.
•
The disorder is typically self-limited. which should not be equated with "nothing can be done:
•
It is important to prevent abnormal compensation in other body regions as soon as possible.
•
Patients with cervical spondylosis, diabetes mellitus, hyperthyroidism, and ischemic heart disease are aSSOciated with the development of adhesive capsulitis. Thus, it may be helpful to alert patients to take seriously any sign(s) attributable to frozen shoulder in order to initiate management as soon as possible.
Prevalence PathologYI Etiology
•
Incidence 10-36% among diabetics, 2-5% among the general population.
•
Pathology is primarily idiopathic but may be due to secondary trauma (e. g
.•
micro-trauma),
diabetes (micro-ischemia, dyslipidemia, glycosylation). or thyroid disease. •
The inferior capsule usually thickens and becomes indurated,
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Adhesive Capsulitis (cant.) Clinical Presentation
•
The patient may present with significant pain and difficulty of any movement in the shoulder. in particular abduction or extension.
•
Examination both active and passive may typically reveal significantly restricted range of motion.
•
Note: Frozen shoulder may appear either alone or in association with other diagnoses consistent with rotator cuff tendinopathy.
Functional Information
•
The patient may have waited for quite some time before deciding to be seen in the office with the hope that "things would resolve" by themselves.
•
Pain and/or loss of ability to do usual work or avocational activities often prompt the patient to
•
The patient may have significant loss of ADL abilities and thus may require assistance by a
see a physician. caregiver (e. g
.•
difficulty putting on or removing clothes. performing activities of daily living).
Examinationf
•
Active and passive restricted range of motion in all planes.
Special Tests
•
The patient may hold the arm with elbow flexed and shoulder adducted.
•
Motion in the spine is reduced in general as the patient typically moves "en bloc."
•
Neurologic examination is usually unremarkable.
•
Even in new-onset cases. there may already have developed sufficient muscle imbalance (e.g
.•
shortened tonic muscles and inhibited/weak phasic muscles). •
Addressing the muscle imbalance through stretching and loosening of the muscles. including trigger point injections. may help reduce the pain.
Diagnostic Adjunctivef
•
Initially. plain radiographs may be of no particular help.
Imaging Studies
•
MRI may be able to detect the thickening of the inferior capsule.
Treatment Options
ConservativefPharmacologlc Approaches and Manual Medicine Approaches •
An appropriately designed physical therapy course with specified activity restrictions may be the initial course. Modalities other than mild heat may not be useful.
•
Medications involve mainly NSAIDs.
•
The patient may benefit from intraarticular corticosteroid injections.
•
Suprascapular nerve blocks may be useful.
•
Manipulation under anesthesia may be a consideration.
•
Distension arthrography is controversial.
•
Arthroscopic capsulotomy is the surgical method of choice.
Surgical Considerations •
Adhesiolysis may be indicated.
•
Open or arthroscopic surgical approach may be necessary.
•
The goal of any treatment is to restore as much function as possible with minimal or no pain and full range of motion. ---_. _-
Differential Diagnosis
•
Impingement syndrome of the rotator cuff.
•
Rotator cuff tear.
•
Shoulder instability.
•
Myofascial pain syndrome.
•
Rib dysfunction especially ribs II and III on the ipsilateral side.
•
Fracture of the proximal humerus.
•
Complex regional pain syndrome.
•
Malignancy.
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Common Shoulder Disorders
Glenohumeral Arthritis Synonyms and Related
•
Arthritis of the shoulder.
Terms
•
Degenerative arthritis/arthrosis of the shoulder.
Key Points
•
Glenohumeral osteoarthritis.
•
Glenohumeral osteoarthrosis.
•
Omarthrosis.
•
Omarthritis.
•
This is a frequent presentation of periarticular shoulder joint and upper arm pain.
•
It is nevertheless relatively uncommon compared with other shoulder disorders.
•
It may present as secondary arthritis due to instability after surgical procedures.
•
Omarthritis may present in conjunction with rheumatoid arthritis.
•
Note that up to 50% of patients with chronic polyarthritis may develop lesions in the rotator cuff.
•
Primary forms of osteoarthrosis include polyarthrosis, chondrocalcinoses, and secondary posttraumatic changes after fractures and luxations/dislocations of the head of the humerus. (Fig. 14.29).
•
Pathology typically seen in a patient with generalized osteoarthrosis, osteoarthritis or chronic polyarthritis.
• •
Consequently, it is seen more often in the elderly patient. In the younger patient, if shoulder osteoarthritis is found, consider this to be posttraumatic, postoperative, or rheumatoid.
Clinical Pearls •
Key to the diagnosis is a thorough history and detailed physical examination, including a structural/functional examination.
Pathologyl
•
Humoral chondromalacia followed by osteophyte formation.
Etiology
•
Subchondral bone cysts.
Clinical Presentation
•
Synovitis.
•
Causes include degeneration, post trauma, and inflammatory arthritides.
•
Older patient: progressive pain is typically of insidious onset and in absence of any recent trauma.
•
Functional Information
•
Young patient: Onset typically after trauma or surgery. As with many shoulder disorders, the patient may tolerate the pain until particular functional activities are sufficiently affected (impairment of vocational or avocationaI activities).
Examinationl
•
Both anterior and posterior joint pain.
Special Tests
•
Possible muscle wasting.
•
Crepitus during induced motion.
Diagnostic Adjunctive
•
Loss of range of motion.
•
Thorough cervical spine examination essential.
•
Studies
Orthopedic radiographic series would be the reasonable next step after a thorough and physical examination that supports a diagnosis of glenohumeral arthritis. The special radiograph with axillary view (see Fig. 14.30) may show: - Marginal osteophytes and subchondral bone cysts - Flattening of the humeral head and joint space narrowing with/without irregularities - Loose bodies. - Glenoid erosion (mostly posterior) and posterior subluxation.
• •
a scan may be helpful to evaluate the posterior glenoid. MRI and ultrasound findings include synovitis and chondromalacia (thinning of the cartilage). These modalities are useful to inspect the rotator cuff. but beyond that there is rather limited added benefit in patients with glenohumeral arthritis.
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Selected Clinical Syndromes
Glenohumeral Arthritis (co nt ) .
Treatment Options
Conservative Approaches Including Manual Medicine Approaches •
The treatment depends on the etiology and severity of the clinical presentation, the patient's perceived pain, and the loss of function.
•
Nonsurgical treatment of osteoarthritis begins with range-of· motion, NSAID medication, and modification of activities.
•
Nonsurgical treatment of rheumatoid arthritis is the mainstay of treatment, and requires a multidisciplinary team including a rheumatologist.
•
Manual medicine approaches address both local and regional dysfunctions, with the goal of minimizing inappropriate compensatory changes in the peri scapular region, thorax, and cervical and lumbar spine (e. g., due to altered motion patterns secondary to painful or restricted shoulder motion).
Surgical Approaches •
Fractures require careful realignment. The patient may progress to develop avascular necrosis of the humeral head and an arthroplasty may be necessary.
•
In the early stages of synovitis in the patient with polyarthritis, either radiosynoviorthesis or arthroscopic synovectomy with radiosynoviorthesis after 6-8 weeks is indicated, assuming an intact rotator cuff.
•
Progression of a painful destruction may require arthroplasty. Best results are obtained with an intact rotator cuff. In primary osteoarthritis this is typically the case. For arthritic shoulders with irreparable rotator cuff tear inverse shoulder arthroplasty may be the treatment of choice.
Differential Diagnosis
• •
Cervical disk herniation. Charcot joint (neuropathic arthropathy due to loss of protection secondary to loss of neural function/denervation).
•
Fracture of humerus.
•
Inflammatory arthritis-polyarthritis.
•
Malignancy.
•
Septic arthritis (see Charcot joint above; this may be mistaken for septic arthritis, but the joint
•
Synovitis.
aspirate is negative with a Charcot joint). •
In general. when the above generalized arthritis or synovitis is considered, there are usually other joints involved as well rather than a singular shoulder joint.
�------�"I--
Fig. 14.29 Multifocal calcifications within the rotator cuff, which
Fig. 14.30 Three- dimensional reconstruction using (T a fter multi
may be expected to resolve only after a number of spontaneous
ple fractures of the proximal head of the humerus.
exacerbations.
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Arthrosis of the Acromioclavicular (AC) Joint Synonyms and Related
•
Arthritis of the AC joint.
Terms
•
Dysfunction of the AC joint.
Key Points
•
The AC joint is often impressively painful upon palpation.
•
Pain may be identified by patient specifically to the AC joint. (Fig. 14.31).
•
It may present as a primary arthrosis or secondary to a previous injury such as dislocation or clavicular fracture.
•
There may be a painful arc between 120° and 180°.
•
The cross- body adduction test is helpful in the evaluation for AC disorders.
•
Acute AC joint injuries (sprains/tears) are classified according to the Rockwood (Tossi) scheme.
Clinical Pearl •
The pain associated with the AC joint typically radiates or refers the pain ·up; that is, superiorly toward the cervical spine, a finding which may help in differentiating this disorder from others (e. g., in rotator cuff arthropathy the pain projects inferiorly, usually into the deltoid or upper arm region).
Pathology/
•
Degenerative changes affecting the AC joint.
Etiology
•
Posttraumatic.
•
The pain may be of insidious onset and may or may not involve a recent or distant trauma.
Clinical Presentation
•
The pain may present more from the shoulder joint toward the neck; this differs from cuff arthropathy which refers pain more typically into the proximal arm.
Functional Information
•
The patient may have difficulty in performing the usual ADls due to progressive pain and loss of associated function.
Examination/
•
Adduction test.
Special Tests
•
Range of motion may be significantly reduced.
Diagnostic/Adjunctive
•
Plain radiographs. JOint narrowing and sclerosis of the acromion, with possible involvement
•
MRI.
•
Test infiltration with local anesthetic
•
An appropriately designated and individually tailored physical therapeutic plan with specific
Imaging Studies
Treatment Options
of distal clavicle. ±
corticosteriod.
activity restrictions is initially indicated. •
Manual medicine approaches emphasize the functional return of the entire cervical spine and upper limb complex.
• •
Muscle stretching and strengthening of the appropriate musculature is indicated. Pharmacologic supportive care through acetaminophen, nonnarcotic analgesics, NSAIDs, for instance.
Differential Diagnosis
•
Failure of conservative measures, or severe pain, warrant surgical consideration.
•
Rotator cuff tendinopathy.
•
Dislocation of the clavicle.
•
Myofascial pain syndrome.
Fig.14.31 Arthrosis (i.
e.,
degenerative changes) involving the acro
mioclavicular joint.
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Selected Q;n;cal Syndromes
SLAP (Superior labrum Anterior Posterior) lesion Synonyms and
•
Related Terms
•
Labral tear.
•
Bankart lesion
•
SLAP stands for a labral tear that occurs at the superior portion of the labrum and which extends
Key Points
Anterior labroligamentous periosteal sleeve avulsion.
(
=
anterior labrum lesion. associated with instability).
from a posterior to an anterior direction and includes the anchor of the biceps tendon to the superior labrum (Snyder et al.. •
1990).
The pain may be posttraumatic (e. g
.•
a fall onto an outstretched arm) or due to certain athletic
(throwing) activities or overuse/chronic repetitive microtrauma. •
The superior labrum of the shoulder joint may be avulsed at its superior end.
•
Pain may be due to a traction injury to the shoulder (inferior traction. from carrying a heavy object;
•
The patient may develop a SLAP lesion after an anterior dislocation.
or superior. from lifting an object overhead). •
A number of staging/grading criteria are described in the literature (Musgrave. al..
•
2001;
Andrews et
1985).
Treatment may require surgical intervention or arthroscopic repair.
•
Initial treatment may be directed through an appropriately tailored physical therapeutic course.
•
Superior labral tears in throwing athletes were first described by Andrews et al. in "SLAP" lesion was coined by Snyder et al. in
1985. The term
1990.
Clinical Pearl •
Patients report mechanical symptoms that include difficulty with overhead tasks during ADLs or
•
A Bankard lesion is a labral tear with ensuing shoulder dislocation.
during sports. •
Of the various special tests available for the shoulder. the O'Brien test the Jobe relocation test
(44% sensitive. 87% specific).
(63% sensitive. 73% specific).
and the apprehension test appear to be the
most useful physical tests. although none of the tests or combinations is specific for a SLAP lesion. while sensitivity and specificity were rather low at
2003).
72% and 73%.
respectively (Guanche and Jones.
The same authors conclude that clinical testing is useful in strengthening a diagnosis of a
glenoid labral lesion. but should not be the sole determinant for deciding surgical candidacy. Prevalence
•
Pathology'
•
Prevalence
5%;
average age
38
years;
90%
of patients are male.
A tear of the superior labrum of the glenoid where the biceps tendon anchors to the glenoid and which extends from anterior to posterior.
Etiology •
The cause of this lesion is due to a traction or a compression injury. (Traction is typically seen in overhead athletic actions; compression is typically seen in falls.)
Clinical Presentation
•
Post-injury involvement: - Status post trauma (traction or fall). - Status post anterior dislocation or after repetitive throwing activities.
•
Poorly localized pain. with crepitus often present.
Functional Infor
•
Patients may have significant restriction in their ADLs as well as avocational interests.
mation
•
In the mild form. patients are able to "tolerate the pain" but are apprehensive about participating in their usual avocational activities.
•
Difficulty in donning a shirt or sweater may cause adaptive and compensatory changes in the other components of the incriminated limb. or the noninvolved limb and even various spinal regions.
Examination'
•
Difficult to diagnose on physical examination; use the anterior slide. O·Brien. or crank tests. None has
Spedal Tests
100%
sensitivity or specificity but they are reasonable when used in combination.
Diagnostic
Plain Radiographs
Adjunctive'
•
The study of choice in the new patient whose shoulder pathology has not been identified. Plain radiography is usually unremarkable with a SLAP lesion but will help identify other shoulder
Imaging Studies
disorders. such as a Bankart lesion. MRI with Contrast Enhancement •
The study of choice for labral tears.
•
Tear at the superior labrum at the biceps anchor.
•
Increased signal intensity in the posterior third of the superior labrum. with laterally curved signal intensity.
•
Many normal variants of labral anatomy are observed.
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Common Shoulder Disorders
SLAP (Superior Labrum Anterior Posterior) Lesion (cont.) Treatment Options
Conservative •
Rehabilitative efforts, carefully chosen without wanting to exacerbate the defect (loss of biceps tendon stabilizing function) may be helpful in some cases.
•
Closed chain exercises that address shoulder instability (supervised) may be the exercises of choice.
•
Initial course should not be longer than 6-8 weeks unless clear progress is demonstrated.
•
Surgery is commonly warranted.
Manual Medicine Approaches •
Manual medicine treatment is directed toward minimized abnormal compensatory changes in the periscapular complex (e. g., locally) and distally in the neighboring regions (thorax, cervical spine, lumbar spine) and the various muscle groups.
Surgical •
Arthroscopic debridement, repair and/or fixation depending on joint stability.
Rehabilitation after Surgery •
With the appropriate program and barring significant complications/co-morbidities, the patient should be able to reach near normal shoulder mobility within 10-14 weeks after surgical intervention.
•
Differential Diagnosis
•
Subsequently the patient should be able to fully start his or her reconditioning program. Non-SLAP lesions, i. e., degenerative, flap, and vertical labral tears. Bankart inferior anterior labral lesion.
•
Impingement/rotator cuff syndrome; 30-40% prevalence of rotator cuff tears in patients with SLAP lesions.
Further Reading
•
Cervical radiculopathy.
•
Myofascial pain syndrome.
•
Referred pain.
•
Shoulder dislocation.
•
Supraspinatus tendonitis.
•
Sublabral hole.
luime JJ et al. Does this patient have an instability of the shoulder or a labrum lesion? JAMA. 2004;292:1989.
Commentary •
apparent from the patient's initial presenting history.
As with many other shoulder disorders, the patient may
Therefore. the initial diagnosis of glenohumeral insta
substitute or compensate for the loss of mobility by
bility and its appropriate treatment course should be
"creating" new motion patterns. resulting in pain else where in the body. either in the opposite limb or the
relatively straightforward. •
spine. for example, including the low back. This needs to
•
It is mentioned, however. that there are a number of single- and multi-directional instabilities as well as
be taken into account especially if there is chronic in
subluxations that appear to exist without ever leading
volvement of the shoulder. It should be remembered
to an overt dislocation. These are typically accompanied
that the pain may be present quite distant from the
by complaints in the shoulder region when certain
initial site of involvement such as the low back or even
movements are performed-primarily those of abduc
the lower limb.
tion and external rotation. less so those of forward flexion, internal rotation. and adduction.
Thus. from a manual medicine standpoint. it is impor tant to evaluate the patient in his or her entirety espe
•
cially with a chronic long-standing shoulder history and
The shoulder instability problems affecting the shoulder joint itself must be clearly differentiated from the vari
pain in another region.
ous tendinopathies and shOUlder disorders described above. Again, the treatment concept for shoulder in stability requires a different approach from those de
Shoulder (Glenohumeral) Instability
scribed above for the other disorders. •
It would be beyond the scope of this text to describe in detail the various forms of shoulder instability and their treatment:
In the evaluation for shoulder instabilities the load and shift drawer test, apprehension relocation tests, and the sulcus test are helpful.
•
These tests should help guide one's further work-up so as to come to a more definitive diagnosis relatively
•
In general. spontaneous as well as recurrent shoulder
effortlessly.
dislocations (luxation and subluxation) are usually quite
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Seleded Oinical Syndromes
Simultaneous Destruction of Shoulder and Elbow
The Elbow
Often a patient suffering from rheumatoid arthritis will have both the shoulder and elbow affected simultaneously.
Take Home Points
Usually the joint that is affected most is the one considered
•
The main function of the elbow is to position and sta
•
Of all the major joints in the body, the elbow continues
to be based on various factors. A number of authors suggest
to be the least involved with pathology.
that the shoulder should be addressed before the elbow,
When the involvement does occur, the elbow is felt to
due to the risk of progressive rotator cuff disease.especially
be one of the most difficult joints to manage.
if one considers the faster rate of progression in the
bilize the hand.
•
for surgical intervention. However, if the degree of degen eration is comparable in both joints.the decision will need
shoulder compared to the elbow.
Surgical Interventions: A Brief Over view
In other authors' experience (Gschwend.personal com munication. 2004). the early implementation of the total elbow arthroplasty has been accompanied by sufficient return of or improvement in elbow function that many patients would view this surgery as a "winner-operation"
Historical Perspective
(Fig. 14.32).
Before Charnley revolutionized artificial joint replacement, the surgical intervention of choice remained the resection arthroplasty. In the 1960s. Gschwend (1977) employed the resection arthroplasty with great success for mobilization of the ankylosed elbow joint. Today.however. the resection arthroplasty has become relegated to use primarily only after failure of an alloarthroplasty. It was not until the 1970s that the first true artificial elbow prostheses were developed, which initially con sisted of cemented hinge-joint prostheses that were fairly stable. However.there was loosening of the humeral com ponent of the prosthesis. which was similar to findings with the GSB-I Prosthesis (Klinik Wilhelm Schulthess, ZOrich.Swi erland Refinement of these prostheses ultimately produced the
a
GSB-III prosthesis in 1978. This ushered in a new era of elbow joint replacement. A 20-year follow-up study of 59 patients (Gschwend et al.. 1999) showed that long-term complications with the GSB-III prosthesis were uncommon since 87.7% of the implants remained in situ. There was reportedly good pain relief and appropriate functional gain with long -lasting improvement overall. In this study. 51 patients carried the diagnosis of rheumatoid arthritis (86%) and eight patients had posttraumatic arthritis (14%). The Indications for Arthroplasty
Indication for a total elbow arthroplasty is progressive chronic polyarthritis where conservative management has failed (Larsen-Dahle-Eek stages IV and V). In the patient with rheumatoid arthritis of the shoulder, the clinical findings correlate poorly with radiographic
b Fig. 14.32 Left elbow of a 49-year-old patient with a long-standing history of chronic polyarthritis.
findings. In patients with rheumatoid arthritis of the elbow,
a
however. there is good correlation between the clinical
b 2 years after a GSB III elbow arthroplasty with autologous bone
symptomatology and the radiographs.
12 years after resection arthroplasty. transplantation for the humerus and epicondyles.
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Surgical Interventions: A Brief Overview
Fig. 14.33 Right elbow: supracondylar humerus- pseudoarthrosis
b After the GSB III prosthesis, the patient was able to return to a
formation 14 years after distal humerus fracture; there is also
near- normal and pain- free elbow function. However, due to
bony ankylosis of the humeroulnar joint.
extremely involved changes of the soft tissues, the anatomic
a
Due to progressive worsening and intolerable painful stiffness,
length of the distal humerus could not be fully realized in this
the patient requested surgical intervention using the GSB III
surgical procedure. In order to prevent elbow dislocation, the
elbow arthroplasty (the patient had a near-normal and virtually
ulnar component was elongated.
pain- free recovery on the opposite side previously).
Lastly, it is not uncommon for the rheumatoid arthritis patient also to have wrist involvement.
Complications of Arthroplasty A number of complications have been observed. The devel opment of the GSB-lll prosthesis significantly reduced the
Posttraumatic Arthrosis
complication rate and it has now reached a level that would
Patients who are affected by arthritic changes of the elbow
be comparable with that of hip or knee replacement.
after trauma can have significant pain, and also may have a
The cumulative complication rate for chronic polyar
prominent functional impairment. Many of these patients
thritis (GSB-III) was 11 %, while for intervention for post-
will have had prior surgical procedures and therefore an
traumatic arthritis, the rate was 34%, which may reflect the
alteration of the original joint architecture. Furthermore, a
higher rate of prior surgical interventions.
number of patients will have developed a condylar or supracondylar pseudoarthrosis (Fig. 14.33). High surgical
Other complications include aseptic loosening of the prosthesis, ulnar nerve neuropathy, and infection.
skills are required for introducing a total arthroplasty in such a situation. One needs to address the bony archi
Outlook
tecture, and also improve the biomechanical relationships
Given the excellent recent results with the GSB-III arthro
by normalizing the joint rotational axes as much as possi
plasty for the elbow, it has become the rational approach
ble.
for the elbow joint affected by rheumatoid or posttrau matic arthritis.
Supracondylar Humerus Pseudoarthrosis
The GSB-III arthroplasty success rate compares favor
Supracondylar fractures of the distal humerus, in the pres
ably with the surgical joint replacement experience in the
ence of elbow arthrosis or arthritis, have a great tendency
lower limb. Thus, the total elbow arthroplasty has become a
to lead to a pseudoarthrosis because of the rather large
good option for relieving pain and enhancing functional
force vectors developed across the elbow. The motion in
abilities in the complicated patient (Fig. 14.34).
such an elbow, with spondylosis, callus, and pseudarthro sis, can be quite pathologic. Joint reconstruction, using a total elbow arthroplasty, may therefore present the most rational approach to a successful surgical procedure (Fig. 14.33).
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Selected Clinical Syndromes
a
b
- r-: Fig. 14.34a. b Improved elbow function in a patient w ho had previously u nd ergone an elbow arthroplasty for chronic polyarthritis.
Elbow Disorders Lateral Epicondylitis Synonyms and
•
Tennis elbow.
Related Terms
•
Cubital pain syndrome.
•
Elbow pain.
•
Elbow injury.
•
lateral epicondylosis.
Key Points
•
Pain over the lateral condyle of the elbow or proximal forearm.
•
lifting activities. especially with the hand pronated. may increase the pain.
•
Pain is most prominent when the wrist and fingers are flexed while the hand is simultaneously pronated
•
Involvement of the common extensor tendon due to either inflammation or overuse/overload.
(stretch induced to the common extensor tendon). •
Typically associated with varus stress component across the elbow joint.
•
More common than medial epicondylitis (golfer's elbow).
•
Usually caused by repetitive strain type of mechanisms rather than one-time trauma.
Pathology{
•
Overload/overuse syndrome due to stresses across the elbow in a region of poor blood supply.
Etiology
•
Degenerative process in the distal 1-2 cm of the extensor tendon origins on the lateral condyle.
•
Inflammation can be associated with development of micro-tears and fibrosis.
•
Usually the extensor carpi radialis brevis is involved more than the extensor carpi radialis longus. extensor digitorum communis. or extensor carpi ulnaris.
Clinical Presentation
History •
lateral elbow pain, typically of insidious onset. Acute onset may indicate a macroscopic tear.
•
Characteristically seen in patients between 30 and 50 years of age.
•
The pain is exacerbated by activity but may be present at rest, especially in more severe cases.
•
When severe, the patient may have difficulty performing even the most routine tasks such as holding a cup or carrying light loads.
•
Night pain.
•
Seen not only in racquet sports, but also in any activity that involves repeated wrist extension against resistance (carpentry. bricklaying, sewing, knitting).
Causes •
Primary: overuse syndrome due to repetitive use of the wrist extensors. Poor technique, excessive loads, and inadequate ergonomics are contributory.
•
Functional
•
Secondary: due to compensatory changes to compensate for other upper-limb muscles. Reduction in the usual vocational or avocational activities to the point of restriction, especially when severe (e. g., difficulty holding an object for work).
Information •
ADls, such as donning and buttoning
a
shirt, hygienic tasks, etc., are typically not affected except in
more severe cases.
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Elbow Disorders
Latera l Epico nd ylitis (c a nt.) Tenderness to palpation anterior and distal to the lateral epicondyle.
Examination/
•
Specific Tests
•
Induction of pain with wrist and finger flexion with hand pronated.
•
Pain can be produced relatively easily upon resisted wrist extension, especially with the wrist radially deviated (Mill's test). Resisted extension of the middle finger is also painful.
•
Weak grip strength may be elicited.
•
Elbow range of motion is restricted minimally if at all.
Diagnostic
Radiographs
Adjunctive
•
Studies
No role other than to exclude other pathology, or when suspicious for fracture or dislocation according to history or physical examination.
MRI •
Increased signal intensity demonstrating the incriminated common extensor tendon at its origin at the
•
Demonstration of partial-thickness or full-thickness tears.
lateral epicondyle.
Treatment
Conservative Approach
Options
•
Initial management is reduction of pain and inflammatory changes, with rest, ice, and the use of
•
Encouragement of healing by use of a wrist splint may be indicated (reducing stress in the extensor
NSAIDs. muscle). Modalities such as ultrasound may encourage healing as well. •
Elbow compression strap, or ·counterforce bracing: to reduce forces on the extensor tendons.
•
Correct predisposing factors such as faulty technique or poor ergonomics.
•
Graduated return to activity.
Manual Medicine Procedures •
Balancing of flexibility, strength, and endurance in the subacute phase.
•
Myofascial release and other gentle soft tissue release techniques of the forearm extensor muscles are
•
Strengthening maneuvers should be introduced only when pain permits, and once appropriate muscle
indicated. length has been accomplished in the wrist flexors, extensors, pronators, and supinators. Injections •
Trigger point injections utilizing local anesthetic solution may be attempted without steroids, if injected directly into the tendon or trigger pOints.
•
Corticosteroid injection into the maximal area of tenderness may be indicated after failure of an appropriate rehabilitation program.
•
Steroid injection should be around the tendon but not into the tendon substance itself, to minimize risk of potential rupture.
Surgical Consideration •
Very occasionally, after 12 months of conservative treatment failure, surgical treatment is indicated. This involves release of the lateral extensor aponeurosis and resection of degenerate tissue.
Differential
•
Diagnosis
•
Fibrosis of the radiohumeral meniscus.
•
Osteochondritis of the capitellum or radial head.
Fracture of the elbow.
•
Radiohumeral somatic dysfunction.
•
Radiohumeral bursitis.
•
Synovitis of the radiohumeral joint.
•
Posterior interosseous nerve palsy (radial tunnel syndrome).
•
Neuralgic amyotrophy.
•
Referred pain from a cervical or upper thoracic radiculopathy.
Commentary •
While initial treatment is directed toward pain reduc tion and functional restoration, an inquiry into the
•
Treatment is typically conservative and should consider more than simply the involved elbow joint. The goal is
predisposing factors must be part of the complete work
to improve mobility and reduce any compensatory
up.
motion patterns distally in the wrist and hand, and proximally in the shoulder especially the acromiocla vicular and sternoclavicular joints. Cervical spine ex amination frequently shows decreased range of motion and may even show joint tenderness.
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Selected Ginical Syndromes
Medial Epicondylitis Synonyms and Related
•
Golfer's elbow, pitcher's elbow.
Terms Key Points
•
Overuse/overload syndrome involving the common origin of the wrist and hand flexor muscles.
•
Typically associated with valgus stress.
•
Occurs less commonly than lateral epicondylitis.
•
May respond well to an individually tailored physical therapeutic management program.
Pathology/
•
Overload/overuse syndrome leading to tendinosis (subacute, chronic situation).
Etiology
•
Tendonitis (overt inflammatory changes) in acute situation.
•
Involvement is typically at the origin on the anterior medial epicondyle.
•
Primarily strain/stress to common origin of the flexor and pronator muscles such as the pronator teres, flexor carpi radialis, and palmaris longus muscles.
•
Flexor carpi ulnaris and flexor digitorum superficialis muscles are less frequently involved.
•
Repetitive stress can lead to scarring of the medial collateral ligament, olecranon impingement, synovitis, or radiocapitellar joint damage. In children, damage may result to the medial epicondylar epiphysis and progress to avulsion.
•
Clinical Presentation
Possible ulnar nerve compression at the level of the medial epicondylar groove.
History •
Medial epicondylar pain.
•
Pain is typically exacerbated when the patient flexes the wrist and pronates the forearm.
•
There may be a history of trauma.
•
Paresthesias (numbness and/or tingling) may be present and would typically involve the fourth and fifth fingers.
Examination/Tests
•
Palpation at the medial epicondyle (anteriorly) can reproduce the pain. Passive wrist flexion and resisted pronation may reproduce the pain.
•
Difficulty in lifting with palm down.
•
Tinel's test to the elbow, behind the medial epicondyle, may indicate ulnar nerve involvement.
•
No particular test is pathognomonic for medial epicondylitis.
•
Range of motion may be restricted, especially in advanced/recalcitrant cases.
Diagnostic Adjunctive
•
Plain radiographs: no pathognomonic findings.
Studies
•
However, they may be used to rule out other pathologies, especially radial head fracture, dislocation, osteochondral loose bodies, calcifications.
MRI Studies
Treatment Options
•
Increased signal intensity demonstrating the involvement of the Incriminated common tendon.
•
Possible findings of stress fracture at the attachment of the origin of the involved muscles.
Conservative Approaches Including Manual Medicine Approaches •
Acute injury: standard "RICE" (rest, ice, compression, and elevation) to control pain and promote healing.
•
Range-of-motion, strengthening, and correction of faulty techniques/ergonomics.
Physical T herapeutic Management •
This is a rehabilitation program involving appropriate stretching of the soft tissues; once appropriate flexibility has been accomplished, strengthening can be initiated of the forearm flexors and pronators.
•
Myofascial release techniques (see below) and medial strapping of the elbow may be helpful.
•
Evaluation and potential treatment of the shoulder and cervicothoracic spine should be included in the overall management due to possibility of significant adaptive/compensatory changes over the course of time.
Goals of Treatment •
Active rehabilitation.
•
Return to functional activities.
•
Independent home exercise.
Surgical Approaches •
In most severe cases or recalcitrant cases, epicondylar debridement or medial collateral ligament reconstruction may be indicated, but benefits should be carefully weighed.
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Elbow Disorders
Medial Epicondylitis (cont.) Treatment Options
Additional Treatment: Manual Medicine Intervention •
Myofascial release.
•
Specific positional/repositional technique.
•
Muscle energy techniques.
Injections •
May be helpful with local anesthetic and/or steroids (to the most tender area or the incriminated myofascial trigger point if present).
•
Anatomic knowledge is important. so as not to inject the ulnar nerve or the brachial artery in this region.
Differential Diagnosis
Prognosis
•
Flexor/pronator strain.
•
Medial collateral ligament strain.
•
Ulnar neuropathy.
•
Avulsion fracture of the medial epicondyle.
•
Apophysitis.
•
Pronator teres syndrome.
•
Shoulder musculoskeletal disorders.
•
Thoracic outlet syndrome.
•
Cervical or upper thoracic radiculopathy.
•
Condylar arthritis.
•
Overall good.
•
Recalcitrant cases may have chronic pain syndrome with significant compensatory/adaptive changes.
Olecranon Bursitis Synonyms and Related
•
Student's elbow. draftsmen's elbow. miner's elbow.
Terms Key Points
•
As the name implies. the olecranon bursa may be inflamed.
•
Prominent swelling about the olecranon that may be painful or nonpainful.
•
Involved olecranon bursa is located between the olecranon process and the triceps muscle.
•
This is often due to repetitive trauma. but may result after a single episode of trauma.
•
Other causes may include gouty or septic arthritis.
•
Suspect an infectious process or trauma if there is exquisite palpatory tenderness.
•
The chronic situation is typically not associated with prominent pains.
Pathology/
•
Inflammation of the olecranon bursa.
Etiology
•
Due to its superficial location between ulna and skin. there is higher risk of susceptibility to inflammatory reactions.
Clinical Presentation
•
Septic bursitis is comparatively rare.
•
Edema/swelling at the elbow posteriorly.
•
Swelling may not always be painful but more typically presents along with the swelling. especially when the patient "bumps· the elbow.
•
Any pressure upon the posterior elbow may cause significant pain.
•
Typically the bursitis is of slow gradual onset.
•
If onset is sudden. consider infection or prominent or significant acute trauma.
Examination/
•
"Goose egg" enlargement of the posterior olecranon readily visible to the eye.
Special Tests
•
Palpatory tenderness over the incriminated elbow.
•
Range of motion is typically unaffected but may reveal compensatory reduction due to pain.
•
Obtain vital signs (temperature) if suspicious of infection.
Special Tests •
No specific test is pathognomonic for olecranon bursitis.
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Selected Clinical Syndromes
Olecranon Bursitis (cont.) Diagnostic Adjunctive
Laboratory Studies
Studies
•
Aspirated fluid may contain blood or serum.
•
Send to laboratory if suspecting gout/pseudogout. sepsis: - Gout
=
monosodium urate crystals
- Pseudogout - calcium pyrophosphate crystals - Rheumatoid arthritis - Infection •
=
=
cholesterol crystals
WBC (white blood cells) -' 5000/mm3
Consider also serum CBC (complete blood count) with differential. ESR (erythrocyte sedimentation rate). uric acid.
Radiographs •
Used to exclude sinister pathology such as fractures. dislocations. loose bodies.
MRI •
Identification of fluid or mass embedded in the superficial soft tissues. -- --
Treatment Options
-
-
-
Conservative Approach •
NSAIDs. rest and firm compression. If this fails. then aspiration and injection with a corticosteroid mixture and local anesthetic will often be effective. the needle should follow a "zig-zag" course to reduce the risk of fistula tract formation. using a posterolateral approach to reduce the risk of damaging the ulnar nerve (which lies medially).
• •
A skilled supervised physical therapy program is typically not necessary. Manual medicine procedures are not indicated as the treatment of choice other than to assist with any potential compensatory changes proximally or distally.
•
Septic bursitis is serious and requires antibiotic therapy. immobilization and drainage.
Surgical Consideration
Differential Diagnosis
•
Bursectomy in advanced cases.
•
Physical therapeutic intervention may be indicated in selected patients after bursectomy.
•
Triceps tendinopathy.
•
Posterior impingement from olecranon osteophytes.
•
Inflammatory arthropathy (gout. pseudogout. rheumatoid arthritis. and septic arthritis) should always be considered.
•
Fracture of the proximal ulna.
•
Synovial cyst of the elbow.
•
Note: Key in the differential diagnosis is to distinguish between an infectious/arthropathic process and repetitive trauma leading to the bursitis.
Prognosis
•
Joint bursa aspiration may be required. but usually response is favorable.
Commentary •
As outlined above. one of the major considerations in
•
Septic bursitis requires antibiotics as well as drainage
olecranon bursitis is to be able to differentiate between
procedures. Ultimately, if recalcitrant, the final treat
septic and gouty bursitis, the latter of which would
ment may consist of bursectomy.
typically reveal tophi. The bursa should be aspirated and be sent to the laboratory for further examination such as Gram stain. cell count, and crystal determination.
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Elbow Disorders
Arthritis of the Elbow Synonyms
•
Rheumatoid arthritis of the elbow.
and Related
•
Traumatic arthritis of the elbow.
Terms
•
Postsurgical arthritis of the elbow.
•
Osteoarthritis of the elbow.
Key Points
•
The elbow jOint is less frequently involved than other joints in the body.
•
Chronic progressive polyarthritis typically results in loss of function often associated with significant pain.
•
Often it is difficult for patient to sleep on incriminated side.
•
Rate of progression is not uniform.
•
Once medical treatment has been exhausted. various surgical procedures can be considered. with total elbow arthroplasty showing ever-improving results in the past 10-20 years.
•
Radiographic findings usually correlate well with the progression of the disease and thus are most valuable in determining the surgical course (in contrast to the shoulder. where the studies do not correlate well).
•
Rheumatoid arthritis and posttraumatic arthritis are the two major groups of disorders that require total
•
Patients with involvement of one elbow due to rheumatoid arthritis will typically have involvement of the
elbow arthroplasty (TEA). other limb as well. Pathology/
•
Progressive cartilage destruction due to rheumatoid disease.
Etiology
•
Synovial proliferation at the radiohumeral joint.
Clinical
•
Progressive functional loss with ultimate prominent impairment of elbow function but may also affect the entire involved upper limb and even other regions such as the cervical. thoracic. or lumbar spine.
Presentation •
Pain especially at the end-range of motion is typically present. and especially in the advanced stages of the disease (e. g
•
Functional
•
.•
rheumatoid arthritis).
Joint swelling. particularly with rheumatoid arthritis. Progressive functional loss not only of the elbow but of the entire affected limb and pain determine the candidacy for surgery. with special consideration given to patient's age and vocational requirements and
Information
projected rational functionally based outcomes. •
Flexion contracture in severe cases.
Examination/
•
limited range of motion to point of flexion contracture (no extension possible).
Special Tests
•
Pain upon motion.
•
Swelling.
•
Crepitus.
•
Rheumatoid nodules.
•
There is no special test that is pathognomonic for elbow arthritis.
Diagnostic
Radiography
Adjunctive/
•
Helpful in determining and correlating with overall status of the joint.
Imaging
•
Prominent loss of joint space.
Studies
•
Bone on bone findings.
Treatment
•
Activity modification and joint protection. with the use of splints and handle-extensions to maintain activities of daily living.
Options •
Initially appropriate pharmacologic intervention is indicated until the disease has progressed to the point where surgery becomes clearly indicated. NSAIDs and acetaminophen can provide short-term relief. more potent agents are available for rheumatoid arthritis.
•
Well-dosed and initially supervised exercises are indicated as long as they are performed carefully and gently and with specific projected long-term functional goals in mind.
•
Modalities such as cold or heat can be very helpful.
•
Surgical Intervention utilizes a variety of procedures. from arthroscopy and synovectomy to total
arthroplasty of the joint (see Fig. 14.33). •
Recent reports (Gschwend et al..
1999) place the success of total joint arthroplasty at the same level as hip
and knee arthroplasty.
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Selected Clinical Syndromes
Arthritis of the Elbow (cont.)
Differential Diagnosis
• •
Septic arthritis.
Prognosis
• •
Surgical outcomes have significantly improved during the past 10-20 years.
•
Surgical intervention differs not only from center to center but also between Europe and North America
Instability.
Treatment success depends not only on patient factors (type of disease, overall bone health, disease progression. existing co-morbidities. motivation. etc.) but also on the expertise of the surgeon. (Kasser, 1996a).
The Wrist Wrist Disorders Carpal Tunnel Syndrome (CTS) Synonyms and Re lated Terms
Key Points
• • • • • • • •
Median nerve compression at the wrist. Median nerve entrapment syndrome. Compressive neuropathy involving median nerve. Hand and wrist pain. Thenar atrophy. Compression neuropathy of the median nerve at the level of the wrist. The most common peripheral nerve compression syndrome. Differentiation into acute and chronic situations assist in the clinical approach. because the dynamics of the disease are different.
Acute as
•
A form of compartment syndrome. with rapid increase in intracarpal tunnel pressure that remains
•
Most frequent cause of acute CTS is after distal radius fracture, especially when the wrist was
relatively constant once it has reached its peak. immobilized in a Hexed position. Alternative etiologies include various trauma. infection (e. g.. after injection). or bleeding into the space.
•
Acute CTS. when sufficiently severe or clear in diagnOSis, is typically an indication for surgical
•
Acute CTS may not produce prolonged median nerve latency, even if there is a considerable amount
decompression. of symptoms. There is actually little conduction slowing. as it takes time for latencies to become prolonged (Kraft. 1996).
Chronic as
• •
Slow increase in intracarpal tunnel pressure. initially intermittent. fOllowed by progressive increase. Gelberman et al. (1988) divides chronic CTS into three stages: early. intermediate. and late forms:
- Early chronic CTS:
The duration of the symptoms is less than one year. and their appearance is
typically on an intermittent basis with periods of clear exacerbation. The symptoms character istically occur during the night or in association with specific. often repetitive. strain/overload activities of the wrist. The median nerve appears typically intact. - In the
intermediate form of as.
the patient typically complains of constant paresthesias and
numbness. The thenar eminence is still relatively maintained without any particular muscle atrophy. although electrodiagnostic studies may reveal an increased distal motor latency. The median nerve reveals chronic changes associated with epineural and intrafascicular edema. These changes are usually reversible after decompression. - In the
late
form of m. there are clear sensory and motor abnormalities that can be visually
demonstrated by clear thenar atrophy. Electrodiagnostically. the EMG reveals fibrillation potentials. Histologically the median nerve reveals at this stage intraneural/endoneural edema with fibrosis, and partial demyelination. all signs of axonal degeneration. These changes are only partially reversible. if at all (Gelberman et al.. 1988) (Fig.
• •
14.35).
Clinically, one can divide chronic CTS into a dynamic or early form. and a static or late form. DynamiC chronic (early) CTS exhibits periods of typical symptoms including paresthesias that alternate intermittently between otherwise normal periods of sensation.
•
Static chronic (late) CTS is associated with rather constant symptoms that may vary somewhat in intensity but never really subside.
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Wrist Disorders
Carpal Tunnel Syndrome (CTS) ( cant ) .
•
Overall prevalence is about 3%, more common in females, and in the middle-age years.
Pathology!
•
Increased intracarpal pressure.
Etiology
Idiopathic Form
Prevalence
• • •
The most common form of CTS. Vascular sclerosis and fibrous hypertrophy of the flexor retinaculum with associated edema. Note: A typical tenosynovitis is usually not the cause of idiopathic CTS.
Intrinsic Factors
• •
Changes in the fluid content of the canal (pregnancy, hemodialysis, alcoholism, hypothyroidism). During pregnancy, CTS symptoms are typically reported in the third trimester and resolve on their own after birth.
•
Rheumatoid arthritis or gout may cause CTS due to hypertrophy of the affected synovium of the flexor tendons and the bony changes in the wrist.
Extrinsic Factors
• • • • • • • •
Scaphoid pseudo-arthrosis. Perilunar dislocation (if untreated). Carpal tunnel collapse due to intercarpal ligamentous insufficiency-SLAC wrist. Diabetes mellitus (increased incidence). ObeSity. Multiple myeloma. Amyloid neuropathy. Repetitive strain syndrome, while seemingly increased in frequency during recent years and alleged to be related to computer use, is controversial.
Clinical Presen tation
• •
See Key Points above. Both a good history and a careful examination, supplemented by electrodiagnostic studies when indicated, should be able to substantiate the initial clinical impression of CTS.
• • • • Functional Information
• • •
Pain is described initially as an ache that spreads from the wrist to the thumb and thenar eminence. The ache/pain may extend as far as the elbow. Paresthesias and numbness in the distribution of the median nerve. Night pain. Patients typically report 'shaking or rubbing" of the hand and wrist. Inability to carry even a filled coffee-cup in the more advanced stage. Difficulty opening jars or cans with a manual can opener. Sometimes difficulty buttoning shirts or other clothing articles. Note: When this is reported or noted upon examination, be sure to examine the patient for potential cervical spine myelopathy including detailed neurologic examination (upper motor neuron findings and hyperreflexia, positive Hoffman's sign, etc.).
Examination! Special Tests
• • • •
Sensory evaluation (two-point discrimination, etc.), in the region supplied by the median nerve. Motor evaluation in the region supplied by the median nerve. Positive Phalen test (forced wrist flexion) or reverse Phalen test (forced extenSion). Positive Tinel test (tapping over the transverse carpal ligament region to elicit any paresthesias or pain).
•
Thenar muscle testing (apposition of thumb strength)-abductor pollicis breviS muscle often shows early involvement.
Diagnostic
•
Thorough examination of the neck and upper limb as well as evaluation of gait should be performed.
•
Electrodiagnostic studies are helpful to evaluate severity, location, and treatment effects. Variability
Adjunctive!
exists regarding the exact clinical and electrophysiologic findings necessary to diagnose CTS. MRI.
Imaging Studies
•
Treatment Options
Conservative Approaches Including Manual Medicine Approaches
•
Initial (not acute-severe)-conservative treatment including various manual medicine technique approaches with appropriate self-stretch exercises (Sucher and Glassman,
• •
1996).
Night rest splint. Corticosteroid injections (may provide temporary relief, which is important both for therapy and diagnosis).
•
Caution: acute nerve entrapment/compression syndromes represent a potential surgical emergency, and therefore attempts to use only conservative measures may not be indicated.
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Selected Cllnlcol Syndromes
Carpal Tunnel Syndrome (CTS) (cont.)
Surgical Approaches • Carpal tunnel decompression: open and endoscopic approaches described with good results. Open
D
reliable. good visualization. slower recovery. Endoscopic - faster recovery. higher complication rate.
• General. regional. or local anesthesia. A toumiquet to the arm allows better visualization in blood-free surgical zones.
• Synovectomy if indicated (rheumatoid arthritis. gout. etc.). • Intraneural neurolysis (not used currently due to lack of adequate success and risk of scarring and intraneural fibroses).
• Reconstruction of flexor retinaculum with Z-plasty. Differential Diagnosis
• • • • • • • •
Arthritis of the CMC (carpometacarpal) joint. Cervical radicular pain. Cervicobrachial pain syndromes (non radicular). Colles' fracture. DeQuervain stenosing synovitis (which have positive Finkelstein's maneuver. while absent with CTS). Endocrine disorders (diabetes mellitus. hypothyroidism. lupus erythematosus).
G out. Kienbock disease.
•
Mononeuritis multiplex.
•
Organic disease with referred pain (viscerosomatic reflex pain: e. g .• angina pectoris If left-sided symptomatology).
• Rheumatoid arthritis. •
Tumors (fibromas. neurilemmoma. hemartoma).
• Ulnar neuropathy. • Volar ganglion cyst. • Aexor carpi tendinopathies. Further Reading
Katz IN et al. Clinical practice. Carpal tunnel syndrome. N Engl
J
Med. 2002:346:1807.
ly-Pen D et al: Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year. prospective. randomized. open. controlled clinical trial. Arthritis Rheum. 2005:52:612. MacDermid JC et al. Clinical diagnosis of carpal tunnel syndrome: a systematic review. Sucher
B.
J
Hand Ther. 2004: 17:309.
Glassman J. Upper extremity syndromes. In Stanton D. Mein E. eds. Manual Medicine. Philadelphia: Saunders:
1996: 787-809. [Physical Medicine and Rehabilitation Clinics of North America. November 19961.
Commentary Historical Comments •
The name was introduced by Brain et al. (1947). Prior to that paper there were a number of similar clinical de scriptions in the literature (Paget. 1854. and others) which. however. did not describe the pathopysiological changes in sufficient detail.
Anatomic Considerations •
The carpal tunnel is a well-defined anatomic space in the wrist that provides passage for the median nerve and the nine flexor tendons supplying the fingers and the thumb.
•
The median nerve lies directly underneath the flexor retinaculum along an imaginary extension of the length
Fig. 14.35 Intraoperative photograph depicting the late stage of an
axis of the middle finger. At the level of the carpal
idiopathic chronic carpal tunnel syndrome. The median nerve was
tunnel. the median nerve consists of approximately
extensively compressed and "thinned out" in the area of compres
30-35 fascicles. which separate distally so as to supply motor innervation to the first three digits-thumb. in dex. and middle fingers-as well as to supply sensory
sion to the point where the nerve appeared to consist only of a few nervous sheaths without axonal content. The peritendinous syno
vial tissu e is only minimally thic kened .
innervation to these and the radial palmar side of the ring finger.
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Wrist Disorders
ted Clinical SyndromesThe sensory palmar median
•
•
normal wrist position the internal tissue pressure
outside of the carpal tunnel, and therefore is not in
measures 2.5 mmHg. whereas in maximal wrist flexion
vo.lved in the carpal tunnel entrapment neuropathy.
this value rose to 31 mmHg, and to 30 mmHg in max
The motor branch, however, runs within the carpal
imal wrist extension.
tunnel to supply the thenar eminence, which can be
•
Gelberman (Gelberman et aI., 1981) reports that in the
branch that supplies the proximal thenar eminence runs
•
Although the carpal tunnel is not a closed space it may
seen when sufficiently compressed as muscle atrophy.
behave like one, as space-occupying changes and swel
Both the contents and the cross-sectional diameter are
ling, as well as position and increased tissue pressure all
variables that depend on the individual but may also be
lead to internally raised pressure and thus to median
significantly influenced by the position of the wrist.
nerve compression.
Dupuytren Contracture Synonyms and Related Terms
Key Points
•
Dupuytren disease (Fig. 14.36).
•
Palmar fasciitis.
•
Palmar fibrosis.
•
Viking disease.
•
Fibrosis of the palmar fascia (not tendons) resulting in contracture of the digits.
•
Metacarpophalangeal joints and proximal interphalangeal joints may be involved.
•
Familial predisposition (autosomal dominant with variable penetrance. typically involves the ring finger and sometimes the small finger).
Prevalence
•
5% in the general population. with male-to-female ratio of 3:1; typically older than 40 years.
Pathology/
•
The palmar fascia is incriminated rather than the tendon of the wrist.
Etiology
•
Aponeurosis.
•
Associated co- morbidities/factors. - Familial involvement (autosomal dominant). - Alcoholism. - Diabetes. - Seizure disorders; some implicate barbiturate anti-epileptic medication. - The disease belongs to a group of fibromatoses that include palmar. penile. and dorsal PIP joint fibromatoses. - Pulmonary disease.
•
Three major phases have been described: 1. Proliferative phase. 2. Involutional phase. 3. Residual phase.
Clinical Presentation
History •
The palmar surface of the hand is described as "knotty· or "thick."
•
The patient in many cases may simply accept the thickness as "a fact of life" until
•
Ultimately. the patient may lose the ability to fully extend the fingers.
functional impairment becomes unacceptable.
Examination/
•
Hand dominance does not appear to be indicative of the disease.
•
The nodules are usually without pain.
•
More common bilaterally than unilaterally.
•
When the IP joint becomes affected. significant functional loss of the hand may ensue.
•
Special Tests
localized thickening of the palmar skin and underlying subcutaneous tissue while the skin can still be moved.
•
Nodules that resemble callus formation.
•
Typically not painful.
Nodular Stage •
Firm fixed nodules. usually well localized.
•
Cord stage: linear thickening resembling the course of a tendon (may be mistaken as a
•
Progressive involvement will ultimately result in flexion deformity.
•
Flexion deformity typically involves at the MCP and PIP joints.
tendon issue. which is not the case).
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Dupuytren Contracture (c an t . ) Diagnostic Adjunctive Studies
•
No specific imaging studies assist in the diagnosis.
Ultrasound •
Treatment Options
Not needed for diagnosis other than when considering injections to specific structures.
Conservative Measures •
Wait and see; Some patients may prefer this option but require medical follow-up on a
•
Controversy surrounds medical interventions such as steroid injections, irradiation,
regular basis close clinical for monitoring, especially for functional losses. allopurinol, ultrasonography, and splinting. •
Collagenase percutaneous needle fasciotomy, treatments with gamma interferon, and calcium-channel blockers are being researched.
•
Manual medicine approaches may exacerbate.
Surgical Approaches (Fig. 14.37a, •
b)
Indicated when contracture is 20-30" or more at the MCP joint and 30° or more at the PIP joints.
•
Surgical intervention should be chosen according to the patient's specifications and vocational and avocational considerations.
•
Fasciectomy .
•
Radical fasciectomy including arthrolysis of PIP-joints and skin flaps.
•
Selective fasciectomy may be performed in the form of open or percutaneous
•
Amputation when flexion contracture is greater than 90° or if there is vascular
•
Postoperative complications rate is 3-20%, and includes reflex sympathetic dystrophy in
fasciectomy. compromise may be considered. as many as 5 % of patients. Differential Diagnosis
•
Flexion contracture due to tendon or joint injury, typically of shoulders/hands (stenosis tenosynovitis).
•
Prognosis
Trigger finger.
•
Ganglion cyst.
•
Soft-tissue mass, epithelial sarcoma, and fibroma.
•
Spontaneous resolution does not occur and progression is unpredictable. However, not all cases progress to contraction deformity. The earlier the onset the more aggressive is the course.
•
Recurrence is related to the initial severity of disease, the extent of multiple lesions, and coexistent diabetes mellitus.
•
Further Reading
long-term postoperative recurrence. Rates have been reported up to
Hart MG et al. Clinical associations of Dupuytren's disease. Postgrad Med J.
.... 50%.
2005;81:425.
Fig. 14.36 Example of an aggress i ve course of a D u puy tren can·
tra ct ure with involvement of the h and and all fingers (stage Ii for
the small fin ge r ; stage I for fing ers Ii-IV). Clinical note: F ing er flexion is not affected by the contracture. and even in cases where there is significant pro gre ssi o n of the disorder. the patient should still be able to make a f ist or close the hand.
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Fig.14.37 Intraoperative photograph
demonstrating
abnormal
b After extensive fasciectomy and excision of the pathologic fas· cial tissue including the intermetacarpal septa. One can eas ily
changes of the palmar aponeurosis.
a The overlying skin at the palm has been removed.
identify the nerve fibers and the flexor tendons whose tendinous sheaths have remained intact.
De Quervain Disease Synonyms and Related Terms
Key Points
•
Stenosing tenosynovitis.
•
Stenosing tenovaginitis.
•
Chronic pain in the anatomic snuffbox.
•
Pain is typically at the styloid process of the radius.
•
The tendons of the abductor pollicis longus and extensor pollicis brevis may be thickened.
•
Reproduction of pain is accomplished through the Finkelstein test (ulnar deviation of the wrist with the thumb cupped in a closed fist).
•
Pain is typically more proximal than that from osteoarthritis of the carpometacarpal joint of the thumb.
Prevalence PathologYI
•
Appears to occur more frequently in women.
•
Essentially unknown but may be due to repetitive trauma.
•
Wrist pain especially over the styloid process in the anatomic snuffbox.
Etiology
Clinical Presentation
•
The patient may have waited for quite some time before coming to the physician but have noted functional deficits such as in lifting even relatively light objects.
Examinationl
•
Tests
Diagnostic Adjunctive Studies
Tenderness along the radial aspect of the wrist, particularly over the styloid process of the radius.
•
Pain with passive range-of-motion of the thumb.
•
Reproduction of pain through the Finkelstein test.
Radiographs • •
No pathognomonic findings for this disorder. Radiographs may be useful in ruling out potential fractures or dislocations, radioscaphoid degenerative arthritis, and foreign bodies.
Treatment Options
Conservative •
Rest, NSAIDs, thumb spica wrist splint.
•
Hydrocortisone injection around the tendons.
•
Surgical intervention is indicated if conservative methods and rest fail to relieve pain.
•
Decompression of the tendons by deroofing the tendon sheath.
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De Quervain Disease (cont.) Differential Diagnosis
•
Arthritis of the thumb CMC joint.
•
Carpal tunnel syndrome.
•
Scaphoid fracture.
•
Kienbock disease.
•
Volar radial/wrist ganglion.
•
Cervical radiculopathy.
•
Disseminated gonoccocal tenosynovitis.
•
Other infectious tenosynovitis.
Prognosis
•
Good with conservative measures.
Historical Note
•
This disorder was described in 1895 by the Swiss surgeon, Fritz de Quervain, looking at five case reports of patients who had presented with tender, thickened first dorsal compartments at the wrist. The condition has subsequently become associated with his name.
Degenerative Arthrosis of the Carpometacarpal Joint (Rhizarthrosis) (Fig. 14.38). Synonyms and Related
•
Basal thumb arthritis.
Terms
•
Carpometacarpal arthritis of the thumb.
•
Carpometacarpal joint arthrosis of the thumb.
•
Osteoarthritis (OA) at the base of the thumb.
Key Points
•
Rhizarthrosis.
•
Thumb osteoarthritis.
•
Trapezio-metacarpal joint arthrosis.
•
Trapezio-metacarpal joint arthritis.
•
Pain, stiffness and weakness of the thumb are the three hallmarks of the disorder (Wajon et aI., 2005).
•
May be associated with carpal tunnel syndrome and scaphotrapezial arthritis.
•
A targeted history (pain and stiffness with loss of motion) and positive examination findings (pain on palpation, crepitus, signs of weakness) provide sufficient clues to make the initial clinical diagnosis (Dias et aI., 2007).
•
Without ligamentous/capsular stability support, this joint is innately 'unstable" due to its
•
The degenerative process is related to deterioration of the deep palmar ligament ("beak
saddle-joint configuration. ligament"), which is critical in assuring translational stability of the metacarpal bone on the trapezium with flexion of the thumb ray (Pellegrini, 1991). •
Initially radiographs are not necessary but may be needed when no or little response to conservative treatment and for surgical planning.
•
Pathology/
•
Conservative treatment is the initial approach of treatment. Progressive degenerative changes in the saddle-shaped articular surface of the base of the first metacarpal bone.
Etiology •
Degeneration of the palmar lip cartilage is associated with attritional detachment of the beak ligament (deep palmar ligament of the thumb) (Pellegrini, 1991) leading to destabilization of the joint (remember that it is inherently ·unstable" due to the saddle-shaped articular contours).
•
Advanced articular disease occurs only in the palmar contact areas and is typically predicted by degeneration of the adjacent beak (deep palmar) ligament (Pellegrini, 1991).
•
Nonprogressive chondromalacia is typically found on the dorsal portions of the articular surfaces (Pellegrini, 1991).
•
Risk of rhizarthrosis is elevated for typists and persons who have to work at a job that requires dexterity (Elsner et aI., 1995).
•
Inreased laxity due to generalized changes (e. g., post-menopause) may play a factor in the worsening of the degenerative process (Bischofberger, 1978; Gschwend and Razavi, 1977b).
Clinical Presentation
•
Pain localized to and most pronounced at the based of the thumb.
•
Pain worse with motion.
•
Difficulty applying a forceful grip.
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Degenerative Arthrosis of the Carpometacarpal JOint (Rhizarthrosis) (cont.) Functional Information
•
Pain may have been tolerated for some time ("toughed out") by the patient until particular functional activities have clearly become adversely affected. especially when the thumb is important for work or avocational interests (e. g
.•
sports).
•
Report of progressive loss of ability to do usual work or avocational activities.
•
Difficulty performing a ·strong grip· (e. g
.•
unable to open cans. pain when shaking hands.
etc.). •
Difficulty holding heavy items.
•
Difficulty opening jars.
•
Signs/history of overuse or repetitive use.
Examination/
•
The base of the thumb is painful upon palpation.
Special Tests
•
Pain with movement.
•
Crepitus at the joint with/without swelling.
•
Finkelstein maneuver to rule out De Quervain disease.
Diagnostic Adjunctive
Plain Radiographs
Studies
•
Typically the initial imaging study of choice. when indicated (e. g
.•
history and physical exam
not sufficient. at least initially or no response to treatment or other potential comorbidities). • •
May help exclude sinister pathology. overt dislocation. or sequelae of trauma. Usually limited information about the ligamentous involvement except in chronic situation where there may be apparent degenerative changes in the jOint itself.
•
In the more advanced stage. joint space narrowing and radial subluxation of the base of the first metacarpal bone. accompanied by osteophytes on the radial and ulnar/palmar side can be seen (Fig. 14.38).
Treatment Options
Conservative Approaches Including Manual Medicine Approaches •
Appropriately designated physical therapeutic management with specified activity restrictions and functionally based goals.
•
Manual medicine approaches emphasizing functional return of the entire wrist. hand. and upper limb complex. and in particular the joints neighboring the base of the thumb.
•
Manual medicine techniques address regional deficits as well as specific dysfunctions associated with particular articulations. especially at the wrist. fingers. elbow and shoulder (look for posturally adaptive changes/compensatory pattems that might require abnormal hand position. e. g
.•
at work).
•
Pharmacologic supportive care (e. g
•
Appropriate exercise instruction (gentle stretches of wrist and thumb. circumduction to
.•
acetaminophen. NSAIDs. etc.).
tolerance. etc.). •
Trial period of wearing a splint.
Injection •
After conservative care and before considering surgery as next step of management
•
Injections may only be of temporary success.
(Buckwalter et al.. 2001; Lane and Thompson. 1997).
Technique/Solution: 3 mL syringe with 25 gauge. 1- in needle; 0.5 mL of 1% lidocaine or 0.25% or 0.5% bupivacaine; 0.25 to 0.5 mL Celestone Soluspan or methylprednisolone. (Caveat: avoid injection into the radial artery or the extensor pollicis tendons [Tallia and Cardone. 2003]). Surgical Considerations •
Consider surgical intervention for recalcitrant cases despite what would appear prior solid physical therapeutic intervention. especially when persistent pain and/or significant dysfunction interferes with daily life activities. vocational or avocational activities.
• •
Various surgical approaches exist. the ·simplest" of which is the trapeziectomy. EVidence-based reviews Indicate that surgery for rhizarthrosis improves pain. function. range of motion. and strength in the thumb and enhances well-being after conservative measures have failed (Wajon et al.. 2005).
•
Trapeziectomy should be the surgical approach of choice as it appears to cause less harm than
•
Trapeziectomy with ligament reconstruction and tendon interposition should be avoided due
•
Patient satisfaction after trapeziectomy with ligament reconstruction and tendon interposi
the others (Wajon et al
.•
2005).
to potentially increasing harm (Wajon et al.. 2005). tion (Aexor carpi radialis tendon) is consistently high. typically >95%.
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Selected Clinical Syndromes
Degenerative Arthrosis of the Carpometacarpal Joint (Rhizarthrosis) (cont.)
Differential Diagnosis
• •
De Quervain tenosynovitis. Degenerative changes involving the three-bone complex of the scaphoid-trapeziumtrapezoid bones.
•
Erosive osteoarthritis and psoriatic arthritis.
•
Referred pain from the abductor pollicis longus muscle (Hwang et aI.,
•
Scaphoid fracture.
•
2005) .
Somatic dysfunctions (e. goo overuse, abnormal use, adaptive/compensatory changes due to postural abnormalities, etc.)
•
Prognosis
•
Trauma to the hand and wrist/fingers with soft-tissue sequelae (e. g., somatic dysfunctions). If objective and functionally meaningful progress is not observed in a reasonable time frame, or there is continued significant pain, the goal of the reevaluation is to determine candidacy for surgery.
•
Primary goal would be reduction of the offending movements, especially if repetitive, while recognizing that this may be difficult (especially when one's job depends on it).
•
If treatment fails despite appropriate ·wait and see" and physical therapeutic or rational use of injections (typically within 1 year), consideration should be given whether surgery would be indicated for pain reduction and functional maintenance.
Fig. 14.38 Rhizarthrosis a
Advanced degenerative changes seen in the joint of the base of the thumb (rhizarthrosis).
b Status after surgical removal of the trapezium with ligament
recon stru ction tendon- interposition plasty using the flexor carpi r adialis tendon. The radiolucent area represents the opening that was drilled at the base of the thumb/metacarpal bone through which the tendon was pulled. Note that despite the removal of the trapezium the overall length of the ray of the thumb could ,
be reasonably maintained.
Wrist Ganglia Synonyms and Related Terms
•
Synovial cyst.
Key Points
•
Painless swelling in the region of the wrist.
•
Due to rupture/tear of synovial lining.
•
Due to communication with joint capsule and/or tendon sheath.
Pathology/ Etiology
•
May be transient.
•
Occult ganglion if area is painful.
•
Pathology and etiology are essentially unknown.
•
Cyst formation to mucoid degeneration of collagen in connective tissues.
•
Recent theory (Angelides, 1999) implicates trauma or tissue irritation. The cyst may be single or multilobulated.
• •
Contents are clear and contain viscous myosin (hyaluronic acid, albumin, globulin, and glucosamine ).
•
The cyst wall consists of collagen fibers.
•
A network may exist between the multilobulated cysts through duct formation.
•
Typically there is no necrosis or epithelial cellularity of the walls.
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Wrist Ganglia (co nt.) Clinical Presentation
•
Typically asymptomatic. painless and unexplainable swelling in the wrist.
•
When seen in the office. presentation is often due to functional loss such as restricted range of motion. or new onset pain. paresthesiae. and/or weakness.
•
May include pain. paresthesiae. and weakness.
•
Size is typically not more than 2 cm diameter.
•
Can involve any joint of the hand and wrist.
•
Dorsal wrist. volar retinacular. and distal interphalangeal ganglion cysts are most common.
Dorsal Wrist Ganglia •
Scapholunate ligament of the wrist is the majority location.
•
Volar wrist is the next most common site (15 % of ganglia).
•
Flexor tendon sheath of the fingers (10-12% ganglia).
Examlnationl
•
Round and rather smooth swelling on dorsal or other involved area of the wrist.
Tests
•
Typically located over the lunate bone or the scapholunate articulation.
•
Volar ganglion location: distal radius at the level of the flexor carpi radialis tendon.
•
Occult dorsal ganglion tenderness around the scapholunate fossa region. Pain is typically noted with extreme wrist extension.
Diagnostic Adjunctive Studies
Radiographs •
No pathognomonic findings for a ganglion cyst.
•
Plain radiographs are helpful in ruling out potential underlying bone or joint disease.
MRI •
For suspicion of occult ganglia. MRI is the study of choice. Sonography may produce similar results.
Treatment Options
Conservative Care •
·Wait-and-see" may be indicated as long as there is no functional loss and after other diagnoses have been adequately excluded.
•
Aspiration with or without steroid injection.
•
Manual therapy. No specific technique is indicated.
Surgical Consideration •
Ganglionectomy with capsulotomy and revision of dorsal scapho-Iunar interosseous ligament.
Complications
Differential Diagnosis
Prognosis
•
Ganglion recurrence is the most common complication.
•
Postoperative joint stiffness and range of motion loss.
•
Intraosseous ganglion (visible on radiographs).
•
Kienbock disease (lunate collapse).
•
Osteoarthritis.
•
Tumors: bone or soft tissues.
•
Recurrence is significantly higher in conservatively treated patients than in the surgically treated.
•
Total ganglionectomy has an 85-95% cure rate as long as the cyst and the associated stalk are removed. Revision of dorsal SL-ligament with excision of dorsal wrist ganglia mandatory.
Bost F, Inman V: The pathological changes in recurrent dislo
Further Reading Akuthota V. Chou LH. Drake OF. et al. Sports and performing arts medicine. 2. Shoulder and elbow overuse injuries in sports. Arch Phys Med Rehabil. 2004 Mar ;85(3 Suppl. 1): 552-58. Badcock LJ. Lewis M. Hay EM. Croft PRo Consultation and the outcome of shoulder-neck pain: a cohort study in the pop ulation. J Rheumatol. 2003 Oec;30(12):2694-2699. Bankart A. The pathology and treatment of recurrent disloca tion of the s hould er-joint. Br J Surg 1938;26:23-29.
cation of the shoulder. A report of Bankart's operative pro cedures. J Bone Joint Surg. 1942;24:595-613. Brukner p. Khan 1<. Clinical Sports Medicine. 2nd ed. New York: McGraw-Hili; 2002. Cartland JP. Crues JV 3 d. Stauffer A. MR imaging in the evalua tion of SLAP injuries of the shoulder: findings in 10 patients. Am J Roentgenol. 1992 Oct; 159(4):787-792. Chandnani VP. Yeager TO. D eB erard i no T. Glenoid labral tears: prospective evaluation with MRI imaging. MR arthrography. and CT arthrography. Am J Roe ntgeno l . 1993 Dec ;161(6): 1229-1235.
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Cooper DE. Arnoczky SP. O'Brien SJ. Anatomy. histology. and vascularity of the glenoid labrum. An anatomical study. J Bone Joint Surg [ Am]. 1992 Jan;74(1 ):46-52. Farin PU. Rasanen H.Jaroma H. et aJ. Rotator cuff calcifications: treatment with ultrasound-guided percutaneous needle as piration and lavage. Skeletal Radiol. 1996;25(6):551-554. Grauer JD. Paulos LE. Smutz WP. Biceps tendon and superior labral injuries. Arthroscopy. 1992;8(4): 488-497. Handoll H. Almaiyah M. Rangan A. Surgical versus non-surgical treatment for acute anterior shoulder dislocation. Cochrane Database Syst Rev. 2004;1 :CD004325. Holtby R. Razmjou H. Accuracy of the Speed's and Yergason's tests in detecting biceps pathology and SLAP lesions: com parison with arthroscopic findings. Arthroscopy. 2004 Mar;20(3):231-236. Itoi E. Kuechle DI<. Newman SR. Stabilising function of the biceps in stable and unstable shoulders. J Bone Joint surg Br. 1993 Jul;75(4):546-550. Jackson D.Turner-Stokes L. Williams H. Das-Gupta RJ. Use of an integrated care pathway: a third round audit of the man agement of shoulder pain in neurological conditions. Reha bil Med. 2003 Nov;35(6):265-270. Jerosch J. Strauss JM. schmiel S. Arthroscopic treatment of cal cific tendinitis of the shoulder. J Shoulder Elbow Surg. 1998;7(1 ):30-37. Kapandji IA. The Physiology of Joints. Annotated Diagrams of the Mechanics of the Human Body. Vol. 1. 2nd English ed. Edinburgh: Churchill Livingstone; 1982:2-20. Loew M. sabo D. Wehrle M. et al. Relationship between calcify ing tendinitis and subacromial impingement: a prospective radiography and magnetic resonance imaging study. J Shoulder Elbow surg. 1996;5(4):314-319. Maffet MW. Gartsman GM.Moseley B. Superior labrum-biceps tendon complex lesions of the shoulder. Am J Sports Med. 1995 Jan-Feb; 23(1 ):93-98. Mayerhofer ME. Breitenseher MJ. Impingement syndrome of the shoulder [in German] Radiologe. 2004 Apr;44(6): 569-577. McGlynn FJ. Caspari RB. Arthroscopic findings in the subluxat ing shoulder. Clin Orthop.1984 Mar;(183):173-178. Neer CS 2d. Welsh RP.The shoulder in sports. Orthop Clin North Am. 1977 Jul;8(3):583-591. Neer CS II: Shoulder Reconstruction. Philadelphia: WB Saun ders; 1990:427-433. Pagnani MJ.Deng XH. Warren RF. Effect of lesions of the supe rior portion of the glenoid labrum on glenohumeral trans lation. J Bone Joint surg Am. 1995 Jul;77(7):1003-101O. Perron M. Malouin F. Acetic acid iontophoresis and ultrasound for the treatment of calcific tendinitis of the shoulder: a randomized control trial. Arch Phys Med Rehabil. 1997;78(4):379-384. Perthes. G. Uber Operationen bei habitueller schulterluxation. Dtsch Z Chir. 1906;85:199-227.
Resch H. et al: Arthroscopic repair of superior glenoid labral detachment (the SLAP lesion). J Shoulder Elbow surg. 1993;2:147-155. Rodosky MW. Harner CD. Fu FH. The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder. Am J Sports Med. 1994 Jan Feb;22(1 ): 121-130. Rompe JD. Rumler F. Hopf C. et al. Extracorporeal shock wave therapy for calcifying tendinitis of the shoulder. Clin Or thop.1995 Dec;321 :196-201. Smith AM. McCauley TR. Jokl P. SLAP lesions of the glenoid labrum diagnosed with MR imaging. Skeletal Radiol 1993 Oct;22(7):507-51O. Snyder sJ.Banas MP.Karzel RP. An analysis of 140 injuries to the superior glenoid labrum. J Shoulder Elbow surg. 1995 Jul Aug;4(4):243-248. Speed CA. Hazleman BL. Calcific tendinitis of the shoulder. N Engl J Med. 1999;340(20):1582-1584. storro S. Moen J. svebak S.Effects on sick-leave of a multi disciplinary rehabilitation programme for chronic low back. neck or shoulder pain: comparison with usual treat ment. J Rehabil Med. 2004 Jan;36(1 ):12-16. Teefey SA. Rubin DA.Middleton WD. et al. Detection and quan tification of rotator cuff tears. Comparison of ultrasono graphic. magnetic resonance imaging. and arthroscopic findings in seventy-one consecutive cases. J Bone Joint surg Am. 2004 Apr;86-A(4):708-716. Tirman PF. Smith ED. Stoller DW. Fritz RC. Shoulder imaging in athletes. semin Musculoskelet Radiol. 2004 Mar;8(1): 29-40. Uhthoff HK. Loehr Jw. Calcific tendinopathy of the rotator cuff: pathogenesis. diagnosis. and management. J Am Acad Or thop surg. 1997;5(4):183-191. Vangsness CT Jr.Jorgenson 55. Watson T. The origin of the long head of the biceps from the scapula and glenoid labrum. An anatomical study of 100 shoulders.J Bone Joint surg Br.1994 Nov;76(6):951-954. Walton J. Mahajan S. Paxinos A. et al. Diagnostic values of tests for acromioclavicular joint pain. J Bone Joint surg Am. 2004 Apr;86-A(4):807-812. Warner JJ. McMahon PJ. The role of the long head of the biceps brachii in superior stability of the glenohumeral joint. J Bone Joint surg Am. 1995 Mar;77(3):366-372. Wittke R. Leading symptom: shoulder pain lin German] MMW Fortschr Med. 2003 sep 25;145(39):37-41. Wolf WB III. Shoulder tendinoses. Clin Sports Med. 1992; 11 (4):871-890. Yoneda M. Hirooka A. Saito S. Arthroscopic stapling for de tached superior glenoid labrum. J Bone Joint surg [Br]. 1991 Sep;73(5):746-750. Zuckerman. J. In Kassel'. J. ed. Orthopaedic Knowledge Update 5. Elbow: Reconstruction. Rosemont. IL: American Academy of Orthopaedic Surgeons; 1996:283-294.
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Copyrighted Material
Disorders of the Hip
joint" to the mechanics of Functional interactions on multi
Clinical Disorders and Syndromes
ple levels. One such connection, For instance is the concept
of the Lower Limb
that the "core stability" of the spine, trunk, and pelvis aFFects function in strength and endurance of the lower limb, and vice versa. (Willson et ai., 2005).
The lower limb comprises the hip-knee-Foot/ankle com
In this part of the text the more commonly encountered
plex, and From a Functional perspective should be viewed
disorders of the lower limb are presented, and where in
as one coordinated stable unit that works in unison to
dicated are integrated into the comprehensive musculos
assure efficient locomotion of the entire body. In its sim
keletal/manual medicine approach. Also, we would not
plest (not simplistic!) terms, the goal is to minimize the
wish this chapter to be viewed in isolation, as some of
vertical translation of the center of mass in relation to
the inFormation presented may be useFul in the later, the
eFficiency of walking. Whether this is done by assuring
practical portions of this book.
the "classic" six determinants of gait or by dismissing two (Gard and Childress, 1997, 1999) or by dismissing another while adding a Further one (Kerrigan et ai., 2001 a and 2000, respectively) is not just a matter of academic or philosoph ical discussion (see I(errigan, 2001 b). The Functional aspect is such that iF one link in the sequence is aFFected, so is the
The Hip Disorders of the Hip
dynamics of gait and thus the rest of the body, which continually attempts to "make up" for functions lost else
Hip problems are a common reason for a musculoskeletal
where. One example is the changes noted with a positive
visit. With the increasing age of the population, the degen
Trendelenburg sign (Fig. 14.39).
erative disorders affecting the various joints, and the hip in
Structure and function not only influence each other
particular, assume a central role in musculoskeletal medi
(one of the Fundamental osteopathic tenets) but may
cine. This is true not only because of the increase in sheer
have efFects quite distant from the area of "dysFunction"
numbers of persons affected, but also because of the de
(e.g., disease), which calls For a comprehensive, complete
mands placed on the musculoskeletal system by participa
evaluation of things that might not be seen as readily
tion in various physical activities, by young and old alike.
"connected." The manual medicine evaluation aims to do
This interplay of increased demand on one hand and on the
just that, and thus expands the directed view from a "single
other the loss of resiliency by the musculoskeletal system over time may set the patient up For an overuse syndrome like situation, and thus requires careFul evaluation of all of the patient's structural and Functional characteristics. Fortunately, within the past 10 to 20 years, total hip arthroplasty has provided such tremendous beneFits that it has become not only one of the most common orthopedic surgical procedures but also one of the most successful (Kasser, 1996a). The various hip disorders can generally be divided into two groups, based on the patient's age: those associated with childhood and adolescence (Table 14.13) and those seen primarily in the adult (Table 14.14). When taking care of the individual patient, the clinical approach to the hip is guided by the standard neuro orthopedic examination. The first goal is to search For any
Fig. 14.39 Trendelenburg sign: observable muscle weakness (neu rogenic or due to significant reflex inhibition) in the gluteus medius muscle of the supporting stance leg that is unable to "anchor down" the pelvis on the side of muscle weakness. This causes the
potential "red flags" or sinister pathology such as develop mental disorders, inFectious or autoimmune processes (e. g., osteomyelitis, infectious arthritis, rheumatoid arthritis of
opposite hemi- pelvis to drop toward the floor. In this example, the
the hip), tumors, Fractures, and sources of hip pain arising
patient stands on the left leg. As the right hip flexes (thus lifting the
From other joints or regions such as the spine or the knee.
foot off the ground), the right pelvis drops toward the floor due to left sided weakness in the gluteal muscle. In the normal/healthy situation, flexing one hip while standing on the opposite leg (one legged stance test
Trendelenburg test) should not cause any
"drop" of the hemipelvis.
The standard neuro-orthopedic examination is Further expanded by considering other important functional fac tors such as gait abnormalities, Foot or knee problems, poor posture or other factors that would cause increased stress
287
Copyrighted Material
Selected Clinical Syndromes
upon
the
hip
joint.
The
expanded
standard
neuro
disorders that are likely associated with hip pathology
orthopedic examination is then followed by a detailed
directly from those that are not, and will guide in the
structural- functional manual medicine examination. As
determination of the necessary specific additional diagnos
outlined in previous chapters, the goal is to identify as
tic stud ies.
much patient-relevant information as possible and then
Tables 14.13 and 14.14 summarize the more common hip
correlate this with the structural, functional, and pain per
disorders based on the age of onset during child hood and
ception levels.
for the adult.
A carefully administered history combined with a rele vant physical examination will help differentiate those
Table 14.13 Common hip disorder in children Diagnosis
Age Range
Comments
Developmental dysplasia
0-6 years
•
Has previously been termed congenital dysplasia of the hip, even though it is not always present at birth
of the hip
4-8 years
legg-Calve-Perthes
•
disease
NecrOSiS/infarction of the center of ossification of the femoral head without fracture resulting in flattening of the articular surface
•
Often begins with a painless limp
•
Later, flexion and abduction contracture
•
Muscle atrophy and a shortened leg on the incriminated side
•
Bone scan and MRI are helpful in establishing disease, while plain radiographs may reveal also signs indicative to the necrosis
10-16 years
Slipped capital femoral ephiphysis (SCFE) Septic arthritis
Transient synovitis
Pain in the hip or achiness in the groin typically associated with a limp
•
The leg is typically externally rotated
Neonate to
•
Pyogenic infection
adolescent
•
Osteomyelitis of the femoral head
3-10 years
•
Also known as toxic arthritis
•
Usually self-limited
•
Juvenile rheumatoid arthritis
•
Associated splenomegaly and lymph node enlargement
6-12 years
Still disease
•
ijuvenile arthritis)
Table 14.14 Common hip disorders in the adult Diagnosis Ankyloslng spondylitis
Age at Onset
Comments
Late teens to 40
•
As in the spine, the combination of reported pain and stiffness may alert to this disorder. Standard radiographs with findings of sacroiliitis are
years
helpful =
Avascular necrosis of
305 to 505
•
the hip Femoral neck fractures
50 years or older
Osteoarthrosis
40 years and
("osteoarthritis")
older
•
Primary ostearthrosis
•
Secondary osteoarthrosis
Rheumatoid arthritis
May require a high index of suspicion when symptoms are vague, and findings are rather minimal on standard radiographs
20-50 years
•
Typically in persons 50 years of age or older
•
If in younger patient, typically due to trauma or suspect other pathology
•
One of the most commonly encountered disorders of the hip
•
Hip evaluation indicated especially when known systemic involvement is present
Secondary bone tumors
40 years or older
•
Primary bone tumors are uncommon in the hip
Trochanteric bursitis
All
•
Often secondary to a biomechanical abnormality or restricted range of motion
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may be the result of an acute epiphysiolysis of the capital
Hip Disorders in Childhood
head of the femur.
The more common hip disorders in childhood include. among others. developmental dysplasia of the hip (the older. and now outdated. term was congenital hip dyspla
Hip Tumors in Children •
femoral epiphysis (SCFE) (Staheli.
Similarly to all other metaphyses. the proximal femur may be affected by bone tumors including osteosar
sia). Legg-Calve-Perthes disease. and the slipped capital
1991).
coma.
Less frequently encountered are coxa vara congenita.
•
in the proximal femoral is due to metastatic spread.
femoral dysplasia. or bony changes due to metabolic or neurologic disorders such as Gaucher disease. osteogenesis
•
Primary changes include fibrous dysplasia. osteoid os teoma. and. in rarer cases, osteochondroma with sec
imperfecta. or poliomyelitis. Secondary changes not only in
ondary chondrosarcoma.
childhood but also in the adult may be seen after both the typical and atypical arthritides due to viral or bacterial
Typically and usually according to age. the bony tumor
•
The final diagnosis of the various hip tumors in children, as in the adult. is established through the standard
causes. Coxitis fugax has an unknown pathogenesis. Chondrolysis involves loss of joint space with progres
evaluations for tumors including specific laboratory
sive articular joint destruction (Waldenstrbm disease). The
parameters and serum electrophoresis. and the appro
effects are similar to effects of prolonged immobilization or
priate imaging studies are utilized. However. a biopsy
repeated manipulative procedures. such as in epiphysioly
may be required to provide a definitive diagnosis.
sis or when the caput femoris or slipped capital femoral epiphysis has been misaligned.
In the following section. the more common childhood dis
Necrosis of the femoral head may also be the result of attempts to perform repositioning for developmental dys
orders of the hip are represented in tabular format for easier overview.
plasia of the hip. Femoral head necrosis (avascular necrosis)
Developmental DysplaSia of the Hip Synonyms and Related Terms Key Points
•
Congenital dislocation of the hip (CDH).
•
Hip dysplasia.
•
Proximal acetabulofemoral disorder.
•
Use of the term "dysplasia" is more encompassing than "dislocation" as the disorder is more part of a spectrum than a single event.
•
The normal relationships between the proximal femur and the acetabulum are disturbed or significantly altered with loss of normal joint stability.
•
Acetabular dysplasia allows the femoral head to migrate in a superior and lateral direction
•
The capital epiphysis is typically hypoplastic.
•
Unilateral or bilateral involvement in which the hip(s) can be subluxed, easily dislocated, or
(Figs.
14.40, 14.41).
overly dislocated. •
Early diagnosis is key to the success of treatment and reduction of permanent functional loss.
•
Suspect CDH in any child who presents with gait abnormalities or changes in posture, hip pain.
•
Higher- risk groups predisposed for this disorder spectrum are those with breech delivery, a
and/or limb length abnormalities. positive family history, especially known congenital abnormalities, e. g., scoliosis, torticollis, and/or clubfoot. •
The first 6-8 weeks of the newborn's life are very critical to normal hip joint development due
•
Ultrasound is the study of choice in children up to
•
Standard/plain radiographs have low sensitivity and expose the child to ionizing radiation.
to bone-cartilage relationships.
Pathology/ Etiology
•
10
months of age.
Aberration in the normal relationships between femoral head and acetabulum. Normal joint partner congruity relationships are required for normal development of the joint, which becomes disturbed in this disorder.
•
The dislocation is in reality an expression of a primary disease, i. e., congenital dysplasia, which
•
There may be laxity of joint capsule ligament.
means a delayed development of the hip joint (Freyschmidt et al.,
2003).
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Developmental Dysplasia of the Hip (cont.) Staging/Grading Criteria
• Type 1: Joint instability (positional). • Type 2: Subluxation. • Type 3: Overt dislocation.
Clinical Presentation
• Incidence: 1 % incidence of all neonates (worldwide) and reported incidence of 1.5 % of neonates in the USA (McMillan et al.. 1999). • More frequently seen in girls than boys. • Early routine screening examination is key to successfully identifying children affected by CDH. • Re-examination is advisable. especially in higher-risk children. •
Despite good screening efforts. the initial presentation may be in a child between the ages 1 and 3 years. which is at the age of walking.
• Note: Gait or postural abnormalities may be the initial presenting complaint by the parents. Functional Information
• The earlier the disorder is picked up the greater the chance of spontaneous recovery (e. g
.•
the
Ortolani test may have been positive initially but appropriate intervention can allow spontaneous recovery). • If dislocation is diagnosed late. the goal of treatment is to restore hip function to as close to normal as possible. Examination and
Neonate
Special Tests
• Ortolani and Barlow maneuvers. • Ortolani maneuver is used to reduce an already dislocated (or dislocatable) hip; that is. the maneuver attempts to see whether the femoral head can be relocated. The examiner passively abducts the hip with the hip flexed to 900 and while applying a posteriorly directed compression force. • Barlow maneuver is used to see whether the hip is dislocatable (the unstable femoral head is dislocated by posterior pressure while examiner adducts and flexes the child's hip. Older child • Gait evaluation. posture evaluation. special tests including adjunct studies (ultrasound). • Note: As the child grows and the initially rather lax joint capsule becomes more taut along with increasing muscle tightness. the sensitivity of Ortolani and Barlow maneuvers is reduced.
Diagnostic Adjunctive Studies
• Infants-10 months of age or younger. Ultrasound • The preferred adjunct diagnostic study. • Ultrasound allows both static and dynamic evaluation (e. g
.•
during introduction of stress/
provocative maneuvers). • Note: Ultrasound application is operator dependent. •
Structures identifiable by ultrasound: femoral capital epiphysis. acetabulum and iliac bone. labrum.
CTscan • Used in complicated dislocations. • Postoperative evaluation. • Helpful in determining acetabular anteversion (Ozonoff. 1992). MRI • Useful for preoperative planning and postoperative evaluation in complicated situations including potential postoperative sequelae such as avascular necrosis. • Able to differentiate between acetabular cartilage. joint capsule. and labrum. • Study of choice for soft-tissue pathology and/or bone tumors. especially in the older child who presents with a limp. Treatment Options
•
The primary goal of treatment is to reduce the abnormal femoral head-acetabulum relationships by maximizing contact between these two joint partners.
• The majority of unstable hips in neonates show spontaneous resolution within 2 to 4 weeks of age. Again. re-examination and continued screening. especially during the first 4 weeks is a critical factor. • Initial treatment in children under 6 months of age utilizes a brace to ensure continued hip flexion and abduction (frog-leg position). •
Children older than 6 months are treated with closed reduction under generalized anesthesia. followed by a spica cast (months).
• If closed reduction fails. open reduction may be indicated. • In older children with bony deformity (e. g
.•
older than 2-3 years). femoral or pelvic osteotomy
and open reduction may be necessary (McMillan et al.. 1999). •
Abductor tenotomy and release of iliopsoas.
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Developmental Dysplasia of the Hip (cont.)
Differential Diagnosis
Prognosis
•
Coxa vara.
120°: pyogenic (septic) arthritis of the hip.
•
Neck- to- shaft angle less than
•
Proximal focal femoral deficiency.
•
Shortening of the proximal segment of the femur.
•
Slipped capital femoral epiphysis.
•
The capital epiphysis maintains acetabular coverage.
•
The outcome is usually good with appropriate treatment. especially if initiated early.
•
Again. early screening. especially in weeks 3 to 4 of the infant's age. is of significant value.
About screening •
Screening (ultrasound and/or physical examination) may be helpful in the early identification of newborns with increased risk for developmental dysplasia of the hip. However. there is a high rate of spontaneous resolution of hip instability and dysplasia and. given the lack of evidence for the effectiveness of intervention on functional outcomes. the net benefits of screening are not clear
(Further reading: Shipman et aI., 2006).
Complications •
Delay in meeting normal walking/ambulation milestones due to the child's being in a cast.
•
Skin irritation from cast or other reduction devices (braces. etc.).
•
If untreated. the disorder may lead to arthritis and deterioration of the hip later in life (due to failure in approximating the normal femoral head-acetabulum relationships which is the desired outcome).
•
Further Reading
Limb length discrepancies may persist through life.
Aronsson DO. Goldberg MJ. Kling TF Jr. Roy DR. Developmental dysplasia of the hip. Pediatrics. 1994 Aug: 94(2 Pt 1):201-8. (Erratum in: Pediatrics 1994 Oct;94(4 Pt 1):470]. Shipman SA. Helfand M. Moyer VA. Yawn BP. Screening for developmental dysplasia of the hip: a systematic literature review for the US Preventive Services Task Force. Pediatrics. 2006 Mar;117(3):e557-576.
Fig. 14.40 Dysplas ti c arthritis of the hip (coxar throsis) with cranial
Fig. 14.41 Schematic representation of hip dysplasia.
shift of the femoral head with pseudo-acetabular formation. Note the advanced arthritic changes in the opposite hi p as well.
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Slipped Capital Femoral Epiphysis (SCFE) Synonyms and Related
•
Terms
•
Salter-Harris fracture type 1.
•
Slipped hip.
Definition
Hip disorder of adolescence.
Painful loosening of the femoral epiphysis with inferior migration of the femoral head in the
•
adolescent often associated with loss of range of motion. Key Points
•
The most common reason for hip pain in the adolescent. More common in boys than girls. while onset in girls is earlier than that in boys (by about 2
•
years; due to earlier bone maturation in gins). •
Risk Factors
Pathologyf
The cause is unknown but hormonal factors have been implicated.
•
Presentation is typically unilateral but may be bilateral in up to 25% of cases.
•
The 'slipped" physis represents a Salter-Harris type 1 fracture.
•
SCFE is not seen in children whose growth plate has closed.
•
MRI is the study of choice for early detection of the disorder.
•
Somewhat more common in boys than girls.
•
Obesity appears to be a significant predisposing factor.
•
Hormonal factors have been implicated but not unequivocally proven (given that the
•
Intrinsic factors such as weakness in the cartilage of the epiphysis.
•
Extrinsic factors include trauma (which may be the precipitating moment in an already
Etiology
disorder occurs during adolescence/growth spurts).
damaged epiphysis. rather than causing the abnormality).
Clinical Presentation
•
Fracture through the physis.
•
Hip pain in approximately half of the presenting population.
•
Knee pain in approximately one-quarter of the presenting population.
•
limping.
•
Symptoms are typically gradual in onset rather than sudden. "Red flag": hip and/or knee pain in an adolescent should alert the initial treating physician to
•
the possibility of SCFE as it is important to make a diagnosis as early as possible so as to minimize potential complications. Functional Information
•
The presenting reason for a medical visit may be a limiting limp or inability to participate in preViously tolerated activities such as certain sports. -
-�----
Examlnatlonf
•
The hip capsule may be tender to palpation.
Special Tests
•
The hip may be held in external rotation (external rotation contracture).
•
limited range of motion in the directions of intemal rotation. abduction. and flexion.
Diagnostic Adjunctive
Plain Radiographs
Studies
• •
AP and frog-leg radiographs typically reveal findings diagnostic of SCFE. Lateral radiograph shows slippage earliest (initial direction of slippage is in the posterior direction).
CT •
Rarely needed if plain radiographs are diagnostic.
•
CT is helpful to determine the extent of the slippage and to allow serial follow-along (if indicated).
MRI •
Detects early changes such as mild slippage and bone marrow edema.
•
Useful in the patient whose examination and history are commensurate with SCFE but
•
Helpful in evaluating the opposite hip.
•
Surgical intervention
•
No weight bearing (crutches. with appropriate instructions how to use them/how not to use
whose plain radiographs appear normal.
Treatment Options
(i. e pinning). .•
them-to avoid crutch-palsy. etc.). •
Traction.
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Slipped Capital Femoral Epiphysis (SCFE) Differential Diagnosis
Prognosis/
(cont.)
•
Femoral neck fracture.
•
Hip tumor.
•
Legg-Calve-Perthes disease.
•
Osteoarthritis.
•
Osteoid osteoma.
•
Rheumatoid arthritis Ouvenile form).
•
Septic arthritis.
•
The ultimate prognosis depends on the time of detection and the severity/progression of the disease at the time it is detected.
Complications •
Early detection and mild disease usually have a better/good outcome compared to late detection and/or severe disease progression.
•
Severe slips will require extensive reconstruction and thus have a greater complication rate.
Complications •
Avascular necrosis of the femoral head (especially if associated with trauma), which may
•
Osteonecrosis.
•
Chondrolysis.
ultimately lead to severe traumatic arthritis of the hip.
legg-Calve-Perthes Disease Synonyms and Related
•
Coxa plana.
Terms
•
Legg-Perthes disease.
•
Perthes disease.
Definition
•
Usually self-limited disorder of the hip due to infarction and necrosis of the bony epiphysis of the femoral head with little pain in children ages
Key Points
•
4-10
years.
This disorder represents a form of avascular necrosis of which the cause essentially unknown.
•
Much more common in boys than girls
•
Unilateral involvement is typical.
•
Bilateral involvement in
(5:1).
10% of cases, either simultaneously or in sequence after some time
interval. •
Presenting complaints may by those of an observed limp associated with rather vague pain in the hip(s), and thigh(s), and knee(s) (referred).
•
Note: Knee pain may be the only presenting symptom, initially.
•
The disorder may be suspected from the history, age, and sex of the child, and by the
•
Age range
•
Hypointensity of the capital epiphysis on coronal MR images.
limited hip range of motion.
Prevalence
4-10
years.
(5:1).
•
Much more common in boys than girls
•
Familial predisposition (sickle cell disease).
Pathology/
•
Insufficient blood supply to the capital epiphysis where the physis acts as a barrier.
Etiology
•
Overgrowth of articular cartilage medially and laterally.
•
Trabecular fracture resulting in diminished epiphyseal height, thus leading to infarction.
•
The disease process is progressive.
Clinical Presentation
•
Limping with or without pain may be the primary complaint that causes parents to bring the child to the attention of the physician.
•
Reported hip pain and thigh pain, which may be rather vague and more of an "ache."
•
Knee pain, either isolated or in conjunction with the hip and/or thigh pain.
•
Reduction in the child's avocational/sports activities associated with the knee pain may be
•
Ambulation restriction due to pain and hip stiffness with a noticeable limp.
Examination and
•
Observable gait abnormalities.
Special/Provocation Tests
•
Limb length abnormality/asymmetry.
•
Reduced hip motion with reduction in rotation.
•
Flexion and abduction contracture.
Functional Information
the initial reason for a medical visit.
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legg-Calve-Perthes Disease (cont.)
Diagnostic Adjunctive Studies
Plain Radiographs •
Initial study of choice as radiographic findings are typically well manifest by the time the child presents for the medical visit.
•
Final stage consists of flattening of the femoral head, and finally cranial dislocation of the femoral neck (Fig.
•
14.42) (Freyschmidt et ai., 2003).
The "pearl necklace" stage of subchondral rarefaction in the femoral neck and acetabulum, together with fragmentation of the necrotic osseous areas and widening of femoral neck, are late developments of the disease (Freyschmidt et ai.,
Treatment Options
•
2003).
Initially, bed rest may be appropriate, weighing the consequences of the risk of potential disuse atrophy; traction.
•
Goals of treatment are primarily twofold: - To reduce further potential destruction of weight-bearing surface. - To establish better joint congruity between femoral head and acetabulum through osteotomy.
• •
50% of patients improve with no treatment. Younger age of presentation implies better prognosis (age greater than 8 years implies poorer prognosis).
•
Girls experience a more severe form of the disease. - Epiphyseal signs (calcification lateral to epiphysis
+
lytic area laterally) and metaphyseal
(hOrizontal inclination of growth plate) signs are associated with poor prognosis. - Bracing or femoral osteotomy.
- 86 % develop osteoarthritis. - Increased epiphyseal extrusion at greater than
Differential Diagnosis
Prognosis
20% implies poor prognosis.
•
Infection
•
Greater soft-tissue reaction and/or inhomogeneous effusion.
•
Erosion of subchondral plate in capital epiphysis.
•
Irritable hip.
•
No marrow necrosis.
•
Typically the outcome is good with initiation of appropriate treatment.
• • •
50% of patients improve in absence of treatment. 50% femoral head involvement implies poor prognosis.
Greater than
Younger age of presentation equals better prognosis (age greater than 8 years implies poor prognosis).
• •
Girls: more severe form of the disease. Epiphyseal signs (calcification lateral to epiphysis
+
lytic area laterally) and metaphyseal
(hOrizontal inclination of growth plate) signs are associated with poor prognosis.
Fig.
14.42 Schematic representation of an epiphysiolysis of the
femoral head with cranial displacement of the femoral head.
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Septic Arthritis of the Hip Synonyms and Related
•
Acute septic hip arthritis.
Terms
•
Bacterial arthritis.
Definitions
•
Infectious arthritis.
•
Nongonococcal arthritis.
•
Pyogenic arthritis.
•
Suppurative arthritis.
•
Acute pyogenic infection of the hip typically in infancy or young childhood due to bacteremia or osteomyelitis of the femoral neck with severe complications if untreated and usually associated with pain upon passive evaluation of the joint.
Key Points
•
A true medical emergency that requires immediate attention to minimize potentially disastrous
•
Sudden onset of intense hip pain typically over the course of 24-48 hours in the presence of
complications. signs/symptoms of systemic involvement. •
Since the inception of routine immunization against H. inf/uenzae type b. the major organism responsible in all age groups is Staphylococcus aureus.
•
Consider any painful hip movement in infancy or childhood as a "red flag" and work up appropriately to rule in or rule out septic arthritis.
Pathology/Etiology
•
Aspiration of the hip prior to starting antibiotic treatment is key for successful treatment.
•
Newborns.
Pathogens •
Staphylococcus aureus is the most common organism in all age groups.
•
Other pathogens include streptococci. Pseudomonas aeruginosa. pneumococci.
•
Neisseria meningitides. Escherichia coli. Klebsiella species. and Enterobacter species.
•
Newborns: consider Neisseria gonorrhoeae from an infected birth canal.
•
Consider gonococcal arthritis in sexually active teenagers. or when considering sexual abuse.
•
Bacteremic spread is typically via the hematogenous route or by proximity of other infected tissues (e.g
•
Clinical Presentation
.•
cellulites).
Again. aspiration of the hip to determine specific organism is a key diagnostic procedure.
History •
Intense reported joint pain with refusal to bear weight to the point at which it may resemble paresis/paralysis (pseudoparesis).
•
Normal activities cause Significant. readily noticeable discomfort (i.e .. diaper change causes the infant to cry).
•
Functional Information
Groin pain may be more prominent than hip pain per se.
•
Inability to move the hip due to pain (pseudoparesis/paralysis).
•
The hip may be held in a position of flexion and external rotation.
Examination/
•
Passive movement. even if performed very carefully. can elicit excruciating pain.
Special Tests
•
Inability or frank refusal to use the involved limb.
Diagnostic Adjunctive
•
Aspiration of the hip to determine the particular pathogen(s) is a key diagnostiC activity.
Studies
•
Laboratory studies to support the clinically suspected entity.
•
Radiographs.
•
Antibiotic therapy.
•
Appropriately dosed bed rest.
Treatment Options
•
The primary goal is to minimize the potentially disastrous complications. which can include total distraction of the femoral head.
Differential Diagnosis
•
Rheumatoid synovitis is not as painful; constitutional symptoms are usually not as pronounced as in septic arthritis of the hip).
Prognosis
•
Toxic synovitis (usually not as painful).
•
Outcome is dependent on early identification of the specific pathogen.
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The goal of surgical intervention is to realign the various
•
Hip Disorders in Adults
pieces so as to restore the most nearly ideal anatomic relationships and to maximize lower-limb function.
Osteoarthritis-or. the preferred term-osteoarthrosis of
Osteosynthesis in the elderly patient may be associated
•
the hip is one the most common musculoskeletal disorders
with prolonged healing and potential pseudoarthrosis
encountered in clinical musculoskeletal practice. The diag
formation or healing in an abnormal position. (Madsen
nosis is relatively straightforward. especially when the
et al..
1987.)
standard radiographs reveal sufficient evidence of the dis order. More challenging may be the management of the
Below.
disease. which can range from a "wait-and-see" approach
osteoarthritis and avascular necrosis of the hip are pre-
to surgical intervention with total arthroplasty. The key
sented.
again
in
table format.
the
salient points
factors in the determination are the patient's true func tional status and the effects that the disease and the symp toms have on the patient's overall vocational requirements and avocational interests. There is no single "right" ap proach; rather it should be based on the patient's age. their psychosocial functioning. and the desired outcomes as de termined by the congruency of patient and physician goals.
Hip Fractures •
Hip fractures involve primarily the proximal femur and. in the absence of trauma. are seen mostly in the elderly patient. In the adolescent. femoral head fractures are more often due to trauma.
•
Two types of fractures are characteristically differenti ated. namely. the intertrochanteric fracture and the subcapital fracture (Fig. 14.43
a,
b).
Fig. 14.43 a,b Fracture sites at the hip. a
Intertrochanteric hip fracture.
b Su bcapita l femoral neck fracture.
Osteoarthritis (OA) Synonyms and Related Terms
Key Points
•
Coxarthrosis.
•
Coxalgia.
•
Degenerative arthritis of the hip.
•
Degenerative joint disease (DJD) of the hip.
•
Osteoarthrosis of the hip.
•
The most common form of articular cartilage degeneration.
•
Affects 85-95% of the population older than 65 years.
•
Consider this not to be a single disease entity but rather the final result of multifactorial
•
Take into account the articular changes, as well as the soft-tissue changes and adaptive!
degenerative processes. maladaptive functional compensatory patterns (reduced function such as ambulation, transfers, etc.). •
It has a major impact on vocational and avocational activities.
•
Primary and secondary forms (congenital dysplasia, legg-Calve-Perthes, old slipped capital femoral epiphysis [SCFEJ).
•
loss of articular cartilage in the hip joint articulation due to various causes including infection, autoimmune disorders, trauma, and idiopathic reasons: - Patient typically complains of gradual onset of painful weight-bearing with progressive loss of range of motion to the point of significant functional impairment. - later, the disorder may lead to pain at rest. - location of the pain is reported directly either deep in the hip joint itself or also in the groin: also periarticular pain. - If the patient reports pain at night, consider this to be severe arthritis. - If night pain is reported. rule out causes such as the possibility of tumor or referred pain from the spine due to other sinister pathology. etc.
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for
Hip Disorders in Adults
Osteoarthritis (OA) (cant.) Pathology/Etiology
• Mismatch between the loading forces and the various joint tissues' ability to withstand the induced stress (Fig. 14.44). • Involves primarily the articular cartilage: - Inflammation contributes to cartilage degeneration. Staging or Grading
• Grade I: chondral inhomogeneity. • Grade II: inhomogeneity plus discontinuity of chondral surface, hypointensity of femoral head and neck, and loss of trabecular detail on Tl-weighted MRI.
• Grade III: grade II changes plus irregular cortical morphology of femoral head and acetabulum plus cystic changes of the femoral head plus indistinct zone between femoral head and acetabulum.
• Grade IV: the addition of femoral head deformity. Staging/Grading
1. Stationary phase: Osteophyte formation with jOint space narrowing (chondral inhomogeneity).
Criteria
2. Further chondral changes (e.g., further narrowing/ioint obliteration). 3. Erosive phase: chondral changes plus subchondral cyst formation.
4. The body's attempt at bone repair/remodeling (e.g., changes in femoral head morphology/ appearance). Clinical Presentation
• Osteoarthritis of the hip is a disorder that increases with age, not necessarily because of it. • Idiopathic or primary forms are seen in patients who are between 50 and 60 years old and older, whereas, trauma-related degenerative changes are seen in younger patients.
• • • • • • •
The patient may complain of deep hip pain typically of gradual onset. There may be reported groin pain as well as buttock and/or lateral thigh pain. Pain is apparent initially only with activity but progresses to the point where the hip is painful. Severe night pain is typically associated with severe forms of arthritis. The patient may present with a prominent coxalgic limp. Incidence of OA increases with advancing age. Early acetabular chondral and subchondral changes may be seen in younger patients aged 30-50 years prior to femoral head findings. These early OA changes may be secondary to trauma.
Functional Aspects
• The patient may have difficulty performing the activities of daily living (ADLs) such as tying shoes, donning and doffing pants, and performing their own foot hygiene.
• Patients have difficulty ambulating for prolonged periods and this may impact their vocational and/ or avocational requirements. The patients may continue to walk for some time while it may be considerably more difficult to sit or lie.
• Long-term involvement without treatment may lead to flexion or adduction contracture with significant functional loss.
• In advanced cases, increased lordosis of the spine is noted as form of compensatory mechanism. Examination/Tests
• Loss of or reduction in internal rotation of the hip is one of the early telltale signs of osteoarthritis. • In more advanced stages, there is noted loss of flexion and extension, and ultimately there may be an adduction contracture as well.
• A typical gait abnormality may be noted such as coxalgic gait or an abductor lurch (moving the trunk over the incriminated hip).
• In the younger patient, the secondary form of hip osteoarthritis must be considered and requires additional workup to rule out hip dysplasia or residuals of Legg-Calve-Perthes disease or slipped capital femoral epiphysis (SCFE). Specific Tests
• Internal rotation testing. • Stinchfield test (resisted hip flexion maneuver): if no pain is directly elicited in the hip joint, this may point to a cause of the pain away from the hip. Diagnostic Adjunc
Plain Radiograph and CT Findings
tive Studies
• • • • •
Plain radiographs are the initial study of choice (Fig.
14.45).
Joint space is typically narrowed. Osteophytes. Subchondral cyst. Sclerosis.
MRI
• MRI may be indicated especially when trying to rule out additional disorders such as avascular necrosis of the hip.
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Selected Clinical Syndromes
Osteoarthritis (OA) (cont.) Treatment Options
•
Intra- articular steroids Uudicious use: especially regarding how often injections are repeated at
•
NSAIDs.
•
Total joint arthroplasty.
what intervals).
•
Physical therapeutic intervention.
•
Assistive devices such as a cane may be useful and one should make sure the patient utilizes it on the correct side.
Conservative Treatment •
The initial treatment of choice utilizing the entire spectrum of physical therapeutic interventions.
•
Water therapy may be helpful as not only the hip but also the other possibly secondarily affected joints are also treated.
•
Strengthening of the lumbar musculature may be helpful and may reduce hip pain.
Surgery •
Differential Diagnosis
•
Total hip orthoplasty (Fig.
14.46).
lumbar disk disease (spondylosis) with or Without disk herniation: referred pain with relatively normal hip motion.
•
Avascular necrosis of the hip: there may be back pain. buttock pain. and deep hip pain with or without groin pain (note that initially standard radiographs may be negative).
Further Reading
•
Rheumatoid arthritis.
•
Space-occupying lesion (innominate bone. pelvis. spine).
•
Pseudogout.
•
Trochanteric bursitis.
•
Undiscovered developmental dysplasia of the hip.
Vignoo
E.
Valat JP. Rossignol
M.
et al. Osteoarthritis of the knee and hip and activity:
review and synthesis (OASIS). joint Bone Spine.
j. Gursche A. Feb:17(1 ):71-85.
Zacher
-
Regional musculoskeletal conditions: 'hlp' pain. Best Pract Res
Fig.
a systematic international
2006 jul:73(4):442 455. Clin Rheumatol. 2003
14.44 Force vector diagram as related to the hip joint.
M Muscle a
Distance between the center of the femoral head and the greater trochanter
b Distance between the center of the femoral head and the body midline
R Resultant force vector W Bodyweight
w
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Hip Disorders in Adults
Fig. 14.45 Bilateral hip arthrosis. The left hip reveals deformities
Fig. 14.46 Bilateral hip replacement with cemented shafts and
and cyst formation. while the right hip joint reveals 1055 of joint
noncemented titanium screw- in acetabular prosthesis (same pa
space superiorly.
tient as in Fig. 14.45).
Commentary
Complications of Surgical Interventions
Surgical Intervention for Osteoarthritis
•
•
most common surgical approaches include one of the
•
following three approaches: 1. Arthrodesis.
more than 1.5 cm, and according to the patient's
2. Resectional arthroplasty (salvage procedure only).
symptoms and signs, may require correction. •
For the elderly patient. the total hip arthroplasty has been one of the great successes in orthopedic surgery as
bolism. •
but also functional restoration is as close to normal as currently possible if not actually normal. A brief over
rial between the femoral head and thejoint surfaceas well
view of hip arthroplasty is presented.
as mechanical destruction (Willert and Semlitsch. 1977). •
Various types of surgical approaches or materials exist,
only radiologic findings but also the severity of the
including the cemented and noncemented implanta
patient's symptoms and functional impact. A bone scan may be required for further delineation.
nents to facilitate a good attachment between the im
•
Since the 1980s various attempts have been made to
order to rule out secondary septic prosthesis Uohnston
utilize uncemented implantation (Morscher, 1983).
et al.. 1990).
In the United States, practitioners prefer a porous sur
•
face, while the primary choice in the European countries is titanium-based implants.
•
If further surgery is required for a loosened prosthesis. it typically requires autologous or homologous grafts.
•
Recovery after a repeat surgery may be quite prolonged
According to Zweymi.iller (1990), studies indicate that
and complicated; therefore. rehabilitative efforts be
these implants reach the reliability of cemented hips.
come extremely important. especially to address the
One of the most significant factors for selection of the type of implant is the patient's age.
•
When clinically suspected. laboratory studies or hip joint aspiration for laboratory study are indicated in
plantation and bone (Mulroy and Harris, 1990).
•
Suspected loosening of the prosthesis will require fur ther diagnostic work-up and should always include not
tions. The cemented implants contain plastic compo
•
Late complications include aseptic loosening of the pros thesis. possibly due to osteolysis secondary to the mate
Total Hip Replacement Surgery
•
General complications after surgery include deep vein thrombosis with potential for secondary thromboem
not only is pain significantly reduced. if not abolished.
•
Leg length discrepancy after surgery may lead to sec ondary changes in the neighboring joints; a difference of
3. Total hip arthroplasty. •
Neurovascular injury, infections, joint loosening or dis location (Hematoma and leg length difference).
A number of surgical interventions are available. The
possible muscle atrophy which goes hand in hand. •
Ultimately, the patient's bone quality is the deciding factor (Wixson et aI., 1991).
Myositis ossificans is a rare but clear possibility of complication after hip surgery (Hedley et aI., 1989).
•
In the presence of myositis ossificans. medication treatment (e. g.. indomethacin or similar nonsteroidal anti-inflammatory medications) or a course of radiation therapy may prove to be quite successful.
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Selected Clinical Syndromes
Avascular Necrosis (AVN) of the Femoral Head Synonyms and
•
Aseptic necrosis of the hip.
Related Terms
•
Ischemic necrosis of the hip.
•
Necrosis of femoral head.
•
Osteonecrosis of the hip.
Definition
•
Relatively uncommon, and initially pain-free, disorder of the femoral head, in which necrosis occurs in response to disrupted blood supply, which may or may not be related to trauma. After appearancE' of pain, it worsens progressively, associated with or without groin and knee pain, then often associated with a limp. High incidence of bilateral involvement indicates systemic underpinnings, and is more typically seen in patients with rheumatoid arthritis, systemic lupus erythematosus, and patients with a history of long-standing alcohol consumption or corticosteroid use.
Key Points
•
The patient typically presents with some hip pain with/without groin pain.
•
There may or may not be a limp initially.
•
Detailed history with regard to potential trauma, even remote, and assessment of risk factors is one of the keys to diagnosis.
•
May be related to trauma: displaced femoral neck fracture and less commonly status post fracture or dislocation of the hip.
•
Disrupted vascular supply leads to bone necrosis of the femoral head.
•
Risk factors include past high-dose corticosteroid use, history of alcohol abuse, primary AVN, rheumatoid arthritis, systemic lupus erythematosus.
•
Other risk factors include Gaucher disease, sickle cell disease, previous radiation exposure, and other situations where there is occlusion of blood vessels (e.g., fat embolism).
Pathologyl
•
Nontraumatic AVN occurs more often in the younger patient and is bilateral.
•
MRI is the study of choice to determine AVN.
•
Disruption of blood supply to the femoral head resulting in necrosis of the bone (primarily trabecular bone).
Etiology •
Disruption of blood supply can be due to various factors: - Mechanical factors (trauma, directly or indirectly). - Occlusion of blood vessel (embolism, sickle cell disease, Caisson disease). - Connective-tissue diseases that affect vessel wall (rheumatoid arthritis, systemic lupus erythematosus, etc.).
•
Other known risk factors include, for reasons not yet understood, alcohol abuse, chronic corticosteroid use, etc.
•
Primary AVN is also known risk factor.
Clinical
•
Initial presentation is typically that of a painful hip with or without a limp.
Presentation
•
Often associated with asymptomatic contralateral involvement (increased risk of contralateral AVN).
•
Hip or groin pain with/without referral pattem to knee and thigh.
Functional
•
Patient may present initially with a mildly symptomatic limp.
Information
•
Initially, vocational or avocational activities may be impacted minimally while patient attempts to compensate for the "minor" losses.
• •
later stages associated with Significant functional loss and major compensatory motion patterns. Pain in areas outside the pelvis-hip region in patient with AVN should alert one to the possibility of significant adaptation/compensation.
Examinationl
•
Special Tests
•
Restricted hip internal or external rotation with or without pain, depending on the stage of the disorder. If there is collapse of femoral head, restriction is rather prominent, with loss of internal rotation, flexion, and abduction.
Diagnostic
Standard Radiographs
Adjunctive
•
Studies
•
If progressed to collapse, standard views will clearly demonstrate the advanced stage of the disease.
•
If standard radiographs are unrevealing but clinical suspicion is suffiCiently, high employ MRI.
AP and frog-leg views may reveal some early signs of the disease (e.g., sclerosis of the femoral head).
MRI •
The study of choice.
Treatment
•
Osteotomy.
Options
•
Total hip arthroplasty.
Note •
Conservative treatment is rarely, if ever, the treatment of choice due to the potential complications and progression of the disease.
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Hip Disorders in Adults
Avascula r Necrosis (AVN ) of the Femoral Head (cont.) Differential Diagnosis
• • • • • • • •
Spo ntaneous fracture of the femoral head (e.g., osteoarthri tis/osteoar throsis). Traumatic facture of the femoral head. Degenerative lumbar disk disease (s pondylos is) with or without disk he miation. Osteoarthrit is/ oste oarthrosi s. Septic arthritis of the hip. Transient osteoporosis of the hip. Musculotendinous injury or overuse . Somatic dysfunctions, primary or secondary to compensatory mechanisms (such as pain arising in the joint, or other joints such as the knee, foot/ankle, or spine).
Prognosis
• Prognosis is poor insofar as there is progression to collapse of the femoral head even if diagnosed prior to such. • Surgical intervention is the key to tr eatment.
Further Reading
Ito H, Matsuno T, Kaneda K. Prognosis of early stage avascular necrosis of the femoral head. (lin Orthop. 1999 Jan;(358):149-157. Mankin HJ. Nontraumatic necrosis of bone (osteonecrosis). Pritchett JW. Stalin therapy decreases the
N Engl J
risk of osteonecrosis
Med. 1992 May 28;326(22):1473-1479.
in patients receiving steroids. (lin Orthop. 2001
May;(386):173-8.
commentary •
Avascular necrosis of the hip. while uncommon. should
The Knee
especially be suspected in patients who do not seem to respond to otherwise appropriate treatment, and espe
Introduction
cially if the symptoms remain vague. A detailed history and a careful search for remote trauma to the hip, po
•
tween the hip and the ankle. The knee joint must optimize
or thigh and knee pain should raise the suspicion for this
two mutually exclusive requirements: stability and flexi
disorder.
bility. Knee function is maintained by a unique anatomical
If the initial standard radiographs are unremarkable,
mechanism (Kapandji, 1982). but the knee remains at risk
and there are continued symptoms despite what would
of injury, especially with motions that involve twisting and
appear to be appropriate therapy. MRI is the study of
rotation.
choice.
•
•
The knee is the intermediate joint of the lower limb, be
tential risk factors, or complaints of hip pain, groin and/
The knee joint is an intricate articular and soft-tissue
The patient's overall vocational and avocational inter
complex that comprises three articulations: the tibiofe
ests or requirements as well as pain tolerance should all
moral. the patellofemoral, and the tibiofibular joints. The
be taken into consideration when setting up the ther
major motion pattern foJlows a path in the sagittal plane.
apeutic plan.
basically a hinge-joint motion but complicated by trans
From a manual medicine standpoint, patients with early
latory gliding motions as well. The patella moves primarily
avascular necrosis may actually find initial benefit from
in the vertical plane and not much in the transverse plane,
treatment as the compensatory patterns can be ad
and can travel a distance equal twice its length (Kapandji,
dressed (e.g., restoring abnormal muscle balance). In
1982). Fibular head motion is tied primarily to foot dorsi
Jight of the progressive pathology, the treatment effect
flexion and plantar flexion, during which there is anterior
is typically not lasting and may provide only limited
and posterior motion, respectively.
improvement over time. As always. the patient's indi
The knee can sustain injury in either position: when
vidual requirements for treatment are multifactorial
flexed it is likely to be dislocated and/or will sustain liga
and require a comprehensive and detailed approach if
mentous or meniscal damage. When extended. it is essen
the functional outcomes are to be maximized over time.
tially "loaded" and therefore there is a transmission of
In any case, when there is no significant improvement.
forces in a way that can result in bony fractures or liga
and employing a high degree of suspicion, further in
mentous rupture of ligaments (Kapandji. 1982).
vestigation is indicated rather than a "wait-and-see" approach.
Clinically. the various disorders of the knee can be div ided into two major categories according to patient age, with 45 years being the "natural" dividing line.
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Selected alnlcol Syndromes
become weaker (e. g., the vastus medialis muscle) and the
Patients Younger than 45 Years
tonic muscles become short, such as the hamstring and
In this population, the following conditions are commonly
to either axial/pelvic dysfunctions or more typically to
observed:
pes planus deformity. Other factors that may contribute
gastrocnemius-soleus muscle complex. This can be due
to the patellofemoral syndrome are abnormally increased •
Patellar syndromes are among the leading reasons, if
tibial torsion or femoral anteversion or a pronounced genu
not the most frequent reason, for a musculoskeletal
valgum, and possibly an increased "Q" angle.
medical visit prompted by knee pain. Trauma is typically
•
•
The patellar syndromes are categorized according to three major groups:
in contrast to the ligamentous or meniscal injuries.
lar instability syndromes; and (3) a combination thereof.
Ligamentous injuries and meniscal tears in this age
The patient's history may reveal a recent trauma or
group are typically related to trauma. They are frequent
typical overuse activities, and the patient may complain
reasons for the musculosekelatal office visit.
of one or more of the following:
With knee pain in children and adolescents, consideration is given to such diagnoses as patellar subluxation, patellar tendinitis ("jumper's knee"), Osgood-Schlatter
1. 2.
disease (tibial apophysitis), osteochondritis dissecans,
•
(1) patellar pain syndromes; (2) patel
not the precipitating incident in the patellar syndromes,
Grinding in the knee. Tenderness upon direct compreSSion of the patella or palpatory tenderness in the peripatellar region.
arthritis, and tumors.
3. Malalignment situations.
Hip pathology can present with knee pain, and thus such
4. A feeling of "subluxation" or overt dislocation.
diagnoses as slipped capital femoral epiphysis or other hip diagnoses should always be considered, especially in the child or adolescent. •
Age and sex help to guide the clinical impressions. For
Knee Pain and Patellar Pain Syndromes •
example, Osgood-Schlatter disease is more common in
Anterior knee pain is the cardinal presenting symptom of the patellar pain syndrome. Pain is typically of slow
teenage boys, while patellofemoral or tracking prob
onset and may be constant, although the intensity can
lems are more commonly seen in teenage girls.
be variable. Bilateral pain would point into the direction of an anatomic/biomechanical cause.
Given the greater frequency of patellar problems in clinical
•
Pain is characteristically worse upon managing stairs, more so when descending, or with prolonged sitting,
practice, they are discussed here before addressing the ligamentous and meniscal pathologies.
especially with the knee flexed, or following repetitive knee activities. •
Patellar Syndromes
The patient may complain of swelling, though interest ingly this is often not evident in the physical examina tion.
Patellar syndromes are a frequent cause of knee pain, less frequently because of trauma but primarily due to inherent anatomic and biomechanical conditions that are prone to "failure" at some point. Both the osseous components and
Patellar Instability Syndromes •
Patellar instability, in addition to pain similar to that
the various soft-tissue structures along with the muscles, in
described above, is often associated with patellofemoral
particular the vasti muscles, contribute to the patellar
subluxation or dislocation.
problems and the associated knee pain.
•
Bony aberrations are associated with static instability (MacDonald et ai.,
1996).
Upon the examination of a knee where there has been a patellofemoral subluxation or dislocation, there may be
They include such factors as the
signs of synovial swelling with an increase in synovial
lack of depth of the femoral trochlea (i. e., shallow trochlea),
fluid and blood.
shape of the lateral femoral condyle (hypoplastic) or the patella itself, and the position of the patella in relationship to the knee (patella alta and patella lateralis). Factors involving failing soft tissues, which otherwise
Physical Examination for Patellar Syndromes •
The examination should start with the evaluation of the
would provide for dynamic stability, include loss of liga
patient's overall posture, followed by evaluation of the
mentous support with recognizable laxity. Muscle imbal
pelvis and lower limb in stance comparing the leg
ance further worsens the situation as the phasic muscles
position and rotation at the hip, knee, and ankle.
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Patients Younger than 45 Years
•
1. Abrupt lateral motion of the patella at the end of
The patient is then eval. and heel walk. to exclude potential radicular contribu
extension motion.
2. An atypical semicircular movement of the patella
tion of the pain. •
The patient is then requested to perform a semi-squat
as it swings around the lateral portion of the trochlea.
and full squat. if possible. If the patient is able to perform
3. A brief but visible medial patellar displacement
the "duck walk" (squatting down fully and then taking
before lateral motion in complete extension.
small alternating ducklike steps forward") this almost certainly rules out acute meniscal involvement. •
•
If possible. observe the patient for how he or she is able
If there is a high riding patella (patella alta). there is usually a compensatory increase in the Hoffa fat pad.
to ascend arid descend stairs. •
Grading
Subsequently. the patient is examined in the seated position. with the hip and knee flexed to 90° while the
Patellar abnormalities are graded according to the degree
foot is off the ground. Of significance is what happens
of cartilage damage:
between 10° and 30° of knee flexion while one observes for the presence of any of the following findings ("]"
Normal Cartilage
signs):
•
Anatomic patellar variations.
•
Overload syndromes involving the quadriceps tendon.
•
Patellar tendinitis ("jumper's knee").
•
Osgood-SChlatter disease.
Variable Cartilage Damage •
Malalignment.
•
Plica synovialis.
Overt Cartilage Damage
The following situations typically lead to involvement of the cartilage:
•
Chondromalacia patellae and femoropatellar arthrosis.
•
Direct trauma.
•
Osteochondral fractures.
•
Osteochondritis dissecans.
Rupture of the Quadriceps and/or Patellar Tendon
Unless the examination is unequivocal. further diagnostic studies may be indicated such as ultrasound or MRI. MRI is better able to demonstrate the remnants/ends of the torn tendons as well as tendinous periostosis ("jumper's knee"). for instance.
Meniscal Tears and Ligament Rupture
Fig. 14.47 Cross-sectional specimen revealing the anterior inser
A second category of frequent knee diagnoses includes
tion of the medial and lateral menisci at the central portion of the
meniscal tears and ligament ruptures (see Fig.14.47 for
tibia ("eminentia"'). Note that the anterior portion of the tiba is at the top of the picture. The anterior cruciate ligament is posterior to the meniscal insertion. The central portion of the tibia at the prominent insertion serves as stabilizer with respect to the condyle. Following the meniscal crescents posteriorly. the insertion of the
normal anatomical relationships). These are usually due to direct or indirect trauma. or chronic degenerative changes that alter the loading forces. The following will summarize the general characteristics of the traumatic
posterior horns of the medial and lateral menisci is at the center of
meniscal and ligamentous injuries. It should be noted
the tibia. close to the attachment of the posterior cruciate (which is
from the outset that these injuries are characteristically
posterior).
more unilateral than bilateral.
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Selected Clinical Syndromes
The patient may also report noticeable knee joint insta
Mechanisms of Injury
bility, often described as the knee "giving way" or "giving
Meniscal tears or ligament ruptures are the result of a
out," especially with specific movements or positioning.
forced rotatory motion that is introduced to the knee while
When taking the patient's history, it is important to listen
the foot remains fixed or stationary. The rotatory forces
and to inquire for any particular clues in the past medical
excessive in relation to the usual anatomically and biome
history such as past similar trauma, or other major trauma
chanically sound situation-can be either medial or lateral
to the body, past surgeries, and a history of arthritis.
rotation. The menisci and the anterior cruciate ligament are the most frequently involved structures, but the posterior
Physical Examination
cruciate ligament must also be evaluated in order not to
Guided by the patient's history, a thorough examination of
overlook an occult tear. The ratio of involvement is approx
the knee will help specify the most appropriate diagnosis
imately 10: 1 "in favor" of the anterior cruciate ligament.
and secure appropriate initial treatment without much
Meniscal tears often are, however, more typically the result of repetitive microtrauma, with variable discomfort
need for adjunct diagnostic studies, except in certain un clear cases.
until further traumatic events precipitate the symptomatic
The patient is examined both statically (posture, stand
knee problem. These events may be trivial, such as donning
ing, weight-bearing, deformities, etc.) and dynamically,
or doffing clothing, or routinely standing up from a squat.
both in unchallenged situations (normal, unforced gait,
Major trauma to the knee can result in extensive dam
toe and heel walk, etc.) and in specific provocative posi
age to both the menisci and the ligaments. However, many
tions such as squatting.
knee problems actually do not arise from a violent contact
To ensure the most accurate diagnosis possible, it is
injury. Often, sudden changes in direction alone place un
crucial that the special testing maneuvers be performed
toward forces to the intra-articular structures of the knee
correctly, and that the examiner be aware of each maneu
and result in ligamentous or meniscal tears. Activities that
ver's sensitivity and, specificity (Table 14.l5). In their de
are routinely implicated are snow skiing, cutting in basket
tailed review, Malanga et al. (2003) emphasize that it is
ball or football, or other similar sporting activities.
important not only to know how to perform the particular test but also to be familiar with the diagnostic accuracy and limitations of each test for knee pathology.
History and Physical Examination Typical Symptoms The patient often reports a history of a loud popping sound
Treatment of Acute ligamentous and Meniscallnjuries
emanating from the knee and usually points spontaneously
The approach to treatment, both conservative and surgical,
to a painful joint line. There may be a report of immediate
is guided by the presumed clinical diagnosis, the extent and
swelling of the knee, which raises the suspicion of possible
severity of the injury, the patient's vocational needs and
hemarthrosis or more extensive injury. Late-onset swelling
avoca tiona I interests, and the presence of co-morbidities
that started hours after the injury would be more indicative
that might interfere with a solid healing process.
of an effusion.
Table 14.15 Common provocative knee tests evaluated as to their sensitivity and specificity Name of Test Lachman test
Anterior eruciate ligament
Sensitivity
Specificity
High
High
High
High
Comments
(for tear) Posterior drawer test
Posterior cruciate ligament
(for tear)
sag sign
McMurray test
Meniscus (tear)
Low
High
Joint-line tenderness
Meniscus
Fairly good
Low
Medial/lateral collateral
Good
Good
Collateral ligament tests
Enhanced by posterior
ligament
Lack of well designed studies that would scientifically validate these tests
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Patients Younger than 45 Years
for this condition (Bjordal et ai., 2004). These authors fur
Conservative Treatment Approaches to
ther conclude that since serious adverse effects are associ
Traumatic Knee Injuries
ated with oral NSAIDs, only limited use can be recom mended.
In general, conservative treatment is the approach of
Early ambulation and functional activities should be
choice, unless the injuries are complex or the functional
introduced as soon as the joint is deemed sufficiently ready.
demands are great. The more recent literature seems to
Knee bracing may be appropriate in the individual case.
indicate that surgical intervention, especially if done early while there is still swelling and joint motion restriction, does not lead to as beneficial an outcome as previously
Meniscal Injury
anticipated, as a number of surgical repairs fail in too many
In certain circumstances, conservative intervention may
patients.
suffice. Nonsurgical intervention is the approach of choice
The goal of treatment is to minimize pain and dysfunc
if the injury is acute and involves the outer, vascularized
tion and if possible to eliminate any residual disability.
zone, or if the tears are partial-thickness tears only that
Treatment should be based on objective findings and func
follow the longitudinal axis but are limited in their extent
tionally meaningful parameters, as well as realistic. pa
(e. g.. less than 50%), assuming no complications or invol
tient-specific projected outcomes or medical end points.
vement of other structures. In the younger patient who did
This should take into account both vocational and recrea
not respond to appropriate conservative treatment for a
tional factors, co-morbidities, and patient expectation, as
suspected meniscal tear, MRI or arthroscopic evaluation
well as motivation.
may be indicated, depending on the overall clinical situa
Conservative rehabilitative measures concentrate on (1)
tion (Fig.14.48).
control of pain and swelling, (2) restoration of functional range of motion, (3) establishing appropriate muscle bal ance with strength development, (4) maximizing endur ance, and
(5)
promoting speed and power in activity-re
Anterior Cruciate ligament Injury There are many reports that favor the conservative ap proach over a surgical one. In any event, the goal is to
lated drills. A recent meta-analysis in the British Medical Journal of
prevent any impairment or disability. In other words, con
NSAlDs in osteoarthritic knee pain concluded that NSAlDs
servative treatment is the preferred approach when treat
reduce short-term pain in osteoarthritis only slightly better
ing a patient who is anticipated to have no greater than
than placebo, and did not support long-term use of NSAlDs
medium-level activity requirements in the absence of any restrictive co-morbidities or injuries, and who is able to tolerate the symptoms without much need for permanent pharmacologic pain coverage.
Surgical Approach to Traumatic Knee Injuries
Indications •
CompJex ligamentous injury.
•
Secondary damage to the menisci and other ligamen tous structures.
Factors Favoring Surgical Intervention •
Fig. 14.48 If the meniscal tear is restricted to the vascularized peripheral third of the meniscus, repair can be done arthroscopi
cally The sutures are anchored to the osseous structures from the joint and then guided through the meniscus toward a posterome dial or pos te ro l ate ral direction to be attached to the peripheral joint capsule. Special care must be taken not to compromise the vessels
•
Note that the healing process takes at least 2 months.
High level of required activities: competitive athlete,job requirements.
.
and nerves in this region (saphenous and fibular nerve) .
Patient-specific functional deficits (impairment, dis ability, handicap).
•
Young age.
•
Substantial instability immediately upon injury.
•
Extensive collateral ligament injury.
•
Generalized ligamentous laxity.
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Selected Clinical Syndromes
Surgical Techniques Surgical techniques for meniscal injury include the follow ing: 1. Partial or total meniscectomy (a) Arthroscopic procedure. (b) Open approach. 2. Suture of peripheral tear (a) Arthroscopic procedure. (b) Open approach. Surgical approaches for anterior ligament injuries: 1. Patellar-bone reconstruction Fig. 14.49 The graft material is usually harvested in the form of a
(a) Arthroscopic procedure.
10 mm sectioned strip from the patellar ligament with bone plug
(b) Open approach.
from the patellar tip and tibial tuberosity. The major task is to place
2. Extra-articular approaches.
the drill holes correctly in the tibia and the lateral femoral condyle. The graft is pulled arthroscopically from distal to proximal.
Patellar- Bone Reconstruction-Arthroscopic Approach •
This is the standard procedure performed today.
•
A free patellar tendon section is harvested (usually the central one-third) with bone plugs on either end from the patella and tubercle. These bone plugs are used for later fixation to bone, and the graft is held with screws on either end. See Figs.14.49 and 14.50 for specific de scription.
•
This intervention has reached success rates upward of 90% with objective joint stability and sufficiently satis factory joint motion and functional abilities Uakob and Staubli,1992).
Postoperative Rehabilitation Postoperative rehabilitation assumes a central role in the recovery toward normal function after the surgical proce
Fig. 14.50 After it has been determined that a good balance has been obtained between appropriate stability and mobility, the sutures will be anchored at a screw that has been placed at the
dure. It requires careful planning with regard to which
tibia and femur. Alternatively, a resorbing interference screw may
therapeutic intervention is to be utilized at what point.
be used for initial fixation Uakob and Staubli, 1992).
Furthermore, it also must take into account both patient goals and motivation, as well as those goals specified by the entire treatment team. This team, ideally, consists of the
tient is ready, early active rehabilitative efforts are intro
treating surgeon, the physiatrist, and the physical therapist
duced in form of exercise routines within a controlled setting supervised by a skilled therapist. Initially, the ther
and occupational therapist. Specific and realistic goals must be established from the
apy may take up to 2 hours per day until a less frequent
outset against which treatment success-or lack thereof-is
schedule can be established, again based on objective and
to be compared over a specified period of time. Ultimate
functionally meaningful parameters.
outcoille goals or Illedical end points must be established
Typically, it takes about 6 Illonths until an athlete can
early and explicitly such that they take into account the
return to training and approxilllately 9 months until. she or
patient's individual deficits and anticipated (if any) residual
he can return to coillpetition, assuilling the absence of
disabilities or impairillents or even handicap within the
complications or other coexisting preventing factors.
context of the patient's job requireillents and vocational interests.
Isokinetic strength Illeasurements help to establish an initial baseline and allow periodic follow-up, but what
Closed-chain muscle
uitilllately decides the success of the program is whether
strengthening exercises are employed. As soon as the pa-
the patient is able to return to return to fully unrestricted
Early
Illobility
is encouraged.
Copyrighted Material
Patients Older than 45 Years
functional abilities. Isolated improvement in isokinetic
injured. This also holds true for the patella, perhaps
strength measurements should be interpreted with cau
because of the rather complex innervation pattern.
tion, to the point of considering them potentially being
•
"Giving-way" and joint locking, while perhaps not as
meaningless, especially when the patient fails to perform
frequent as in the younger patient, are nonetheless
even the most basic activity routines.
common complaints in the older patient and are usually associated with loose bodies, bone fragments, bone-on bone motion, or pain.
Patients Older than 45 Years In this population, the degenerative problems predo minate, especially in the presence of increased physical
Functional Assessment and Impairment •
Assessment of the functional activities of the patient
demand, sporting activities, or prolonged overload situa
older than 45 years is of paramount importance not only
tions:
during the initial management but also for long term planning and goal-setting.
•
•
•
Degenerative disorders with or without associated
•
The functional history should elicit the patient's ability
overload syndromes and osteonecrosis (avascular ne
to wall< a certain distance or to manage stairs, and the
crosis) are the predominating considerations in this age
duration the patient is able to stand in one position or sit
group.
in a chair or how long it takes to rise from a chair. Also of
Meniscal tears are seen and cruciate ligament ruptures,
significance is any reported history of observed or near
but the majority of such injuries are due to a combina
falls as well as their need to use an assistive device. One
tion of degenerative causes and overload or overt
should ask whether there is pain only with certain
trauma, rather than trauma alone.
activities
Anterior knee pain may reflect the onset of femoropa
•
or
with rest.
There is a rapid Iy growing number of very active elderly
tellar arthritic changes, typically in the form of a mala
persons who participate in physically demanding ac
lignment syndrome. Pain and instability are the cardinal
tivities such as cycling, cross-country and down-hill
symptoms. In clinical practice, it is actually patellar
skiing,jogging, and mountain-biking, among others. The
issues that represent the most frequent problem due to
clinician should investigate the possibility of activity
anatomic degenerative processes (rather than trauma
related injuries because the patient may not spontane
related injuries).
ously report them, espeCially if there is a gradual onset of symptoms. New-onset knee pain may be related to osteoarthritis and/or femoropatellar osteoarthrosis, es
Temporal Profile of Symptoms •
pecially when the patient has just started such activities or has been participating in them for some time.
A detailed and patient-specific history that inquires about the particular onset and the temporal course of
•
In addition to the standard radiographic views, stress
the painful involvement of the knee will provide im
views may be required in the AP and/or lateral views,
pOl'tant clues. While degenerative pathology is usually
and in some cases specific axial patellar views (Insall,
bilateral and associated with rather slow disease
1993).
progression, osteonecrosis typically begins with one particular and often dramatic painful episode that the
Treatment
patient recalls very readily.
Treatment consists primarily of the following four options:
Pain localization and Other Symptoms •
It should be remembered that knee pain may actually
1. Conservative treatment with the major goal being that
"start" in the hip. Therefore a new complaint of knee
of pain reduction, edema control, and restoration of
pain should alert the clinician to also evaluate the hip for
range-of-motion.
pathology as the potential source of the presenting knee
(b) Appropriate physical therapeutic measures.
whether there is advanced osteoarthrosis/osteoarthritis
(c) Activity modification to minimize abnormal loading conditions.
in the hip that may cause the patient's knee pain. •
(a) Pharmacologic intervention.
pain. In the older patient, one should determine
2. Arthroscopy
Conversely, particular knee pathology refers pain to specific areas in the knee, the location of which already
(a) Removal of the bony fragments.
provides valuable clues as to which part may have been
(b) Drilling of the involved bone.
307
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Selected Clinical Syndromes
3. Proximal tibial osteotomy (a) For better load distribution. (b) May be combined with arthroscopy. 4. Arthroplasty-especially if there is collapse of the tibial plateau.
Gonarthrosis or Osteoarthritis of the Knee: Surgical Considerations Surgical treatment of the patient with demonstrated de generative knee arthropathy (osteoarthritis/osteoarthrosis) falls into three major categories: Fig.14.51 Valgus osteotomy of the proximal tibia to correct
1. Arthroscopic debridement.
gonarthrosis that had resulted in a varus deformity. Surgical indi cations include unicompartmental degeneration with varus de
2. Corrective osteotomy/ 3. Knee replacement: uni-, bi-, and tricompartmental.
formity; in order to undergo the surgical correction the patient must be able to shift his weight to the uninvolved side.
A wedge is removed from the lateral basis of the tibia. This redirects the mechanical axis from a medial position to the lateral compart
Arthrosco pic Debridement •
ment. The reduction of weight-bearing loads allows a reduction of
In gonarthrosis, results are more usually unsatisfactory than satisfactory, and especially in more advanced dis
the sclerosis at the condyle and the tibial plateau (Insall, 1993; Morrey 1996).
ease. •
Indications may include the following, but should be
Recovery Period
carefully weighed as to risk-benefit:
•
-
•
Six weeks to 6 months.
Osteophyte removal.
-
Subchondral cartilage treatment.
Comp lications
-
Meniscectomy.
•
Under- or overcorrection (the most frequent causes for
gonarthrosis of the knee and/or when considering re
•
Infection (especially with pins).
moval of well-demonstrated meniscal tears.
•
Peroneal nerve palsy due to pin placement.
•
Thrombosis/pulmonary embolism.
treatment failure).
Debridement may be helpful during the early stages of
Corrective Osteotomy Knee Replacement
(Fig. 14.51 )
•
•
•
This remains a valuable procedure as long as the ap
•
The aim of procedure is pain reduction.
•
110° of flexion may be the best results obtained (135°
propriate indications are observed.
would allow activities of daily living without any loss of
Success rates are upward of 70% in 10-year follow-up.
function).
Valgus deformity: correction is proximal to the knee
•
•
The most important factor for successful result is being able to obtain as normal a mechanical axis as possible (a
joint at the distal femur.
line that connects the centers of the hip, knee, and ankle).
Varus deformity: correction is distal to the knee joint at the proximal tibia.
•
In the absence of particular complications, the new prosthesis should last at least 10-15 years, assuring
Indications •
•
functional abilities during that period.
Determined by patient age and activity restrictions and
In selected cases, it may be possible to replace only one
outcome expectations.
compartment that is affected (unicompartmental dis
Unicompartmental degeneration must ensure that the
ease, either the medial or the lateral compartment).
patient is able to actively unload the involved leg. •
•
•
If the degeneration is massive with pronounced angular
Note: concurrent arthrosis of the femoropatellar joint is
formation, it may be necessary to utilize a prosthesis
not a contraindication to osteotomy; however, a diligent
with a long central stem in order to provide stability
history and careful examination are necessary to differ
both anteroposteriorly and mediolaterally (Figs. 14.52
entiate between femoropatellar and femorotibial pain.
and 14.53.
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Disorders of the Knee
Fig. 14.52 Advanced bilateral gonarthrosis. Due to loss in the me
Fig. 14.53 The goal of the arthroplasty is the restoration of as close
dial joint structures. the knee undergoes a varus deformity. The
to normal as possible an axis of motion and to maximize stability at
medial axis no longer remains at the center of the knee joint
the joint. The bone defect at the tibial plateau was corrected with
as
it is
now displaced outside of the knee and more medial. The instability
an autologous bone graft. If it has been medially determined that
is due the loss in joint height medially while the lateral ligaments
there is no increased surgical risk, then the patient may undergo
become stretched secondarily.
bilateral surgical correction at the same time.
Complications
•
Pain that becomes apparent years after the surgical
•
Deep vein thrombosis.
intervention may be due to material degeneration or
•
Poor wound healing.
loosening of the prosthesis.
•
Insufficient flexion motion (restricted): manipulation under anesthesia may be necessary in 10% of cases (if 90° of flexion has not been obtained within 2-3
Further Reading
weeks).
Jackson JL. O'Malley PG, Kroenke K. Evaluation of acute k nee
pai n in pr i m ary care. Ann Intern Med. 2003:139:575-588.
Residual Sequelae •
Postoperative pain. especially when the leg is at rest, may be an indication of infection.
•
Pain with movement may be present for up to 6-12 months.
Disorders of the Knee Osteonecrosis of the Knee Synonyms and Related Tenns Key Points
•
Avascular ne cro s is of the knee.
•
Osteon ecros is of the femoral condyle.
•
Sudden onset of medial knee pain.
•
Patient typically older than 60 years.
•
Kn ee motion is initially restricted in flexion and extension ("blocked").
•
Hematoma medially.
•
Bilateral presentation in less than 20% of patients.
•
Potential for being mistaken for meniscal tear especially if initial radiographs are read as "normal" (compare with Fig. 14.54).
Pathology/Etiology
•
If suspecting this diagnosis. confirm with MRI or bone scan (Fig. 14.55).
•
Early disease: slightly flattened condyle.
•
Late disease: cartilage fragments that emerge from the necrotic bone tissue with a new thin cartilage surface.
•
Clinical Presentation
•
Arthritic jOint degeneration of the compartment (stages I-V radiologically).
Severe medial knee pain with hematoma formation and joint "blockage" OOint is "locked up").
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Selected Clinical Syndromes
Osteonecrosis of the Knee (cont.) Functional Information
•
lack of full knee extension and flexion.
•
Knee may be "blocked" or "stuck" with adaptive or compensatory motions in neighboring joint.
ExamlnatlonfTests
•
Exquisite tendemess is elicited on palpation over the medial condyle with the knee flexed.
Diagnostic Adjunctive Studies
Treatment Options
•
Reduced range of motion.
•
Hematoma.
•
AP
•
MRI and/or bone scan to confirm diagnosis and determine extent of involvement.
+
lateral views allow measurement of the fragments.
Conser vative Approaches •
Reduce weight bearing.
•
Unloading brace.
•
NSA I Ds pain medication.
•
Conditioning program emphasizing quadriceps function.
.
Surgical Considerations •
Arthroscopic removal of the necrotic bone fragment with drilling of the affected bone
•
Proximal tibial osteotomy.
•
Arthroplasty (unicompartmental or condylar).
region.
Differential Diagnosis
•
Medial meniscal tear.
•
Osteoarthritis.
•
Condylar fracture.
•
Osteochondritis dissecans.
•
Pes anserina bursitis.
F ig. 14.54 Note the lighter areas. which represent joint sclerosis, possibly some seque st rat ion .
G.L.08 12.82 1-
re
VENTRAL
Ii
Fig. 14.55 I n iti ally the patient complains about significant pain. while there is hematoma formation and loss of range of motion. If the initial radiog raph is found to be negative. then a SCintigram or
MRI should be used to ascertain the diagnosis. In the latter. one often finds extensive subchondral edema.
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Disorders of the Knee
Meniscus Injury Meniscal tear.
Synonyms and
•
Related Terms
•
Meniscus tear.
•
Medial meniscal tear.
Definition
•
Lateral meniscal tear.
•
Locked knee syndrome.
•
Knee pain.
•
Medial or lateral knee meniscus tissue overload due to excessive stress either caused by sudden forces during trauma or due to degenerative changes. Presentation is typically characterized by pain, various degrees of swelling, loss of function, and/or maladaptive changes in other parts of the musculoskeletal system (e.g., adaptive hip and ankle motion, back pain, and others).
Key Points
•
Meniscal injuries may occur by themselves or in conjunction with ligamentous injury.
•
Typically due to excessive rotatory or twisting forces introduced to the knee while the foot is planted firmly on the ground.
•
Degenerative processes may play prominent role due to alteration of biomechanics (adaptation, compensation).
•
Associated sports are basketball, football, skiing, snow boarding, and tennis due to abrupt stop-go and rotatory force.
•
Components of presentation include any or all of the following: - Pain. - Swelling. - Functional loss of using knee ("locked" or ·stiff"). - History of injury mechanism (if known, or degenerative).
•
Tenderness along joint line (medial or lateral).
•
Clinical Pearls
•
Significant swelling and hemarthrosis immediately after a traumatic event should raise suspicion of
•
If there is hemarthrosis, arthrocentesis of the knee will show fatty "bubbles' floating on the surface of
involvement of structures other than meniscal tear alone. the aspirated fluid if the injury is extensive (place fluid into a small tray or bowl). Pathology/
•
Excessive loading stress introduced to the knee during trauma or due to changes associated with degenerative processes.
Etiology •
Rotatory/twisting component to the knee while the foot is kept stationary.
Clinical
Two Scenarios
Presentation
,. Presentation after overt trauma (patient is able to describe specifically what happened) or patient unable to describe any particular trauma. 2. Degenerative; ·trivial" movement is reported by the patient to have ·caused" the pain; further questioning may then reveal repeated knee swelling that may have been "ignored" by the patient. Four Components of Presentation • •
Joint line tenderness. Swelling (acute or recurrent), often insidious, developing over 2-3 days.
•
Restricted range-of-motion with "locking," stiffness, clicking.
•
Pain with functional use, especially present on squatting.
•
The mechanism of injury is often not clearly evident in degenerative changes but readily is described by patient when there has been overt trauma.
•
Note: If hemarthrosis is noted shortly after a traumatic event, consider involvement of other knee structures (e.g., fracture or cruciate ligament tear).
Functional
•
Information
A clue to underlying degenerative meniscal changes is progressively worsening knee ·stiffness· and/or periods of "locking up."
•
There may be significant adaptive changes involving other areas of the body, with involvement being ipsilateral or contralateral or both.
•
Back and thoracic pain and shoulder pain may be late sequelae as forms of adaptive/compensatory changes, but may be the initial presentation.
•
There may be prominent muscle imbalances far beyond the lower limb.
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Meniscus Injury (cont.) Examination/
•
Pain: evaluate for joint line tenderness. This is easiest with the knee flexed at 45-90°.
Special Tests
•
Effusion: may be present or absent.
•
Knee motion may be limited secondarily to pain or effusion.
Special Tests •
McMurray flexion/rotation test.
•
Steinman test (internal rotation causes pain in the lateral meniscus area; extemal rotation of the leg
•
Apley compression test.
causes pain in medial meniscus area).
Diagnostic
Standard Radiographs
Adjunctive
•
studies
•
Lateral view.
•
Merchant view.
•
Especially in patients older than 45 years of age to rule out other pathologies such as osteoarthritis.
•
Weight-bearing views are recommended.
AP view with knee extended; "tunnel" view with knee flexed to 30°.
osteonecrosis. fracture. MRI •
This is becoming the study of choice but findings should be Interpreted by an experienced practitioner.
Arthroscopy •
There is individual variation as to when this is most appropriate.
•
The advantage is that the procedure is both diagnostic and therapeutic at same time. expediting interventional treatment when necessary.
Treatment
•
Options
Conservative Treatment •
Management depends on the severity of the condition and on treatment goals. Nonsurgical candidates. treated initially symptomatically and with RICE (rest. ice. compression. elevation).
•
NSAIDs as indicated and tolerated.
•
Physical therapy protocols usually require 3-5 weeks of training.
Surgical •
If the diagnosis is clear. with significant findings. or there are ongoing symptoms despite conservative treatment. consider surgical intervention. Postoperative rehabilitation protocols follow.
Differential
•
Cruciate ligament tear (anterior, posterior).
Diagnosis
•
Crystal disease.
Prognosis
•
Collateral ligament tear (medial/lateral).
•
loose body.
•
Osteoarthritis.
•
Osteochondritis dissecans.
•
Osteonecrosis of the femoral condyle.
•
Patellar subluxation or dislocation.
•
Pes anserine bursitis.
•
Saphenous neuritis.
•
Tibial plateau fracture.
•
Minor tears may heal by themselves.
Anterior Cruciate Ligament (ACL) Tear Synonyms and
•
ACl tear.
Related Terms
•
Anterior cruciate deficiency.
•
Cruciate ligament tear.
•
Rotary and anterior dysfunction/instability of the knee.
Definition
•
Tissue overload resulting in disruption or complete tearing of the anterior cruciate ligament due to excessive stress due to trauma. degenerative changes. or a combination.
•
The clinical presentation depends on the etiology, whether it is from an acute trauma or chronic joint degeneration.
•
The three cardinal presenting signs/symptoms are: pain and swelling and laxity of the knee. There may be associated injuries in the menisci. in particular the medial meniscus. or severe collateral ligament injuries.
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Disorders of the Knee
Anterior Cruciate Ligament (ACL) Tear (cont.) Key Points
•
ACl tears may occur by themselves or in conjunction with meniscal injury.
•
Medial meniscal tears may be a ·set- up' for anterior cruciate ligament tears.
•
Typically due to excessive rotatory or twisting forces with anterior force vector component.
•
Acute injury typically associated by an audible "pop" and prominent swelling that peaks within
12
hours. •
Degenerative processes may play a prominent role due to alteration of biomechanics (adaptation. compensation) and the patient recalls the knee "giving way."
•
Associated sports are basketball. football. skiing. snow boarding. and tennis due to abrupt stop-go and rotatory force.
• •
Much more common than the posterior cruciate ligament tears. Note: Significant swelling and hemarthrosis immediately after the traumatic event should raise suspicion of involvement of structures other than ligamentous tear alone.
Pathology}
•
Excessive loading stress introduced to the knee during trauma.
Etiology
•
Excessive loading stress and abnormal load vectors due to changes associated with degenerative
•
Associated with a sudden stop and shift in direction in the lower limb.
process.
Clinical
Two Scenarios
Presentation
1.
Presentation after overt trauma (the patient is able to describe specifically what happened): (a) Sudden painful knee motion. (b) Difficulty in weight-bearing or ambulation. In a sports setting. the athlete is usually unable to continue participating in the activity. (c) The patient heard an audible "pop." (d) Immediate swelling that peaks around
2. •
10-12 hours after injury.
The patient is unable to describe any particular trauma: Typically with an underlying osteoarthrotic/osteoarthritic process. patients provide a history of the knee "giving out." The patient may present after "trivial" movement is reported by patient to have "caused" the pain; further questioning may reveal a repeated history of the knee giving out.
•
Note: If hemarthrosis is noted shortly after a traumatic event. consider involvement of other knee structures (e.g., fracture or meniscal injury).
Functional
•
A clue to underlying degenerative anterior cruciate ligament dysfunction is the history of the knee
•
There may be significant adaptive changes involving other regions of the body, with involvement of
"giving out" repeatedly over a period of time with or without pain.
Information
ipsilateral and/or contralateral joints. proximal or distal to the knee. •
Back and thoracic pain and shoulder pain may be late sequelae as a form of adaptive/compensatory change. but may be the initial presentation.
•
There may be prominent muscle imbalances far beyond the lower limb and these should be evaluated. especially in the chronic situation (adaptive/compensatory changes).
Examinationl
•
Evaluate the patient's gait: are they able to bear weight?
Provocation
•
Evaluate for location and intensity of the pain.
Maneuvers
•
Effusion may be present or absent.
•
Active and passive range of motion: differentiate between pain-reaction (e.g., soft end-feel) and mechanical restriction (hard-elastic end-feel, or bony restriction if the knee is subluxed).
Special Tests •
Anterior drawer test (knee flexed
•
Lachman test (knee flexed
900). 200-300) has high sensitivity and specificity). It may be performed with
greater ease than the anterior drawer test, especially immediately after injury. •
Active motion test: "hopping: etc.
Diagnostic
Standard Radiographs
Adjunctive
•
AP view with knee extended; "tunnel" view with knee flexed to 450•
Studies
•
Lateral view.
•
Merchant view.
•
Usually the radiographs are positive only for an effusion. Occasionally they may reveal a pathognomonic "Segond fracture: which is an avulsion fracture of the tibial lateral capsular margin.
•
Especially in patients older than 45 years, obtain radiographs to rule out other pathologies such as osteoarthritis. osteonecrosis. or fracture.
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Selected Clinical Syndromes
Anterior Cruciate ligament (ACL) Tear (cont.) MRI •
This is becoming the study of choice but findings should be interpreted by an experienced practitioner and correlated with the clinical situation.
Arthroscopy • •
Treatment
•
There is individual variation as to when this is most appropriate. An advantage is that the procedure is both diagnostic and therapeutic at same time. expediting interventional treatment when necessary. Determined by various factors. not only the type of injury and degree of instability: Vocational/avocational considerations. Involvement of other knee structures (menisci. collateral ligaments). Existing co-morbidity (severe osteoarthritis/arthrosis). Patient goals (are they realistic?). Social factors such as cost of treatment or time off work. Patient age. A key factor is the anticipated best functional outcome taking all factors into consideration.
1. 2. 3. 4. 5. 6. 7.
Options
Conservative Treatment •
•
• • • • •
• • •
May be sufficient for the recreational athlete if physical therapy. activity modification. and/or bracing have been successful and if no other structures are significantly involved. Nonsurgical candidates. initially treated symptomatically and with RICE (rest. ice. compression. elevation). The use of crutches in the acute stage if the patient is unable to ambulate without a limp. NSAIDs as indicated and as tolerated. If the knee effusion is tense. aspiration may be indicated to relieve symptoms. Bracing. Targeted physical therapy and exercise training (with appropriate weight-bearing considerations). Early range-of-motion exercises are important. Full return to sporting activity usually takes 6-12 months. Quadriceps strengthening. Establishing muscle balance between weak phasic muscles and shortened tonic muscles. Activity modification.
Surgical Treatment • • •
•
Differential
•
Diagnosis
• • • • •
Surgical reconstruction of the incriminated ligament. Repair of associated damaged knee structures. Individually tailored rehabilitation course with specific goals to be set right from the beginning and against which progress should be ·plotted." Offers the best chance for a successful retum to agility and sporting activity in the young. active patient. Meniscal tear. Collateral ligament tear. Fracture (tibial plateau. osteochondral). Patellar tendon or quadriceps rupture. Patellar dislocation or subluxation. Posterior cruciate ligament tear.
Posterior Cruciate Ligament (PCl) Tear Synonyms
•
and Related
•
Terms
• • •
Definition
•
PCl sprain. Posterior cruciate deficiency. Cruciate ligament tear. Posterior instability of the knee. Posterior laxity of the knee. Tissue overload resulting in disruption or complete tearing of the posterior cruciate ligament. Presentation is dependent on whether there is an acute injury or whether the dysfunction is the result of progressive knee joint degeneration. Comparatively little pain (e.g .. to the anterior cruciate tears). swelling. laxity and difficulty walking for prolonged periods of time may be clues to the disorder. especially if the range of motion is full. There may be associated injuries to the other knee ligaments.
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Disorders of the Knee
Posterior Cruciate Ligament (PCl) Tear (can t ) .
Key Points
•
The posterior cruciate ligament is longer and stronger than the anterior cruciate ligament (ACL).
•
PCl tears occur less often than ACl tears.
•
PCl tears may occur by themselves (rare) or in conjunction with other ligamentous our meniscal injuries (frequent) (Mink et al..
1993).
•
PCl tears occur with hyperflexion or hyperextension of the knee or excess valgus stress.
•
Dashboard injuries or falling onto the knee are common mechanisms of injury.
•
Degenerative processes may play a prominent role due to alteration of biomechanics (adaptation. compensation. degeneration). With chronic tears. patient may have particular difficulty climbing or descending stairs. as if the knee "slide off."
•
Associated sports are football. soccer. skiing. snow boarding. volleyball. and wrestling. Mechanisms are different for the various sports.
Notes •
PCl tears may be overlooked as the initial presentation may not be very impressive. especially if there is only little swelling and essentially normal range of motion. Early diagnosis is key to successful treatment. The sequelae of a PCl tear. if undetected. may result in significant disability due to advanced degenerative changes and loss of stability.
•
Pay attention to potential complications including vascular injury (e.g
.•
genicular artery off the popliteal
artery) that might lead to compartment syndrome. •
Pathology/
•
Etiology
Pay attention to potential nerve injury (peroneal nerve or tibial nerve impingements). Excessive loading stress introduced to the knee during trauma or abnormal biomechanics associated with degenerative processes.
•
Four injury patterns suggest the possibility of a PCL tear: - Dashboard injury with force directed posteriorly force to the anterior knee in flexion. - Fall onto a flexed knee. - Pure hyperflexion injury to the knee. - Pure hyperextension injury to the knee. with ACl rupture.
•
Partial tears.
•
Complete tears with/without avulsion fracture.
Clinical
Two Scenarios
Presen
1.
Presentation after trauma: (a) Careful history is the key to diagnosis. especially the circumstances of the injury mechanism.
tation
(b) Acutely. there may be prominent swelling and pain. (c) Pronounced difficulty ambulating.
2. •
The patient does not recall any particular trauma: Typically with an underlying osteoarthrotic/osteoarthritic process. patients provide a history of difficulty in climbing or descending stairs. or walking on uneven terrain.
•
The patient may present reporting "trivial" movement to have "caused" the pain.
•
The initial examination may be rather "benign" as there may be normal-near normal range of motion. minimal swelling. and/or little hemarthrosis.
Functional
•
Information
A clue to underlying degenerative posterior cruciate ligament dysfunction is the history of the leg ·sliding off" the lower leg. especially when managing uneven terrain or managing stairs.
•
There may be significant adaptive changes involving the knee. with advancing degenerative changes of the knee leading compartmental cartilage degeneration. especially the medial compartment.
•
Note: In patients with undetected PCl tears. the initial presentation may be due to the compensatory
changes elsewhere in the musculoskeletal system as the pain in that region may become the focus of attention. •
There may be prominent muscle imbalances far beyond the lower limb and these should be evaluated. especially in the chronic situation (adaptive/compensatory changes).
•
PCl injuries are particularly disabling for downhill skiers. who rely on the ligament to maintain a tucked position for racing.
Examina
•
tion/
•
Effusion: may be present or absent.
Provocation
•
Active and passive range of motion:
Maneuvers
Evaluate for location and intensity of the pain.
- May be entirely normal. - Differentiate between pain-reaction (e.g
.•
soft end-feel) and mechanical restriction (hard-elastic end-feel.
or bony restriction if the knee is subluxed). •
In the case of an unrecognized dislocation with spontaneous reduction. there may be a limb-threatening vascular injury. This requires emergent treatment.
•
Evaluate patient's gait and ability to bear weight.
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Selected dinlcol Syndromes
Posterior Cruciate Ligament (PCL) Tear (cont.) ---
Special Tests •
A thorough examination of knee stability must be perfonmed because of the ass ociation of combined ligamentous injury: - Posterior drawer test (analogous to the anterior drawer test) is the most sensitive. A translation force is introduced to the proximal tibia. Sometimes the return to neutral position is falsely interpreted as a positive anterior drawer test. Also. the examination can be complicated by the coexistence of an ACl tear. - Posterior sag test or posterior gravity test (hip and knee are flexed to
Diagnostic
Standard Radiographs
Adjunctive
•
AP view (with knee extended and flexed to
Studies
•
lateral view (swelling. fracture. etc.).
90°).
30°).
•
Radiographs should be done to exclude PCl bony avulsion. which should be surgically repaired acutely.
•
Radiographs should be done especially in patients older than 45 years to rule out other pathologies such as osteoarthritis. osteonecrosis. fracture/dislocation. joint diffusion. or soft-tissue injuries.
MRI •
Routinely the study of choice. Findings should always be correlated with the clinical situation. especially when suspecting coexisting multiligamentous and/or meniscal injuries. or fractures.
•
It is not possible to specifically correlate MRI findings with level of clinical instability or prediction thereof.
Arthroscopy •
Specific patient populations (e.g patients unable to undergo MRI due to metal implants. pacemakers, etc.).
Treatment
•
Initial treatment in uncomplicated isolated injury is conservative.
Options
•
.•
Determined by various factors. not only the type of injury and degree of instability:
1.
Vocational/avocational considerations.
2.
Involvement of other knee structures (menisci. collateral ligaments).
3.
Existing co-morbidity (severe osteoarthritis/arthrosis).
4.
Patient goals (are they realistic?).
5.
Social factors such as cost of treatment or time off work.
6.
Patient age.
7.
A key factor is the anticipated best functional outcome taking all factors into consideration.
Conservative Treatment •
Nonsurgical candidates are treated initially symptomatically and with RICE (rest. ice. compression. elevation).
•
NSAIDs as indicated and as tolerated.
•
Bracing can be helpful. especially when there is a return to sports.
•
Targeted physical therapy and exercise training (appropriate weight-bearing considerations) over 6-8-weeks. First. emphasis on edema control and restoring range of motion. subsequent emphasis on intensive quadriceps exercise.
•
Establishing muscle balance between weak phasic muscles and shortened tonic muscles.
•
Activity modification.
Surgical Treatment •
Surgical intervention is indicated when there is significant rotatory instability or combined injuries to other knee structures.
•
Failure of nonoperative treatment is usually determined by recurrent instability. or subsequent meniscal tears.
•
Surgical reconstruction of the incriminated ligament.
•
Repair of associated damaged knee structures.
•
After surgery. instability is usually improved. but some degree of residual laxity to translation is often present.
Differential
•
ACl tear.
Diagnosis
•
Articular cartilage injury.
Prognosis
Further Reading
•
Meniscal tear.
•
Collateral ligament tear.
•
Combined ligament tear.
•
Knee fracture (tibial plateau. osteochondral).
•
Patellar or quadriceps tendon rupture.
•
Patellofemoral dislocation.
•
Isolated injury has relatively good prognosis (potential of revascularization with supply from the genicular artery).
•
Osteoarthritis. recurrent instability. and meniscal tears are potential complications.
•
Avascular necrosis of the knee.
Mink IH. The cruciate and collateral ligaments. In: Mink IH. Reicher MA. (rues IV. Deutsch AL. eds. MRI of the Knee. 2 nd ed. New York: Raven Press; 1993: 141-187.
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Disorders of the Toes
The examination of the foot should follow a rational
The Foot and Ankle
progression from a careful history to a detailed and ortho pedic neurovascular examination while trying to rule out
In the foot, acquired hallux valgus is the most frequent
such specific diagnoses as Morton's neuralgia or fractures
deformity.
and dislocations, systemic disorders, as well as potential
Usually the causes of the deformities are multifactorial, but more typically they are due to inappropriate shoes that
spinal or muscular pathology that might refer pain to the toes or foot.
are too tight and narrow, significantly altering the usual biomechanics.
Disorders of the Toes Hallux Valgus of the Great Toe Synonyms and
•
Bunion.
Related Terms Key Points
•
Static subluxation with lateral deviation of the great toe at the first metatarsophalangeal joint and medial deviation of the first metatarsal head.
•
The involved region may become quite painful.
•
The normal metatarsophalangeal angle is no larger than
•
The normal intermetatarsal angle between the first and second rays is no larger than
•
Juvenile hallux valgus, however, should be considered a variation of normal despite the apparent
•
Asymptomatic hallux valgus may become symptomatic upon wearing tight or fashionably narrow
15°
(Fig.
14.56).
10°.
larger metatarsophalangeal angle (joint surface inclination accommodates those changes). shoes. Multifactorial with extrinsic and intrinsic factors.
Etiology/
•
Pathophysiology
Extrinsic Factors •
Footwear (tight, short. compressive) may play a significant role.
•
Nonshoe-wearing populations seem not to develop spontaneously a hallux valgus deformity (lam Sim-Fook and Hodgson.
1958).
Intrinsic Factors •
Familial or congenital.
•
Forefoot configuration: great toe that is longer than the remaining toes.
•
Abnormal position (pes planus).
•
Joint instability (hypermobility in the metatarso-cuneiform joint of the first ray).
Biomechanical
Abnormal Biomechanical Considerations
Changes
•
Progressive changes in the pulley action/direction (deviation toward one side) in the muscles
•
With progressive involvement. the incriminated metatarsal head is subject to ever-increasing
•
With continued medial displacement of the metatarsal head. the tendon of the abductor hallucis is
associated with the first ray. eccentric pressure which forces the metatarsal bone into a varus position. allowed to slip under it and it is no longer able to abduct the toe. ultimately resulting in valgus and pronation formation of the first phalanx. •
The tendons of both the flexor hallucis and extensor hallucis are also involved as they pull outside of the midline.
•
Ultimately the lateral portion of the joint capsule and the abductor hallucis undergo contracture. leaving the hallux valgus in a fixed position.
•
Due to the deformity. the great toe loses its supportive function, which necessitates the neighboring rays. especially the second. taking more of the load during weight bearing and especially in toe-off action during walking.
•
Consequently. there may be painful callus formation under the lesser metatarsal head.
•
The plantar plate may ultimately rupture due to the chronic overload situation. leading to subluxation or frank dislocation of the metatarsal phalangeal jOints. further contributing to additional hammertoe deformity.
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Selected Clinical Syndromes
Hallux Valgus of the Great Toe (cont.) Clinical
•
Pain at the metatarsophalangeal joint (early stage) and the area over the metatarsal head medially in shoes (pressure).
Presentation •
In advanced stage, and especially with instability at the metatarsophalangeal joint, pain may be reported at the dorsal surface of the foot.
•
Functional loss, pain, and/or cosmesis may be what finally prompt the patient to seek advice in the medical office.
•
·Pseudoexostosis" with skin irritation and even paresthesias along the medial side of the great toe due
•
In up to 50% of patients with hallux valgus, there is also involvement of the second toe as well (Mann
to direct nerve involvement (late or advanced stage). et aI.,
1992).
Functional
•
Difficulty walking or standing in shoes due to pain or discomfort.
Information
•
The patient may have waited or "ignored" the problem for quite some time, in the hope that things
•
Adaptation to footwear is a good indication of prolonged presence of problems (e.g., the patient may
would "get better over time: have cut holes in shoes, or may wear only open shoes, etc.). Examination/
•
V isible hallux valgus formation.
Special Tests
•
The medial side of the area overlying the metatarsal head may be erythematous and painful, due to
•
Examination should include complete neurovascular examination of the foot to rule out other
irritation of the incriminated bursa. potential diagnoses. •
Include digital compression from lateral to medial (of the entire forefoot) and dorsal-plantar compression of the web-space to rule out Morton's neuralgia.
Adjunct Studies/
Standard Radiographs
Imaging
•
Weight-bearing/standing AP view to objectively demonstrate the severity of the deformity and DD hallux rigidus.
Treatment
Conservative Measures •
Early stage: - Initially, the patient may attempt a number of self-corrective measures, including wearing open shoes or cutting around the areas of tightness. - Many different trials of various soft or even hard orthoses or commercial inserts without much lasting success. - Night splints may slow the process but are typically unable to arrest the progression. - Exercises that involve the abductor hallucis may initially be helpful but cannot ultimately correct the deformity. - Manual medicine intervention is directed primarily at maintaining highest level of function in the neighboring articulations, including the foot, knee, and hip to minimize the effects of abnormal compensatory changes. - Restoration or improvement of muscular imbalance and endurance are necessary components of a detailed manual medicine program.
•
Advanced stage: - Specifically fabricated shoes may be required but are used primarily for comfort measures as they do not arrest the progression.
Surgical Considerations •
The goal is to restore the usual anatomic relationships as much as possible.
•
Surgical planning takes into account contributing factors such as hypermobility of the metatarso cuneiform articulation of the first ray or too long a base phalanx in order to minimize recurrences.
Surgical Approaches •
Among others, surgical approaches include the following: - Distal or proximal osteotomy of the first metatarsal bone with lateral release and combined tightening of the metatarsophalangeal joint capsule medially. - Additionally shortening or varisation (Akin) osteotomy of the phalanx of big toe might be necessary. - Arthrodesis of the metatarsocuneiform joint. Hallux rigidus.
Differential
•
Diagnosis
•
Hallux varus.
•
Gouty arthritis.
•
The term "hallux valgus· was introduced in 1870 by Hueter.
Historical Perspective
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Disorders of the Toes
Fig. 14.56 Physiological angle of the long axis of the first ray.
Hallux Rigidus Synonyms and
•
Arthritis of the great toe.
Related Terms
•
Dorsal bunion.
Key Points
•
Hallux f1exus.
•
Hallux limitus.
•
Significant loss of extension motion involving the metatarsophalangeal joint (thus. hallux f1exus. or flexed great toe) due to localized arthrotic degeneration.
•
After hallux valgus. this is the next most common disorder involving the first metatarsophalangeal joint.
•
However. there is usually no Significant change in the physiological angle of the first digit (in contrast to hallux valgus).
•
Typical age of presentation is in middle age.
•
Juvenile forms may be encountered but are comparatively rare.
Potential A ssociated Factors •
Prior history of direct. repetitive axial trauma (e.g
•
History of fracture(s).
•
.•
from soccer).
Osteochondrosis dissecans.
•
Abnormally long great toe with increased pressure at the metatarsophalangeal joint.
•
Systemic disorders including chronic polyarthritis. gout. and psoriasis.
Etiologyl
Early Stage
Pathophysiology
•
Painful cartilage degeneration with associated synovitis.
Advanced Stage •
Osteophyte formation. typically at the dorsal and lateral side of the metatarsal head (Fig. 14.57); hence also referred to as dorsal bunion.
•
The axes of the metatarsophalangeal joint of the great toe remain essentially unchanged. unlike in
•
Progressive growth of the osteophyte will ultimately lead to impingement between the phalanx and
the case of hallux valgus. the metatarsal head during extension. •
Impingement leads to further loss of great toe extension such that toe-off during the gait cycle becomes more and more painful.
•
Ultimately the osteophyte may become so large that the proximal phalanx is pushed into a relatively flexed position (hallux f1exus) and further progression will result in ankylOSis of the articulation.
Clinical Presentation
•
Pain and discomfort with loss of extension at the metatarsophalangeal articulation.
•
Difficulty in walking (impingement) or standing (shoe pressure) due to pain or discomfort.
•
Patient may have waited or "ignored" the problem for quite some time. in the hope that things would "get better over time."
•
Adaptation to footwear is a good indication of prolonged presence of problems (e.g
.•
the patient
may have cut holes in shoes. or may wear only open shoes. etc.). Functional Information
•
Painful toe-off may lead to prominent adaptive or compensatory changes in motion in the ankle. knee. and hip. and/or spine. including the opposite limb.
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Selected Clinical Syndromes
Hallux Rigidus (cont.) Examination/
•
Erythematous swelling over the area of the osteophyte on the dorsum of the foot at the level of the
•
The cardinal finding is that of significant restriction or total loss of toe extension.
•
Flexion of the great toe is typically less restricted. if at all impaired. but may be very painful
Special Tests
metatarsophalangeal jOint of the great toe.
(osteophyte dorsally "hurts" the capsule). •
Enlargement dorsal and medial MP1 due to osteophyte formation.
Adjunct Studies/
•
Standard radiographs. weight- bearing. AP and lateral.
Imaging
•
Narrowing of the joint space (AP projection) and lateral.
•
An osteophyte is best demonstrated on the lateral view (Fig.
•
The metatarsal head may be flattened with or without possible subchondral cysts.
Differential
•
Gouty arthritis.
Diagnosis
•
Hallux valgus (plantar bunion).
Treatment
Conservative Approaches
14.58).
--------....,.- ----- --
•
Adapted footwear (cut-outs. large toe box). Rigid shoe-sole to prevent/reduce motion at MTP joint
•
May require referral to prosthetist for special shoe fabrication.
plus rocking bottom; rigid insert. Surgical Considerations •
Osteophyte resection (cheilectomy).
•
Osteotomy.
•
Arthrodesis in advanced cases.
•
Base resection of the proximal phalanx (Keller-Brandes procedure) may be a good alternative for the elderly patient (excellent rehabilitation potential).
Historical
•
Artificial joint replacements have not been shown to be adequately successful to date.
•
The name was introduced in 1887 by Cotterill.
Perspective
14.58
Fig. 14.57 Intraoperative p ho tograph showing the prominent de
Fig.
generative process at the meta tarsophalan geal jOint with a large
formation.
dorsal osteophyte.
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Classic lateral ra diograph demonstrating hallux rigid us
Disorders of the Toes
Deformities of the lesser Toes 14.59): this represents a flexion deformity in the proximal interphalangeal joint (PIP).
Synonyms/Related
•
Hammertoe (Fig.
Terms
•
Claw toe (flexion deformity in both PIP and distal interphalangeal joint [DIP]).
•
Mallet toe.
Note: Terminology is not consistent throughout the literature. Key Points
Deformity
Joint involvement MTP
PIP
DIP
Hammertoe
Hyperextended
Hyperflexed
Hyperextended
Claw toe
Hyperextended
Hyperflexed
Hyperflexed
Mallet toe •
Flexed/hyperflexed
Deformity of the lesser toes, with the second toe being involved the most.
•
Deformities are mostly acquired (external factors).
•
Rarely seen in nonshoe-wearing populations (Engle and Morton,
•
Intrinsic muscle action can also be adversely affected by tight shoes with loss of stability in the
•
Deformity of the second row is typically seen in association with hallux valgus deformity.
•
Deformities may be particularly severe (e.g., grotesque) in patients with chronic polyarthritis.
1931;
James,
1939;
Wells,
1931).
metatarsophalangeal joints.
Etiology/
•
Idiopathic.
Pathophysiology
•
Multifactorial.
•
Trauma.
•
Congenital long toes (rays 2 and/or
3)
may play a role in developing deformities, especially when
confined to tight, narrow shoes. •
Intrinsic factors (in the absence of external trauma, or compression).
•
Systemic disorders: - Polyarthritis. - Psoriasis.
•
Neuromuscular disorders: - Charcot-Marie-Tooth disease. - Cerebral palsy. - Poliomyelitis. - Pes cavus.
Clinical Presen
•
tation
•
Pain and/or callus formation at the incriminated toe(s) (PIP) and/or at the tip of the toe(s). Secondary metatarsalgia due to changes in pressure distribution upon the metatarsal heads (especially severe in chronic polyarthritis).
Functional
•
Patient may indicate spontaneously in the history that shoes have become "too tight" over time.
Information
•
Gait may be altered due to adaptive or compensatory changes in motion in the ankle, knee, and hip, and/or the spine as result of trying to minimize the pain in the foot.
Examination
Early Stage •
Abnormal position of the toe can be reduced manually.
Late Stage •
Abnormal position cannot be reduced and ultimately becomes fixed/ankylosed.
•
Callus formation over the incriminated toe(s) with erythema and tenderness.
Adjunctive
•
laboratory studies to determine possible associated or underlying systemic disease.
Studies/
•
If radiographs of the foot are considered, perform them with the patient weight bearing.
Imaging Differential
•
Differentiation between the three major deformity possibilities of the lesser toes.
Diagnosis
•
Fracture of the toe(s).
•
Arthritides: - Rheumatoid arthritis. - Seronegative arthritis (e.g., psoriatic arthritis).
•
Morton disease.
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Selected Clinical Syndromes
Deformities of the Lesser Toes (cont.)
Treatment
Conservative Approach •
Pressure relief through use of soft-soled. cushioned shoes that are sufficiently wide and with cut-outs or additional toe room.
• •
Nonrigid. soft toe orthoses or protectors. Associated metatarsalgia may benefit from orthoses that provide retrocapital support.
Surgical Considerations • Indications: - Painful deformity that cannot be corrected with conservative measures. - Intolerable pain. - Significant functional impairment (vocational and avocational impact). - Cosmesis (rare). •
Goals: - Restoration of as normal toe function as possible. - Determination of functional goals and anticipated outcomes after surgery.
Surgical Procedures •
In general. the chosen procedure should be well-planned and take the patient's individual requirements into account. both anatomically and functionally specifically addressing vocational and avocational requirements.
•
Tenotomy with/without capsular release and/or pinning.
•
Condylectomy (fixed deformity).
•
Fusion (PIP joint).
•
Resection PIP joint (Hohmann procedure).
•
Amputation (infected or ulcerated toe. which may require more extensive amputation of the foot. etc.).
Postoperative Rehabilitation •
General guidelines for postoperative care apply (elevation. rest. ice. etc.).
•
Most important is the immediate postoperative period (first few weeks).
•
Individually applied splints to maintain the toe(s) in correct position.
•
Weight bearing in postoperative boot.
•
The metatarsophalangeal joint should be ranged passively and. if possible. actively.
Potential Complications •
Prolonged swelling.
•
Recurrence.
•
Flail toe.
•
Neuroma (extremely seldom).
Fig.14.59 Hammertoe of the second ray.
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Disorders of the Toes
Morton Neuralgia Synonyms and
•
Morton neuroma (an antiquated and incorrect term. but one routinely found in clinical language).
Related Terms
•
Morton toe.
Key Points
•
Plantar digital neuroma.
•
Traumatic digital neuropathy with metatarsalgia.
•
Durlacher-Morton disease.
•
This painful condition is not neoplastic.
•
Typically unilateral
•
The most frequent region is the third web-space. followed by the second web-space.
•
This is a chronic compression type of neuropathy that involves one or several plantar digital nerves
(85%).
in the vicinity of the involved metatarsal head. •
In the first and fourth web-spaces there is virtually no involvement of the nerves.
•
It is more frequent in women than in men.
•
Conservative measures may help initially or in some patients. but ultimately surgical intervention may be necessary.
Clinical Pearl •
Rather than "neuroma: the pathophysiologically correct term for this disorder is "neuralgia: inasmuch as histological preparations have failed so far to demonstrate a "neuroma" formation.
Etiology/
•
Entrapment type of neuropathy due to chronic compression resulting from changes in anatomic relationships of the bones and ligaments. The most frequent cause is tight or overly narrow shoes.
Pathophysiology •
Intrinsic Factors -
Ganglia.
- Bursitis. - Lipoma. - Bone abnormalities. - Trauma/fracture/dislocation. •
The transverse metatarsal ligament. which holds the two metatarsal bones together distally. is a
•
The common interdigital nerves run under transverse metatarsal ligament until they divide into the
crucial structure in the development of this disorder. final digital branches more distally. Clinical Presentation
•
Pain is typically in the vicinity of the metatarsal heads. and is worse after pain-free walking for about
30
min. or weight-bearing. Usually disappears with rest.
•
Initially. the patient may report the disturbance as an ache surrounding the fourth metatarsal head
•
The pain is often described as extremely intense burning.
(the most frequent presentation). •
Pain may extend distally into the respective incriminated toe or prOXimally to the distal leg.
•
Reports of hypoesthesia are relatively rare (fewer than
50% of
the cases).
Functional
•
Patients may find it difficult to walk or stand in one place. especially for prolonged periods.
Information
•
Adaptive or compensatory changes in the knee. hip. or spine may occur over time. especially if the patient has to remain in an uncomfortable position due to vocational requirements (standing at a conveyer belt. for instance).
•
Often. the patient has tried to relieve the discomfort/pain using different types of inserts or orthoses. some of which may actually have worsened the symptoms.
Examination/
•
Special Tests
Dorsal-plantar digital compression of the incriminated web-space helps to elicit the typical. often exquisite pain.
•
lateral compression of the forefoot with one hand may elicit a painful snapping type of patient reaction when the incriminated nerve is compressed between two metatarsal bones (also known as the Mulder sign).
Adjunct Studies/
•
Electrodiagnostic studies and MRI are not specific and should only be utilized when ruling out other disorders (Mann.
Imaging
1993).
Hallux valgus.
Differential
•
Diagnosis
•
Metatarsalgia.
•
Synovitis (metatarsophalangeal joint).
•
Stress fracture.
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Selected Clinical Syndromes
Morton Neuralgia (cont.)
Treatment
Conservative Approaches •
Typically, conservative approaches have low success rates as continued irritation and compression continue to compromise the anatomic relationships.
•
Wide, flat, soft-soled shoes may help in the early disease.
•
Conventional inserts or off-the-shelf orthoses may actually worsen the symptoms due to increased
•
Localized corticosteroid perineural injections (limited in number, due to risk of tissue necrosis) may
retrocapital pressure. bring initial relief or even lasting relief in the early stages of the disease (Greenfield et aI., 1984). However, appropriate postinjection care must be assured, including appropriate activity restrictions and specific orthoses, as indicated. •
The majority of patients will nevertheless ultimately require surgical intervention.
Surgical Considerations •
Resection of the involved nerve segment (Fig. 14.60).
•
This has an approximate success rate of 80% (pain free) while an additional 15% of patients report
•
Approximately 30% of the operated patients report no sensory abnormalities in their toes, while the
improvement, albeit no resolution, of their symptoms. remaining patients have noted some, albeit tolerable, hypoesthesia (Mann, 1993).
Historical Perspectives
•
While this disorder has been widely credited to Morton's publication of 1876, a good 30 years before that Durlacher (1845) had already published an account and description of the same disorder. For this reason, some purists prefer the double designation of Durlacher-Morton disease.
Heel Pain Heel pain can be divided into two major categories accord ing to the location of the pain:
1. Subcalcaneal pain with plantar fasciitis as the major representative.
2. Retrocalcaneal pain, as represented by Achilles' tendo nitis/tendinosis.
Fig. 14.60 Photograph of an excised nerve segment. The morpho· logical abnormality is readily visible to the naked eye.
Subcalcaneal Pain Synonyms and Related Terms
•
Plantar fasciitis.
•
Painful heel syndrome.
Key Points
•
Pain at the region of the proximal attachment of the plantar fascia/plantar aponeurosis on the medial side of the calcaneus.
•
Patients typically complain of pain upon rising in the morning and when first placing weight onto the incriminated heel and foot. After a few steps the pain characteristically improves.
•
Represents possible traction type of periostitis, as there is increased loading upon the plantar fascia/ plantar aponeurosis due to mechanical overload associated with physical activities or foot deformities, such as pes planus or pes cavus.
•
This focal inflammatory response extension can also extend secondarily in the vicinity of the attachment.
•
Additional pain may be due to possible entrapment of the medial calcaneal nerve and/or the motor branch of the abductor digiti minimi nerves (Fig. 14.61).
•
Entrapment of the above nerves is a relatively rare primary cause of subcalcaneal heel pain.
•
Radiologically a calcaneus spur may be noted which. however, may play little, if any, role in the development of the heel pain per se (Williams et al.. 1987).
•
Patients presenting with subcalcaneal heel pain should also always be evaluated for any potential underlying or associated rheumatic disease.
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Heel Pain
Subcalcaneal Pain ( cont ) .
Pathologyl
•
Shortening of gastrocnemius muscles.
Etiology
•
Nonspecific inflammatory reaction in response to repetitive overload/strain.
•
Compensatory patterns due to changes in the mechanics of foot and ankle action (which may, however, be the result of adaptations or compensations to other failing joints with altered gait patterns, or due to changes in activities (e.g., new sports or leisure activities).
Clinical
History
Presentation
•
The pain is typically well localized underneath the calcaneus along the anteromedial margin of the
•
The patient characteristically reports pain upon rising in the morning and while taking the first few
heel. steps. •
After the first few steps the pain gradually improves. However, after increased or additionally applied loading/overload the pain again sets in and worsens in intensity.
•
A single precipitating traumatic event or a particular change in activity is often not recalled by the patient (unless possibly pointed out later).
Examination/Tests
•
Well-localized, exquisite pain that is unequivocally elicited upon palpatory examination under the calcaneus at the anteromedial border along the heel.
• •
A pes cavus or pes planus deformity may be present. Neurologic involvement or nerve involvement is difficult to determine on clinical basis alone as classical neurological signs such as dysesthesias or hypoesthesias, Tinel's sign, or muscle weakness are rare.
Diagnostic
•
Studies
Radiographs may not be required initially, especially if the history and the examination would clearly support the diagnosis of plantar fasciitis.
Adjunctive •
If radiographs are considered at some point then weight-bearing views would be the best choice of approach.
•
MRI or CT scan are rarely indicated if ever, especially in the initial phase of the disease and treatment plan.
•
Patients who do have continued pain, especially at rest, and despite extensive appropriate conservative therapy, may require further radiographic and/or laboratory studies with a comprehensive but rational additional work-up.
Treatment
Conservative Approaches
Options
•
Treatment is primarily conservative and may take up to 6 months (O'Brien, 1985; Shikoff et aI., 1986; Snook and Chrisman, 1972).
•
Localized treatment including lotions, iontophoresis, ultrasound, and cold application may be of some benefit but may not be restorative.
• •
The patient may benefit from a limited trial of corticosteroid injections (caveat: tissue necrosis). Care must also be taken not to inject into the fatty tissue due to the potential risk of fat atrophy, which can precipitate a subcalcaneal inflammatory reaction.
•
Orthoses, especially those that dampen the impact upon heel strike during the gait cycle, should be
•
Stretching of the gastrocnemius-soleus complex (triceps surae muscle) can be initiated once the acute
worn consistently. pain has subsided (in fact this is the most important treatment). •
Abnormalities of the foot architecture or deformities should be addressed and if possible corrected (pes planus, pes cavus).
Surgical Considerations •
If surgery is indicated, the plantar fascia is partially separated at its attachment at the calcaneus (very rare).
•
The calcaneal spur may require resection and the nerves may need to be laid bare.
Functional
Functional Impact
Information
•
Appropriate activity restrictions should be provided in the form of instruction to the patient to
•
Specific stretching exercises that can be performed for the gastrocnemius should be taught
minimize any exacerbations that occur with activities at work and/or in leisure. appropriately initially and can then be performed by the patient independently several times during the day. •
A night splint that keeps the foot in extension may be of help inasfar as it may prevent contracture of the gastrocnemius.
•
In addition, systemic approaches, especially pharmacologic, may be utilized, such as anti-inflammatory medications.
•
Again, if there is failure after 6 months to a year despite appropriate conservative treatment, surgical intervention should be considered.
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Selected Clinical Syndromes
Subcalcaneal Pain (cont.)
Differential Diagnosis
•
Acute traumatic rupture of the plantar fascia.
•
Bony tumor.
•
Distal plantar fasciitis.
•
Entrapment of the first branch of the lateral plantar nerve (maximal tenderness over medial plantar hindfoot).
Prognosis
•
Fat pad atrophy/contusion.
•
Myofascial pain syndrome (gastrocnemius muscle, deep intrinsic muscles of the foot. etc.).
•
Radicular pain syndromes (radiculitis/radiculopathy).
•
Stress fracture of the calcaneus.
•
Tarsal tunnel syndrome (first symptom RA).
•
Typically favorable. even though the patient's recovery may well take 1-2 years.
Fig. 14.61 Top ographi c relationship between the two major nerves responsible for heel p