This book is dedicated to my wife and to those of my pupils from whom I have learnt most of all.
For Elsevier Publisher: Sarena Wolfaard Development Editor: Sally Davies Project Managers: Anne Dickie and Sukanthi Sukumar Designer: Kirsteen Wright Translators: Elaine Richards and David Beattie Illustration Manager: Bruce Hogarth Illustrators: Gerda Istlerová, Prague, Henriette Rintelen and Velbert Photographs: Jitka Fabianová, Prague
First edition published in English © 2010, Elsevier Limited. All rights reserved. First published in Czech (original Czech title Manipulacˇní lécˇba v myoskeletální medicíneˇ) and subsequent other editions in Swedish, Dutch, Bulgarian, Polish, English (under the title Manipulative Therapy in Rehabilitation of the Locomotor System, 1985), Italian, Spanish, Russian, German and Japanese Eighth Edition published in German under the title Manuelle Medizin 8. Auflage © 2007 Elsevier GmBH, Urban & Fischer Urban & Fischer is an imprint of Elsevier GmBH No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail:
[email protected]. You may also complete your request online via the Elsevier website at http://www.elsevier.com/permissions. ISBN: 978-0-7020-3056-7 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notice Neither the Publisher nor the Author assume any responsibility for any loss or injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method of application for the patient. The Publisher
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Foreword My professional life has been enormously enhanced by Karel Lewit’s teaching and I am so pleased that he has continued to enhance his book, for this latest edition, by adding his further distillation of how recent research should refine our management of locomotor pain. If you liked a previous edition, you will definitely want this one. Although many would consider this a textbook, Professor Lewit has said that it is not one; he has always wanted to make us think, and to enable us to work out our puzzles and problems with the aid of the principles and approaches which he outlines in this book. I can remember, as a medical student, how my teachers gave me the impression that I was learning, at that hospital, all that could be learnt about humankind’s suffering, illnesses and diseases. How wrong they were! Karel Lewit’s teaching has certainly ‘shone light where there was darkness’ on my understanding of musculoskeletal pain. Even after many years it remains a source of pleasure and even excitement that our ‘clinical experience in the use of manipulation for diagnosis and treatment constantly reaffirms, in countless patients, the principle that treatment, if technically successful, brings normalization of restricted mobility in the joint or motion segment. Normalization of function also brings relief of pain.’ But we must take it further than being proud of technique. ‘It is as important – and still more difficult – to adjust our thinking to the functional approach as to master the technical aspect of manual medicine.’ Following this statement Lewit gives important differences between the usual, pathomorphological understanding and the functional approach. The fourteenth of these is, ‘When treating dysfunction, the practitioner is lost – or
rather his patient is – if he treats it at the point where pain is felt’. I can remember being so confused when Philip Greenman said this same thing. This book helps us understand more deeply about how the motor system works and how dysfunction causes pain, and why that statement is true: compared to doctors with our ‘structural’ training, you chiropractors, osteopaths and physiotherapists are fortunate! It is wonderful to see how manipulative therapy and musculoskeletal medicine have developed during Karel Lewit’s lifetime – not least through his own research and that of his younger colleague Vladimir Janda, and then Vojta and Kolárˇ. I remember John Mennell in his later years insisting that it is the muscles that are important’ but not quite being able to explain why. Mitchell, Greenman and others had of course shown, with the muscleenergy technique, that the patient’s own muscles can achieve reversal of dysfunction. But one cannot underestimate the influence of Karel Lewit in stimulating the Czech school and many others to show the underlying neuromuscular causative mechanisms of dysfunction. And nowhere have the clinical manifestations and treatment implications of this newer understanding been better explained than in this book. Karel Lewit can sift the pearls of wisdom from the side-issues, misunderstandings and downright wrong very effectively, as we know (sometimes to our cost!) at meetings of the multidisciplinary International Academy of Manual and Musculoskeletal Medicine (formerly the FIMM Academy). So, he has done all the hard work for you: read on, and give the benefit to your patients. Richard Ellis
vii
Preface The first Czech edition of this book was published in 1967 out of the necessity of providing instructional material. There was a need to teach physicians and, later, physical therapists a new specialty – the diagnosis and treatment of dysfunction of the locomotor system. A way of teaching both theory and practical skills was required that did not involve spending too much time in lectures. There was no comprehensive textbook to teach fundamental theory, functional anatomy, clinical aspects of dysfunction of the locomotor system, relevant treatment indications and appropriate preventive measures based on the findings. Nor is there any such textbook to this day, apart from an increasing number of technical manuals representing various schools of manual medicine. This is probably the reason that translations of this book have appeared in numerous languages: German, Swedish, Dutch, Bulgarian, Polish, English, Italian, Spanish, Russian and Japanese. The first English edition was published by Butterworth in 1985. This was a shortened and therefore more concise version of the original Czech and the seven German editions. The second and third English editions were published by Butterworth-Heinemann. The last two Czech and the eighth German editions were restructured according to the English editions. This eighth (2006) German edition has been translated and updated for the present English version. The starting point was initially manual therapy, but it soon became evident that the true object of ‘manual medicine’ is dysfunction of the locomotor system; such dysfunctions account for 90% of the vast number of patients suffering from painful conditions of the locomotor system. Despite this, afflictions of this nature are termed ‘unspecific,’ hence without diagnosis and consequently inadequately treated. Nevertheless, these complaints are specific disturbances of function: they can be precisely diagnosed by clinical means, requiring in the first place specific physiological methods of treatment. Knowledge about this largely unexplored field grew rapidly, and Professor Janda and I decided to use the term ‘functional pathology of the motor system’. As our knowledge kept increasing, it became
necessary to revise each new edition, which was the main source of the truly dramatic development of what was originally called manual medicine – for which we are in no small degree responsible. The main interest at first was clearly in joints and therefore in manipulative techniques. However, the function and the physiology of the joints were unthinkable without the muscles, controlled by the nervous system. Since (passive) manipulation appeared from the outset to be untenable without (active) rehabilitation to obtain lasting results, our interest in the musculature became obvious. Through their ‘muscle energy technique,’ the osteopathic school of Fred Mitchell senior showed convincingly that the patient’s own musculature does have an effective role to play in manipulative therapy. This prompted us to develop techniques facilitating and inhibiting muscles, which had to be as simple as possible, so as to bring into play the patient’s own muscles, since using the patient’s own muscles is a more physiological approach than that of even the best practitioners. For this reason, selftreatment is of great importance. Soon it became obvious that joint movement restriction was regularly released when muscle relaxation was complete. This promoted the con clusion that a tense musculature and myofas cial trigger points play a predominant role in joint restriction. This point was made in 1975 by the great physiologist of osteopathy, Irwin Korr. We now devote out attention as much to the diagnosis and treatment of trigger points as to that of joint restriction. A further significant step was that it became obvious that trigger points and joint restriction do not occur in an isolated and haphazard manner, but appear according to certain fundamental rules. The practical importance of this principle is that if the most important link of the chain is treated, the entire clinical picture could be normalized. This does not only make treatment more economical, it makes it possible to plan further treatment and rehabilitation, and is the basis of a rational holistic approach. ix
Preface
The next question to be pursued was to find the most important causes of these chain reactions. These were closely related to the role of the musculature maintaining the human upright posture, which is very labile. A crucial role is played by the recently discovered deep stabilization system – of the feet, the trunk, the shoulder blades, and the craniocervical junction. This is closely linked, via the diaphragm, to respiration. Dysfunction of these mostly short muscles must be compensated by movement restriction due to trigger points in the long muscles which, by co-contractions of flexors and extensors, stabilize the upright posture with the spinal column in the sagittal plane. Activation is training the deep stabilization system and diaphragmatic respiration, thus normalizes chains of trigger points and joint restriction, without passive mobilization and even relaxation. Only well localized dysfunctions, frequently found
x
at the extremities, remain to be mobilized. This is also true of the soft tissues and the internal organs, which have to move in harmony with the motor system even during respiration. Manual diagnosis and therapy of these tissues often play a dominant role, particularly with scars. What then remains of manual medicine? It is clinical diagnosis with our palpating hands, without which no chains of trigger points, movement restriction or soft tissue change can be diagnosed. The object of treatment is, however, solving dysfunction of the motor system and all the methods of treatment have to serve this purpose. Analysis of the findings and problem-solving are thus our main tasks. This book has therefore gradually changed into a textbook not just of manipulation, but of ‘musculoskeletal’ or ‘neuromusculoskeletal’ medicine. Prof. Karel Lewit
Acknowledgments The first English edition would have been impossible without the devoted care and critical help of my English wife. To deal with such a vast, in many ways new, field made it necessary to work in a team, one in which we were simultaneously both teachers and students. It was Professor Henner’s Neurological Clinic that made this possible. Thus it was that my first students were my neuroradiology teacher, Professor Jirout, Professor Janda, to whom I gave instruction in neurology and who did pioneering work on dysfunction of the musculature, and the ˇihák, to whom I explained anatomist Professor C functional radiology and who was my constant advisor in questions of anatomy. It is to Dr Véle that I owe what little I understand of EMG and a more sophisticated way to examine reflexes. My thanks are due to Dr Zbojan for the use of gravity for the relaxation of many muscles, to Dr Rosina for the reliable diagnosis of sacroiliac restriction, to Dr Kubis for the diagnosis of restriction of the upper ribs, and to Dr Sachse for the accurate diagnosis of hypermobility. In the scientific field, I learned in particular from the histologist, Professor Wolf, from Professor Berger and Professor Ivanichev. I learned also a great deal from the physical therapists who were my students: from Mrs Hermach I learned about exteroceptive stimulation, and got much practical advice from Mrs Kafková and Klierovám Verchozinová; in recent years in particular from Professor Kolárˇ about developmental kinesionology and stabilization. Others from whom I learned were Professor Starý, Professor Macek, Dr Strˇeda, Dr Gutmann, Dr Biedermann, Dr Wolff, Dr Gaymans, Professor Greenman, Professor Ward, and finally,
indeed most of all, from Professor Simons. Many of those I named are no longer alive. I should like to express my thanks to the Central Railway Health Institute, where I was able to pursue the work in my field from 1973 to 1990, and to Dr Sereghy, who made it possible for me to return to the neurological clinic, which I was forced to leave in 1972. When Dr Sereghy ceased to head the clinic, it was thanks to Professor Kucˇera and Professor Bojar that I was able to move to the rehabilitation clinic in Prague – Motol. This clinic offers at present the most favorable conditions for the further development of musculoskeletal medicine, under the leadership of Professor Kolárˇ, and not only in the Czech Republic. It was a particular honor that the last Czech edition, which was translated for Elsevier into German and now into English, was published under the name of the Czech J E Purkynje Medical Associations, for which I express my special thanks to Professor J Blahoš. My thanks for the quality of the illustrations are due to Mrs Istlerová and Mrs Fabianová. My thanks are also due to Elsevier who pleasantly surprised me in 2004 by requesting a new edition of Manuelle Medizin, and in particular to the translators, Mr Beattie and Miss Richards, who put up with all my suggestions, corrections, even criticisms, to Ms S Davies, who took the responsibility for the editorial development, and to Ms S Wolfaard, who initiated it all. Prof. Karel Lewit Dobrˇichovice
xi
Abbreviations ASIS CT DC DO EMG HAZ MET
Anterior superior iliac spine Computerized tomography Doctor of Chiropractic Doctor of Osteopathy Electromyography Hyperalgesic (skin) zone Muscle-energy technique
MRI PIR PSIS RI TeP TrP
Magnetic resonance imaging Post-isometric relaxation Posterior superior iliac spine Reciprocal inhibition Tender point Trigger point
xiii
Chapter One
1
History and fundamental principles
Chapter contents 1.1 The history of manipulative therapy . . . . . 1 1.2 Fundamental principles of reflex therapy . . . . . . . . . . . . . . . . . 4
1.2.1 Nociceptive stimulation . . . . . . . . 4 1.3 Reflex therapy . . . . . . . . . . . . . . . . 6
1.3.1 Indications and methods . . . . . . . 1.3.2 Choice of method . . . . . . . . . . . 1.3.3 Structural and functional changes . . 1.3.4 The place of reflex therapy . . . . . .
6 6 7 7
1.1 The history of manipulative therapy To begin with a chapter giving a brief outline of the history of manipulative therapy is helpful for several reasons; not least because it is hard to appreciate its unique place in medicine without such an introduc tion. It is also important for the avoidance of mistakes and a correct appraisal of its further development. Manipulative therapy is probably as old as the history of humankind. Throughout that history there have been healers who knew how to reposi tion or ‘set’ joints, including the spine. Among some peoples it was the custom for children to run bare foot over the backs of their weary parents following heavy work. Importantly in this history, in the fifth century bc, Hippocrates, founder of European medicine, listed rachiotherapy as a further fundamental ele ment of medicine alongside surgery and medicinal
therapy. In his treatise on joints, he speaks of parathremata, a concept which corresponded to what chiropractors would recognize as slight disloca tion or subluxation. Waerland expresses it in these words: ‘the vertebrae are not displaced by very much; only to a very small extent.’ Hippocrates goes on to say that ‘it is necessary to have a good knowledge of the spine, because many disorders are associated with the spine, and a knowledge of it is therefore necessary for healing a number of dis orders.’ He also describes how to treat the spine: ‘This is an ancient art. I have the greatest respect for those who first discovered it, and also for their successors, whose discoveries will contribute to the further development of the art of healing in a natu ral way. Nothing should escape the eye and hands of the skillful physician, so that he can reposition the displaced vertebrae on the treatment table without harm to the patient. No damage can occur as long as the treatment is undertaken in the correct way.’ According to Hippocrates, the list of disorders caused by displacement of vertebrae includes phar yngitis, laryngitis, bronchial asthma, tuberculosis of the lungs, nephritis and cystitis, inadequate gonadal development, constipation, enuresis, etc. Manipulation therapy in ancient classical times can be seen on many reliefs. Patients would lie prone on a bed specially constructed for the pur pose, while longitudinal traction to the head and legs was carried out. The physician performed manipulation of a particular vertebra. This type of therapy was evidently practiced throughout antiquity; Galen knew that the peripheral nerves emerged from the spinal cord and that they were susceptible to damage at this point, as is clear from
Manipulative Therapy
his account of the treatment of the Greek Sophist Pausanias. Over the course of time – particularly in the last two centuries – development took place in the primi tive medicinal (herbal) therapy and the surgery of the Ancients, giving rise to modern pharmacotherapy and surgery; however, manipulation therapy continued in the same state as when the ancient classical civiliza tions had received it from the peoples of earlier antiq uity. Consequently the successes of modern medicine completely eclipsed primitive manipulation therapy, causing it to slip to a great extent into oblivion. The medical press, which enjoys generous support from the pharmaceutical industry, contributed to this pro cess. What we now see, therefore, is unequal develop ment in the field of medicine, leading to a situation in which one discipline, failing to keep pace with the progress in the other specialisms, became almost for gotten. All that persisted, as far as we can tell, was a group of lay persons – to some degree established – called ‘bone setters’ who practiced manipulation therapy. This remained the situation until into the second half of the nineteenth century. It was Andrew Taylor Still (born 1828), who practiced as a doctor in the American Civil War, who rediscovered the importance of manipulation of the spine. In 1874 he founded a school on a pro fessional basis in Kirksville, USA, with 17 students. From the outset he also provided training to lay persons. At first the courses lasted two years; later they were extended to four years. At the present day, the length of training for a doctor of osteopa thy (DO) in the United States is the same as that for medical students and permits them both to exercise their profession in general practice and to progress to specialization. Around the year 1895, DD Palmer founded the chiropractic school in Davenport. Until then he had worked as a grocer and in magnetic healing. According to his own account, he wit nessed manipulation being practiced by a phy sician by the name of Atkinson. Other sources say that he himself received treatment from Still. At first, the courses he provided lasted only around two weeks, and cost 500 dollars. By 1911 the courses lasted a year. At present, the training consists of four years of universitylevel study in the United States. Graduates obtain the title DC (doctor of chiropractic), which enables them to practice as primary care physicians. Differences between osteopathy and chiropractic persist to this day. The training given to osteopaths 2
in the United States endeavors to provide a com plete body of medical knowledge, whereas schools of chiropractic will not teach pharmacotherapy and sur gery. Among chiropractors, there is a substantial diff erence between those of the older and the younger generation. The older generation adheres dogmati cally to the outdated theoretical and technical tradi tion; the younger rejects the traditional dogmas – it strives for a rational, scientific method and strongly desires to cooperate at the professional level with medical practitioners. From the technical point of view, chiropractors confine their approach for the most part to highvelocity, low-amplitude (HVLA) treatment using short-lever techniques, taking very little interest in soft-tissue techniques. They are increasingly inter ested in rehabilitation and lifestyle (dietetics). Osteopaths, in contrast, place emphasis on soft mobilization and soft-tissue techniques as well as HVLA treatments; however, they show a pre ference for long-lever techniques, using indirect (unlatching) techniques to be able to work in a targeted way. Neuromuscular techniques – muscleenergy techniques (MET) – derive from the school of Fred Mitchell, sen, Greenman and Mitchell, jun. Although physicians in Europe initially knew little of manipulative therapy, even completely rejecting the concept, here too they gradually began to take an interest in spinal manipulation. The dis covery of a mechanical disorder, the herniated intervertebral disk, was partly responsible for this interest. Attempts were made to provide relief by means of traction, and even to perform manipula tion under anesthetic. While, on the one hand, osteopaths and chiro practors were regarded as charlatans, on the other, attempts at manipulation by physicians of tradi tional (allopathic) medicine were rough and ready. Nevertheless, physicians in Europe were beginning to concern themselves with maneuvers applied to the spinal column. As long ago as 1903, the Swiss physician O Naegeli published his book on neu rological complaints, Nervenleiden und Nervenschmerzen. Ihre Behandlung und Heilung durch Handgriffe. The most important proponent of manipulation therapy in Europe was the British professor of physiotherapy, JA Mennell. He made no secret of having received instruction from osteopaths. His many publications (including manuals) remain to this day exemplary models of their kind. How ever, he mainly trained physiotherapists (physical
History and fundamental principles
therapists). His successor, J Cyriax, was a passion ate proponent of manipulation therapy as well as an outstanding clinician and diagnostician. His Textbook of Orthopaedic Medicine remains to this day a classical textbook of the locomotor system. However, the techniques he describes and teaches do not measure up to comparison with those of Mennell. Another individual deserving of mention is A Stoddard. He was originally an osteopath, and later studied medicine. His Manual of Osteopathic Techniques can be regarded as a classical textbook of manipulative techniques for the spine. The London College of Osteopathic Medicine was the first institution to provide instruction in osteopathic techniques to physicians trained in traditional medicine, and these individuals played a role in the further development that took place in Europe. The French physician, R Maigne, is one example; he also studied under the neurologist and rheuma tologist, de Sèze, who was long the most influen tial proponent and teacher of manual medicine in France. He systematically held courses for phy sicians at the medical faculty in Paris and wrote textbooks. Despite the leading role played by Maigne, there are many splinter groups in France. In Britain, on the other hand, the British Institute of Musculoskeletal Medicine (BIMM, and its pred ecessor the BAMM) is organized in a unified way, holds courses and, under Dr Richard Ellis, pub lishes probably the most important medical journal in the field, International Musculoskeletal Medicine (formerly entitled the Journal of Orthopaedic Medicine). The development that has occurred in the German-speaking countries is also of particular interest. After the end of the war, a number of German physicians began, out of necessity, to take an interest in manipulation therapy. Soon they began to found specialist scientific associations concerned both with the critical study of the issue and with courses of instruction. In Germany there were two groups involved at this time, the Forschungsgemeinschaft für Arthrologie und Chirotherapie (FAC), initially based in Hamm but later in Boppard, whose leading figures were G Gutmann, F Biedermann, A Cramer, and HD Wolff, and the Gesellschaft für manuelle Wirbelsäulen-und Extremitätengelenkstherapie (MWE) under K Sell, which was based in Neutrauchburg. Physicians from the former German Democratic Republic of East Germany also took part in these
Chapter 1
courses up until the beginning of the 1960s. After 1961 this was no longer possible. Students of the FAC were therefore commissioned to organize courses in East Germany, which were to be on the same lines as the FAC, and at the Charité in Berlin, under Professor H Krauss and K Lewit from Prague. This task was more than could be done by just one person, so it was necessary to train instructors who would later take over the leadership of the Associa tion. The most important of these were E Kubis, J Sachse, K Schildt-Rutlow, and H Tlustek. After the reunification of Germany this group became established as the Ärzteseminar Berlin (ÄMM). Today the FAC, MWE and ÄMM together make up the Deutsche Gesellschaft für Manuelle Medizin (DGMM). The development in former Czechoslovakia is also of great interest, as a result of the profoundly different political situation and especially in view of the fundamental role it served as a model for other then-communist countries (including East Ger many). At the end of 1951 the Ministry of Health commissioned the university hospitals to undertake a review of the methods used by lay practitioners and practitioners of complementary medicine. To this end a chiropractor with a practice in Prague was reviewed at the neurological clinic (under Professor Henner). It was an ideal moment, when interest was focused on the intervertebral disk problem, and also on exploring the feasibility of reflex therapy. An additional factor there was the position of neurology in Czechoslovakia in Professor Henner’s time: there was an interest in problems of pain and the locomotor system, and neuro logy also had a leading role in the development of rehabilitation. This made it possible for the technique of manipulation therapy to be reviewed in a clinical domain. Later there came the provision of instruc tion too, emanating from a prominent university hospital and later also provided by the Institute of Postgraduate Medical Training (under Professor Z Macek). Instruction was given in the form of a series of three two-week courses. Later, physi otherapists began increasingly to be trained in neu romuscular mobilization techniques. This is done in association with their university training. This model was then taken up in East Germany, Poland, the former Soviet Union, and to some extent in Hungary and Bulgaria. Professional bodies for physicians working in manual medicine were founded in most of the 3
Manipulative Therapy
countries of Europe, beginning in Switzerland, as well as in Australia and New Zealand; a body was also set up in cooperation with osteopaths in the United States. The International Federation for Manual Medicine (FIMM) was founded in 1965 in London, with the Swiss physician JC Terrier as its first president. His son, B Terrier, has held this post since 2004. A world congress is held every five years. In this way manual therapy has become a medical discipline. A professional body whose name refers merely to a method is not entirely satisfactory to physicians, however, given that the object concerned is the locomotor system and especially its dysfunctions. A number of bodies therefore decided to reinterpret the initials FIMM to represent the name Fédération Internationale de Médecine Musculosquelettale (International Federation for Musculoskeletal Medicine). Despite considerable activity in scientific work, manipulation has continued to be regarded by a great number of traditional physicians as an outsid er’s method; dysfunctions are little understood and, in matters at the practical level, physicians find it difficult to keep pace with physiotherapists, osteo paths, and chiropractors.
1.2 Fundamental principles of reflex therapy Pain – both in general and in disorders of the loco motor system – is a curse that humanity has always suffered. The constant search for relief has led to a great range of treatments of all kinds. The tradi tional approach has regarded bed rest and – to an extent and with some reserve – pharmacotherapy as the only reliable answer. From another standpoint there are many other methods that belong mainly, although not exclusively, to the realm of physical therapy, and these all have their eager proponents. These include massage, various kinds of electro therapy, laser and magnet therapies, acupuncture, neural therapy, manipulation, local cold or hot applications, cupping, wheal therapy, remedial exer cise, and movement therapy. The common feature of all these methods is their reflex effect. We may ask why, when treating essentially the same disorders, preference is given sometimes to one method and sometimes to another. This some times gives the impression that the choice of method 4
depends on which treatment the practitioner is best able to perform, irrespective of actual suitability. The pathomechanism underlying most of these methods is the reflex effect; they act on sensory receptors to produce a reflex response in the region where the pain originates. They can therefore be termed methods of reflex therapy. We must next ask which receptors are activated and which struc tures they supply. The route by which the control by the nervous system operates is primarily that of reflex reac tion; it would be helpful to proceed from this to an understanding of where, how, and why we should apply one or the other method. The better we com prehend the various methods, the more effective the treatment we can deliver. Since these methods are most frequently applied in painful conditions, there follows a description of nociceptive (pain) stimulation.
1.2.1 Nociceptive stimulation Any localized pain stimulation begins by provok ing a reflex in the segment to which the stimulated structure belongs. In this segment we usually find a hyperalgesic zone (HAZ) in the skin, muscle hardening, trigger points (TrPs), painful periosteal points, movement restriction of the corresponding segment of the spinal column, and (perhaps) some dysfunction of a visceral organ (see Figure 1.1). This enables us to diagnose the changes present and use whichever method is appropriate to exert an effect on the skin, soft tissues, muscles, peri osteum, motion segment of the spinal column, or visceral organ involved. Working in this way and on a case by case basis, we can decide in each case which structure is the location of the most intense changes, and which is the probable source of the pain.
Figure 1.1 • Reflex relations within the segment.
History and fundamental principles
Figure 1.2 • Schematic overview of afferent and efferent connections between the periphery and central nervous system.
These reflex changes are not confined to a single motion segment. For example, visceral disturbances are accompanied by viscerovisceral reflexes: pain in the region of the gall bladder produces nausea; pain in the region of the heart produces a sense of oppression, etc. This kind of effect is still more strikingly seen in the locomotor system: an acute disturbance in one segment of the spinal column produces muscle spasm in substantial sections of the erector spinae; any local movement restriction produces effects in distant segments of the spinal column, after the manner of a chain reaction. Any serious lesion at the periphery also brings about a central response: the motor pattern, or stereotype, will change in order to spare the affected structure. In this way altered patterns of movement are formed, and can sometimes persist after the peripheral lesion has disappeared (see Figure 1.2).
Reflex relations between the periphery and the central nervous system Pain stimuli produce both somatic and autonomic responses at all levels. The somatic response to the stimulus consists mainly of muscle hardening or the opposite response of hypotension (inhibition of the muscle). The expression of pain is found in the form of trigger points both in hypertonic muscles and in (otherwise) hypotonic ones. The autonomic response takes the form of reac tions in HAZs and soft tissues, and of a vasomotor reaction (mainly vasoconstriction) within the seg ment. At the level of the central nervous system, these reactions may occur as stress affecting respi ration, the cardiovascular or the digestive system. At this level there can also be changes in motor pat terns, the stereotypes of muscle action.
Chapter 1
Once we know the source of nociceptive stimu lation, for example movement restriction of a spinal segment, and can assess its severity, then the inten sity of these reflex changes can provide information about the reaction of the patient and of the particu lar segment. We can use the subjective assessment of the pain to evaluate the nociceptive stimulus, the reflex reaction, and the central (psychological) susceptibility of the patient to pain. These somewhat schematic guidelines indicate some possible lines of action to take in painful dis orders, using essentially the same approach as a neurologist would employ in disturbances of mobil ity. This approach is essential if we are to act in a targeted way, that is if we are to know why, when, and where we should use one or other of the meth ods of reflex therapy. First, therefore, we need to distinguish the source of pain and the reflex effects in the segment, at the suprasegmental level and at the level of the central nervous system.
As a rule a nociceptive stimulus produces somatic and autonomic changes. It is necessary to understand these changes in order to arrive at a rational, targeted course of treatment.
The key to this difficult task lies in the functions, or the dysfunctions, of the locomotor system. Since this subject is the main theme of the present book, no more need be said at this stage than to point out that the locomotor system is by far the most frequent source of pain in the body. This is readily understandable, because not only does the locomotor system constitute about three-quarters of our body weight, but it is under the control of our will – consequently even at the mercy of our whims – and has no other way of protecting itself against misuse than by causing pain. First and fore most, then, pain warns us of harmful function or malfunction. Conversely dysfunction is the most common cause of pain originating in the locomotor system. Movement restriction in a segment and disturbed motor patterns or stereotypes at the central level are typical examples. It is no coincidence that pain from a wide variety of causes (e.g. visceral pain) is accompanied by muscular trigger points and is usu ally felt in the locomotor system; (for example the heart causes pain in the left arm, the shoulder, and 5
Manipulative Therapy
the chest wall; the gall bladder causes pain in the shoulder blade, etc.).
Dysfunctions of the locomotor system are the most frequent cause of pain, and pain is the most frequent symptom of dysfunction of the locomotor system.
A sound knowledge of the dysfunctions of the loco motor system is therefore essential for successful therapy.
1.3 Reflex therapy 1.3.1 Indications and methods Clearly the chosen therapy and method must depend on the structure upon which we wish to act. In our approach to the skin, for example, a great variety of methods are available, as the recep tors in the skin are easy to access (e.g. by mas sage, electrotherapy, wheal therapy, or simple skin stretching). Muscle hardness (myogelosis; TrP) can be treated by massage, and more effectively by post-isometric relaxation (PIR), reciprocal inhibition (RI), pressure and needling. Manipulation and mobilization are mainly used to treat functional, reversible movement restrictions of joints or segments of the spinal column. Painful periosteal points can be treated by mas sage, soft tissue techniques, needling, or, if they are the insertion points of muscles, by PIR and RI of the muscles concerned. The most appropriate treatment for disturbed motor patterns is remedial exercise.
1.3.2 Choice of method The next step is to decide which of the affected structures is most important and which less so; which change is probably primary and which sec ondary. The severity of the disturbance is also significant. Even at the segmental level, there is a kind of hierarchy: in general, visceral disorders and abnormal motor patterns tend to be primary. The 6
significance of disturbances in muscles, joints, and soft tissues can only be decided based on an analy sis of the pathogenesis. The particular importance of the fasciae and active scars should be emphasized in this connection. In the locomotor system and in the spinal column, there are regions of greater and of lesser importance. There are some sections in which primary lesions occur more frequently than in others. It is vital to recognize those faulty motor patterns which are regularly found to cause relapses if left untreated. In this connection psychological factors play a major part, because motor patterns are in part expressions of the state of mind: anxiety, depres sion, and an inability to relax exert a considerable influence on motor function; no less important is the subject’s psychological attitude to pain, since pain is the most frequent symptom in our patients. In addition to issues of pathogenesis, there are certain practical aspects of technique to be consid ered, since not all methods are equally effective or ‘economical.’ For example, needling or soft-tissue techniques are usually more economical for the treatment of periosteal pain points than periosteal massage, but wherever possible (i.e. if the perio steal point is a point of muscle insertion) we pre fer to use PIR with RI of the muscle, because these techniques are painless and usually suitable for selftreatment. The attractiveness of manipulation tech niques lies mainly in the fact that they are effective and quick to perform. We can see from this that there is a wide range of possible treatments from which to select the most suitable. The decision as to which to use is reached by making as accurate a diagnosis as possible of the individual changes, and from this make what is known as the ‘present relevance’ diagnosis – what Gutmann (1975) calls the pathogenetische Aktualitätsdiagnose. This aims to identify the change that is the most important link in the chain of pathology at a given moment. All too frequently methods are applied which, for example, stimulate the skin when no signs of a HAZ have been found, or relax a muscle when no tension has been diagnosed (no TrPs found); we even find manipulations being performed when no restriction was present. Clearly, too, it is a waste of time to prescribe remedial exercise when there is no diagnosis of faulty muscle control. Naturally, in order to produce an accurate ‘present relevance’ diagnosis of pathogenesis as explained above, we need to have identified the
History and fundamental principles
individual links in the chain of pathology and ana lyzed their significance. We must proceed in a sys tematic fashion, starting at the peripheral level and working up to the central, applying treatment according to our findings.
The ‘present relevance’ diagnosis according to Gutmann enables us to identify the most significant link in the chain of pathogenesis.
Nevertheless, at times the results of treatment fail to meet expectations. One of the reasons for this is the presence of a lesion which causes intense nociceptive stimulation and dominates the clinical picture without the patient being aware of it. This may be referred to as a field of disturbance. Most commonly the source of this is an ‘active scar,’ the expression of which is a HAZ, increased resistance to shifting, and, in the abdominal cavity, a resist ance that is tender on examination. If the usual methods of therapy are unsuccessful, it is essential to treat the scar. Another cause of repeated failure is masked depression. This should always be consid ered in patients presenting with chronic pain, and needs to be treated.
The dysfunctions of the locomotor system that are described here, together with the reflex changes they produce, may aptly be called the ‘functional pathology of the locomotor system.’
1.3.3 Structural and functional changes In this connection the unfortunate but frequent use of the term ‘functional’ as a euphemism for ‘psy chological’ is most regrettable – it implies a grave underestimation of the importance of function and its role in pathogenesis. In rehabilitation we are primarily concerned with function, and seek at the very least to improve it when dealing with conditions where there is underlying pathomor phological, structural change. This is readily under standable; dysfunction is the form in which any relevant structural lesion is clinically expressed. It
Chapter 1
is fundamentally important to distinguish structural disturbances from functional ones. Where the disturbance is functional, it would be a mistake to think of the dysfunction as being exclusively a matter of reflex changes and reflex control. What we are dealing with here is more than just ‘reflexes’; these are rather ‘programs,’ having memory and capable of being elicited. They affect the entire locomotor system and its disturbances. The most common disturbances, which are also the object of manipulation therapy, concern the spinal column. The term ‘vertebrogenic’ is often used for these, although it is not entirely applica ble, since vertebrogenic disorders often include diseases with a pathomorphological definition, such as ankylosing spondylitis, osteoporosis, neoplasms, etc. Those which interest us, on the other hand, are mainly dysfunctions. They are not confined to the spinal column but also affect the limbs, soft tissues and, most of all, the musculature, which is control led by the nervous system. In view of this it is more appropriate to speak of dysfunctions of the locomo tor system, rather than vertebrogenic disturbances.
1.3.4 The place of reflex therapy The question as to the place of reflex therapy is as difficult to answer as that of the importance of pharmacotherapy. Whereas pharmacotherapy has developed into a significant science, methods of reflex therapy for some time remained empirical, and the indications for their use are ill-defined. The indication for a given treatment is not gov erned by the particular disease (diagnosis), but rather is based on the findings that are significant in terms of the pathogenesis. If, for example, head ache is due to muscular tension, then muscle relax ation is most important. If this muscular tension is associated with joint restriction, then manipulation (mobilization) is indicated; if faulty posture is the cause, it is this that has to be corrected. The advantages of this type of therapy over pharmacotherapy are that the methods used are entirely physiological and (usually) incur no side effects; further – because of their reflex nature – their effectiveness can generally be checked at once. It is worth saying a few words here about the role of pharmacotherapy in dysfunctions of the locomotor system. It would be difficult to conceive 7
Manipulative Therapy
of a drug that could restore a specific motor func tion, although it is possible to alleviate muscle ten sion, ease pain, and damp down some of the reflex effects involved, all of which can facilitate the res toration of function. Additionally, they are a neces sary means of treating depression and anxiety. To sum up, neither the diagnosis nor individual clinical findings in themselves suffice as the basis for deciding the most appropriate therapy. An analysis of pathogenesis is the only means of iden tifying the disturbance that is the most important at a given moment.
8
After treatment the patient must be re-examined to assess the effect, and from this we can make further judgments about the appropriateness of the approach taken. If treatment has been effec tive, the follow-up examination will show a change in the patient’s condition (short term evidence). The task then begins again to decide which distur bance is now the most important. Therapy is therefore never a monotonous rou tine; at the same time the success of treatment is always verifiable, and this aids the practitioner in applying a reasoned, scientific approach.
Chapter Two
2
Etiology and pathogenesis
Chapter contents 2.1 The significance of morphological changes . . . . . . . . . . . . . . . . . . . 9 2.2 Theoretical aspects of manipulation therapy . . . . . . . . . . . . . . . . . . . 10 2.3 The significance of functional disturbances . . . . . . . . . . . . . . . . 12 2.4 Motion segment and joint dysfunctions . . 13
2.4.1 The barrier . . . . . . . . . . . . . . 13 2.4.2 Joint play and restriction . . . . . . 14 2.4.3 Reflex changes in joint restriction . 15 2.4.4 Is restriction an articular phenomenon? . . . . . . . . . . . . 16 2.4.5 The possible mechanism of restriction and manipulation . . . . 16 2.4.6 The effect of manipulation . . . . . 17 2.4.7 The pathogenesis of restriction . . . 17 2.5 The spinal column as a functional unit . . 19
2.5.1 The spinal column and balance . . 20 2.5.2 Key regions of the spinal column in dysfunctions . . . . . . . . . . . 20 2.5.3 The importance of nervous control . . . . . . . . . . . . . . . . 21 2.6 Dysfunctions of the spinal column in childhood . . . . . . . . . . . . . . . . . . 24 2.7 Restrictions and their sequelae . . . . . . 26 2.8 The significance of disturbed motor patterns (stereotypes) . . . . . . . . . . . 27 2.9 Sequelae of disturbed movement patterns . . . . . . . . . . . . . . . . . . . 29
2.9.1 Walking and standing . . . . . . . . 29
2.9.2 Straightening up from a forward-flexed position . . . . . . . 29 2.9.3 Raising the arms . . . . . . . . . . . 30 2.9.4 Weight carrying . . . . . . . . . . . 30 2.9.5 The effect of respiration on the locomotor system . . . . . . . . . . 30 2.10 The significance of constitutional hypermobility . . . . . . . . . . . . . . . 33 2.11 Reflex processes in vertebrogenic dysfunctions . . . . . . . . . . . . . . . 34 2.12 Radicular pain . . . . . . . . . . . . . . . 36 2.13 The term ‘vertebrogenic’ . . . . . . . . . 37 2.14 Conclusions . . . . . . . . . . . . . . . . 38
2.1 The significance of morphological changes Chapter 1 indicated the great range of application of manipulative therapy and most methods of reflex therapy, which can be used for many different cases of pain in the locomotor system; these often involve pain whose cause and therefore treatment remain controversial. For a long time they were generally considered to be of inflammatory origin, for the simple reason that this provided the easiest explanation for the pain. Indeed we still speak of rheumatic diseases, for example ‘soft tissue rheumatism,’ and many terms ending in ‘-itis’ bear witness to this attitude (spondylitis, arthritis, radiculitis, neuritis, fibrositis, myositis, and panniculitis, for example). Since, however, inflammation is a well-defined pathological condition which
Manipulative Therapy
can be demonstrated or disproved, the inflammation theory became untenable and had to be abandoned for lack of evidence. Pathological anatomy and the use of radiology to examine pathology in living patients (X-rays) played their part by demonstrating degenerative changes. In place of terms ending in ‘-itis’ we speak of spondylosis, arthroses, and ‘diskopathy.’ This approach offers the possibility of explaining the changes in tissues that are sometimes bradytrophic. Vascularization of the intervertebral disk becomes reduced at quite a young age and the nucleus pulposus dries out: the water content decreases from 90% in the first decade of life to 70% in the third decade. According to Schmorl, 60% of women and 80% of men at age 50 show evidence of degenerative changes of the spinal column, while by the age of 70 the figure is 95% for both sexes. The very abundance of degenerative changes makes it difficult to define their pathogenetic significance. Whereas the number of degenerative changes increases with age, back pain occurs most often between the fourth and sixth decade, to become less common in old age. Subjects with considerable degenerative changes may be completely without clinical symptoms; alternatively they may suffer an attack of acute pain which subsides after a time (while the degenerative changes remain the same) to leave them once more symptom free. There can even be severe pain in young patients with no degenerative changes at all. The main difficulty is the fact that the term ‘degenerative’ is so poorly defined. It is used on the one hand for destructive lesions typically only found in the hip and knee, and on the other hand for changes of little clinical significance, and which are better described as normal ‘wear and tear.’ Often the change is a compensatory process or adaptation – as in scolioses, in hypermobility, or even instability (for example in spondylolisthesis) which can thus be stabilized. It is often difficult to distinguish between changes resulting from trauma and degenerative ones. When we find degenerative changes, we should begin by asking about their clinical relevance. It is a mistake to draw clinical conclusions without good reason from the mere existence of non-destructive degenerative changes seen on X-ray; they do not in themselves justify speaking of ‘degenerative disease.’ There is certainly some correlation between degenerative changes and herniated disk; with a few exceptions, herniation occurs mainly in disks already showing some degenerative change. The 10
discovery that disk herniation can be a cause of pain was an important step historically, but the success of surgical treatment was often so striking that disk lesions came to be held responsible for most of the many instances of pain related to the spinal column. The principles that applied to radicular syndromes, mainly in the lumbosacral region, were uncritically applied to a whole range of complaints in all parts of the spinal column. ‘Diskopathy’ became the fashionable word for what we now refer to as vertebrogenic (or spondylogenic) disease. Everyday practice contradicts this view and serves to correct it. Although disk surgery is a routine procedure for radicular syndromes of the lower limbs, it is rarely performed for low-back pain or radicular syndromes of the upper limbs, and not at all for simple neck pain or vertebrogenic headache. Nor is disk herniation the only possible cause of pain in radicular syndromes of the lower limbs: in operation statistics no disk herniation is found in about 10% of the cases; many radicular syndromes resolve without operation, and this is true even of cases in which medical imaging had found a herniated disk. Disk herniation can sometimes persist after the symptoms have disappeared, although resorption is also possible. Not only that; computerized tomography (CT) or magnetic resonance imaging (MRI) examination frequently reveals a herniated disk in healthy individuals in whom it is of little relevance. It is only significant when it correlates with clinical findings. To conclude, in the overwhelming majority of cases of back pain and associated clinical symptoms the morphological changes discussed above do not provide an explanation. For this reason this type of pain is referred to as ‘nonspecific’ (Jayson 1970) or ‘idiopathic’ (without any morphological diagnosis).
The vast majority of cases of pain are not associated with demonstrable morphological changes in the locomotor system. In effect, therefore, these are patients with ‘no diagnosis.’
2.2 Theoretical aspects of manipulation therapy Successful manipulative treatment usually results in relief of pain. We may conclude from this that an
Etiology and pathogenesis
understanding of how this therapy works will give us a better insight into what causes pain in the locomotor system, especially in cases where no pathological changes are present. The explanation originally given for the effect of manipulative therapy was that it involved ‘repositioning’; the understanding was that what was being treated was an incomplete dislocation, for which ‘subluxation’ became the accepted term. This was what Hippocrates believed, and probably also Still and most practitioners providing manipulative treatment down the ages. Indeed, the sight of a patient with acute lumbago or wry neck, unable to straighten up, who receives successful manipulation treatment and becomes able to stand erect, makes it little wonder that they did see this as the likely explanation. The reason that physicians have had to abandon the subluxation theory lies in the radiographic findings, since X-rays show no change for the individual segments before and after manipulation. The only change is in the abnormal posture, whose cause is muscular. It has been shown by M Berger (personal communication) by means of cineradiography that when the head moves to an extreme position and back, it does not return to the same neutral position as before. We were able to confirm this by means of transoral radiography (see Figure 2.1). An analogous effect was demonstrated by Jirout (1979a) for synkineses of the cervical spine in the sagittal plane on side-bending; when images were taken in the neutral position before and after
Chapter 2
maximum side-bending, the position of the spinous processes was generally found to be changed. The conclusion that can be drawn from these observations is that in a structure consisting of such a number of mobile elements there can be no absolute, fixed neutral position. The same applies to any changes there may be following manipulation. It will be shown below that manipulation operates only on disturbed function, that is mobility in the affected motion segment. If, however, there is no absolute neutral position, it follows that manipulation enables the motion segments of the spinal column to adopt the position that is most favorable in the particular circumstances.
If the mobility of the motion segments of the spinal column is normal, the spinal column itself knows far better than the person giving treatment which position it should adopt for each particular posture or load.
According to the literature, some authors, such as Cyriax, Maigne, and Stoddard, believe that manipulation exerts some kind of effect on the disks. However, it is difficult to see how manipulation could achieve repositioning of a herniated disk when its exact position can never be known. Another point to consider is that manipulation is also effective in treating other locations, where
Figure 2.1 • (A) Almost symmetrical position of C2 in the neutral position. (B) On returning to the same neutral position immediately after maximum rotation of the head to the left there is marked rotation of C2 to the left.
11
Manipulative Therapy
there are no disks, such as the limb joints, the atlanto-occipital and atlantoaxial joints and the pelvis. Clinical experience supports this: manipulation is most effective in situations where there is no disk herniation, and often fails precisely in cases where there is. The precise examination techniques used by osteopaths have also provided a clearer idea of the effect of manipulation therapies; these are indicated when we find movement restriction in a joint or a vertebral motion segment, and if manipulation is successful, normal mobility is restored. In other words, manipulation does not achieve a change of structure, as Still thought, but normalization of mobility; that is of function. This is also true in cases of acute lumbago or acute wry neck: the position of the neck or the back in such cases is not in fact abnormal in itself; it is only the fact that the patient is unable to straighten from a position, such as flexion, or rotation plus inclination, that is pathological. Manipulation (mobilization) simply frees mobility and thus enables the patient to return to the neutral position. Acute lumbago and wry neck are in fact an exception in this regard; in the vast majority of cases the position observed is normal and the finding is simply one of movement restriction in the joint (or vertebral motion segment).
Manipulative techniques are used to diagnose and treat only functional movement restrictions in a joint or vertebral motion segment. The purpose of manipulation techniques is simply to normalize disturbed function.
2.3 The significance of functional disturbances As the above makes clear, it is above all clinical experience in the use of manipulation for diagnosis and treatment that constantly reaffirms, in countless patients, the principle that treatment, if technically successful, brings normalization of restricted mobility in the joint or motion segment. Normalization goes hand in hand with the restoration of function (bending or rotation to the left or right; in the case of the limbs, symmetrical findings in the left and right limb). Normalization of function also brings relief of pain. 12
A similar principle applies not only to the passive mobility of joints, but also to active muscle function. Janda in particular demonstrated the significance of muscular stereotypes and showed that faulty movement patterns (disturbances of these stereotypes) produce abnormal stress on passive structures, especially joints. Closely associated with movement patterns is the matter of body statics. In fact, static overload and its consequences have become an extremely important issue in our modern technologically developed society with its general lack of mobility. Here too we find that correction of faulty posture frequently relieves pain. The contribution made by Brügger is particularly helpful in this connection, since he has made a special study of the hunched sitting posture and its treatment. Manual functional diagnosis thus served as a model for many other dysfunctions of the locomotor system. The muscle trigger point (TrP) most clearly demonstrates the close connection with pain. In saying so we should stress that morphological lesions are also associated with disturbances of function. This is most clearly the case for herniated disks and may explain spontaneous recovery and recovery after conservative treatment (including manipulation). A similar situation applies to rehabilitation in traumatology, where our primary aim is to improve function despite the presence of irreversible structural changes, where the aim of rehabilitation is to achieve functional compensation. As will be shown in more detail later, function and its disturbances are rarely confined to one site or structure. Diagnosis must therefore take in the locomotor system as a whole, and consequently the terms ‘vertebrogenic’ or ‘spondylogenic’ will no longer suffice. Even in back pain, muscle function and its nervous control play an important role, as do the functions of the pelvis and lower limbs. Since ‘vertebrogenic’ diseases or lesions include such well-defined pathological conditions as ankylosing spondylitis and osteoporosis, the decisive criterion for the use of manipulation and other measures aimed at restoring function is whether the patient’s complaint is due (mainly or exclusively) to dysfunction, or to structural (pathomorphological) changes. The solution is not simple, and the problem lies in the fact that the method of examination has not yet been precisely defined. It is the great weakness of important methods of treatment – such as manipulative therapy, remedial exercise, and other methods concerned with improving the functioning
Etiology and pathogenesis
of the motor system – that they are often more concerned with the method than with its object or its potential for diagnosis. In many fields of medicine the significance of findings relating primarily to function is now well recognized. In the locomotor system, however, where function is paramount, this aspect finds least acceptance. Yet the functioning of the locomotor system is extremely complex, and diagnosis of disturbed function is correspondingly difficult. Nor is there a specific medical specialty responsible for this area; functional disturbances seem to be the realm of everyone and of no one. There is an additional disadvantage in that, for the most part, the only means of investigating dysfunctions of the locomotor system is by inspection and palpation. Today these are often regarded as ‘subjective’ and dismissed, while instrumental and laboratory methods are regarded as objective.
2.4 Motion segment and joint dysfunctions Dysfunctions of joints and vertebral motion segments (see Figure 2.2) fall into two categories: hypermobility and restricted mobility; manipulative therapy is concerned only with restricted mobility.
Chapter 2
Clinical criteria are the decisive factor in identifying such restriction, and are judged from the qualitative point of view as well as quantitatively. A reduced range of motion is easy to recognize and measure in a joint, but much more difficult in motion segments of the spinal column. Qualitative changes are therefore of considerable diagnostic value when dealing with the spinal column. This is the case when the finding is one of increased resistance, and especially a lack of ‘springing’ at the end of the range of motion, with abrupt resistance encountered in the end position of the joint or motion segment. In a normal joint the extreme position is never reached abruptly, and a slight increase of pressure can always increase the range of motion. In a joint with functionally restricted mobility, this springing or giving way has been lost and we abruptly encounter a hard barrier. This, termed joint ‘restriction’ (sometimes ‘blocking’ or ‘blockage’), is perhaps the most significant sign in diagnosis.
2.4.1 The barrier The concept of the ‘barrier’ is a familiar one in the osteopathic literature. Three kinds of barrier can be identified: 1. The anatomical barrier, created by the bony structures. 2. The physiological barrier, which is clinically significant and is found at that point in the examination where the first, minute degree of resistance is felt; the barrier yields slightly with a sense of ‘springing.’ 3. The pathological barrier, which restricts motion and is felt as a hard, abrupt stop, lacking the sense of spring. In addition there is often a change in the neutral position; for example in rotation of the head or trunk, so that this becomes asymmetrical (see Figure 2.3).
Figure 2.3 • The barrier phenomenon. A–A: the anatomical Figure 2.2 • The motion segment (after Junghanns).
barrier; Ph–Ph: the physiological barrier; Path: the pathological barrier; N0: neutral position; N1: shifted neutral position when a pathological barrier is present.
13
Manipulative Therapy
The barrier as a phenomenon was originally defined with reference to joints, but is also useful in relation to the elasticity and mobility of soft tissues, including muscles. The barrier is therefore relevant for all mobile structures; it has a protective function. The definition of the physiological barrier given above is not universally accepted. It is defined in an osteopathic publication (Kuchera 1997) as the limit of active motion. We consider this definition to be of no practical use on the grounds that passive examination of the barrier is used to investigate movement restrictions, both for motion segments and for joint play. The objection applies all the more to soft tissue diagnosis. In chiropractic, this barrier is defined as the limit of maximum passive motion, the important point being that passive motion has a greater range than active motion. If manipulation were to be performed on a barrier defined in such terms, it would elicit an intense stretch reflex. This would rule out any gentle techniques, let alone relaxation on the part of the patient. Perhaps there is an explanation here for the harshness of technique used by some chiropractors. The definition we have given above for the physiological barrier must therefore stand. It is useful both in diagnosis and as a principle that underlies our treatment, which produces release. We recognize fully that this does involve subjective evaluation. The first, minute resistance is found by means of palpation, which of course depends on the experience of the practitioner.
only be sensed by palpation, but can be demonstrated radiographically (see Figures 2.4 and 2.5). Joint play is by no means only a matter of theoretical interest: its practical clinical importance lies in the fact that joint play reveals restriction at a stage when functional mobility is still normal, and – as can be seen from Figures 2.5 and 2.6 – translational
2.4.2 Joint play and restriction There are two types of joint movement, both of which are affected by restriction: 1. Functional movement: movement that can also be performed actively. 2. Joint play (according to Mennell 1964): movement of the joint which can only be brought about passively. This comprises a translatory (sliding) movement of one joint surface against the other, sometimes also rotation, and also distraction of the joint facets. To give an example, actively we can flex, extend, or side-bend a finger, whereas passively it can be shifted against the metacarpal in any direction, rotated, or distracted by axial pull. These movements can not 14
Figure 2.4 • Lateral and medial gapping of the knee joint, visualized radiographically.
Etiology and pathogenesis
Chapter 2
Figure 2.7 • Direction of joint mobilization according to
Kaltenborn. With fixation of the concave partner of the joint, mobilization is performed in the opposite direction to that of functional movement. With fixation of the convex partner, mobilization is performed in the same direction.
Figure 2.5 • Distraction of the metacarpophalangeal joint, visualized radiographically.
Joint play can be likened to a drawer that has stuck: any attempt to open it forcefully could damage it, but if we shift it slightly to and fro in the sideways direction, we can then open it easily. The diagram according to Kaltenborn (1989) (see Figure 2.7) shows the direction in which joint play is freest.
2.4.3 Reflex changes in joint restriction Figure 2.6 • Joint play according to Mennell. (A) Normal
gliding motion during joint flexion. (B) Where there is a dysfunction of gliding motion, passive functional movement can injure the joint.
movements and distraction provide a much more gentle method of treatment than passive functional movement.
Normal joint play is necessary for normal joint movement.
Restriction in a joint and particularly in a vertebral motion segment produces reflex changes, mainly in the segment concerned, affecting the cutaneous and subcutaneous tissue and muscles. Korr (1975) speaks of ‘facilitation’ in the segment. The movement restriction itself is associated with muscular tension (TrP or spasm); this can similarly be said of the straight-leg raising test and of the antalgic posture in lumbago or acute wry neck. Korr, a physiologist who worked on the problem of manipulative therapy, said of the role of the muscles: ‘While usually thinking of muscles as the motors of the body, producing motion by their 15
Manipulative Therapy
contraction, it is important to remember that the same contractile forces are also used to oppose motion’ (Korr 1975). From this we can conclude that, in their role as a brake, muscles act as a considerable and highly variable impediment to mobility in a dysfunctional joint. Korr continues: ‘The high-gain hypothesis is consistent with, and offers an explanation for, the steeply rising resistance to motion (‘bind’) in one direction and the equally precipitous collapse of resistance (increasing ‘ease’) in the opposite direction … They [the muscles] would also be provoked into stronger and stronger contraction by the exaggerated spindle discharges as motions that tend to lengthen the affected muscles occur’ (Korr 1975). This would also explain the hard ‘feel’ in the end position. All the clinical findings encountered in restriction might therefore be explained as the result of muscle activity and not as a disturbance of the joint itself. That is why osteopaths prefer to speak of ‘somatic dysfunction’ (Greenman), a term that includes the dysfunction of the joint, the muscles, and the soft tissues. The role of shortened muscles in movement restriction is emphasized by Janda. Muscle relaxation techniques are used with much success in order to mobilize joints. It is therefore appropriate at this point to consider the actual role of the joint in restriction.
2.4.4 Is restriction an articular phenomenon? Clearly the view that passive movement is exclusively the expression of articular function is not one that can be maintained. In fact, as Korr has shown, most clinical findings in joint restriction can be explained by muscle activity controlled by the gamma system. If this is the case, what role is played by the joint itself? If we are dealing with a reflex response, what is the origin of the stimulus that evokes it? It must surely be more than mere coincidence that techniques which have been found in a purely empirical manner to be effective in manipulation correspond to joint anatomy. The importance of joint play is also consistent with this, as is the fact that the popping sound, or ‘click,’ that is heard on successful manipulation comes from the joint. The hypotonus regularly observed following such manipulation is however a muscular phenomenon. 16
There are some joints that are not under the direct control of a particular muscle; obvious examples are the sacroiliac, the acromioclavicular and the tibiofibular joints. Yet muscular fixation of these joints (other than the acromioclavicular joint) is regularly found. In the case of the sacroiliac joint, for example, this is caused by the pelvic floor, the ischiocrural muscles, or the piriformis; in the tibiofibular joint by the biceps femoris. In order to investigate further the role of the joint, we undertook the following experiments: in patients who were about to undergo operation under anesthetic with artificial respiration, the cervical spine was examined shortly before operation. Restrictions were found in ten patients, and the exact location and direction determined. The patients were re-examined under anesthesia, which used mainly thiopental, nitrous oxide and 100 g succinylcholine iodide, the patients being in a state of complete muscle relaxation. This involved brief interruption of the intubation. In all cases the movement restriction remained unchanged during narcosis.
2.4.5 The possible mechanism of restriction and manipulation The importance of the experiment just referred to lies first in demonstrating that the joint does also play a part in restriction; and second in showing that there is (also) a mechanical resistance. It was Emminger (1967) who first suggested that this might be attributed to a trapping of the meniscoids as previously described by Töndury and others. Kos & Wolf (1972) showed in addition that these meniscoids do also exist in the limb joints. The physiological role of the meniscoids is to fill the changing joint space as it alters during movement, since they are a highly mobile structure. Most joints have very incongruous facets; without the meniscoids to perform this role, gapping of the joint would occur during movement. The meniscoid is intimately connected with the joint capsule. Clearly such wellnigh chaotic-seeming motion must be prone to disturbance. However, Cihák (1981) points out that the deep layers of the multifidus muscles are linked with the joint capsule and so control this mechanism. This theory has been further elaborated by Kos & Wolf (1972). They describe the following hypothetical pathogenetic mechanism:
Etiology and pathogenesis
Chapter 2
Figure 2.8 • The entrapment of a meniscoid and its
emergence, according to Wolf & Kos (1972). The meniscoid normally lying in position a has moved between the joint facets, b; following treatment, the meniscoid overcomes the slight resistance offered by the constriction from c to d.
• The main body of the meniscoid is soft,
connected with the joint capsule. It has a hard free edge, which cannot easily be compressed and projects into the joint space. • Joint cartilage is hard and elastic only if the force that acts on it does so briefly. If, however, we subject the cartilage to constant pressure, it adapts to the material exerting that pressure as though it were fluid. If, therefore, the meniscoid is caught between the gliding surfaces of the joint facets, the cartilage adapts to the hard meniscoid, embedding it (viscoelasticity) (Figure 2.8). This diagram clearly illustrates the mechanism of manipulative techniques. High-velocity, low-amplitude (HVLA) techniques cause gapping of the joint capsule, as a result of which the meniscoid has only a short constricted area to overcome (Figure 2.9). In repetitive mobilization, the meniscoid is freed during the back-and-forth movement of the joint facets, and all that is apparently needed as we wait for release to occur is the relaxation of the muscles, which widens the joint space.
2.4.6 The effect of manipulation The effect of successful manipulation is two-fold: 1. It restores mobility, including joint play. 2. It produces an intense reflex reaction in all structures where changes had been present before manipulation. This occurs most strongly in the musculature, where a previous state of increased tension (TrPs; occasionally spasm) is replaced following manipulation by hypotonia. The skin, too, becomes easier to fold and stretch, and soft tissues easier to shift against each other. Tension is thus reduced in all tissues, especially in the corresponding segment. Depending on
Figure 2.9 • The effect of therapy. (A) High-velocity, low-
amplitude thrust. (B) Repetitive mobilization. (C) Widening of the joint space by release technique.
the significance of the vertebral motion segment or the joint concerned, the effect of the manipulation also extends to distant segments; this will be discussed later. The effects referred to here can not only be observed clinically, but can also be objectively demonstrated by physiological methods (see Figures 2.10–2.13).
2.4.7 The pathogenesis of restriction Overload and abnormal load In the case of the most minor restrictions, we know from our own experience how these come about: sitting or working for a long period in an unfavorable position, we sense a need to stretch 17
Manipulative Therapy
Figure 2.10 • Changes in skin temperature after root infiltration in root compression syndromes. (A) Temperature reaction. (B) (Slow) course of reaction: the ‘overall mean temperature change’ curve also includes decreases in temperature. The changes in temperature pursue a much slower course than occurs in traction therapy (see Figure 2.11).
Figure 2.11 • Changes in skin temperature following traction therapy of the spinal column in root compression syndrome of the upper and lower limbs. (A) Temperature reaction. (B) (Rapid) course of this reaction; ‘overall mean temperature change’ curve also includes decreases in temperature. The changes in temperature pursue a much more rapid course than occurs in root infiltration (See Figure 2.10).
Figure 2.12 • Summation electromyogram showing the
increase in muscle activity (force) in the triceps brachii during cervical traction.
18
Figure 2.13 • Summation electromyogram of the triceps brachii taken from three leads in a C8 root compression syndrome (A) before and (B) after cervical manipulation.
Etiology and pathogenesis
and move, that is to ease such minor inhibitions of movement. This is the stiffness that causes us to stretch ourselves on getting up in the morning. Minor restrictions can therefore arise even in physiological situations and in healthy individuals; and these resolve spontaneously. There is a fluid transition between such minor restrictions following physiological stress, and persistent restrictions following pathogenic, harmful stress. Both the stress itself and the neuromuscular system of the patient play a role here. One pathogenic factor is overload; another, more frequent cause is a disturbed movement pattern (motor stereotype) on the part of the patient, consisting of an imbalance of muscle function which impairs the joint (Janda). Modern civilization brings with it very one-sided, unvaried posture and movement, causing muscular imbalance. Lack of movement together with static or postural overload are a characteristic feature of modern life. Disturbed movement patterns and static overload are probably the most frequent causes of reversible restrictions and of their occurrence and recurrence.
Trauma Trauma is a further potential cause. It is important to point out that the borderline between patient groups suffering from overload and those suffering the effects of trauma can in fact be very fluid, because it is not always easy to say what should and should not be interpreted as trauma. It is usually defined as a force acting on the body and capable of damaging structure or function. However, even under normal conditions the forces acting on the spinal column are considerable. If these forces are suddenly increased because of sudden, unexpected movement, especially if this involves contraction of the powerful muscles of the back, it becomes extremely difficult to distinguish between overload and trauma. The somewhat vague term ‘microtrauma’ is then used.
Reflex processes A further complex of causes involves reflex processes within the segment. As has been stated already, the spinal column is routinely involved in disease processes in the body. Vertebral restrictions can therefore occur following – and also as a result of – disease elsewhere in the body. The primary
Chapter 2
condition creates a stimulus in the segment, which in turn produces a spasm (TrP) in the corresponding region of the erector spinae muscle, in particular in the deep layer. The effect is muscular fixation of the vertebral motion segment: a restriction. This is the same mechanism that, according to Hansen & Schliack (1962), leads to scoliosis in visceral disease. Today it is possible to distinguish a number of characteristic patterns related to visceral disease (see Chapter 7) which points to certain pathogenetic rules. Another characteristic feature of this type of restriction is its recurrence if the internal disease relapses or exacerbates. Admittedly, however, we know more about visceral influence upon the spinal column than about the influence of the spinal column on visceral organs.
2.5 The spinal column as a functional unit The most important functions performed by the spinal column are: • giving support and protection to neural structures • being the axis of motion for the body • helping to maintain the balance of the body. As we can see from the first two functions listed, these roles are contradictory; Gutmann (1965) expressed this succinctly when he said: ‘the spinal column should be as mobile as possible and as firm as necessary.’ The implications of this become clear when we consider the remarkable range of movement of the atlanto-occipital and atlantoaxial joints, and the fact that vital centers of the medulla oblongata are located at this level; these twin facts explain why disturbances of these two basic functions are linked. If a dysfunction produces a pain stimulus, a muscular defense reaction blocks the damaging movement. A spinal column with restricted mobility is no longer properly able to carry out its protective function. The effects extend to the structures of the nervous system, which in turn exerts an effect on the spinal column that is causing the damage to them. Sobotka (1956) demonstrated that damage to a nerve root causes trophic changes of the intervertebral disks. The function of the spinal column affects not only the structures inside the spinal canal, but also the entire locomotor system, including the limbs, and probably also internal organs. 19
Manipulative Therapy
The existence of all these functional interconnections means that the spinal column should always also be considered when the object of concern is the pelvis, limbs, or especially the muscles under central nervous system control.
2.5.1 The spinal column and balance The importance of the spinal column in the maintenance of balance is usually underestimated. This applies in particular to the craniocervical junction. It is often forgotten that the labyrinth is not absolutely essential for the maintenance of balance and posture, whereas proprioception is, especially in the spinal column. Clinical evidence confirms this (see Chapter 7). The experiments carried out by Norré and coworkers (1976), using Greiner and coworkers’ (1967) flexible-support chair, are particularly valuable in this respect. The method they used involves keeping the subject’s head fixed in position while turning the trunk from side to side with a pendular motion. They were able in this way to produce nystagmus, purely by stimulation of the cervical proprioceptors (Greiner et al 1967, Hülse 1983, Moser et al 1974, Norré et al 1976, Simon & Moser 1976). The effects are not limited to the cervical spine. Komendantov (1945, 1948) demonstrated in rabbits that tonic reflexes can originate not only from the neck but also from the lumbar spine. He distinguishes the lumbosacral-eyes and lumbosacral-head reflexes. On side-bending of the animal’s trunk in the lumbar region around a dorsoventral axis, with the upper body and head fixed, the eyes move in the opposite direction to the trunk. If the head is not held fixed, there is an additional slight turning of the head, also in the opposite direction. Leads from the muscles of the nictitating membrane and the rectus muscles (of the eye) showed this to be a tonic reflex. Komendantov’s experimental design enabled him to make neck and lumbosacral reflexes compete, with the neck reflexes usually proving stronger. However, the effect was dependent on the extent of side-bending; the greater the side-bending, the stronger the effect. Interestingly in the course over time, it was seen that immediately following the effect of a neck reflex, even a relatively weak lumbosacral reflex can also assert itself. This mechanism apparently enables the animal to keep the visual field constant during locomotion, despite the motion of the head 20
and trunk. The reflexes therefore have very short transmission times; changes were still being registered in the activity of the muscles investigated, even at a side-bending frequency of 200 side-bends per minute. These experiments demonstrate that the spinal column is a functional unit governed by reflex response; if certain changes in position or function occur at one end of the spinal column, these exert an instant reflex effect along the entire spine. It should be stressed that, in humans, both ends of the spinal column are held relatively constant: in the case of the pelvis this is achieved because of the length of the legs; in the case of the head, through reflex fixation of the plane of the eyes and labyrinth in space. This preservation of the head position is strongly maintained as a movement pattern (motor stereotype). Ushio and coworkers (1973) demonstrated the deleterious effect of low-back pain on vertigo and the beneficial effect of immobilizing the lumbar spine in lumbago.
2.5.2 Key regions of the spinal column in dysfunctions So far we have considered restriction and its origins without reference to its effects on the rest of the spinal column. This, however, would be to ignore one of the most frequent causes of restrictions: a restriction or trigger point in another section of the spinal column. These bring about a compensatory increase in mobility in the neighboring segment, which leads to overload and ultimately a further restriction. Chain reactions therefore come about, which explains why vertebrogenic disturbances tend over time to involve the entire locomotor system. Therefore we should always examine the entire spinal column, at least in terms of screening assessment. It is important to realize, not least in this respect, that not all vertebral segments have the same importance for the overall function. When performing a brief assessment we should therefore focus on ‘key regions.’ In most cases these are transition zones from one type of movement to another: • The craniocervical junction: the delicate vertebrae of the upper cervical spine bear the heavy weight of the human head and also enable extensive mobility in all directions. Dysfunctions here affect muscle tone in the postural musculature and lead to disturbances of balance. Restrictions of the atlanto-occipital and atlantoaxial joints impair the mobility of the
Etiology and pathogenesis
rest of the cervical spine. The most important type of motion between the atlas and the axis is rotation; the rest of the cervical spine is less well adapted for this, and so suffers if forced to compensate for a craniocervical rotation dysfunction. The vertebral artery runs through the atlanto-occipital and atlantoaxial joints, and can also be affected by dysfunctions in this region. • The cervicothoracic junction: this is the region in which the most mobile section of the spinal column meets the relatively rigid upper thoracic spine. It is also the place where the powerful muscles of the shoulder girdle have their attachment, providing the main connection with the upper limbs and explaining why this region is particularly susceptible to dysfunctions. • The middle thoracic spine is to some extent the ‘weak point’ of the muscles of the back, since the lumbar and cervical parts of the erector spinae muscles end here, and kyphosis is usually greatest at this point. • One of the reasons for the considerable load borne by the thoracolumbar junction is that here the mechanism of motion typical of the thoracic spine changes within a short distance (at vertebra T12) to the lumbar pattern. This can be seen from the difference in shape of the upper and lower articular processes. If during walking the pelvis tilts from one side to the other, the lumbar spine side-bends so that the vertex of the scoliotic curve lies at the level of L3, the thoracolumbar junction remaining vertically in line with the sacrum; the thoracic spine then forms a scoliotic curve in the opposite direction. Consequently the thoracolumbar junction does indeed represent a junction. • The lumbosacroiliac joint region forms the base of the spinal column and is therefore extremely important to spinal column statics. At the same time the sacroiliac joints transmit movement from the legs to the spinal column and act as shock absorbers. • In humans the feet are the body’s actual base; also the greatest density of proprioceptive, exteroceptive, and nociceptive receptors is found there. Dysfunctions in this region consequently have an effect on the whole of the locomotor system; they should not be overlooked.
Chapter 2
2.5.3 The importance of nervous control The spinal column could not act as a functional unit unless all its reactions were coordinated, under control of the nervous system. Certain kinds of posture and movement sequences play the major role in this respect; these, following the proposal of Janda, are termed ‘motor patterns.’ These motor stereotypes are so characteristic of an individual that we can recognize people by their gait. There is considerable variation in the quality of these patterns, and this goes hand in hand with the susceptibility to disturbance of the locomotor system in the individual case. Any disturbance of function in a single motion segment will have its repercussions throughout the spinal column and must be compensated. The decisive role in this is played by the nervous system, which is similarly important in the matter of pain, for it is the nervous system that determines how intensely the segment will react, and where the threshold of pain lies. In other words, it is the nervous system that determines whether the dysfunction will manifest itself clinically. If the reaction to the nociceptive stimulus is intense, dysfunction in one motion segment will produce an antalgic response and alter the normal movement pattern, causing the dysfunction to become fixed, so that the condition becomes chronic. It is, therefore, no coincidence that dysfunctions of the motor system are more likely to be found in subjects with labile nervous regulation, and this tends to be evidenced psychologically as well. The point was emphasized by Gutzeit (1951), who saw the psychological factor as being characteristic for patients presenting with vertebrogenic disturbances. Kunc and coworkers (1955) showed that the psychological condition of patients plays a major part in recovery after disk operation. They demonstrated by means of experiment that these patients very easily formed conditioned reflexes to other pain stimuli, and that these reflexes were more difficult to extinguish than in healthy controls. Šrácek & Škrabal (1975) observed two groups of psychiatric patients: 50 cases of neurosis with symptoms of anxiety and depression, and 25 schizophrenics with blunted affect. Restriction, most frequently in the cervical spine, was absent in only 5 neurotic patients and in 16 schizophrenic patients. This difference is statistically highly significant (p < 0.01). Buran & Novák (1984), studying a group of 105 21
Manipulative Therapy
chronic patients, distinguished constitutionally neurotic and psychopathic patients from those who were psychologically normal. They found a preponderance of the fatigue reaction in the electromyogram (EMG) in the neurotic patients, and more frequent occurrence of positive F-waves, indicating a correspondence between psychological lability and labile nervous regulation. Lisý (1983) found similar results in EMG studies of patients with cervical syndrome. The clinical findings made by Janda (1978) are also worthy of note: in 100 patients with poor motor patterns, he found: • minor neurological signs of ‘microspasticity,’ in which movements were not fully coordinated, appearing as clumsiness • slight sensory impairment, especially of proprioception • poor adaptation to stress situations and inadequate, ‘uncoordinated’ behavior. All these clinical signs correspond to ‘minimal brain damage’ (MBD). Found in 10–15% of the child population, this is quietly assumed to disappear without trace in adulthood. However, Janda’s findings suggest that this brain dysfunction is in fact manifested in adult patients in the form of vertebrogenic disorders, poor motor patterns, and a considerable degree of labile nervous and emotional regulation. Despite the role played by muscular imbalance and faulty neural control, these should not be equated with joint dysfunction or restriction of a vertebral motion segment. Dysfunctions of the joints or vertebral segments do occasionally appear even in subjects with good motor patterns, yet may be absent in patients with neurological disease. Tilscher and coworkers (1979) found that of 27 spastic subjects, only 18.5% complained of backache. In our experience, most patients with Parkinson’s disease complain of backache; this is clearly associated with the muscle rigidity, which also affects the spinal column.
Faulty neurological and psychological control are among the factors involved in the pathogenesis and clinical signs and symptoms of locomotor dysfunctions. However, they are not identical with them.
22
The importance of developmental kinesiology It is no coincidence that Janda associates disturbances of motor pattern in adults with disturbances of the central nervous system in infants. Developmental kinesiology can indeed help us better understand the pathogenesis of dysfunctions, especially the effects that a structure belonging to the locomotor system can exert on distant regions; in other words, on the entire system. In this context we shall attempt to present the essential thinking of Vojta & Peters (1992) and Kolárˇ (1996, 1999, 2006) on the present subject. Neurophysiology today has no explanation for the effects exerted on each other by parts of the locomotor system that are situated far apart, which are found as a matter of everyday experience in manipulative therapy; nor can it explain the chains of trigger points. The principles governing these can however be explained by developmental kinesiology. The first reflexes in the newborn (stepping reflex, crossed extension reflex) are spinal cord reflexes. They offer no stability and do not enable posture of any kind. The first postural reflexes arise when the infant begins to observe its surroundings, raising and holding up its head. This is the point when the flexion posture of the newborn (see Figure 2.14) is brought into balance with the developing extensors. This development is complete roughly at the end of the third month (see Figure 2.15). The difference observed in the limbs is that the flexion posture gives way to a balanced, neutral posture with slight abduction, external rotation, and extension. It should be stressed that this posture can be achieved shortly after birth, according to Vojta & Peters (1992), who states that this can be done by
Figure 2.14 • Posture of the newborn in the prone position.
Etiology and pathogenesis
Figure 2.15 • Posture of the infant in the prone position at the end of the third month of life. The infant is able to support itself on forearms, pubic symphysis, and knees.
stimulating points where there is an abundance of proprioceptors. These points are structures on which we support ourselves; as soon as we rest on one of these points (forearm, elbow, or knee) for support, our posture changes automatically, remaining balanced in each case. This enables us to achieve the most favorable position (centering) of our joints. The extensor system is therefore younger in developmental terms than the ‘tonic’ flexor system, and therefore more susceptible to disturbance. This explains why the tonic system always predominates in pathological states, pain, and even in mere fatigue. Both systems are involved in upright posture; it is therefore inappropriate to use the term ‘postural muscles’ for the tonic system alone. The decisive issue is which system is older or younger in developmental terms. This course of development gives rise to the coactivity of antagonists, which enables balanced, upright posture and can be seen at two levels. As an example, the erector spinae is the antagonist that corresponds to the pectoralis major muscle. The relationship is so specific that certain bundles of fibers of the pectoralis major correspond only to certain bundles of fibers of the erector spinae. The same kind of correspondence applies to adductors and abductors in the limbs, for instance. Clinically this is seen in the localization of trigger points. However, this antagonism applies not only to individual muscles, but to the entire system. This fact is extremely important: stimulation of a muscle that belongs to the extensor system inhibits the whole of the flexor system. The effect can most clearly be seen when stimulation is applied to one of the points where most receptors are located, such as the fingers and toes. To give an example, stimulation of the finger extensors can produce inhibition in the straight-leg raising test.
Chapter 2
The coactivity pattern relates to upright posture as a whole. Muscles that maintain the position of the head over the shoulders have their fixed point of attachment in the region of the shoulder girdle, the muscles of the thorax and scapula in the pelvic region, and the muscles of the pelvis in the region of the lower limb, down as far as the foot. As soon as the position of one of these superposed sections changes, the entire system has to react. Control of these reflex processes in the maintenance of human upright posture is located above the brainstem; it has been little researched experimentally. The long chains of antagonists which subserve upright posture act on the spinal column like ropes stabilizing a mast. However, unlike a stiff mast, the spinal column is formed by 24 vertebrae and the sacrum which, according to Panjabi (1992a, 1992b), are unstable and would buckle under the strain. This is prevented by what is called the ‘deep stabilization system.’ Another system that is developed only in humans is that of the ‘deep stabilizers,’ which serves to maintain the upright posture of the spinal column. It consists of the deep layers of the erector spinae and transversus abdominis muscles, the diaphragm, and the pelvic floor. The last three of these support the abdominal wall. The abdominal cavity and its internal pressure provide the anterior support of the lumbar spine. In humans, the diaphragm plays a significant role as a postural muscle; only in humans is there a close link between respiration and posture, with the diaphragm lying horizontally. A further function, which develops relatively late in infants (after the sixth month) and which is therefore also susceptible to disturbance, is (active) rotation of the trunk. This plays a particularly important role in humans, since the most forceful movements, such as throwing a discus or boxing, proceed from a rotation of the trunk. At every step the shoulder girdle rotates in the opposite direction to the pelvis. The significance of this movement can be seen in the rehabilitation of leg amputees and paraplegic patients, because it is this mechanism that enables them to learn to walk. According to Farfan et al (1996), however, the spinal column is less well adapted to rotation movements in terms of its constituent parts; this applies especially to the intervertebral disks. In practical terms, both for the facilitation of muscle activity and in mobilization, it makes sense to utilize the posture that most closely matches development. In the model of the three-monthold infant, the limbs are brought into the optimum 23
Manipulative Therapy
Figure 2.16 • Weight-lifter’s posture.
(centered) position and the muscles activated. This posture also corresponds to that of a weight-lifter (see Figure 2.16).
Vojta’s developmental kinesiology offers an explanation for the physiological principles governing the upright posture of humans.
2.6 Dysfunctions of the spinal column in childhood From what has been said it follows that dysfunctions are regarded as primary phenomena in the pathogenesis of vertebrogenic disorders. Hence studies try to investigate them in their pure form, that is in the absence of degenerative changes, which can be done by studying them in children and young people. Schön (1956), and later Gutmann & Wolff (1959), have shown the average age at which the first symptoms appear to be much earlier than the age when they become evident 24
radiographically. Dysfunctions, however, appear at the same time as clinical symptoms. The most typical clinical condition in children is cervical myalgia (acute wry neck). Although this usually remits spontaneously, traction and gentle mobilization techniques, if well applied, should give immediate relief. This is particularly true for neuromuscular techniques. In children with headache, the cervical spine plays an important role. This is true of various types of headache, including migraine. In a group of 30 children suffering from vasomotor headache, manipulation produced improvement in 28 cases. Janda (1959) reported similar success following traction of the cervical spine. In a group of 27 children suffering from migraine, only 3 failed to respond to manipulation treatment (Lewit 1959). Similar results were reported by Kabátníková & Kabátník (1966). A particularly important type of headache in children, known as ‘school headache’ and generally believed to be of psychological origin, was proved by Gutmann (1968) to be due to head anteflexion during school hours, when the children were reading and writing at horizontal desks. This was confirmed by Lewit & Kuncová (1971). One clinical manifestation of disturbed function in the lumbosacral and pelvic region frequently found in young girls is dysmenorrhea with negative gynecological findings; this can frequently start as early as the menarche. Patients complain not only of pain in the lower abdomen; they also experience low-back pain. Manipulative therapy is the treatment of choice in such cases. The point should be made here that dysmenorrhea at an early age is frequently the first sign of dysfunction of the spinal column in women. True lumbago is much less frequent in childhood, but there are rare cases of true disk herniation as early as puberty. With the exception of acute wry neck, dysfunctions in the spinal column tend to be manifested indirectly in the form of referred pain, as headache, and in girls as dysmenorrhea. We were interested to see how frequently dysfunctions could be found in healthy children of different age groups. The most striking finding in children and adolescents is pelvic distortion which is dealt with in detail in later chapters. In serial studies we found this in 11 of 80 children (aged 14–41 months) examined in crèches, in 81 out of 181 children (aged 3–6 years) in nursery school and in 199 out of 459 schoolchildren aged 9–15 years. Statistical evaluation showed no significant difference between the incidence in boys and girls.
Etiology and pathogenesis
Movement restriction in the cervical spine (mainly at the atlanto-occipital and atlantoaxial joints) was found in none of the infants in crèches, in only 8 out of 181 nursery school children examined, and in 73 of the 459 schoolchildren. These investigations were carried out over 40 years ago, when the technique of examination for the upper cervical spine was much less sophisticated than it is today. It has since been found that pelvic distortion in children is generally associated with craniocervical joint restriction, mainly in the C0/C1 segment; there is normalization of the pelvic findings after the C0/C1 joint has been treated. In 1982 we therefore examined a group of 75 nursery school children (aged 3–6 years). We found pelvic distortion in 24, of whom 23 had movement restriction of C0/C1. In 12 of these children manipulation of the craniocervical joints was carried out, following which there was normalization of the pelvic distortion in all cases. There is thus good reason to believe that most of the children in whom we found pelvic distortion in the examination we performed over 40 years ago also suffered from restriction at the craniocervical junction. We also found slight scolioses in 175 of the 459 schoolchildren examined at that time, and in 15 out of the 181 nursery school children. Among the children in crèches, this finding was made in only 1 out of 80 children. The overwhelming importance of the craniocervical (atlanto-occipital and atlantoaxial) joints
Chapter 2
in infants was pointed out by Seifert (1975). In children in whom function is normal, they found that, on turning the head to one side, the pelvis turns to the opposite side. This reaction was absent in 298 of the 1093 infants examined. Over a period of 4–9 months restriction of the atlantooccipital and atlantoaxial joints was found in 58% of this group. Biedermann (1993) described what he termed ‘KISS syndrome,’ characterized by a forced attitude of the head in the side-bending position, often found in association with considerable somatic and autonomic disturbances. These he treated by manipulation. In a study group of 76 children suffering from chronic tonsillitis, Lewit & Abrahamovicˇ (1976), found restriction of the atlanto-occipital and atlantoaxial joints in 70 (92%) of the subjects, mainly in the C0/C1 segment. In evaluating these results we needed to discover whether they were chance findings or represented continuing, constant dysfunctions. In collaboration with Janda we therefore followed up a group of 72 children who started school attendance in 1960, carrying out regular examinations over a period of eight years. Half the number with dysfunctions of the spinal column were treated, and the other half left untreated as controls. In addition to the spinal column, the rest of the locomotor system and particularly the musculature were tested. The results are summarized in Figure 2.17.
Figure 2.17 • Follow-up study of 72 schoolchildren of various class age groups over a period of eight years to find the incidence of pelvic distortion, scoliosis, difference in leg length, and cervical restriction.
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Manipulative Therapy
The most important finding for our conclusions was that dysfunctions in the regions of the pelvis and cervical spine remained constant and seldom showed spontaneous improvement. The tendency to remain constant was greater for these than for scolioses or differences in leg length. There were only a few relapses after treatment.
Dysfunctions of the spinal column can be found even at a very young age, and even in subjects who are clinically healthy. However, they can be clinically manifested, usually as acute wry neck, headache and, in girls, as dysmenorrhea. These symptoms can occur in the absence of any degenerative changes.
2.7 Restrictions and their sequelae If a restriction occurs in the intact terrain of the spinal column of a child or an adolescent, for example, the consequences may seem at first sight to be minor: there may be some transitory pain, which usually disappears quickly as tends to be the case with acute wry neck. The dysfunction is compensated. Of course, a restriction occurring in the rest of the locomotor system, particularly the limbs, becomes clinically evident immediately. In the spinal column, consisting as it does of complex parts (54 intervertebral joints, including the atlantooccipital and atlantoaxial joints and the sacroiliac joints), the lack of mobility of a single joint or motion segment can go unnoticed. There is, however, a price to be paid for this capacity of compensation: increased demands or abnormal stress on the compensating structures. This becomes especially evident when the restriction occurs in a key region (see Section 2.5.2), because neighboring regions cannot easily compensate. As mentioned previously, restriction of rotation between the atlas and the axis means that their role in the rotation of the head has to be taken on by the rest of the cervical spine, which is far less suited to the task. This may help explain why osteochondrosis of the lower cervical spine is so commonly found. As a general principle, then, movement restriction in one segment produces hypermobility in its 26
neighbor, and this is most marked in the case of restrictions in key regions. The most frequent consequence of chronic overload is the formation of osteophytes to stabilize the motion segment. The lack of motion in the restricted segment often leads to disturbances of trophicity, which particularly affects bradytrophic tissues such as ligaments and disks. This is confirmed by radiographic evidence, which shows osteophyte formation in temporarily hypermobile segments (above block vertebrae). The usual findings in restricted segments are that two adjacent vertebrae form a block with the narrowed disk showing degenerative changes. Müller (1960) have shown how the hypermobile segment, initially created to compensate for a hypomobile one, stiffens in its turn as a result of osteophyte formation, so that the osteochondrosis spreads from one vertebral segment to the next. The stabilizing role of the osteophytes, which are plate-like in shape, can best be seen in chronic spondylolisthesis. Degenerative changes in themselves need not produce clinical symptoms. They do, however, make the spinal column more susceptible to disturbance, and the same applies to dysfunctions. Even patients with degenerative changes experience no symptoms as long as function remains compensated, but there is a risk of decompensation. This explains why the sequelae of trauma are usually more severe when degenerative changes are already present. Frequently, what are called degenerative changes are better described as adaptive ones, or an attempt to compensate dysfunction. One important sequela of degenerative changes can be a herniated disk. Here too there is a close relationship between structural change and dysfunction. With modern imaging techniques we find that disk herniation revealed by CT or MRI need not be accompanied by any symptoms; also that, in cases where the herniated disk does produce pain, the clinical symptoms may disappear despite the fact that the herniation continues to be evident on CT or MRI examination. The relationship between function and structural pathology is clearly very complicated here. Nevertheless, in cases of disk herniation, dysfunction can be treated at joints and trigger points, in soft tissue and in the stabilization system, to produce clinical compensation. The close association of structural and functional changes is clearly seen in carpal tunnel syndrome, which involves compression of the median nerve. On close examination we regularly find increased
Etiology and pathogenesis
resistance to the translatory displacement of neighboring carpal bones. When mobility is restored in the early stages, the symptoms of paresthesia disappear. In other words, it is only when there is free mobility between the bones forming the tunnel that the walls can adapt themselves to the contents of the tunnel in all the movements of the wrist. We should remember that one wall of the carpal tunnel is formed by the flexor retinaculum.
The dynamic role – usually also the primary role – in the interrelation between dysfunction and morphological change is that of function.
2.8 The significance of disturbed motor patterns (stereotypes) Disturbed motor stereotypes are perhaps the most important factor in the etiology of functional, reversible restrictions. This would make remedial exercise the treatment of choice and especially the best means of prevention. It is less clear what the actual content of such therapy should be when treating – usually painful – dysfunctions of the locomotor system, since remedial exercise expects to deal with a well-defined lesion (for example paresis), and that is not what we are dealing with here. It was Janda who first addressed this problem. The main object of remedial exercise in dysfunctions of the locomotor system is the correction of faulty motor patterning (disturbed movement patterns or stereotypes), that is faulty coordination of muscle function due to disturbed central nervous control. The problem here lies in defining what is the norm, since these movement patterns are very different and highly individual, consisting of programs built up by each subject in the course of life on the basis of chains of unconditioned and acquired (conditioned) reflexes. The way each individual moves is so characteristic that we can recognize people by their gait, their gestures, or their handwriting. Ideally, motor patterns should allow movement to be as economical as possible, that is to consume the smallest possible quantity of energy. As in many other situations, it makes sense for our purposes to take the dysfunction as the
Chapter 2
starting point. Even a layman will recognize awkwardness of movement, and, more often than not, such movement is uneconomical in energy expenditure; therefore the layman is also able to correct the most obvious aspects – just as sports trainers, for instance, correct the movements of sportsmen and women. In patients with vertebrogenic pain, Janda systematically applied the classic muscle test to the individual muscles involved in particular movements. His results revealed that the simple movements used to examine muscle function in fact study a (fairly simple) movement pattern, involving a number of muscles, rather than a particular individual muscle. Examining hip extension by polyelectromyography, Janda showed that it is not only the gluteus maximus muscle which contracts in hip extension, as had been thought, but that the ischiocrural muscles are the first to contract, followed shortly afterwards by the erector spinae. The typical disturbance of movement pattern found in hip extension is the belated and inadequate activity of the gluteus maximus (see Figure 2.18).
Figure 2.18 • EMG study during extension of the right hip:
contraction of the right gluteus maximus is slight and occurs at a late stage. There is increased activity of the ischiocrural muscles and erector spinae bilaterally. (By kind permission of Janda.)
27
Manipulative Therapy
We learned over time to recognize in clinical examination which muscles actually take part in simple test movements, by means of palpation. This enables us to assess not only muscle force, but also quality of performance. This quality may be considerably altered while force remains normal. The strength of hip extension may remain normal, even if it is carried out only by contraction of the ischiocrural muscles and the erector spinae. In this case there is considerable disturbance of the movement pattern, with important consequences for locomotor function, as will be explained later. Regular testing of simple movements using the muscle test revealed a surprisingly constant pattern: certain muscle groups repeatedly showed a tendency to lesser activity (weakness) and hypotonia, whereas others equally regularly tended to hyperactivity and tension. This resulted in characteristic patterns of imbalance which are so constant and typical that we can identify them as syndromes with a clinical significance. They are each characteristic of a particular clinical picture: in some cases there is a preponderance of weakness, flabbiness going hand in hand with hypermobility, whereas in others there is increased muscle tension and stiffness. Table 2.1 sets out those muscles with a tendency to hyperactivity and those that tend to hypoactivity. This difference in the behavior of these two muscle groups can be seen under various clinical conditions and is regularly found in painful states: in a painful hip it is always the flexors and adductors that are tense and the glutei weak; in shoulder pain the pectoralis and subscapularis muscles and the superior part of the trapezius are taut whereas the supraspinatus, infraspinatus, and deltoid muscles are weak; in chronic painful conditions of the knee the vasti are atrophic while the rectus femoris is like a tight band. The findings are similar for fatigue: again the same muscles will be inhibited and their activity frequently taken over by those with a tendency to hyperactivity. This behavior continues to be found in central paresis, when again we find that muscles with a tendency to hyperactivity become spastic, and those with a tendency to hypoactivity become flabby. Neurologically, this kind of muscle imbalance can be termed ‘microspasticity.’ Janda referred to those muscles with a tendency to hypoactivity as predominantly ‘phasic,’ and muscles with a tendency to hyperactivity as predominantly ‘postural.’ In terms of develop28
Table 2.1 Muscle groups exhibiting a tendency to hyperactivity or hypoactivity
Hyperactivity
Hypoactivity
On the dorsal aspect of the body Triceps surae
Gluteal muscles
Ischiocrural muscles
Inferior part of trapezius
Lumbar section of the erector spinae
Serratus anterior
Quadratus lumborum
Supraspinatus
Superior part of trapezius
Infraspinatus
Cervical extensors
Deltoid
On the ventral aspect of the body Thigh adductors
Tibialis anterior
Rectus femoris
Extensors of the toes
Tensor fasciae latae
Peronei
Iliopsoas
Vasti
Obliquus externus
Rectus abdominis
Pectoralis major and minor
Deep neck flexors
Subscapularis
Digastric
Scalenes Sternocleidomastoid Masticatory
Upper limbs Flexors
Extensors
mental kinesiology (see Section 2.5.3), those of the first group belong to the younger system and the second group to the older one. It should be stressed that there is no substantial difference between the types of muscle fiber or the biochemistry of these two groups; the physiological reason for the difference between them rests on the developmental kinesiology. Both systems evidently have a postural function. Examination of simple movements by applying the muscle test is no more than the first step in investigating muscle function; our habitual movements are individually acquired patterns or stereotypes.
Etiology and pathogenesis
The concept of patterning is clearly illustrated by looking at antagonists. For example, the ischiocrural muscles and the quadriceps femoris can be considered as antagonists if we are thinking of the movement of knee flexion and extension. However, during walking both these muscle groups are acting primarily to stabilize the leg. A similar principle applies to the abdominal and back muscles, and to the flexors and extensors of the cervical spine. In fact, in well-coordinated straightening up from a stooping position it is mainly the deep abdominal muscles that provide stability, a point to be remembered in remedial exercise. It should be stressed here that when treating muscle imbalance involving a predominance of the muscles that regularly tend to hyperactivity, the effect of strengthening the weakened (hypoactive) muscle is not only experienced in the particular segment but also influences the overall balance between ‘phasic’ and ‘postural’ muscles. This is particularly important where there is a greater density of afferent nerve receptors, so that afferent stimuli are more strongly felt; it is the case at the fingers and toes, as Brügger has shown. He found that, following stimulation of the extensors of the fingers and toes, the patient finds it easier to resume upright posture; one of the other consequences is improvement in the straight-leg raising test. The training of different movement patterns involves the interplay of a number of muscles reacting in sequence, whose reaction can be triggered if specific stimuli are employed. For movements of the limbs, stimulation of the periphery is most effective, since receptors are numerous here. To facilitate walking, lifting the big toe is helpful: the patient will then find it easier to dorsiflex the foot; that in turn helps the flexion of the knee and hip. Similarly, flexion of the fingers helps anteversion of the elbow and shoulder. What the fingers and toes are for the function of the limbs, the eyes are for the trunk: looking up facilitates straightening of the body, looking down facilitates bending forward, while looking to the side facilitates rotation. Furthermore, as straightening of the body is connected with inhalation, and bending forward with exhalation, it is enough for the patient to look up to facilitate inhalation (as when sighing). Similarly, directing the gaze downward assists exhalation. Returning to the question of imbalance between those muscle groups which are older and those which are younger in developmental terms, the problem here is a form of defective coordination.
Chapter 2
This is particularly so in the interrelationship of antagonists, where the hyperactive muscle generally has an inhibitory effect on its weak antagonist. For example, hyperactive lumbar erector spinae muscles inhibit the abdominal muscles, and hyperactive adductors the glutei. This disturbs the centering of the joints involved, imposing excessive stress on them.
2.9 Sequelae of disturbed movement patterns Having looked in detail at the nature of disturbed movement patterns, we now turn to the mechanisms by which they impair the locomotor system.
2.9.1 Walking and standing The most frequent findings here are an imbalance between weak gluteal muscles and hyperactive hip flexors, between hyperactive lumbar erectores spinae and weak abdominal muscles, and between hyperactive adductors and weak abductors of the hip. In standing we see increased pelvic tilt, a protruding abdomen, and lumbar hyperlordosis. The actual pathogenic mechanism in standing is overload of the lumbar spine as a result of increased tension of the erector spinae muscles; in walking, overload results mainly from the fact that pelvic tilt places the hip joints in extension, and also from the weak gluteus maximus. As a result, the extension of the patient’s legs in walking is mainly achieved by extending the lumbar spine still more. This produces hypermobility of the lumbar spine in the sagittal plane. Hyperactivity of the adductor muscles and above all the weak gluteus medius causes instability in the frontal plane, especially when the patient is standing on one leg. The result is increased swaying of the pelvis from side to side while walking; causing, in other words, hypermobility and overload of the lumbar spine in the frontal plane.
2.9.2 Straightening up from a forward-flexed position If the trunk is imagined as a straight lever with the L5–S1 disk as the fulcrum, calculation of the 29
Manipulative Therapy
stress involved during weight-lifting has produced values of 1000 kg and above (Matthiasch 1956, Morris 1973). Such a force is more than the disk could bear. Measuring intradiskal pressure, Nachemson (1959) found that the pressure during weight-lifting from a sitting position was 275% of that when standing upright. The reason, according to Gracovetsky (1988), lies in the role of the lumbodorsal fascia, into which the erector spinae, the glutei, and the ischiocrural muscles fan out. The tension from the ischiocrural muscles enables the spinal column to ‘hook in’ to this fascia, as it were, so that the lever effect is eliminated. This mechanism is further supported by the abdominal muscles, which also fan out into this fascia and in addition draw the thorax toward the pelvis and maintain intraabdominal pressure. The effect is that the correct movement pattern assists this ‘unreeling’ mechanism and avoids the lever effect.
2.9.3 Raising the arms Here the decisive factor is correct fixation of the shoulder girdle; this is the function of the superior part of the trapezius and the levator scapulae from above, and of the inferior part of the trapezius and the serratus anterior, the first two muscles being attached to the cervical spine and the last two to the thoracic spine. The faulty movement pattern typically found here is tension in the muscles providing fixation superiorly and weakness of those providing stabilization inferiorly. The effect is to lift the shoulder blades and place excessive load on the cervical spine.
2.9.4 Weight carrying The key factor here from the point of view of the biomechanics is the position of the shoulder joint: if the shoulder of the weight-bearing arm is behind the line of gravity of the body, the shoulder girdle is fixed at the thorax by the serratus anterior, the inferior part of the trapezius, the rhomboid major and rhomboid minor. If the shoulder is in a raised and forward position, then the muscles providing fixation are the superior part of the trapezius and the levator scapulae, placing undue load on the cervical spine and at the same time to destabilize the lumbar spine. It is the upright positioning of the head that ensures the correct position of the shoulder. 30
The muscular imbalance involved here is a hyperactive pectoralis major, in particular the clavicular head of the muscle, hypoactivity of the weak rhomboid and serratus muscles and the inferior part of the trapezius, and increased activity of the superior part of the trapezius and the levator scapulae. The hyperactivity of the pectoralis major causes kyphosis in the lower part and hyperlordosis in the upper part of the cervical spine. These examples illustrate the pathogenic effects of faulty movement patterns on the locomotor system and spinal column. The motor stereotype which leads to the most marked consequences, however, is faulty breathing.
2.9.5 The effect of respiration on the locomotor system When we think of respiration, we tend to focus almost entirely on the organs of the respiratory system. In doing so, however, we forget that the thorax and diaphragm are essential to the function of the lungs. The locomotor system has to coordinate the specific function of respiratory movement with the function of locomotor activity. This task is so complex that it would be a miracle if disturbances did not occur. The most important issue here is the close link between respiration and the postural function. Skládal et al (1970) observed on radiographic images that the diaphragm became flatter and contracted when the patient stood on tiptoe during the exposure. They interpreted this as being a postural reaction, and drew the further conclusion that: ‘The diaphragm is a respiratory muscle with a postural function, and the abdominal muscles are postural muscles with a respiratory function.’ The way this is understood today is as follows: the diaphragm attaches dorsally to the spinal column and laterally to the inferior costal arch, while ventrally the fixed point is provided by the abdominal wall. Here, the co-contraction of the deep layer of the abdominal muscles has a key role. Kolárˇ (2006) showed radiographically that the diaphragm was angled downward in the ventral to dorsal direction if the abdominal muscles were weak. If the abdominal muscles are functioning normally, contraction of the diaphragm during inhalation is accompanied by eccentric contraction of the deep abdominal muscles. This can be clearly palpated laterally above the iliac crest. The effect is not only to
Etiology and pathogenesis
enable the diaphragm to function in the most efficient way and, as shown by Kapandji (1974), to expand the thorax, but also to fix the thorax to the pelvis and so stabilize the lumbar spine. The activation of the abdominal muscles during inhalation was also described by Campbell (1978) and Basmajian (1978). Holding the breath (the Valsalva maneuver) reinforces this postural function. Morris et al (1961) showed that the spinal column is supported on the diaphragm when bending forward (see Figure 2.19). Experience does indeed show that when we are about to lift a heavy weight using maximum force, or to perform a heavy blow or vigorous throw, we hold our breath. This is such an important mechanism that athletes hold their breath during demanding activity such as sprinting over short distances, sacrificing the respiratory to the postural function. The most important faulty respiratory stereotype, seen from the point of view of the locomotor system, is that in which the thorax is lifted during inhalation (Parow 1954). In this pattern the thorax is lifted in the cranial direction by the scalene and sternocleidomastoid muscles and the superior fixator muscles of the shoulder girdle, but without expansion of the chest. Termed ‘clavicular breathing,’ it involves a reversal of the normal
Chapter 2
respiratory mechanism, since the scalene muscles, which normally only fix the thorax, raise the lung; resistance is offered by the diaphragm. This is inefficient, not only from the respiratory point of view, in that the volume of the chest increases very little, but also for the locomotor system, because of the chronic overload that this causes to the cervical spine. A further effect is that fixation of the thorax to the pelvis no longer occurs, causing instability of the lumbar spine. The pattern of lifting the thorax during inhalation, or clavicular breathing, can be asymmetric, if one shoulder is raised more than the other. The stress on the cervical spine is then greater on this side. Clavicular breathing is the disturbance that typically occurs when sitting but not maintaining a straight posture, because this makes expansion of the thorax difficult. An extreme form of this breathing pattern is paradoxical breathing, in which the patient draws in the abdomen during inspiration. ‘Passive’ exhalation is brought about mainly through the elasticity of the lung. Active exhalation, including that against resistance, is brought about mainly by the abdominal muscles as well as the erector spinae, which contract strongly when exhaling deeply in a lordotic posture (Lewit, Janda, Veverkova 1998). Here too the facilitation of
Figure 2.19 • The stress on the lumbosacral junction (A) without and (B) with simultaneous contraction of the abdominal wall (Diagram after Kapandji).
31
Manipulative Therapy
postural activity is important. The shouts uttered by attacking soldiers and weight-lifters serve a practical purpose. The effect of respiration is significant above all for the spinal column, which means that it can be employed to outstanding effect in neuromuscular techniques. As a general rule, muscle activity is facilitated during inhalation, and exhalation produces relaxation. The actual situation is a little more complicated: the abdominal muscles are facilitated during active exhalation, especially against resistance, and, as mentioned previously, raising the gaze of the eyes is associated with inhalation and lowering the gaze with exhalation. It is appropriate at this point to explain the concept of ‘respiratory synkinesis,’ in which movement in one direction is linked with inhalation and in the other with exhalation. Where this is the case, it is difficult to do the reverse. Typical respiratory synkinesis can be observed during forward flexion of the trunk, and when straightening up from forward flexion. The fact that straightening up is usually associated with looking up, and forward flexion with looking down, makes clear why the initial act of looking up facilitates inhalation, and looking down, exhalation. Inhalation facilitates straightening up, not only from forward flexion, but also from side-bending. Side-bending itself is facilitated by looking down while exhaling. Another very important example of respiratory synkinesis is the opening of the mouth during inhalation, and the closing of the mouth during exhalation. This facilitates first the masticatory muscles, and then in particular the digastric muscle. Inhalation facilitates kyphosis of the thoracic spine, and active exhalation lordosis of the thoracolumbar spine, especially in lordotic posture (Lewit, Janda, Veverkova 2000). Resistance to traction of the cervical spine increases during inhalation; also during distraction of the hip. The resistance decreases during exhalation. Conversely, resistance increases in the lumbar spine on traction in the prone position, and decreases during inhalation. Clearly, then, these respiratory synkineses are extremely effective in mobilization and relaxation techniques for the spinal column. One especially remarkable example of synkinesis is that described by Gaymans (1980) in the cervical and thoracic spine. He found that, during side-bending, resistance increases in the even segments (in C0, C2, C4, and C6 and in T2, T4, T6, T8, and T10) during inhalation; it disappears 32
during exhalation. Conversely, resistance increases in the odd segments (C1, C3, and C5 and T3, T5, T7, and T9) during exhalation, and disappears during inhalation. At the cervicothoracic junction, and only here, in the region between C6 and T2, resistance always increases during inhalation and decreases during exhalation. This synkinesis is so effective that during side-bending all that is needed is to take up the slack to the point of initial tension, then (in the case of an even-numbered segment) to ask the patient to inhale, and then to wait during the period of exhalation for mobilization to take place automatically. An exception to this rule is found in the atlanto-occipital segment; here this synkinesis operates not only in sidebending but in all directions. The phenomenon described here is so reliable that it can be used to correct the diagnosis as to the level of the vertebral segment. It is most marked at the cranial end of the spinal column and decreases somewhat in a caudal direction; in particular, the relaxation that accompanies exhalation diminishes in the lower thoracic spine. The reason for this may be connected with the fact that the thorax is stabilized during inhalation, and the diaphragm and quadratus lumborum as well as the deep layer of the abdominal muscles contract. We can therefore refer to inhalation–exhalation segments and exhalation–inhalation segments. Marked respiratory synkinesis can also be found in trunk rotation; in the upright position, rotation of the trunk (including active rotation) increases during inhalation, while considerable resistance appears on exhalation. In a kyphotic sitting position, in contrast, resistance increases on inhalation and mobilization is therefore performed on exhalation. Too little attention is paid to the effect of respiration on the locomotor system and vice versa. There is little awareness of the respiratory synkineses, and too little use is made of them by manual therapists, despite the fact that they are physiological methods. Empirically, many of these effects are employed in yoga; these include not only the effects on motor functions but also those on autonomic ones. This is understandable when we remember that respiration is the only ‘autonomic’ function on which we are able to exert any degree of direct influence voluntarily, that is using the voluntary muscles. In this section we have attempted to show the importance of faulty movement patterns for the
Etiology and pathogenesis
pathogenesis of dysfunctions and to explain the processes involved. It seems all the more important to do so since modern civilization is guilty not only of chemically polluting the environment, but also of causing extensive changes to the human locomotor system. We move around too little, but suffer static overload, creating conditions that produce muscular imbalance, among them that of faulty breathing while sitting in a hunched posture. Rehabilitation focuses on faulty movement patterns, and their diagnosis and therapy will be explored in more detail in the relevant sections of this book. As we come to understand them, it becomes clear that the methods used in manual medicine, which are predominantly passive ones, are usually only lastingly effective if accompanied by the active participation of the patient.
Faulty muscle control originating from the central nervous system plays a significant part in the pathogenesis of dysfunctions of the locomotor system. Often, however, they are also a consequence of disturbances involving chronic pain. They, in turn, can then perpetuate and intensify the basic disturbance.
2.10 The significance of constitutional hypermobility Movement restrictions, dealt with in the foregoing sections, are the true focus of manipulation therapy; however, the experienced clinician is well aware that hypermobility is frequently an even more difficult problem. The contributions made by Sachse (1984, Sachse et al 2004) have been fundamental in this area. The following categories can be distinguished: • Localized pathological hypermobility. This may be primary or secondary (it is usually compensatory, occurring in the neighboring segment to a restricted joint). As such it is most frequently found in the spinal column. • Generalized pathological hypermobility. This is most often found in certain congenital neurological conditions.
Chapter 2
• Constitutional hypermobility. This type is
of the greatest interest to us. In essence it is a variant of the norm, but under certain conditions it can be significant for pathogenesis. As a general rule, mobility is greater in childhood than in adulthood, is greater in women than in men and, in the limbs, tends to be greater on the non-dominant side (Sachse et al 2004). There are conditions in which hypermobility may be an advantage, for instance in certain sports and in employment where mobility is a requirement. However, it involves the risk of decreased stability, and given the predominance of static load and overload in most occupations today, hypermobility is inappropriate. Individuals with constitutional hypermobility are at a particular disadvantage when working at a computer, as a driver, or in the majority of sedentary occupations, especially if the hypermobility is accompanied by laxity of the ligaments and weakness of the muscles. The situation is still more unfavorable if the hypermobility is accompanied by poor coordination and qualitatively poor movement patterns (Sachse 1984). The problem may even cross the boundary into minimal brain damage (MBD) as described by Janda (1978). In a study of 100 cases in which rehabilitation proved difficult, he distinguishes three types: 1. The first is ‘microspasticity,’ showing mild signs of first motor neuron lesion which is often asymmetrical. 2. The second is characterized by hypotonicity, with asymmetrical tendon and periosteal reflexes, signs of instability and restlessness, and – consistently with the account given by Sachse – severe hypermobility. 3. The third type shows disturbances of proprioception, which become more evident with eyes closed. This is expressed as a certain marked ‘clumsiness’ and accompanied by poor psychological adaptability, which makes rehabilitation more difficult. Hypermobility in itself is no more than a constitutional characteristic; however, there is a tendency toward instability that is pathological. The most important role here is that played by the deep stabilization system. 33
Manipulative Therapy
Figure 2.20 • Causes and sequelae of restrictions and dysfunctions of the spinal column.
So far we have dealt mainly with the locomotor system and dysfunctions of that system, in particular mechanical disturbances (Figure 2.20).
The dynamic role – usually also the primary role – in the interplay between dysfunction and morphological change is that of function.
2.11 Reflex processes in vertebrogenic dysfunctions Despite the importance of the mechanical factor for pathogenesis, it is not identical with clinical disease. Patients do not generally tend to complain of disturbances of mobility, but rather of pain, whether in the back, limbs, head, or viscera. They may even be suffering from considerable movement restrictions, yet they do not notice these. Examination may sometimes even reveal signs of nociceptive irritation (latent trigger points or hyperalgesic zones on the skin), yet the patient does not feel pain. The explanation lies in the capacity of the nervous system to react. We now need to know how it is that dysfunction produces pain. 34
Before presenting an explanation I should stress that it is not the purpose of this book to deal with the purely theoretical aspects of the pathogenesis of pain; we do however need to deal with the theoretical inferences that can be drawn from clinical diagnosis and therapy. Examination before and after therapy enables us to arrive at certain theoretical conclusions, as we might from an experiment, and the findings that are made after therapy not only show a normalization of mobility, but also a reduction of tension in the affected muscles, and that of the soft tissues. The effect is observed after manipulation, local anesthesia, needling, relaxation of trigger points, and massage. In each case, pain too is relieved. If the pain arises as a result of having to maintain an uncomfortable forced position, correction of the position is often enough to bring relief. The same is true of strenuous work; when we work beyond our strength we hardly notice it at first, but eventually pain forces it to our attention and we suspend the activity. After a short while the pain subsides. The common denominator in all this is the close connection between tension and pain in the locomotor system. Daily evidence of this is seen in the post-isometric relaxation of tense muscles; as the tension reduces, so the pain subsides, not only in the muscle itself but also in its attachments (see Chapter 6). This experience is in fact a general principle: any disturbance of function is bound to produce
Etiology and pathogenesis
increased tension: when there is a restriction, there will be increased tension when the patient tries to move in the restricted direction; hypermobility will produce tension in the end position as a result of excessive range of movement; static overload, strenuous movements, or any faulty motor pattern must also lead eventually to increased tension. The muscular TrPs provide direct evidence of this, since these involve a close association between tension and pain. This is in keeping with the biological role of pain as a warning sign: increased tension constitutes a threat, and it is pain that delivers the warning. The nociceptive stimulus – in the form of overload – warns us at the stage when the disturbance is still functional and reversible. As soon as we correct the posture or cease the activity causing the pain, and as soon as we treat the restriction or muscular TrP, the tension is eased and the pain subsides. If pain made its appearance only when morphological (pathological) changes had occurred, it would fail to fulfill its biological function. Since the locomotor system is controlled by our will – and whim – it has no way of protecting itself other than by causing pain. In this way the voluntary activity of the locomotor system is kept within due bounds by pain. The locomotor system is therefore by far the most frequent source of pain in the human body; it is more than mere coincidence that referred pain from other organs or systems is perceived in the locomotor system, and that pain receptors are located in those places where tension in the locomotor system is expressed: in muscles, joint capsules, the attachments of tendons and ligaments, root sheaths, and the anulus fibrosus of intervertebral disks.
Pain is the most common symptom of dysfunction, and functional disturbances of the locomotor system are the most common cause of pain.
The close connection between physical and psychological factors in the production of pain is easy to understand: pain itself is both a physical and a psychological phenomenon. The same is true of tension and also, especially, of relaxation: it would be difficult to imagine psychological relaxation without relaxed muscles, or to imagine relaxing the muscles without being mentally relaxed. This close interrelationship is true for the locomotor system in
Chapter 2
general, since movement is the effect of voluntary motion that originates in the psyche.
Since movement is an outward effect of psychological activity, it is also true that psychological activity is a factor in motor function.
The nociceptive stimulus produces a reaction in the segment, and the intensity of the reaction can vary enormously. This is clinically significant, because it allows us to estimate the capacity for reaction in the individual case. This applies not only to autonomic reactions, but also to those of the muscles, whose response may take the form of TrPs or spasm. Korr’s concept of ‘segment facilitation’ is therefore appropriate here. There may be considerable differences between patients, and reactions may also vary considerably in the same individual under different circumstances. If, for instance, acute pain has been provoked by a draught, it should not simply be ascribed to the cold air alone, for in such patients we find restrictions in at least one segment, with severe muscle spasm. The restrictions are clinically latent, but produce a skin hyperalgesic zone (HAZ) in the segment. The cold draught striking this HAZ is an additional stimulus which intensifies the patient’s reaction and causes muscle spasm which makes the clinically latent lesions manifest. It is a mistake to explain the pain as due to mechanical irritation of nerve fibers, as is frequently suggested. It would be a peculiar concept of the nervous system (a system whose purpose is to process information) that would have it reacting, not to stimulation of its receptors, but to mechanical damage to its own structures. Referred pain from the viscera is the typical model, or experimentally-induced referred pain from the infiltration of hypertonic saline solution into ligamentous structures of the spinal column, as performed by Kellgren (1939) and later by Feinstein et al (1954) and by Hockaday & Whitty (1967), and in the zygapophysial cervical joints by Pi’tha & Drobný (1972). Just as in these model experiments, pain arising from deep structures (joints, muscles, ligaments, and internal organs) is referred, especially within the affected segment, and also gives rise to corresponding HAZs, sometimes even paresthesia, imitating radicular pain and so leading Brügger (1962) to refer to it as ‘pseudoradicular.’ Other terms often used, 35
Manipulative Therapy
where there is a combination of pain in the muscles, tendons, and insertions, are ‘myotendinosis’ (Brügger 1962) or ‘myofascial pain’ (Travell & Simons 1999). The soft-tissue changes, such as HAZs in the skin and subcutaneous tissue, have mainly been described as reflex changes or as secondary phenomena. This is usually true in acute cases where there is no long history, and these changes are generally found to subside when the joints and spinal column are treated. However, in the later, chronic stage, these changes – especially in fasciae and muscles – can become chronic; resistance is found in the fasciae, muscles become shortened, and chronic TrPs form. Some authors call this the ‘dystrophic stage’ (Popelyanski 1983, Popelyanski 1984). Pathological barriers are also present in such cases, however, and it is possible to achieve release. When dealing with chronic TrPs, this can be done by means of needling. In such cases, even these changes may turn out to be functional and reversible. Nevertheless it is important to note that where there are ‘sticky’ fasciae (which do not shift), shortened muscles, or chronic TrPs, these do not subside following manipulative treatment of joint restrictions. On the contrary, if they do not receive specific treatment, they can cause chronic recurrent restrictions. The model described here has been that of characteristic painful disturbances within the segment. However, it should not be forgotten that the pain threshold, which is under central nervous control, is only crossed when the nociceptive stimulus has reached a particular intensity. Only then is it actually experienced as pain. So it is that, on careful examination, very frequently we find clinical changes when patients have no sense of pain at all. It can therefore be seen that dysfunctions of the locomotor system produce nociceptive stimulation whose effects are felt both suprasegmentally and also at the level of the central nervous system. The entire complex of function-related disturbance can be called the ‘functional pathology of the locomotor system.’
kind of excuse for ignorance of the true causes or the true pathology in most cases of pain affecting the locomotor system and spinal column. Yet what other explanation is there for the fact that, following manipulation, not only does the pain cease, but mobility is restored to clinical normality and muscle TrPs and HAZs instantly disappear? These are not mere coincidence; careful clinical examination can predict the rapid appearance of the effect. If these were pathomorphological changes they would need to heal, and this requires time. The situation can best be explained by comparing it to the working of a car: it may break down because of a burst cylinder or a damaged ball bearing (a pathomorphological change), but another reason for it to fail may be that the ignition is out of order, or the carburetor needs adjusting; the structure is intact, and the disorder is a functional, reversible one. Following a simple adjustment, the problem is instantly resolved. One of the reasons for the failure to recognize that dysfunction is the most frequent cause of pain in the locomotor system is that the evidence is simply based on clinical findings, often relying on palpation, and this is rejected as ‘subjective.’ Connected to this we see a systematical underestimation of clinical diagnosis as a scientific discipline, and neglect accorded to it in practice. Much the same applies to the solving of the ‘puzzle of pain’ in dysfunctions of the locomotor system: pain is closely linked to tension and the release of tension to relief of pain, and the key to understanding this lies in palpation. In differential diagnosis of conditions affecting the locomotor system, the fundamental distinction to be made is therefore between conditions due primarily to pathomorphological changes and those caused by dysfunction. Yet even where a morphological lesion is present, dysfunctions may still play a significant role and should be treated accordingly; rehabilitation is included here.
2.12 Radicular pain The complex of predominantly mechanical dysfunctions and reflex changes can be termed ‘functional pathology of the locomotor system.’
Unfortunately, so widespread is the lack of knowledge, often combined with skepticism, that the concept of ‘functional pathology’ is viewed as a 36
The point having clearly been made that pain in the locomotor system is due to nociceptive stimulation of pain receptors, we must proceed to look at how and why pain arises in cases of root compression. The mechanical compression of a nerve does not itself cause pain but anesthesia, paresthesia, and paresis. However, we should bear in mind that the herniated disk causing the compression
Etiology and pathogenesis
cannot impinge on the nerve fibers until after it has affected the dura and the dural sheaths, which are richly supplied with pain receptors (Wyke 1980), and that with every movement of the legs and trunk the dura is being rubbed against the disk. Nor should it be forgotten that Lasègue’s sign indicates meningeal involvement, even in root compression syndromes. This is in keeping with the clinical course: first of all there is usually severe pain, and the signs of neurological deficit appear later. Other clinical observations support this. Cerný (1948), using autodermography to study patients with radicular pain, found that this method was more reliable in localizing the disk herniation to the particular segment than the typical signs of neurological deficit. This can be understood anatomically in that spinal nerves do not contain fibers from one segment only; they also carry many transitory fibers from neighboring segments. As a result, the failure of a single spinal nerve does not usually lead to signs of deficit. There is an overlap of the areas of nerve roots. Hanraets (1959), however, demonstrated that this is not always the case. He frequently found, during neurological surgery, that spinal nerves vary considerably in thickness: if one is very thick, its neighbor is likely to be much thinner, because of the number of transitory fibers in individual spinal nerves. If a thin spinal nerve is compressed or even severed, deficit will not be observed, because the transitory fibers in the neighboring nerve roots are able to compensate sufficiently, but if a thick root is severed, the consequences are quite different. Most thin neighboring roots have very few transitory fibers that can provide compensation. When Hanraets (1959) stimulated such a spinal nerve during operation (at that time his operations were still being performed under local anesthetic), his patients also felt paresthesia in the neighboring segments. Our own findings (1958), working together with Starý, are also consistent with this. We examined patients following intervertebral disk operations. At that time, in cases where no disk herniation was found, the neurosurgeon cut the sensory spinal nerve. Most of these patients experienced little effect, but some complained of permanent numbness and especially disturbances of proprioception following the procedure. In these cases a thick nerve root had evidently been cut, as described by Hanraets (1959). The pain resulting from irritation of dural receptors is referred pain, which corresponds precisely to the segment affected. It is this projection pain that is shown by Cerný’s autodermography. We
Chapter 2
can conclude that radicular pain is a combination of referred pain originating from dural receptors, and signs of neurological deficit. This explains why autodermography, in which patients themselves draw their projection pain, produces the most accurate clinical localization of a herniated disk. There is yet another observation that points to a functional factor in root compression: this is the frequent immediate improvement of muscle strength in weak muscles and sometimes even of tendon reflexes, immediately after manipulation and even after traction. This has been demonstrated by electromyography (see Figures 2.12 and 2.13), and also shown by the work of Drechsler (1970) and Hanák et al (1970). They showed that, even in true radicular syndromes with muscle weakness, the speed of nerve conduction may be normal. In the light of this they interpreted the weakness as reflex inhibition. Drechsler also concluded that decreased conduction speed indicates a poor clinical prognosis.
Radicular compression syndrome is a mixture of root compression and reflex phenomena. The decisive factor for localizing the cause of pain is referred pain produced by stimulation of receptors.
2.13 The term ‘vertebrogenic’ Once the terms ‘degenerative disease’ and ‘diskopathy’ had been abandoned as inappropriate, ‘vertebrogenic’ became widely adopted as a concept. It too is not quite appropriate: it includes pathological conditions such as ankylosing spondylitis, and does not cover dysfunctions that lie outside the spinal column. The term is therefore acceptable only if it is used as a pars pro toto. So long as it is used for back pain and very closely related disorders, there can be little objection to it; the term becomes controversial if the attempt is made to apply it to pain deriving from the internal organs, as might particularly tend to happen if treatment of the pain is successful. A correct understanding of referred pain, or pseudoradicular pain (to use a less accurate term), leaves little room for controversy. We see from the publications of Melzack & Wall (1965), Bonica & Albefessard (1976) and Milne et al (1981) that impulses from nociceptive stimuli arriving from all structures in a segment converge to spinal cord cells in the lamina V 37
Manipulative Therapy
of the dorsal horn. This also applies to stimuli from receptors in the joint capsules of zygapophysial joints, from the anulus fibrosus, or from internal organs. So it is easy to see how the locomotor system (the spinal column) can readily simulate visceral pain, or how pain from an internal organ might simulate that from the locomotor system. Therefore we must constantly take this problem into account in differential diagnosis. The therapeutic consequences are clear. We should not forget, however, that many instances of pain described as ‘functional’ in fact have their origin in the locomotor system. As will be seen in further chapters, vertebrovisceral relations are very complex; the term ‘vertebrogenic’ should therefore be applied with caution. In many cases pathogenesis is due to more than one factor, and it is then better to speak of disease with a vertebrogenic factor. Migraine is a good example, since the true cause is unknown, although it is usually accompanied by findings in the locomotor system that do cause significant pain. We should reserve the term vertebrogenic for those conditions in which the spinal column (the locomotor system) is the decisive factor, for example when we describe a case of vertigo as vertebrogenic. As Junghanns (1957) has pointed out, the role of the vertebrogenic factor may change over the course of time. It may trigger the disease process, but once this has started it may develop independently. Gutzeit (1953) very aptly characterized the spinal column as being sometimes the ‘initiator,’ sometimes the ‘provoker,’ and in yet a third way as being the ‘multiplier’ of a disease state.
We should speak of vertebrogenic disturbance only when we wish to say that the spinal column is the primary and decisive factor in pathogenesis in a given case of disease.
2.14 Conclusions • Morphological changes cannot explain
pathogenesis in the great majority of painful conditions of the locomotor system. These changes often have the role of a locus minoris resistentiae. • The most frequent cause of pain in the locomotor system is dysfunction, in a joint, 38
muscle, soft tissue, body statics, or dynamics (the movement patterns or motor stereotypes). • The most important cause of dysfunction is overload caused by overexertion, faulty movement patterns or body statics, trauma, or visceral disease. This includes joint restrictions, muscle TrPs, and soft tissue lesions, especially of fasciae and active scars. All these cause an increase in tension. • When dysfunctions in the segment persist for a long time they eventually lead to degenerative (adaptive) changes, and do not remain confined to the segment concerned but affect the entire system. • The locomotor system and the spinal column together make up a functional unit which has to compensate for any dysfunction, so that equilibrium is always maintained. In other words, the ‘motor program’ is reprogrammed. This gives rise to compensatory movement patterns, often designed to reduce pain. These can persist even when the primary cause is no longer present. • Mechanical disturbance of function alone is insufficient to cause pain. However, it does represent a nociceptive stimulus which produces reflex changes, especially within the segment. If these are of sufficient intensity to pass the pain threshold, they are experienced as pain. The specific nociceptive stimulus in the case of dysfunctions is understood to be increased tension. • Pain in the locomotor system is primarily a warning signal of harmful functioning, which should cause us to correct this before it causes permanent morphological damage. It is the type of pain that occurs most frequently in the human body. • If the patient is able to describe and localize the pain, and if on clinical examination we find corresponding changes, above all reflex signs, then the diagnosis (once we have excluded gross pathology) must be the relevant dysfunction. Undiagnosed dysfunctions are the most frequent cause of pain in the locomotor system, and treatment which is directed only at the symptom of pain, without a thorough understanding and analysis of the dysfunction causing that pain, will be frustrating and ineffective. • The complex of changes in function of the locomotor system and the reflex effects caused by these changes constitute what may be called the ‘functional pathology of the locomotor system.’
Chapter Three
3
Functional anatomy and radiology of the spinal column
Chapter contents 3.1 General principles . . . . . . . . . . . . . 39
3.1.1 Structural diagnosis . . . . . . . . . 39 3.1.2 Functional diagnosis of spinal column mobility (kinematics) . . . . 40 3.1.3 Functional diagnosis of body statics . . . . . . . . . . . . . 40 3.2 Technique in functional diagnosis . . . . . 40 3.3 The lumbar spine and pelvis . . . . . . . . 41
3.3.1 X-ray of the lumbar spine and the pelvis . . . . . . . . . . . . . . . 41 3.3.2 X-ray evaluation of lumbar spinal statics . . . . . . . . . . . . . 43 3.3.3 The pelvis . . . . . . . . . . . . . . 49 3.3.4 The lumbar spine . . . . . . . . . . 54 3.4 The thoracic spine . . . . . . . . . . . . . 58
3.4.1 Functional anatomy . . . . . . . . . 58 3.4.2 X-ray anatomy of the thoracic spine . . . . . . . . . . . . 59 3.4.3 Evaluating functional aspects . . . 60 3.5 The cervical spine . . . . . . . . . . . . . 62
3.5.1 X-ray technique . . . . . . . . . . . 62 3.5.2 Assessment of X-ray films . . . . . 63 3.5.3 Functional anatomy of the cervical spine . . . . . . . . . . . . 65 3.5.4 X-ray anatomy of the cervical spine . . . . . . . . . . . . 71 3.5.5 Evaluation with respect to functional implications . . . . . . . 74 3.5.6 Movement studies . . . . . . . . . . 77 3.5.7 Morphological changes . . . . . . . 82
Manual techniques call for an accurate understanding of anatomy, especially when treating the spinal column. Textbooks of radiology are interested mainly in morphology, while our concern is mainly with function, the consistent focus of the present book. The use of radiology for functional studies can greatly improve our understanding in manual diagnosis. However, if we are to be able to interpret radiographic images from the functional point of view, we need a good knowledge of X-ray anatomy, such as we present here, as well as certain requirements as regards technique.
3.1 General principles For our purposes, X-ray diagnosis fulfills three basic tasks: 1. Structural diagnosis. 2. Functional diagnosis of spinal column mobility (kinematics). 3. Functional diagnosis of body statics (interpretation of curvatures of the spinal column).
3.1.1 Structural diagnosis Structural diagnosis provides information about the morphology of the bony structures. This is the essential focus of classic X-ray diagnosis, which is mainly concerned with form and structure and constitutes the basis of our knowledge. This type of diagnosis is very important for manual therapy in
Manipulative Therapy
that it alerts us to potential serious errors of diagnosis, providing a warning against manual therapy where inflammation, tumors, fractures, or other contraindications are present. It also reveals abnormalities and changes in structure, such as asymmetries, which can be significant for function. Diagnosis of structure can be found in the classic textbooks of radiology, so we shall deal here only with those morphological changes that are important for an understanding of dysfunctions.
3.1.2 Functional diagnosis of spinal column mobility (kinematics) Functional diagnosis in the narrower sense involves movement studies of the spinal column in which X-rays are taken in end of range positions, in anteand retroflexion (extension), side-bending and, less frequently, rotation. Examination of this kind is the only approach that can provide direct information about dysfunctions in the motion segment. It can also be used before and after treatment. It is of value for documentation and assessment, but is too time-consuming and uneconomical and the radiation exposure is too great for use as a routine procedure. Since manual therapy examination gives good information on mobility and disturbances of mobility, it is generally possible to dispense with movement studies. They do have an important role to play in research, however, and provide an understanding of the biomechanics of movement processes.
3.1.3 Functional diagnosis of body statics Although movement studies come first to mind when we think of functional diagnosis, it is no less important to diagnose disturbances of body statics. The images used to assess this must be taken standing (or, for the cervical spine, sitting), under static loading and under standard conditions. The curvatures of the spine, as explained below, should mainly be assessed from the point of view of static function. This applies not only to the sagittal but also the frontal plane, in which every obliquity (e.g. of the pelvis during walking) produces a corresponding scoliotic curvature and rotation. Curvature may be regular or irregular, so that a marked 40
deviation may be observed in one particular segment. This may be scoliotic, increased lordosis or kyphosis, rotation, or lateral shift (‘offset’). The significance of these signs of irregularities in the position of neighboring vertebrae (relational diagnosis) is highly controversial, and closely connected with the discredited subluxation theory. It is also closely linked to the problem of asymmetry, bearing in mind the fact that a degree of asymmetry is the rule rather than the exception. Jirout (1978) has shown that asymmetry of the position of the atlas in relation to the axis is present in the majority of adults. In a study to compare children of various ages, he found that its incidence increases with age. This can be shown particularly easily by observing the position of the spinous processes. He concluded that these asymmetries were the result of asymmetrical pull of the muscles due to the dominance of one cerebral hemisphere. From this we can conclude that asymmetry and other kinds of irregularity are not in themselves pathological, although they can be the expression of functional asymmetries. We know, for example, that if the axis is asymmetrically rotated in neutral position, the entire cervical spine will rotate asymmetrically during side-bending. In general it is advisable to be cautious when drawing conclusions about examples of asymmetry observed on an X-ray film, and always to take the clinical findings into account when interpreting the radiographic findings. One advantage of static functional diagnosis is that the examination is economical: only two X-rays are required, two projections, which must correspond to each other vertically. Standard conditions must be observed as regards static loading. As individual posture is highly characteristic, it also remains fairly constant. Gutmann & Véle (1978) said of static function: ‘The dominating principle of the spinal column is body statics. All other functions are subordinate to the requirements of upright posture on two legs. The human body is more ready to accept loss of mobility or painful impingement of nerve roots than to sacrifice erect posture.’
3.2 Technique in functional diagnosis Functional diagnosis of the spinal column makes considerable demands as to technique. The following criteria must be observed: the X-rays should be
Functional anatomy and radiology of the spinal column
taken in a position that corresponds as closely as possible to the patient’s natural posture, normally either standing or sitting (with the exception of the anteroposterior (AP) view of the cervical spine, which is taken with the patient supine). In general, then, any slight inclination or rotation in the patient’s posture ought not to be corrected. However, it may become necessary to do so in order to achieve: • assessability of the X-ray films • reproducibility and comparability. Reliable criteria for comparability are therefore necessary. Assessability is, of course, absolutely essential in order to be able to evaluate the films, so it is important to avoid distortion through errors of projection. To achieve this, it will sometimes be necessary to correct side-bending (in the lateral projection) or rotation (in both projections). As to the format, it is essential to visualize a sufficiently large area to provide landmarks as means of comparison. In the lateral projection of the cervical spine in the sitting position, the hard palate must be visible to enable you to assess the posture of the head, and the mandible needs to be visible so as to indicate any side-bending or distortion. The lumbar AP projection must include the coccyx and the pubic symphysis, to enable you to assess correct positioning. As long as these requirements are observed, it will be possible to evaluate and compare the films successfully, even if there are very minor errors of centering. Since the spinal column is a functional unit, the most appropriate format for the X-ray examination is to show the entire spinal column on a single film. An AP and a lateral view with the patient standing are required, with the feet placed in a standardized position. If this cannot be done, the sections of the spinal column that have been imaged need to be assessed in the light of the clinical findings. These can then make good whatever is missing in the X-ray.
3.3 The lumbar spine and pelvis 3.3.1 X-ray of the lumbar spine and the pelvis The imaging projections needed for routine examination of the static function and morphological changes of the spinal column are simply one AP and one lateral view with the patient standing.
Chapter 3
This is done using a device described by Gutmann (1970), in which a plumb line indicates the vertical line from the head. The procedure is illustrated in Figure 3.1A–D and is as follows: A line which corresponds to the center of the cassette is drawn on the floor in front of the middle of the stand. For the AP view the patient places one foot symmetrically on each side of the line, and is requested to distribute the weight of standing equally between both feet, with legs straight, so as to rest on a base that is in line with the center of the cassette. A plumb line extended downward from the center of the cassette will therefore meet the floor at the mid point between the patient’s heels, setting the base line. A movable plumb line of metal wire (so as to create contrast) is attached to the screen. The cassette is first raised to the level of the patient’s occiput and this metal wire plumb line moved to a point precisely below the middle of the occipital squama, where the external occipital protuberance can be palpated. This sets the plumb line that marks the head position. The cassette is then adjusted (taking care not to displace it to the side) to the height required to take a view of the lumbar region and the pelvis (with the central ray of the X-ray beam and the center of the cassette roughly at the height of the navel). By setting up the AP view in this way, the shadow of the metal wire marks the plumb line representing the head position, and the center of the film represents that of the base line. The same procedure is used for the lateral view of the lumbar spine, except that this time the patient stands with feet across the line on the floor that represents the center of the cassette, with ankles one finger’s breadth behind the line. The plumb line for the head is positioned at a point in line with the external acoustic meatus. Here – as in the procedure described for the cervical spine – it is helpful to align the central ray below rather than on the center of the cassette, directing the beam off-center to focus approximately on the lumbosacral junction, midway between the iliac crest and the greater trochanter. This technique has two great advantages: 1. There is considerably greater absorption of radiation at the lumbosacral junction (on which the pelvis is superimposed) than in the lumbar spine. If the central ray is aligned as usual on the middle of the lumbar spine, the result is either under-exposure of the lumbosacral junction, while the rest of the lumbar spine is correctly exposed, or 41
Manipulative Therapy
Figure 3.1 • X-ray technique for the lumbar spine after Gutmann (1970). (A) Positioning of the plumb line for the head and (B) patient position during radiography, as prepared for the AP view. (C) Positioning of the plumb line for the head and (D) patient position during radiography, as prepared for the lateral view.
42
Functional anatomy and radiology of the spinal column
Chapter 3
arms folded in front of the chest (see Figure 3.1D). The final step, once the apparatus and the patient’s position have been set up, is to tape the wire to the cassette so that it cannot be displaced, and then instruct the patient to lean against the screen so as to remain steady during the long film exposure.
3.3.2 X-ray evaluation of lumbar spinal statics
Figure 3.2 • Lateral view of the lumbar spine with perfect demonstration of the entire pelvis, including the iliac crests and femoral heads.
over-exposure of the lumbar spine while exposure of the lumbosacral junction is good. Aligning the beam on the lumbosacral junction evens out the exposure, and has the additional advantage of providing good imaging of the hip joints (see Figure 3.2). 2. If the beam is aligned to the center of the cassette (middle of the lumbar spine), the effect is to project the iliac crests away from each other, lying well apart as they do, although they are very important for body statics. The projection error produced at the much slimmer lumbar spine, on the other hand, is only slight. For both projections the focus-film distance should be as great as possible, depending on the power of the apparatus and the corpulence of the patient, the ideal distance being at least 2 m (78 inches). For technical reasons, the patient needs to stand with
The purpose of the films taken in the standing position is mainly to study body statics. The only structures in the frontal plane that can be assessed by clinical examination are the occipital protuberance, spinous processes, iliac crests, intergluteal cleft, and the midpoint between the heels. In the sagittal plane, clinical examination can show the posture of the head, position of the shoulders, the trochanters and the heels in relation to the plumb line, which takes the line from a fixed point at the external auditory meatus. Clinical examination cannot provide information about the position and inclination of the sacrum and the most caudal vertebrae (which mark the true base of the spinal column), information which is essential for a full understanding and evaluation of spinal statics. This may explain why clinicians interested in body statics have devoted their attention mainly to the question of body equilibrium as a whole, studying deviation of the head and deviation from the line of gravity by means of statovectography. However, Rash & Burke (1971) pointed out that with static load each body segment should be vertically above the center of the segment on which it rests. The principle is violated if tension of the ligaments or excessive muscular contraction are required to maintain balance. X-ray examination under static conditions provides information on precisely this type of static disturbance. The mechanism of body statics differs considerably in the frontal and the sagittal planes. One way to appreciate this is to observe the effect of a heel insert, a pad or block placed under one foot. A healthy subject experiences a height difference of as little as 1 cm as uncomfortable, whereas if a heel insert of 1 cm is placed under both feet it is hardly noticed. This is because in the frontal plane the center of gravity lies over both feet, such that body equilibrium is (relatively) stable. As a result, any mechanical change (the insert under the foot) has an immediate effect. In the sagittal plane, in contrast, body equilibrium is labile, over the two 43
Manipulative Therapy
Figure 3.3 • Normal body statics: (A) with the subject standing with his weight equally on both feet; (B) with support to raise the right foot; (C) with weight shifted onto the right leg.
44
Functional anatomy and radiology of the spinal column
Chapter 3
perfectly round surfaces of the hip joints. A slight mechanical change has little effect, because it is dynamic muscle function that is maintaining balance in this plane. The muscular force required should, however, be minimal.
Lumbar spinal statics in the frontal plane In the ‘ideal’ case the pelvis and spinal column lie symmetrically in a straight line in the AP view. The external occipital protuberance, spinous processes, pubic symphysis, and coccyx lie in the midline. Such a spinal column is the exception in real life; people simply do not place their weight symmetrically on both feet, but stand in a relaxed posture in which the weight is taken mainly on one leg. During walking, the pelvis constantly swings from one side to the other. The result is the constant creation of oblique planes. The main concern in assessing these is to discover how the spinal column reacts to obliquity in the frontal plane. The physiological reaction to obliquity can be seen by performing a test in healthy subjects: the subject must first relax, stand with legs straight, and rest the weight of the body on both feet; a block of wood is then placed under one foot. The subject’s pelvis then shifts to the higher side (see Figure 3.3). The radiographic image shows not only the shift to the side, but also scoliosis and rotation to the lower side. The summit of the scoliotic curve is usually at the mid-lumbar region, with the thoracolumbar junction vertically above the sacrum. The degree of rotation depends on the degree of lordosis of the lumbar spine. If there is no lordosis – as is often the case in acute lumbago – there is also no rotation. If there is kyphosis, there may even be rotation to the same side as the concavity. Reaction by the spinal column to an oblique plane is normal if: • scoliosis to the lower side results • there is rotation to the same side (when there is lordosis) • the thoracolumbar junction is vertically above the sacrum • the pelvis shifts to the higher side (see Figure 3.4). Slight thoracic scoliosis occurs in the opposite direction.
Figure 3.4 • Normal reaction of the lumbar spine and pelvis to standing on an unlevel plane.
These features reflect normal spinal statics and are closely associated with the problem of difference in leg length. From the point of view of body statics, a difference in leg length becomes significant only when accompanied by obliquity of the base of the spinal column (see Figure 3.5). In the light of this fact, the age-old dispute over how to measure a difference in leg length is beside the point. While it is possible clinically to establish the presence of pelvic tilt, we cannot determine the position of the sacrum relative to the sacral promontory and the lumbar vertebrae that constitute the base of the spinal column proper, as the pelvis may be straight while the sacrum is tilted, or vice versa. The determining factor in spinal column and body statics is the base of the spinal column. The only way to establish the position of these, and find how the spinal column reacts to an oblique base, is by X-ray examination with the patient standing (see Figure 3.6). 45
Manipulative Therapy
Figure 3.5 • (A) Pelvic obliquity with level promontory and straight spinal column. (B) Following placement of a support to raise the foot, straightening of the pelvis but oblique promontory and deviation of the lumbar spine from the plumb line.
Figure 3.6 • (A) Pelvic obliquity with oblique sacrum, which is lower on the left. Left scoliosis with deviation of the head and
neck to the left. (B) Straightening of the lumbar spine and head position following placement of a support to raise the right foot.
46
Functional anatomy and radiology of the spinal column
The most important findings where there is a disturbance of body statics are: • obliquity of the base of the spine without scoliosis or with inadequate scoliosis, so that the thoracolumbar junction is not vertically above the lumbosacral • no lateral pelvic shift to the higher side • no rotation when there is scoliosis together with lordotic posture of the lumbar spine or even rotation in the direction of the concavity. The practical decision to be made is whether to order a corrective heel insert. This is primarily a clinical decision, although the X-ray can provide useful clues. The following radiological criteria show when a heel insert can be helpful in the case of obliquity of the base of the spine: • If scoliosis is not sufficient to bring the thoracolumbar junction into a position vertically above the lumbosacral, or if scoliosis is absent. Use of a heel insert to raise one heel should bring the thoracolumbar junction to the vertical, or at least nearly so.
Chapter 3
• If the pelvis is shifted, usually toward the higher side, it should then return to the midline.
• If the scoliosis was statically balanced, it should decrease.
These criteria should all be checked again by X-ray. The spinal column may react positively or negatively to the heel insert, either ‘accepting’ or ‘rejecting’ the correction. If the response is negative it would be wrong to force correction upon the patient, because this would only worsen the situation at the base (see Figure 3.7). The typical reaction to obliquity as seen radiographically has been studied by Illi (1954) and Edinger & Biedermann (1957), with the subject walking on the spot. At each step, oblique planes appeared together with corresponding scoliosis to the side concerned; the summit of the scoliotic curve appeared at L3. The thoracolumbar junction remained vertically above the sacrum. Above T12 there was a scoliosis of the thoracic spine to the opposite side, but it was shallow. According to Edinger & Biedermann (1957), the thoracolumbar junction forms a kind of point of interchange, and
Figure 3.7 • (A) Pelvic obliquity with oblique sacrum, which is lower on the left, and uncompensated left scoliosis.
(B) Following placement of a support to raise the left foot, the pelvis and sacrum are more horizontal, but not L5. No change can be seen in the rest of the spinal column. The displacement of the pelvis and plumb line to the left indicates that the patient is placing more weight on the left leg. Positioning from L5 to S1 is exacerbated.
47
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should not swing more than 4 cm from one side to the other. The relation of the scoliosis to rotation and its dependence on the presence of curvature in the sagittal plane was studied by Lovett (1907), who found that rotation of the lumbar spine (in the sense of scoliosis) occurs if lordosis is present, but not in kyphosis. The explanation for this lies in the fact that, whereas the vertebral bodies have good mobility during side-bending, the joints of the vertebral arches are forced together in lordosis and so resist movement. In contrast, in kyphosis there is less close contact between the joints of the vertebral arches; but the vertebral bodies are pressed more firmly against each other, so that these are less free to side-bend. As a result, either there is no rotation at all or rotation occurs in the opposite direction. This is sometimes the case in patients with acute lumbago or in radicular compression syndrome (see Figure 3.8). The situation can also be found clinically in healthy subjects. On passive side-bending of a subject in lordosis, the spinous processes remain in the midline, and the vertebrae rotate in the sense of scoliosis. If the same is done in kyphosis, the spinous processes form a scoliotic curve: in other words, they move in parallel with the vertebral bodies.
Lumbar spinal statics in the sagittal plane In the sagittal plane, we often speak of ‘normal’ curvatures; these are generally held to be the convex cervical curve (lordosis), concave thoracic curve (kyphosis), convex lumbar curve (lordosis), and concave sacral curve (kyphosis). Sollmann & Breitenbach (1961) demonstrated on the basis of 1000 X-ray films in the sagittal plane that there is no such thing as a general norm; at best we can speak of an ‘individual norm.’ They do not, however, lay down any criteria for this kind of norm. Cramer (1958) showed, on the basis of 150 measurements of the lumbar spine with the subject standing, that there is a constant correlation between the tilt of L5 and that of T12, and more important still, that the T12 vertebra lies an average of 4 cm dorsally to L5. The results of our own study (Lewit 1973) gave complete confirmation of Cramer’s findings and also showed that the plumb line for the head follows a line down from the external acoustic meatus exactly to the navicular bone. We found that the sacral promontory lay an average of 4 mm 48
Figure 3.8 • Typical relief position in lumbago or radicular
compression syndrome (‘paradoxical scoliosis’). Level pelvis, uncompensated right scoliosis with left rotation and deviation of the thorax and head to the left; lumbar lordosis absent.
Functional anatomy and radiology of the spinal column
Figure 3.9 • Lateral view of the lumbar spine with forwardthrust position of the thoracolumbar junction.
anterior to this plumb line, and the transverse axis of the hip joints 12 mm anterior to the plumb line. Deviations from this norm indicate a disturbance of body statics as a result of lack of muscle coordination. This is most evident in muscle spasm due to acute lumbago or radicular pain, when there is forward-thrust posture (see Figure 3.9), in which the thoracolumbar junction lies exactly over or ventral to the lumbosacral junction. The reverse is found in ‘flabby’ posture, in which the sacral promontory lies well forward of the plumb line for the head, and T12 lies dorsal to L5 by some distance (see Figure 3.10). ‘Flabby’ posture is the expression of imbalance of the muscles of the pelvic girdle; it may be the result of weakened abdominal and gluteal muscles, but equally well of hyperactive hip flexors. The curvature of the lumbar spine is of course also dependent on pelvic tilt which, in turn, varies according to the ‘type’ of pelvis, as is shown in the following section. One further point to note is that a slight curvature (a ‘flat’ spine) goes hand in hand with hypermobility and lack of stability, while greater curvature (in both the sagittal and the coronal plane) corresponds to stability and less mobility.
Chapter 3
Figure 3.10 • Lateral view of the lumbar spine with anteposition due to ‘flabby’ posture.
The curvatures of the spine are an expression of static function, and should therefore be interpreted in terms of whether they fulfill this function. In the frontal plane, balance is relatively stable; in the sagittal plane, muscle activity is the determining factor. Curvature of the lumbar spine in the sagittal plane is normal if the thoracolumbar junction is dorsal to the lumbosacral, if there is no forward shifting of the sacral promontory (no more than 8 cm in front of the center of the cassette, which is double the average). The position of the thoracolumbar junction vertically above the lumbosacral is also the most important criterion in the frontal plane. If there is obliquity at the base, the normal reaction is scoliosis and rotation of the spinal column (if lordosis is present) and a shift of the pelvis to the higher side.
3.3.3 The pelvis The pelvis and the spinal column together constitute a functional unity, in which the pelvis serves 49
Manipulative Therapy
both as the base of the column and at the same time as the connection with the lower limbs. The pelvis transmits motion from the lower limbs, at the same time acting as a shock-absorber. The spinal column rests on the pelvis much as the mast of a boat rests securely on the firm base of the mast step (Benninghoff, 1944). The sacroiliac joints and the pubic symphysis allow for a degree of mobility with enough spring to act as a buffer while also providing adequate stability.
Pelvic types The function of the pelvis and its influence on body statics depend largely on its type; we owe the recognition of this relationship to Erdmann & Gutmann (1965). The variability observed here is evidence of the phylogenetic instability of this region; evidence of this variability can be seen in our description of the last lumbar vertebra as a ‘transitional’ vertebra; it is difficult here to speak of any such thing as a ‘norm.’ If the variations are asymmetrical as between the two sides, this results in obliquity at the base of the spinal column, and the effects on spinal statics are considerable. If the variations are symmetrical, this affects the length of the sacrum, which is closely associated with its position and inclination. Erdmann & Gutmann (1965) distinguish the following pelvic types with respect to the associated mechanism of pathology (see Figure 3.11 and Table 3.1). The authors call these Hohes Assimiliationsbecken (high promontory assimilation pelvis), Normalbecken (normal pelvis) and Überlastungsbecken (overload pelvis): • High promontory: the ‘assimilation’ type presents a long sacrum and high sacral promontory, with a tendency to hypermobility (see Figure 3.17) • Normal type: this is of average length, with a tendency to restrictions. • Low promontory: the ‘overload’ type has a low promontory and marked inclination of the sacrum. All the points summarized in Table 3.1 should be borne in mind when evaluating X-ray films; it will be seen that the type of pelvis affects the spinal curvatures, the height of the last intervertebral disk, and the shape of the vertebral bodies, and therefore also the mobility of the most caudal motion segments. The assessment to be made when 50
hyperlordosis is found will therefore be different in the case of a high promontory (assimilation) type and in that of a low promontory (overload) type. Similarly, a low L5/S1 intervertebral disk will be differently assessed.
Identification of pelvic type (see Figure 3.11 and Table 3.1) is extremely important for the assessment of dysfunctions, especially in the lumbar and pelvic region.
The sacroiliac joints There is some mobility of the otherwise firm pelvic girdle, due to the role of the sacroiliac joints and the pubic symphysis. The major role is that of the sacroiliac joints. The sacrum is wedge shaped in two directions; first the whole structure tapers in the caudal direction. A double contour is usually seen in the AP view, since there is another wedge in the ventrodorsal direction; the sacrum is somewhat broader ventrally, at least in its craniad part, although in this respect too there are considerable variations. It is helpful to note that the greater the distance between the two contours of the joint, the narrower the joint space appears. If on the other hand we see only one contour, the joint space appears to be wide and clearly defined. This is often the case with the high promontory type, and is a further sign of hypermobility. It is important to point out that, despite its unusual shape and limited mobility and the fact that there are no muscles to move the sacrum against the ilium, the sacroiliac joint is a true synovial joint (Colachis et al 1963; Duckworth 1970; Mennell 1952; Weisl 1954). According to Duckworth, the sacrum rotates relative to the ilia around an axis corresponding to the shortest sacroiliac ligaments, at the level of S2. This movement is one of nutation; with each step taken during walking, the weight of the spinal column produces a forward nodding motion of the sacrum, together with the sacral promontory, acting as a shockabsorber. This mobility of the sacrum within the pelvic girdle is easily palpated and is familiar to gynecologists in the management of labor. Perpendicular to this ‘functional’ motion, the joint play consists in a springing, wing-like motion about a
Functional anatomy and radiology of the spinal column
Chapter 3
Figure 3.11 • The pelvic types. Angle a = angle of inclination of sacral promontory; angle d = angle of inclination of sacrum. 1, Head and base plumb line; 2, plumb line of promontory. (A) High promontory. (B) Normal type. (C) Low promontory.
craniocaudal axis, the effect of which is a distraction of the joint.
The degree of mobility in the sacroiliac joint should be as little as possible, yet never to the point of restriction, just as a shock-absorber is firm but never immobile.
It is appropriate at this point to deal with a condition described as pelvic distortion, which requires explanation from the functional anatomical point of view. The finding on palpation is that the posterior superior iliac spine (PSIS) is lower on one side than the other. The finding is the same if the finding is made at the posterior border of the iliac crests at the point where they can be palpated in the vertebral region. Ventrally the opposite is found: on the side where the PSIS is lower, the anterior superior iliac spine (ASIS) is 51
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Table 3.1 Pelvic types
High promontory (assimilation)
Normal
Low promontory (overload)
Inclination of sacrum
50˚–70˚
35˚–50˚
15˚–30˚
Inclination of end-plate of S1
15˚–30˚
30˚–50˚
50˚–70˚
Position of L4 disk
Above the line of the iliac crests
At the height of the iliac crests
Below the line of the iliac crests
Position of the promontory in the pelvic girdle
Eccentric (dorsal)
At the center
At the center or ventral
Shape of L5 vertebra
Rectangular
Trapeze shaped
Trapeze shaped
Shape of L5 disk
Rectangular and higher than L4
Wedge shaped and thinner than L4
Wedge shaped and thinner than L4
Segment with maximum mobility
L5/S1
L4/L5
L4/L5
Effect of iliolumbar ligament
Slight fixation of L5
Good fixation of L5
Good fixation of L4 and L5
Weight-bearing structure
End-plate of S1
End-plate of S1
L5/S1 joints and sacroiliac joint
Spinal curvature
Flat
Average
Considerable
X-ray statics
Promontory and hip joints lie in front of plumb line for head
Promontory and hip joints almost on line of plumb line for head
Promontory and hip joints lie behind plumb line for head
Clinical signs
Hypermobility, pathological changes of L5 disk; ligament pain
Restrictions, pathological changes of L4 disk
Arthroses of L5/S1, sacroiliac joint and hip
found to be higher than on the contralateral side, and vice versa. The ventral parts of the iliac crests behave in the same way as the anterior iliac spines. The middle portion of the iliac crests may be symmetrical, although this need not be so. On first impression it seems as if one ilium is twisted relative to the other about a frontal transverse axis, although this is in fact impossible if the pubic symphysis is intact. The functional anatomy involved can best be illustrated anatomically by Cramer’s diagram (1965) (Figure 3.12). This shows a one-sided nutation of the sacrum brought about by its rotation between the ilia around its longitudinal axis. This in turn results in rotation of one ilium about a horizontal axis and of the other about a vertical one. All attempts to visualize these changes radiographically have remained without success as far as we know. However, we have been successful in 52
Figure 3.12 • The mechanism of pelvic distortion (after Cramer 1965).
Functional anatomy and radiology of the spinal column
showing X-ray evidence of a disturbance of body statics in the presence of pelvic distortion (see Figure 3.13). The pelvis was found to be shifted toward the higher side, and there was deviation
Chapter 3
of the angle between the sacrum and the lumbar spine. This disappeared following treatment of the atlanto-occipital and atlantoaxial joints. Lewit & Rosina (1999) were able to induce pelvic distortion
Figure 3.13 • Disturbed statics in pelvic distortion. (A) With deviation between the lumbar spine and the sacrum. (B) No
improvement after insertion of support to raise the left foot. (C) Normal findings following treatment of atlanto-occipital and atlantoaxial joints.
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by rotating the head to one side and then the other, but radiographic examination showed this effect to have been a palpatory illusion.
3.3.4 The lumbar spine Although only a little shorter than the thoracic spine, the lumbar spine consists of only five vertebrae. However, in ante- and retroflexion as well as in side-bending, the corresponding motion segments play a significant part in ensuring the mobility of the trunk. Meanwhile the inferior part of the lumbar spine also carries the weight of the trunk, so the vertebral bodies and articular processes of the lumbar spine are the most robust. The joints of the vertebral arches form massive gliding surfaces that can enable considerable excursion and also provide stability. The greater part of the articular facets runs vertically, almost in the sagittal plane. Ventrally, the smaller part is turned almost at a right angle to point medially, in the frontal plane. Frequently, however, the articular facets simply form an arc, whose concave aspect faces dorsally. If the two parts do stand at right angles to each other, the joint spaces can be easily visualized by X-ray; if they form an arc, this cannot be done. Given that the joints of the vertebral arches only develop their final shape after birth, during the first years of life there is considerable variation in this respect.
The shape of the joints determines the function of the lumbar spine; it mainly allows for anteand retroflexion and tends to inhibit side-bending, which occurs in combination with rotation. The joints inhibit rotation about a sagittal axis. Just as side-bending happens in combination with rotation, so rotation of the trunk produces the effect of lateral flexion. If the joints of the vertebral arches determine the quality of the movements of the lumbar spine, its great mobility depends on the thickness of the lumbar intervertebral disks. Their thickness usually increases from L1 down to L4; consequently maximum mobility is usually found at the L4/5 segment. Only in the ‘high promontory’ pelvic type is maximum thickness and mobility found at L5/S1. Retroflexion, however, is usually most extensive in the L5/S1 segment.
X-ray anatomy of the lumbar spine The oval shadow of the pedicles of the vertebral arches are the most striking feature in the AP views of the lumbar spine (see Figures 3.14 and 3.15). The last pedicles (only) are projected onto the lateral edge of the fifth lumbar vertebra; they are also less distinct. This is partly owing to the triangular shape of the spinal canal in the inferior lumbar spine. Taking the pedicle as a starting point, it is
Figure 3.14 • Anatomical structures of the lumbar spine. (A) Dorsal aspect of the lumbar spine and sacrum. (B) X-ray: AP
projection. (C) Ventral aspect of the lumbar spine and sacrum. 1, Spinous process; 2, superior articular process; 3, lamina of the vertebral arch; 4, pars interarticularis; 5, joint space; 6, inferior articular process; 7, glimpse into the spinal canal; 8, posterior superior iliac spine; 9, dorsal part of the sacroiliac joint; 10, intervertebral disk; 11, transverse process; 12, vertebral body; 13, pedicle; 14, ventral part of the sacroiliac joint.
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Figure 3.15 • Schematic drawing of the AP X-ray view of a lumbar vertebra (after de Sèze et al 1969).
Chapter 3
possible to identify the lamina of the vertebral arch and trace it along to the spinous process. Lateral to and above the pedicle we find the superior articular processes; from the vertebral arch downwards and below the pedicle, the inferior articular processes can be traced in a caudal and lateral direction toward the superior articular processes of the next vertebra below. The two inferior articular processes form an arch; this, together with the spinous process of the caudal neighboring vertebra, forms a frame around a lucency which offers a glimpse into the spinal canal. At this point the canal is not covered by bone, and this is the location where lumbar puncture can be performed. Where both articular processes meet is the joint space. It is possible to see into the joint space if part of it is aligned in the sagittal plane. The lateral view (see Figure 3.16) also shows the thick pedicles, situated immediately behind
Figure 3.16 • Anatomical structures of the lumbar spine. (A) Lateral view. (B) Lateral view (X-ray). 1, Pedicle; 2, pars interarticularis; 3, inferior articular process; 4, superior articular process; 5, joint space; 6, intervertebral foramen; 7, transverse process.
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the bodies of the vertebrae. The superior and inferior articular processes arise from the pedicles. It is often also possible to see the joint space if the medial part of the joint lies in the frontal plane. Between the superior and inferior articular processes is the pars interarticularis (pars isthmica), which tends to be the site of spondylolysis in true spondylolisthesis. Between the pedicles of adjacent vertebrae can be seen the intervertebral foramen, dorsal to the vertebral bodies and intervertebral disk and bordered dorsally by the articular processes. It lies almost exactly in the frontal plane, and its width is almost that of the spinal canal. The lamina is covered by the articular processes, and dorsal to these can be seen the massive spinous processes. The transverse processes are projected onto the articular processes, appearing as a thick shadow. The fifth (last) lumbar vertebra occupies a special position in that it serves a transitional function between the mobile lumbar spine and the rigid pelvis. In terms of its shape, it is therefore adapted to the base (craniad end) of the sacrum. In the lateral view, the vertebral body of L5 is trapezoid. An important point to note is that the powerfully developed transverse processes of L5 – often resembling the pars lateralis of the sacrum – provide attachment to the iliolumbar ligaments, which stabilize the last lumbar vertebra in the pelvis. L5 therefore plays a part in the shock-absorbing function of the pelvis. The intervertebral foramen of L5 is usually narrower than the others of the lumbar spine, despite the generally powerfully developed pedicle of L5. This vertebra is usually considerably inclined, so the L5/S1 joints usually lie in the frontal plane, to prevent forward gliding. The most important anomalies of the lumbosacral junction have already been dealt with under ‘pelvic types’ (see Section 3.3.3). When there is a transitional vertebra, it can be difficult to decide whether this is a sacralized L5 or a lumbarized S1. It is especially difficult if the image shows six vertebrae with lumbar characteristics and the task is to decide whether the last is indeed a lumbar vertebra or a lumbarized sacral vertebra. In cases where a neurosurgical intervention is to be carried out, this decision can be very important. The most reliable criterion to use is an imaginary line drawn between the two iliac crests: this line usually corresponds to the fourth intervertebral disk (see Figure 3.17). If, however, this line projects across the middle of a vertebral body, the 56
Figure 3.17 • High promontory pelvic type with obliquity at
L4, left scoliosis, and rotation. Here the line between the two iliac crests runs level with the L5/S1 disk.
identification becomes well-nigh impossible, unless an X-ray of the thoracic spine is also available. Sometimes, instead of the massive transverse process of L5, a transitional lumbosacral vertebra may have a pars lateralis which forms a pseudarthrosis with the pars lateralis of S1, and may even cause clinical symptoms. The most serious anomaly, clinically, is probably spinal canal stenosis. In the lateral view the usual finding shows massive vertebral bodies with short, stubby pedicles and markedly narrow intervertebral foramina. The line of the inferior articular processes is noticeably steep. In the AP view the massive appearance of the articular processes is striking, it is possible to see clearly into the joint space, and the lucency between the inferior articular processes below the spinous process is particularly narrow. The effect is to give the spinal canal a trefoil shape. CT offers the best insight into the anatomical relations in the spinal canal; it can also visualize the narrow lateral recesses and the narrowed, trefoilshaped spinal canal. A narrow spinal canal adversely affects root compression and is often accompanied by radicular claudication. It is of course important to be able to assess the thickness of the intervertebral disks correctly. Straightforward disk hypoplasia is a quite common anomaly, and should not be confused with disk
Functional anatomy and radiology of the spinal column
Figure 3.18 • The anterior inferior border of the vertebral
body of L5 is lower (arrow) in relation to the sacrum on the left side than on the right. The L5/S1 disk is therefore narrower on the left. There is compensatory lumbar scoliosis with marked rotation.
degeneration. This is especially true in the case of an L5 transitional disk. If this vertebra shows no signs of degenerative changes and no shift that might indicate laxity, the practitioner should not be too hasty in diagnosing a narrow disk as degeneration. A useful sign of disk hypoplasia is a finding that shows abbreviated end-plates either side of a narrow disk. Although we usually rely on lateral views for the assessment of disks, marked asymmetry in the AP view can be a useful sign, particularly for the L5/S1 disk, where anomalies are frequently found (asymmetrical L5/S1 disk, see Figure 3.18).
Evaluation of function from X-rays In order to evaluate radiographic films from the point of view of function, they must be taken under standard conditions. The film must be taken with the patient standing erect, and if possible using the technique described in Section 3.3.1. A functional evaluation of the lumbar spine can only be done if the pelvis, hip joints and pubic symphysis are included on the film. A 30 × 40 format is therefore recommended for both projections, so that the entire sacrum and hip joints can also be seen
Chapter 3
in the lateral projection. A focus-film distance of at least 1.5 meters is needed to keep distortion to a minimum. Careful assessment of rotation can be important, because rotation is to some extent related to scoliosis and the degree of lordosis; if the relationship is disproportionate, this can be a sign of dysfunction. Rotation of a vertebra is recognized by a deviation of the spinous process and the pedicles in the direction opposite to that of rotation. On the side of rotation the pedicle appears wider and it is easier to see into the joint space; the transverse process is slightly shorter (because it is nearer the cassette). Deviation of the spinous process alone should never be taken to be a sign of rotation; absence of the other criteria, especially the corresponding asymmetry of the pedicles and the row of transverse processes, etc., indicates that the deviation observed is simply asymmetry and not rotation. Scoliosis should always be assessed according to the principles of body statics. The lateral view is used to assess lordosis, kyphosis and ventral or dorsal shift. If an apparently blocked position is found, this can also be significant. Slight shifting (ventrally or dorsally) is a sign of instability. This may become more marked during ante- or retroflexion. However, very slight, proportional shifts in ante- or retroflexion, especially in young patients, may be normal. There are two potential pitfalls to beware of: 1. Incongruence of the end-plates of two adjacent vertebrae, most frequently observed between L5 and S1 in the lateral view. In such cases the superior end-plate of S1 is usually slightly longer than the inferior endplate of L5, and the shift that is observed can be seen either only at the dorsal or ventral edge of the adjacent vertebra. 2. Slight rotation in patient positioning: here the shadows of the anterior and posterior borders form a double contour which can be mistaken for a shift. Slight shifts due to hypermobility or slight instability need to be distinguished from true spondylolisthesis (with spondylolysis) and from degenerative ‘pseudospondylolisthesis or spondylotic listhesis’ as described by Junghanns (1930), in which the superior articular process of the adjacent vertebra below (most frequently L5) is bent in the ventral direction, so that the vertebra above it (usually L4) glides ventrally over it. 57
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Radiographic movement studies Films taken in erect posture may not always provide any clues to disturbed function, which only becomes evident in movement studies. These are usually performed to study ante- and retroflexion and side-bending. In the normal case, movement is fluid and all segments of the lumbar spine participate. Where there is disturbed function, it is possible to distinguish segments of reduced or increased mobility. We find a sign of reduced mobility at a block vertebra position, and the segment concerned does not participate in the movement. Where there is increased mobility, local ventral or dorsal shifts may be observed in ante- and retroflexion. In young and hypermobile subjects, slight step-like shifting of vertebrae and shifting that occurs to an equal degree in all segments may be considered normal (Jirout 1956). Even the formation of an exaggerated sharp bend is a sign of local hypermobility. However, if this sharp bend is accompanied by a ventral narrowing of the disk in anteflexion, without a corresponding dorsal widening, this is indicative of a disk lesion. The same can be said if it is accompanied by dorsal narrowing of the disk without a corresponding widening ventrally (Jirout 1965). In the lumbosacral segment a ‘paradoxical’ shift sometimes occurs; instead of the ventral shift in anteflexion and dorsal shift in retroflexion that is observed in the other segments, there is a ventral shift during retroflexion and dorsal shift during anteflexion (Jirout 1957). This presumably occurs as a kind of leverage mechanism. Movement studies are mainly indicated where there is a clinical reason for doing so; usually where particular movements give rise to symptoms. These studies are particularly important in order to find out whether or not spondylolisthesis is already fixed. In side-bending, the main object is to look for asymmetry and to assess the relationship between flexion and rotation.
3.4 The thoracic spine 3.4.1 Functional anatomy The thoracic spine is the longest section of the spinal column, but also the one with the least mobi lity. The main reason for this is its firm, though 58
jointed, connection to the relatively rigid thoracic cage. The narrowness of the intervertebral disks is the morphological expression of this minimal mobility. In the frontal plane the joint spaces are almost vertical, but laterally they fall away anteriorly, as if on the periphery of a circle (cylinder) whose center is ventral to the vertebral body. This arrangement would allow for considerable rotation in the thoracic region were it not for the ribs and the intervertebral disks. Side-bending, and to some degree also anteflexion, are similarly limited by the thoracic cage. Anteflexion is also held in check by the tension of the inter- and supraspinal ligaments. Retroflexion is limited mainly by the articular and the spinous processes, which overlie each other in the manner of tiles on a roof. At a certain point in retroflexion this arrangement therefore obstructs bending in this direction.
Transitional regions One important reason for the significance of the thoracolumbar junction is that there is a sudden change in joint structure occurring in the region of a single vertebra (T12): whereas the articular processes above this point are those of the thoracic spine, those below it have the form and mechanical features of the lumbar spine. During walking on the spot, the thoracolumbar junction acts as a fixed point, where scoliosis of the lumbar spine to one side changes to scoliosis of the thoracic spine to the opposite side. The anatomists’ view that trunk rotation takes place mainly in the thoracolumbar junction was refuted by Singer & Giles (1990). They demonstrated directly by means of CT during trunk rotation that the rotation occurring in this segment was hardly any greater than that in the neighboring thoracic and lumbar motion segments. We confirmed these findings using AP films of trunk rotation taken in the sitting position with fixed pelvis. We demonstrated that scoliosis with rotation occurs in the entire lumbar spine (see Figure 3.19).
Just as side-bending (scoliosis) of the trunk is combined with rotation, so rotation of the trunk is accompanied by side-bending. In principle, movement of the spine occurs by coupled movements in all three planes.
Functional anatomy and radiology of the spinal column
Chapter 3
The ribs
Figure 3.19 • Right rotation with right lumbar scoliosis
during right rotation of the trunk in the sitting position, with fixed pelvis.
Another transition region which is commonly the site of dysfunctions is the cervicothoracic junction down to T3/T4; this is where movements of the head and neck end, as is most clearly seen in ante- and retroflexion. The same is true for sidebending and rotation, though it is evident only in erect posture. One possible reason for the frequency of dysfunctions in this region may be that it is the point of transition between the most mobile section of the spine and the least mobile section. Another is that this is the site where the powerful muscles and tendons of the upper limbs have their origin. The middle thoracic spine is an important transitional region, because this is where the cervical erector spinae muscle ends and the lumbar portion of the muscle begins. Around T5, therefore, the apex of the thoracic curvature of the spine, is the weakest point of the muscles of the back. All transitional regions are rich in anomalies. There may be rudimentary ribs at T12 or lumbar ribs at L1; cervical ribs at C7 or enlarged transverse processes at C7 are quite common. It is rare, on the other hand, for the first rib at T1 to be absent. The uncinate process at C7 may sometimes be absent on one or both sides.
The ribs articulate with the vertebrae at the costovertebral and costotransverse joints. The head of the rib articulates with the superior border of the body of the corresponding vertebra and with the inferior border of the next vertebral body above. The tip of the head of the rib (crista capituli) is attached to the intervertebral disk by ligaments. The third rib therefore articulates with the bodies of T2 and T3, and is attached to the T2 intervertebral disk. Exceptions to this rule are the first rib, which articulates exclusively with the body of the first thoracic vertebra, and the last two floating ribs, which are attached simply by a syndesmosis to the rudimentary transverse processes of the corresponding last thoracic vertebrae. Rib movement occurs about an axis running from the head of the rib through the neck of the rib to the costotransverse joint. In the upper thoracic spine, this axis is horizontal in the frontal plane. The movement about this axis causes the thorax to rise and fall and the sternum to undergo a pumping motion. In the inferior thoracic spine, the axis runs in an oblique, laterodorsocaudal direction, and produces a wing-like movement. At the last floating ribs there is no joint, so there will be no motion restriction here. If pain occurs here it is due to muscle attachments, especially that of the quadratus lumborum. The articulation between the ribs and sternum is often painful; this too is usually due to muscle attachments with TrPs in the pectoralis and scalene muscles.
3.4.2 X-ray anatomy of the thoracic spine X-ray imaging of the thoracic spine demonstrates the structural details less clearly than imaging of the lumbar spine. In the AP view (see Figure 3.20) the vertebral bodies, pedicles, and spinous processes can be clearly seen. The joint spaces are not visible because they lie in the frontal plane; the laminae of the vertebral arches and the superior and inferior articular processes can also not be seen. The spinous processes are angled downward. As a result, from about T4 to T10 the tip of the spinous process is projected onto the body of the next vertebra below. The characteristic feature of the thoracic spine is the costovertebral joint. The head of the rib can 59
Manipulative Therapy
Figure 3.20 • Anatomical structures of the thoracic spine. (A) AP radiograph. (B) Dorsal aspect of the thoracic spine. 1, Spinous process; 2, pedicle; 3, rib; 4, transverse process; 5, costotransverse joint.
be seen in close contact with the intervertebral disk and, laterally to it, the neck and tubercle of the rib are superimposed on the transverse process. The costotransverse joint space usually runs at a steep angle from dorsocranial to ventrocaudal, so is difficult to visualize much or at all. Sometimes, especially in the lower thoracic region, the joint space runs more dorsoventrally and horizontally, and is then easily seen. In this case the superimposed rib lies approximately on the transverse process. The first rib articulates only with the first thoracic vertebra. The two last ribs only contact the rudimentary transverse processes of the last thoracic vertebrae. The sternum and sternocostal joints are not generally visualized when the usual technique is used. In the lateral view (see Figure 3.21) the ribs and structures of the lungs are superimposed on the vertebral bodies and disks. At the vertebral arches this superimposition is still more troublesome. Nevertheless, if the film is technically successful enough to give good visualization, the pedicles and intervertebral foramen are easily seen. The foramen opens ventrally at an angle of approximately 15° to the frontal plane, but there need be little distortion 60
if the lateral projection is set up accurately. The joint space and articular processes are clearly visualized. The ribs are superimposed on the laminae and the greater part of the spinous processes, although the tips of the spinous processes can be seen if the image is good. The superior portion of the thoracic spine (approximately above T3) is completely hidden in the lateral projection and can only be demonstrated using oblique views or by tomography. It can sometimes be difficult to identify which thoracic vertebra is which in the lateral view, as T1 cannot be seen and it is hard to be sure of identifying T12, because the last rib can sometimes be rudimentary. It is therefore useful to look for the inferior angle of the scapula (which is usually at the level of T7), the bifurcation of the trachea (approximately at T5), the arch of the aorta (level with T4), and the dome of the diaphragm (usually level with T10).
3.4.3 Evaluating functional aspects The curvatures of the spine are important here as they are in all sections of the spinal column.
Functional anatomy and radiology of the spinal column
Chapter 3
Figure 3.21 • Anatomical structures of the thoracic spine. (A) Lateral aspect of the thoracic spine. (B) Radiograph, lateral
view. 1, Inferior articular process; 2, joint space; 3, superior articular process; 4, intervertebral foramen; 5, pedicle; 6, rib; 7, transverse process.
Scoliosis and increased kyphosis are the most frequent findings. It is always useful to know whether the curvatures are in static equilibrium. For this, the films must be taken under static conditions. It is important to note that the greater the curvature, the less the mobility and the greater the stability. Conversely, if the curve is flat, this indicates hypermobility and a tendency to instability. Dysfunctions may be associated with rotation, in which a sudden deviation is found in the line of the spinous processes (see Figure 3.20). The asymmetrical position of the spinous process is insufficient on its own to enable a diagnosis of rotation to be made; for this, there must also be a shift in the position of the pedicles in the same direction (see Figure 3.22). In the lateral view of the thoracic spine it is rare to see shifts between two adjacent vertebrae, or a lordotic or kyphotic deviation between neighboring vertebrae in cases of simple dysfunction. Kyphotic deformity, on the other hand, whose cause is morphological, does frequently occur here in the
Figure 3.22 • Schematic drawing to illustrate rotation of a vertebra.
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context of juvenile osteochondrosis (Scheuermann’s disease), following a traumatic compression fracture, or as a consequence of osteoporosis. Dysfunctions of the ribs can be recognized by changes in the spaces between them.
3.5 The cervical spine The cervical spine is the most mobile section of the whole spinal column; it is also the most vulnerable. This region is the richest in afferent proprioceptive nerves, which exercise an effect on the entire locomotor system. Dysfunctions here are therefore particularly important, and their treatment is correspondingly rewarding.
3.5.1 X-ray technique A suitable and effective technique is essential in order to obtain pictures that can be evaluated for function. The usual technique, which usually produces very poor visualization of the upper portion of the cervical spine in the lateral view and does not visualize it at all in the AP one, is not even adequate for morphological diagnosis and is completely useless for the evaluation of function. The Sandberg–Gutmann technique (Sandberg 1955) (see Figure 3.23A) best meets the requirements for a successful image in the AP projection. For this,
the patient is supine. Positioning is done using the following technique, so as to represent the patient’s posture accurately: the patient begins by sitting on the X-ray table, intergluteal cleft exactly on the midline of the table and legs extended, symmetrically side by side. Only then is the patient requested to lie down. Ask your patient to do so without use of the arms, looking straight ahead and in a completely natural manner. To check that the finding is representative rather than chance, this procedure may be repeated. If the head regularly deviates to one side, this must not be corrected; instead you should adjust the cassette and the X-ray tube accordingly. If you correct the head position you might either correct or artificially produce cervical scoliosis and at the same time induce axis rotation and lateral deviation of the atlas. The film format used is either 18 × 24 cm or 15 × 40 cm; it can be helpful to include the upper thoracic spine as well. Position the cassette so as to be able to assess the upper margin of the foramen magnum, the front incisors and, caudally, at least T1. This is usually achieved when the upper edge of the cassette is aligned slightly craniad to the patient’s external ear. Ask the patient to open her mouth as wide as possible and place a cork between her front teeth. The patient should then draw in her chin until the forehead (glabella) and upper lip (filtrum) are on the same horizontal plane. For this, a pillow beneath the head is often necessary, except when the patient is a child.
Figure 3.23 • X-ray technique for the cervical spine according to Sandberg–Gutmann. (A) Alignment of the central ray for the AP projection with the aid of a string. (B) Alignment for the lateral view of the cervical spine.
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Now the X-ray tube can be centered. The central ray must be aligned through a point one finger’s breadth below the upper premolars to a point one finger’s breadth above the palpable inferior border of the occiput (posterior margin of the foramen magnum) in the midline. Either a light field indicator or a piece of string running from the center of the focal spot to the appropriate position on the patient’s face can be used for this alignment. The X-ray tube is then aligned so that the line of the central ray is an extension of that of the string (or light) (see Figure 3.23A). For edentulous patients, the central ray is aligned through a point one finger’s breadth below the maxilla to the border of the occipital squama, and in infants who do not yet have teeth, from the inferior border of the maxilla to the border of the occipital squama. Finally, correct any rotation of the patient’s head since this would make the film hard to evaluate. This projection can also be taken with the patient seated, aligning the beam in an analogous manner. This approach is slightly more difficult but has the advantage of being performed under static conditions. Nevertheless, there can be an advantage in having taken the AP projection with the patient supine and the lateral one with the patient seated, if the findings reveal discrepancies. It is always possible then to perform an additional AP view taken in the sitting position. One objection to the open-mouth technique is that the mandible is superimposed on the mid-cervical spine. This problem can be avoided if the patient rapidly opens and shuts her mouth while the film is being taken; in this way the shadow of the mandible is blurred. The risk in this case is that there will be slight associated movement of the head, which might cause blurring of the image at the craniocervical junction. For the lateral view the patient is seated relaxed in front of a vertical stand (see Figure 3.23B). The film may be 18 × 24 cm or 24 × 30 cm, and must be placed so that the image demonstrates the cranial base as far as the sella turcica, and the cervical spine down to the cervicothoracic junction. In subjects with very tapering shoulders it will also be possible to include the first thoracic vertebra. The patient’s gaze should be fixed on a distant object at eye level, maintaining the hard palate horizontal. Take care that there is no inclination or rotation of the patient’s head, so that the two mandibles are exactly superimposed. This is necessary for accurate assessment of the film. Do not align the central ray on the mid-cervical region as is usually done, but on the tip of the mastoid process. The light field indicator can be used for this. It is best to use a film-focus distance of
Chapter 3
1.5 meters or more. This produces an undistorted image of the cranial base and the entire cervical spine and also evens the exposure; the density of the cranial base means that it demands more irradiation than the cervical spine.
X-ray films of the cervical spine that do not provide good visualization of the atlanto-occipital and atlantoaxial joints and cranial base and of the cervicothoracic junction are inadequate for the evaluation of function.
3.5.2 Assessment of X-ray films The technique described here provides sufficient criteria to evaluate all the images and to repeat them for comparison, even if all structures are asymmetrical. In the AP projection (see Figure 3.24) the first task is to make sure that both
Figure 3.24 • Anatomical structures of the craniocervical
junction, anteroposterior view. 1, Inferior border of the clivus; 2, foramen magnum; 3, occipital condyle; 4, inferior border of the anterior arch of the atlas; 5, lateral triangle; 6, foramen transversarium of the axis; 7, inferior contour of the occipital squama; 8, medial lucency of the atlas; 9, transverse process of the atlas; 10, inferior border of the posterior arch of the atlas; 11, pedicle of the arch of the axis; 12, lamina of the axis (superior border).
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occipital condyles, the atlas, and the axis are well visualized, and whether it is possible to look into both foramina transversaria (which give passage to the vertebral artery). At the caudal end, ensure that at least the first thoracic vertebra is included in the image. Next the centering should be checked, to make sure that the image is straight. If the positioning is correct, the middle point between the incisors should be vertically in line with the middle of the dens of the axis and of the occipital squama. The tip of the chin will be projected onto the middle of the cervical spine, which must run symmetrically between the two rami of the mandible. The position of the mastoid processes should also be symmetrical. In order to evaluate the inferior part of the cervical spine, it is necessary to ensure that the superior thoracic spine is not rotated. In the lateral projection (see Figure 3.25), first ensure that the cranial base, including the sella turcica and hard palate, can all be seen. If possible the cervical spine should be shown as far down as C7, although this is often not possible in heavily built patients or those with high shoulders. Check that the alignment is perfect before beginning to evaluate the findings on the film. It is particularly
important that the line of the hard palate should be horizontal. Fineman et al (1963) showed that a difference of only 10° in inclination of the head is sufficient to change lordotic to linear posture, or even to change it to the extent that lordosis becomes kyphosis. It is important that the two halves of the mandible should overlie each other exactly. If the vertical borders of the rami appear projected side by side, the head is rotated to one side. Projection of the horizontal line of the mandible one above the other indicates that the head is inclined to one side. Another sign of rotation is if the shoulders are projected apart. The oblique projection (for which the patient adopts a position turned at an angle of 45°) gives the clearest imaging of the intervertebral foramina. This projection is indicated especially for radicular syndromes and vertebral artery syndrome. As recommended by Gutmann (1956), this projection should be taken with the patient’s head in retroflexion, because this more clearly displays any narrowing of the intervertebral foramen. It is also recommended to take it not with the patient’s back to the cassette, but with the patient facing toward it (see Figure 3.26).
Figure 3.25 • Lateral view of the cervical spine, indicating
the plane of the foramen magnum, of the atlas and of the axis. Dotted lines indicate the clivus and basion (white), and the posterior border of the spinal canal (black).
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Figure 3.26 • Oblique view of the cervical spine showing a narrowed intervertebral foramen of C5/6.
Functional anatomy and radiology of the spinal column
3.5.3 Functional anatomy of the cervical spine The cervical spine has two distinct sections: the atlanto-occipital and atlantoaxial joints, and the rest of the cervical spine from C3 to C7; nevertheless it is a functional unity, since all the movements it performs originate at the atlanto-occipital and atlantoaxial joints, these movements being anticipated by eye movements. The anatomical description will accordingly be treated in separate sections. The function of the cervical spine will then be dealt with as a whole.
Functional anatomy of C3–C7 As in other parts of the spinal column, the degree of mobility in the cervical spine corresponds to the thickness of the intervertebral disk, which is greatest in the segments C3/C4 and C4/C5. The characteristic feature of the cervical spine is the raised lateral margins of the vertebral bodies, the uncinate processes. The disk therefore thins laterally, with the consequence that thinning of the disk brings about contact in this lateral region. This is where early degenerative changes occur, tending to form unco vertebral joints (neoarthroses). The position of these is very close to the intervertebral foramen. The significance for cervical function is that the shape of the vertebrae with their lateral margins limits sidebending and favors ante- and retroflexion. The intervertebral joints are almost parallel, inclined at an angle of about 45° from ventrocranial to dorsocaudal. The angle is greatest at C2/C3. In this segment the joints are frequently not parallel but arranged as if on the circumference of a cylinder with its center behind the vertebra; it is therefore not pathological if the joint space at C2/C3 is less clearly delineated than in the other segments of the cervical spine in the lateral projection. As a general principle, laterally the joints in the lordotic section of the cervical spine are inclined slightly posteriorly and in the kyphotic section slightly anteriorly. According to Janda (2002) the transition from the one to the other occurs roughly at C3/ C4. The inclination of the intervertebral joints in the sagittal plane means that side-bending produces rotation, the two kinds of movement being coupled. Similarly, rotation brings about side-bending, always to the same side (see Figure 3.30A and B). During anteflexion, a slight ventral shift of the cranial partner vertebra relative to its caudal neighbor is
Chapter 3
often observed. In retroflexion there is a slight caudad shift. This too is associated with the inclination of the joints. Penning (1968) describes this motion as a rotation of the upper vertebra relative to the lower one, around a frontal axis in the dorsal part of the vertebral body. Experience shows this motion to be physiological, as long as it occurs evenly in the motion segments of the cervical spine. It is regularly seen in young subjects with good mobility. If it is not observed in less mobile, older patients, this absence is not pathological. The shift is greatest between C2/C3 (see Figure 3.32 B and D) where the range of motion is least in adulthood. It is also important to note that the cervical spinal canal lengthens considerably during anteflexion, shortening during retroflexion. This produces a significant movement of the meninges and dural sheaths of the nerve roots relative to the spinal cord, which becomes longer and thinner in anteflexion and shorter and thicker in retroflexion. The course of the vertebral artery also has an important role. This enters its bony canal at C6, passing upward through the intervertebral foramina in close contact with the intervertebral joints and uncinate processes almost at right angles to the course of the nerve roots. Therefore, as the intervertebral foramen (canal) narrows in retroflexion, this may affect both the nerve root and the vertebral artery.
Functional anatomy of the craniocervical junction In order to understand function it is important to look first at the anatomy of the individual articular structures and ligaments. The superior articular surfaces of the atlas run obliquely from dorsolateral to ventromedial. The facets are oval in shape, converging anteriorly like a section of the surface of a sphere with its center located above both articular surfaces. The most important movement of the atlanto-occipital joint is ante- and retroflexion of about 16° (see Figure 3.27). Gliding of the
Figure 3.27 • Diagram to illustrate ante- and retroflexion between the occipital condyles and the atlas.
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Figure 3.28 • AP X-rays of an isolated axis: (A) in neutral position and (B–H) in various positions of rotation. These images provide a suitable reference for evaluating X-ray films.
occipital condyles occurs in the dorsal direction during anteflexion and in the ventral direction during retroflexion. Very slight rotation is also possible, which Jirout (1981) was able to demonstrate as a synkinetic movement during side-bending of the head. Slight side-bending is also possible, coupled with rotation in the opposite direction. The atlantoaxial joint is made up of the articulation between the anterior arch of the atlas and the dens of the axis, between the dens and the transverse ligament of the atlas with its articular cartilage, and between the lateral mass of the atlas and the body of the axis. Its main function is that of rotation, and it also performs ante- and retroflexion. All these articulations participate in rotation. On one side the lateral mass of the atlas glides ventrally on the body of the axis, rising as it does so, while on the other side the lateral mass of the atlas glides dorsally and downward. The rotation is limited by the joint capsules and the strong alar ligaments, which have their attachment to the margins of the foramen magnum. The average range of motion of this rotation (our own results) is 25° in each direction, although we have found a range of motion up to as much as 40° (see Figure 3.28). Dvorák, using CT, even obtained average measurements of 41.1° to the right and 44° to the left. Huguenin, on the other hand, in measurements made using CT, obtained figures corresponding to our own. 66
Figure 3.29 • X-ray film of rotation between atlas and axis. With the subject erect and head fixed, the subject’s body was turned in maximum rotation counter to the sagittal beam (here at 40° axis rotation).
Ante- and retroflexion between atlas and axis is considerable, amounting on average to 15°. The anterior arch of the atlas slides up and down on the dens of the axis, while the atlas itself performs a tipping motion (see Figure 3.29).
Kinematics of the cervical spine Rotation Rotation begins between the atlas and the axis and the movement takes place mainly there until
Functional anatomy and radiology of the spinal column
the range of motion in this segment is exhausted, that is to about 25° to each side. Up to this point the head rotates about a vertical axis in the horizontal plane. From this point onwards the other segments participate in succession in the rotation movement, from C2/C3 to C6/C7, as long as the cervical spine is in a position of slight kyphosis. If the neck is completely upright the cervicothoracic junction also rotates, down to and including T3. In passive rotation there is still some slight additional rotation between the atlas and the occiput. The moment rotation below C2 begins, the inclined course of the intervertebral joints brings about simultaneous lateroflexion to the same side unless the subject deliberately resists this synkinesis.
Side-bending Side-bending can be studied only by X-ray, hence the decision to deal with it under functional radio graphic studies (see Figure 3.30). Like rotation, it begins at the atlanto-occipital and atlantoaxial joints. This can be demonstrated by looking at the craniocervical region in passive side-bending (‘side-nodding’). This shows that side-bending starts with rotation of the axis relative to the atlas. At the same time we find a synkinesis in which the atlas shifts relative to the occipital condyles and C2 in the direction of the side-bending (see Figure 3.30C). During this side-bending the cervical spine rotates, maximum rotation occurring at C2. Jirout (1968) demonstrated that this rotation is absent in the lower cervical spine during side-bending to the right, but during side-bending to the left it continues down into the upper thoracic spine. He explains this as being due to the stronger pull of the muscles of the shoulder girdle on the right side, whose attachment to the spinous processes exerts a pull to the right and so brings about left rotation. This combination of side-bending and rotation is consistent with the positioning of the intervertebral joints, although this cannot be the true cause, as is usually thought, because the side-bending originates at the axis. This rotates even with the slightest side-bending, followed by the other segments. If rotation of the axis does not take place, there is no rotation of the rest of the cervical spine (see Figure 3.47B) According to Jirout (1968), the forces that bring about axis rotation are the product of side-bending
Chapter 3
of the head (see Figure 3.31). Side-bending of the head involves rotation of the head about a sagittal axis at the level of the root of the nose. This creates a pull on the spinous process of the axis, which causes rotation of the axis with simultaneous tipping in the sagittal direction. This tipping motion in the sagittal plane, which takes place both in side-bending and in rotation, is, according to Jirout (1968), the joint play of the cervical spine. The sideways shift of the spinous process can easily be palpated, and occurs as soon as the subject’s head inclines to the side even to a slight degree. Interestingly, Gaymans (1973) demonstrated that a shifting of the spinous process of the axis (rotation of the axis) occurs even on mere leaning against slight resistance in the neutral position and with minimum pressure, thus simply through the pull of the muscles. He obtained radiological evidence of this.
Rotation of the axis on side-bending of the cervical spine is not simply the combined result of rotation movements of the individual vertebrae, due to the inclination of the zygapophysial joints of C7, C6, etc.; on the contrary it results from the inclination of the head itself, in which the head rotates about a sagittal axis and exerts a pull on C2. If there is no rotation of the axis, there is also no rotation of the other vertebrae of the cervical spine during side-bending. At the same time there is a tipping motion in the sagittal plane, so that the movement occurs in a coupled way in all three planes.
Anteflexion and retroflexion Two distinct kinds of anteflexion should be distinguished. The first is a nodding movement limited to the atlanto-occipital and atlantoaxial joints. The other is a forward flexion involving the entire cervical spine. This distinction does not exist for retroflexion. The two kinds of anteflexion of the head are to some extent mutually exclusive. If we draw the chin in toward the chest (forward nodding), this usually inhibits full anteflexion. If we drop the head far forward in anteflexion, this renders nodding more difficult except in hypermobile subjects. The explanation lies in the tipping mechanism of the atlas. 67
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Figure 3.30 • AP X-ray of the cervical spine of a healthy subject, to compare the (asymmetrical) neutral position, active
side-bending, and passive ‘side-nodding.’ (A) In neutral position the atlas is to the right in relation to the condyles and axis; the plane of the condyles and that of the axis therefore converge on the right, with the axis rotated about 5° to the left. (B) In active side-bending to the left the atlas is still slightly to the right, and the plane of the condyles and that of the axis still converge to some extent to the right, while the axis is now more markedly rotated (about 10°) to the left. (C) In passive ‘side-nodding’ to the left, the atlas is now clearly to the left of the condyles and the plane of the condyles and that of the axis are parallel. The axis is rotated about 10° to the left. Transmission of the axis rotation to the next vertebra below can clearly be seen. (D) Diagram to illustrate the rotation of C2.
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Chapter 3
spine according to Jirout (1968). During side-bending the head inclines about a sagittal axis (x) passing through the anterior cranial fossa. The diagram shows how the cranial base, together with the occipital condyles, shifts relative to the atlas in the opposite direction to the side-bending, and how the axis, together with the lower cervical vertebrae, is brought into rotation in the direction of the side-bending, while the axis is tilted ventrally by a cranial pull on the spinous process.
atlanto-occipital and atlantoaxial joints are in maximum anteflexion. • In maximum anteflexion (see Figure 3.32C), the cervical spine is almost horizontal; there is a proportional slight ventral shift of the individual cervical vertebrae up to C2. Anteflexion between C1 and C2 is at its maximum. In contrast to the situation in the erect posture and in forward nodding there is now retroflexion of the head relative to the atlas, which can be greater than in retroflexion with the subject seated. Anteflexion of the atlanto-occipital and atlantoaxial joints is thus reduced as compared to forward nodding, closer to the degree of anteflexion in the erect posture. Consequently the angle between the clivus and dens is usually the same with the head erect as during maximum anteflexion. There is also a forward shift of the clivus (basion), together with the atlas, relative to the tip of the dens. • In maximum retroflexion with the subject seated (see Figure 3.32D), there is maximum retroflexion of the atlas (relative to the axis). Retroflexion of the cranium, on the other hand, is seldom at its maximum (it is usually very little greater than during anteflexion of the head). Here, too, we see a proportional dorsal shift of the individual cervical vertebrae from C7 to C2 and of the clivus and atlas relative to the tip of the dens. • In passive retroflexion with the subject sidelying and so without the effect of gravity (see Figure 3.32E), there is now maximum retroflexion of the head relative to the atlas, while retroflexion of the atlas relative to C2 is even less than in the erect posture. There is no dorsal shift of the basion with the atlas.
The following changes can be observed in X-ray studies of anteflexion and retroflexion (see Figure 3.32): • In the erect posture (see Figure 3.32A), the atlas is already in a position of slight retroflexion with an average angle of about 5°. • During forward nodding (see Figure 3.32B), anteflexion of the atlas increases only slightly. This movement causes an anteflexion of the head (the plane of the foramen magnum); in the erect posture the head had been in a position of anteflexion relative to the atlas. In this position the
The mechanism underlying these processes, which appear paradoxical at first sight, has been termed the tipping of the atlas. It is based on the following (see Figure 3.33): in anteflexion with the subject sitting, as soon as the center of gravity of the head shifts ventrally, the occipital condyles exert pressure on the anterior, rising part of the concave articular surface of the atlas. This causes the atlas to tip forward and downward. There is an analogous process in retroflexion with the subject sitting: the atlas tips backward. This does not happen, however, with the subject lying on one side, which explains why in this case retroflexion of the occiput relative to the atlas attains its maximum.
Figure 3.31 • Mechanism of side-bending of the cervical
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Figure 3.32 • Ante- and retroflexion of the cervical spine. (A) Erect posture. (B) Forward nodding. (C) Maximum anteflexion. (D) Maximum retroflexion. (E) Passive retroflexion.
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Chapter 3
Figure 3.33 • Diagram to illustrate tipping of the atlas: 1, in erect posture; 2, in ‘forward nodding’; 3, in maximum anteflexion; 4, in maximum retroflexion; 5, in passive retroflexion.
3.5.4 X-ray anatomy of the cervical spine Anteroposterior view The AP view (see Figures 3.34 and 3.35) shows the arc of the anterior margin of the foramen magnum,
at the cranial end of the cervical spine. Its superior border is formed by the clivus and its lateral part by the occipital condyles. Beneath the condyles lie the two articulations of the atlanto-occipital joint, meeting at an angle of about 125–130°. Below the condyles, to either side of the dens of the axis, can be seen the lateral masses of the atlas. These are wedge shaped, tapering towards their medial
Figure 3.34 • The cervical spine (ventral aspect) to enable comparison of the anatomical structures. (A) Skeleton. (B) AP X-ray. 1, Anterior margin of the foramen magnum; 2, inferior border of the anterior arch of the atlas; 3, foramen transversarium; 4, intervertebral foramen; 5, course of the vertebral artery; 6, uncinate process; 7, pedicle of the vertebral arch.
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Figure 3.35 • The cervical spine (dorsal aspect) to enable comparison of the anatomical structures. (A) Skeleton. (B) AP
X-ray. 1, Foramen transversarium; 2, inferior border of the posterior arch of the atlas; 3, lateral mass of the atlas with lateral triangle, 4; 5, joint space; 6, spinous process.
border. Close to this border we often see a medial lucency which should be interpreted as a normal finding. Laterally to the lateral mass, the transverse processes can be seen. It is sometimes possible to see into the foramen transversarium, which gives passage to the vertebral artery. The spindle-like posterior arch (broadest in its medial portion) can be traced from one transverse process to the other. It separates the ‘lateral triangle’ from the lateral mass. Sometimes the anterior arch can also be seen, projected across the tip of the dens. The inferior contour of the lateral mass forms the superior articular surface of the joint between C1 and C2. At the medial border of the joint facet of the axis there is a tiny notch marking the border of the dens. The tip of the dens usually lies well below the superior border of the foramen magnum. Just below the lateral end of the superior joint facets of the axis is the foramen transversarium. Medial to this foramen, the point-like projection of the pedicles of the axis can be seen. From here can be traced the shadow of the arch of the axis on both sides, through to the spinous process. If there is hyperlordosis it is sometimes possible to see into the spinal canal above the arch of the axis. Below the axis can be seen the typical cervical vertebrae with their characteristic uncinate process either side. This causes the intervertebral disk to be 72
much higher medially than laterally. Beneath the unciform processes lies the shadow of the pointlike pedicles. The spinous processes can be seen in the midline and the lateral contour is formed by the transverse processes. The intervertebral foramen is visible, but less clearly. Rarely, the intervertebral joint space can be seen.
Lateral view The lateral view (see Figure 3.36) offers an undistorted image of the cranial base and the atlantooccipital and atlantoaxial joints. The clivus can be followed in its entirety down from the sella turcica to the anterior margin of the foramen magnum (basion) which is situated directly above the tip of the dens. The posterior margin of the foramen magnum (opisthion) cannot always be clearly distinguished from the squama of the occipital bone; it helps to follow the posterior margin of the cervical spinal canal from caudad to craniad. Where the arc-shaped prolongation of this margin meets the occiput is the opisthion. The mastoid process frequently overlaps the condyle and atlanto-occipital joint; therefore this joint is not always visualized in the lateral view, although it is often clearly seen (see Figure 3.37).
Functional anatomy and radiology of the spinal column
Chapter 3
Figure 3.36 • The cervical spine (lateral aspect) to enable comparison of the anatomical structures. (A) Skeleton.
(B) Lateral X-ray. 1, Transverse process; 2, width of the spinal canal; 3, joint space; 4, inferior articular process; 5, intervertebral foramen; 6, superior articular process.
The plane of the foramen magnum can be established by drawing a line from the basion to the opisthion on the posterior margin of the foramen magnum. The plane of the atlas corresponds to a straight line through the middle of the anterior and posterior arches of the atlas.
The plane of the axis lies on a straight line linking the inferior border of the transverse processes and the inferior border of the spinous process. These lines are used to determine the ante- or retroflexion of the occiput, atlas, and axis (see Figures 3.25 and 3.38).
Figure 3.37 • Atlanto-occipital joint, lateral view.
Figure 3.38 • Anteflexion of the atlas (relative to the axis).
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The dens of the axis is projected just behind the anterior arch of the atlas. The tip of the dens is usually at the same level as the superior border of the anterior arch of the atlas. It should not be much above the palato-occipital line; this is the case in basilar impression. In this section of the spinal column, unlike the others, the pedicles and transverse processes are projected onto the vertebral bodies in the lateral view but not in the AP view, because here the spinal canal is wider than the vertebral bodies. The superior border of the transverse processes lies slightly above the superior end-plate of the vertebral bodies, which can cause them to appear somewhat blurred. In the lower cervical spine the shadow of the transverse processes lies more in the dorsal direction and in the superior cervical spine more ventrally; at C2 the position of this shadow of the transverse process is such that its anterior border overlies the anterior border of the vertebral body. The shadows of the articular processes and joint spaces are projected behind the vertebral bodies. If the projection is well executed, all that can be seen is a lucency, showing that the joints are essentially parallel. This need not be so at C2/C3, where it can be quite normal to see some fuzziness of outline. The posterior margin of the spinal canal corresponds to a line linking the bases of the spinous processes (posterior border of the vertebral arch) – a rule that thus also applies to the atlas, which does not have a spinous process. If, however, this shadow is absent at the atlas, this is a sign of spina bifida atlantis, a frequently-found anomaly.
3.5.5 Evaluation with respect to functional implications The most characteristic disturbance of statics in the cervical region is the forward-drawn posture (see Figure 3.39). Even when statics are normal, the centre of gravity of the head is slightly in front of its support, so that electromyographic studies reveal a slight degree of muscular activity in the nuchal muscles even with the subject in normal erect posture. As soon as there is any forward inclination (not flexion!), whether of the entire body or of the neck alone, tension can immediately be palpated in the muscles of the back of the neck. The forwarddrawn position therefore creates overload of the cervical spine and compensatory hyperlordosis at 74
Figure 3.39 • Typical forward-drawn position of the head.
the atlanto-occipital and atlantoaxial joints, and tension in the short extensor muscles of the neck. In order to demonstrate the patient’s natural posture radiographically, lateral projections should be taken with the subject seated in a relaxed manner, in a backless chair, as described by Gaizler (1973). It is important to ensure that the patient remains relaxed, with gaze fixed on an object at eye level, so that there is no anteflexion of the head despite the natural posture. We took projections of a group of 50 patients with the patients in erect posture (kneeling), and sitting both upright and relaxed. Whereas with the subject sitting upright the external auditory meatus was projected almost exactly above the anterior border of C7, in the erect posture it was 7 mm in front of C7, and sitting relaxed it was projected forward by 16 mm; in individual cases even by 5 cm. This was particularly the case where a patient’s relaxed sitting position involved lumbar kyphosis. In addition to disturbances of statics, localized irregularities can be observed. Examples of these are slight relative shifts in neighboring vertebrae or local lordotic or kyphotic deviations. In the
Functional anatomy and radiology of the spinal column
craniocervical region the atlas may be in a position of ante- or retroflexion in relation to the axis. The older expressions ‘atlas superior’ or ‘atlas inferior,’ which were adopted by chiropractors, are less appropriate because they refer to the position of the atlas relative to the occiput rather than the axis, whereas the criterion being assessed in the rest of the spine is always the position of the upper of two vertebrae relative to the one below it. The tipping of the atlas means that the atlas is usually in a slightly retroflexed position if there is cervical lordosis, with the occiput in anteflexion; if the posture is kyphotic the atlas would be in anteflexion and the occiput in retroflexion (see Figures 3.33, 3.39 and 3.40). Other frequent findings are the rotation of several vertebrae (see Figure 3.46) and, in the region
Chapter 3
of the atlanto-occipital and atlantoaxial joints, lateral shifting, an asymmetrical position of the condyles relative to the atlas, and of the atlas in relation to the axis. This is often described as a shift of the atlas to one side relative to the condyles and to the axis, which is not quite appropriate: the description should always be given in terms of the upper element relative to the lower. The description in this case would not be of the atlas to the right relative to the condyles and axis, but of the atlas to the right relative to the axis, and the condyles to the left relative to the atlas (see Figures 3.41–3.43). Isolated rotation of the atlas in relation to both the occiput and the axis is fairly uncommon. The joint space between atlas and axis is narrower on the side of rotation, the lateral triangle of the lateral mass becomes larger, the center of the posterior arch is shifted in the opposite direction to the rotation, and the lateral mass becomes larger on the side opposite to rotation. Much more frequent than rotation of the atlas is axis rotation in neutral posture (see Figure 3.44). A 5° or occasionally even 10° rotation of the axis is not unusual. Interestingly, the rotation of the axis is caudally transmitted, down to the rest of the cervical vertebrae and even down as far as the cervicothoracic junction, particularly when rotation is to the left. This can happen even in the simple case of lateral deviation of the spinous process. The mechanism clearly seems to be the same as that discussed in connection with side-bending, which brings about left rotation of the lower cervical spine and cervicothoracic junction.
Figure 3.40 • Kyphotic posture of the mid-cervical spine
with balanced body statics: the external auditory meatus and the dens of the axis are not projected in front of the anterior border of C7. The position of C7 is consistent with a flat thoracic spine.
Figure 3.41 • Diagram to illustrate the asymmetrical position of the atlas relative to the occipital condyles and the axis.
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Figure 3.42 • (A) Asymmetrical position of the atlas relative to the occipital condyles and axis. (B) After manual therapy the position is symmetrical.
Figure 3.44 • Dextrorotation of the axis. (A) X-ray. (B) Diagram.
Figure 3.43 • Dextrorotation of the atlas. (A) X-ray. (B) Diagram.
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Figure 3.46 • Rotation of the cervical spine: X-ray, lateral view. The joint spaces, articular processes and transverse processes are projected apart.
Figure 3.45 • Schematic drawing to illustrate the rotation of a cervical vertebra in the AP view.
The characteristic features of axis rotation in the AP view are the deviation and position of the pedicles and the spinous process to that of rotation. The foramen transversarium widens on the side of rotation and the joint space narrows on the opposite side. Rotation of the other cervical vertebrae is characterized not only by the deviation of the spinous process and rotation of the pedicles to the opposite side, but also by distortion of the unciform processes (see Figure 3.45). In the lateral view, the structures that usually overlap are projected apart. This applies particularly to the joint spaces,
together with the articular processes and transverse processes. At C2 one transverse process is projected in front of the vertebral body (see Figure 3.46). An important sign of static disturbance is discrepancy between the AP view taken with the patient supine and the lateral view with the patient sitting, in particular if there is rotation in the view taken sitting and none at all in the AP view with the patient supine. The cause may be an oblique plane below the cervical spine.
3.5.6 Movement studies Radiographic movement studies are used to investigate restrictions and hypermobility. X-rays are taken in ante- and retroflexion and side-bending. Rotation is less studied by this method because interpretation is difficult. 77
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The physiological reaction of the cervical spine during side-bending has been described in Section 3.5.3. The study of side-bending is useful in the diagnosis of movement restrictions. We
find that if there is no rotation of the axis, there will be none in the rest of the cervical spine (see Figure 3.47). Even if, on side-bending, an asymmetrical spinous process of the axis fails to
Figure 3.47 • (A) Neutral position. (B) Side-bending with absence of axis rotation. Rotation of the other motion segments is also absent. (C) After treatment, rotation of the axis is restored and the other motion segments now also rotate. The extent of side-bending has also increased.
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Functional anatomy and radiology of the spinal column
Chapter 3
It is not usually difficult to demonstrate a restriction of side-bending between the atlas and axis. When this is done, rotation is (also) seen to be blocked (see Figures 3.47 and 3.49). The radiological evidence of restriction in the other motion segments of the cervical spine is much more difficult to achieve. According to Jirout (1971) side-bending is accompanied by slight synkineses in the sagittal plane, consisting of ante- and retroflexion movements that can be recognized by a change in the position of the spinous processes relative to the vertebral bodies. Comparison of the films taken before and after manipulation found a more marked reaction of these synkineses in restrictions than actual side-bending as seen radiographically. To summarize: Figure 3.48 • Schematic drawing to illustrate the effect
of asymmetry of the spinous process of C2 on the caudad vertebrae during side-bending. (A) Neutral posture with spinous process of the axis to the right of the midline. (B) On inclination to the right the axis rotates to the right in the normal way, but the asymmetrical spinous process travels no further than the midline. The vertebrae below therefore remain in the central position and do not rotate.
reach any further than the midline, the rest of the cervical spine will not rotate. This demonstrates that the rotation is transmitted through the spinous processes in a caudal direction. Lack of rotation in the lower cervical spine does not in any way impair rotation above the restriction (Jirout 1972) (Figure 3.48). Although lateral shifting of the atlas occurs in side-bending, this shifting can sometimes be absent without implying any movement restriction, especially if there is marked asymmetry. More importantly, the shifting may still be seen in the radiographic image even in cases where there is restriction. If there is restriction blocking axis rotation, no side-bending occurs at the atlanto-occipital and atlantoaxial joints (see Figure 3.49). This is in keeping with the fact that in cases of atlas assimilation, side-bending at the craniocervical junction occurs in the normal way. This raises the question as to whether restriction between occiput and atlas on side-bending can be demonstrated radiographically at all. We have shown this to be possible (Lewit & Krausová 1967) with the head rotated to the side, locking the atlas/ axis motion segment. This is necessary to obtain an accurate diagnosis.
• Lateroflexion of the head against the cervical
spine (side-bending; ‘side-nodding’) is mainly performed by means of rotation of the axis relative to the atlas. Normalization of sidebending at the atlanto-occipital and atlantoaxial joints also normalizes this rotation. • Lateroflexion between occiput and atlas can be established radiographically and clinically only if the more mobile segment (C1/C2) is locked, that is if the head and atlas are rotated by at least 45°. The movement restriction between occiput and atlas does not affect sidebending in the frontal plane or the synkinesis between occiput and atlas during side-bending in the sense of a lateral shift accompanied by simultaneous rotation of the axis. • Ante- and retroflexion is the movement most frequently examined by X-ray. The disadvantage of this examination from the point of view of manipulation therapy is that this is the movement most frequently and preferentially performed and so the least susceptible to dysfunction. Hypermobility, on the other hand, is more readily revealed here. This can reveal increased shift between neighboring vertebrae, increased lordosis or kyphosis between neighboring vertebrae, and the following signs of hypermobility at the craniocervical junction: - Laxity of the transverse ligament of the atlas and a widening of the joint space between the anterior arch of the atlas and the dens of the axis, especially the superior part (see Figure 3.50). As a consequence the basion also shifts anteriorly. During anteflexion the distance between the anterior arch of the atlas 79
Manipulative Therapy
Figure 3.49 • Restriction of side-bending between atlas and axis. (A) In the neutral posture the position of the atlas is
slightly asymmetrical, to the left relative to the condyles. (B) On attempted left lateroflexion there is almost no side-bending at the craniocervical junction, although the atlas has moved markedly to the left. (C) After manipulation, normal lateroflexion is restored, with (slight) rotation of the axis. (D) Spontaneous side-bending to the left; position analogous to (C) with acute cervical myalgia.
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Functional anatomy and radiology of the spinal column
Chapter 3
Figure 3.50 • Increased distance between the anterior
arch of the atlas and the dens of the axis, especially in the superior part, with anterior shift of the basion.
and the dens and the angle between the clivus and the dens decreases. This happens not only on forward-nodding, but also anteflexion (see Figure 3.51). - Hypermobility between the occipital condyles and the atlas without laxity of the transverse ligament of the atlas can be recognized by a shift of the basion and opisthion in relation to the dens of the axis (see Figure 3.52).
Figure 3.52 • Hypermobility between the occiput and
atlas during ante- and retroflexion of the head. (A) During anteflexion, the basion lies above the anterior arch of the atlas and the opisthion above the posterior arch. (B) On retroflexion the occiput is shifted posteriorly by about 2 cm.
Figure 3.51 • Hypermobility of the atlas on anteflexion of the head with slackening of the transverse ligament of the atlas.
(A) Neutral posture. The articular facet of the anterior arch of the atlas lies parallel to the dens of the axis. (B) On maximum anteflexion the anterior arch of the atlas and dens of the axis create a gap that is open cranially, the basion shifts anteriorly, and the angle between the clivus and dens (obtuse) becomes noticeably smaller than in the neutral posture.
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3.5.7 Morphological changes It is not the task of this book to deal in detail with morphological and structural changes; nor is it necessary to do so, since this field forms the subject of textbooks of radiology and orthopedics. Therefore only certain aspects, the limited number of those that are particularly important from the point of view of manual medicine, are touched on here.
Anomalies Block vertebrae Block vertebrae lead to a compensatory hypermobility in the neighboring segments. The coalescence may be complete or partial, or sometimes simply consist of a hypoplastic intervertebral disk, in which case the vertebral bodies adjacent to the hypoplastic disk are narrower (see Figure 3.53). This occurs because the adjacent end-plates – between which the hypoplastic disk lies – are also the zone of
growth. This anomaly could easily be confused with the consequences of childhood rheumatoid arthritis (Still’s disease). The difference lies in the obliteration of the joints, while the vertebral arches and spinous processes are normally developed.
Cervicothoracic transitional vertebra A transitional C7 cervicothoracic vertebra with a very large transverse process or with a cervical rib is another frequent anomaly. There may also be an absence of the unciform process on one or both sides. A transitional T1 vertebra is however rare.
Spinal canal stenosis A narrow spinal canal is particularly important clinically, because it is the most important cause of cervical myelopathy. From the practical point of view in diagnosis it is more helpful to look at the change in the proportions of the individual anatomical structures than to measure the sagittal diameter of the spinal canal; the proportions of the structures can be seen at first glance. Normally, in the cervical spine, the spinal canal is wider than the vertebral bodies. In spinal canal stenosis this is not so; also (if there is no rotation in the radiograph) the articular processes overlie the entire width of the spinal canal (see Figure 3.54).
Figure 3.53 • Incomplete block vertebra (congenital
coalesence) of C5/C6 with a hypoplastic intervertebral disk and narrowing of the vertebral bodies in the region of the narrowed disk. The articular processes and vertebral arches are normally developed.
82
Figure 3.54 • Spinal canal stenosis. The spinal canal
is markedly narrower than the vertebral bodies, and the articular processes cover its entire width.
Functional anatomy and radiology of the spinal column
Basilar impression As a region of transition, the craniocervical junction, the region of the atlanto-occipital and atlantoaxial joints, is the site of many anomalies. Probably the most important of these is basilar impression (see Figure 3.55), which is the result of hypoplasia of the basiocciput. In this condition the occipital part of the clivus is shortened and therefore the dens axis appears as if shifted into the foramen magnum, so as to lie above the palato-occipital line in the lateral view (see Figure 3.55A). In the AP view the dens can be above the occipital condyles, placing it
Chapter 3
well above the line between the mastoid processes and digastric muscles (see Figure 3.55B). At the same time the foramen magnum may be narrower than usual, unless there is also an Arnold–Chiari malformation, in which case displacement of the tonsils of the cerebellum below the foramen magnum has the effect of widening it. These changes can cause syndromes associated with compression of the medulla oblongata, similar to those of spinal canal stenosis in the cervical region. Frequently basilar impression is accompanied by hypoplasia or assimilation of the atlas to the occipital bone and its condyles. Less frequently there can
Figure 3.55 • Basilar impression. (A) The lateral view shows hypoplasia of the clivus, and the dens high in the foramen
magnum. (B) In the AP view the dens of the axis is again seen in a high position. (C) Diagram: a, sphenoid part of the clivus; b, occipital part of the clivus; c, palato-occipital line; d, distance (according to Klaus 1974) of the dens of the axis from a line joining the tuberculum sellae and the internal occipital protuberance; e, plane of the foramen magnum.
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be a block vertebra involving coalescence of the axis with a lateral mass of the atlas. All the anomalies listed here are frequently asymmetrical, so that lateral displacement of the atlas and also rotated positions of the axis can be found simultaneously. In addition there can also be hyperlordosis. It is therefore little wonder that these anomalies often also lead to dysfunctions which in turn cause pain.
Hypoplasia of the dens of the axis Hypoplasia of the dens or especially the os odontoideum leads to pathological instability (see Figure 3.56). Another anomaly deserving of mention is reclination of the dens (Gutmann 1981), which results in retroflexion of the atlas and therefore places increased strain on the transverse ligament of the atlas during head anteflexion.
Figure 3.56 • Os odontoideum, lateral view in neutral position (B). Pathological shift of the atlas relative to the axis (A) during retroflexion and (C) during anteflexion.
Figure 3.57 • Spondylarthrosis in a case with a horizontal course of the articular facets. (A) Joint spaces well visualized
in the AP projection as a result of the horizontal direction of the beam; also the condensation. (B) The lateral view provides clear evidence of the horizontal course; the condensation and extension of the articular processes can clearly be seen.
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Chapter 3
Degenerative changes Degenerative changes can be of clinical significance, especially if they affect the intervertebral foramen, if they are closely associated with the nerve root and the vertebral artery, or if they cause additional narrowing of an already narrow spinal canal. These changes mainly develop in the region of the uncinate processes when there is thinning of the disk, bringing the uncinate processes into close contact with the body of the vertebra above. This can lead to the formation of uncovertebral joints (neoarthroses) and osteophytes. Degeneration of the articular processes also has an effect on the intervertebral foramina. Arthroses of the zygapophysial joints often occur as a consequence of their horizontal position, whether this has come about as an anomaly or in the case of hyperlordosis. In such cases the joint facets, rather than the end-plates of the vertebral bodies, become the weight-bearing structures. This causes a broadening and condensation of these joints, and they can therefore be clearly seen in the AP view (see Figure 3.57) as well as the lateral view. Finally, the significance of a divergent course of the paired joints in the cervical spine needs to be highlighted. This change can clearly be seen in a well-centered lateral view. It causes rotation of the
Figure 3.58 • Difference in the inclination of the articular facets in the C3/C4 segment.
upper of two neighboring vertebrae, relative to the caudally adjacent one, during retroflexion, and consequent narrowing of the intervertebral foramen on the side of the rotation (see Figure 3.58).
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Chapter Four
4
Diagnosis of dysfunctions of the locomotor system
Chapter contents 4.1 Patient history . . . . . . . . . . . . . . . 88
4.1.1 Course of the disease . . . . . . . . 88 4.1.2 Localization . . . . . . . . . . . . . 89 4.1.3 Trauma . . . . . . . . . . . . . . . . 89 4.1.4 Load, posture, and position . . . . 89 4.1.5 Non-mechanical factors . . . . . . 90 4.1.6 Psychological factors . . . . . . . . 90 4.1.7 Paroxysmal character . . . . . . . . 90 4.1.8 The significance of patient age . . . 90 4.2 The inspection: posture . . . . . . . . . . 90
4.2.1 The dorsal aspect . . . . . . . . . . 91 4.2.2 The lateral aspect . . . . . . . . . . 91 4.2.3 The ventral aspect . . . . . . . . . . 92 4.2.4 Inspection of the seated patient . . 93 4.3 Palpation (soft-tissue examination) . . . . 93
4.3.1 Hyperalgesic zones . . . . . . . . . 93 4.3.2 Subcutaneous tissue and fasciae . 94 4.3.3 Trigger points . . . . . . . . . . . . 94 4.3.4 Periosteal pain points . . . . . . . . 96 4.3.5 Radicular syndromes . . . . . . . . 96 4.3.6 Conclusion . . . . . . . . . . . . . 100 4.4 Mobility testing . . . . . . . . . . . . . . 100
4.4.1 Active mobility . . . . . . . . . . . 100 4.4.2 Movement against resistance . . . 100 4.4.3 Passive mobility . . . . . . . . . . 100 4.5 Examination of the pelvis . . . . . . . . . 101
4.5.1 Screening examination . . . . . . 101 4.5.2 Pelvic obliquity . . . . . . . . . . . 102
4.5.3 Pelvic distortion . . . . . . . . . . 4.5.4 Pelvic tilt . . . . . . . . . . . . . . 4.5.5 Restriction of the sacroiliac joint . 4.5.6 Shear dysfunction (Greenman) (upslip and downslip) . . . . . . . 4.5.7 Outflare and inflare . . . . . . . . . 4.5.8 The pelvic floor and coccygeus muscle . . . . . . . . . . . . . . . 4.5.9 The painful coccyx . . . . . . . . . 4.5.10 Ligament pain . . . . . . . . . . .
102 103 103 106 106 106 107 107
4.6 Examination of the lumbar spine . . . . . 108
4.6.1 Screening examination of active movement . . . . . . . . . . . . . 108 4.6.2 Examination of individual motion segments . . . . . . . . . . . . . . 109 4.7 Examination of the thoracic spine . . . . 112
4.7.1 Screening examination of active movement . . . . . . . . . . . . . 4.7.2 Palpation of mobility . . . . . . . . 4.7.3 Anteflexion . . . . . . . . . . . . . 4.7.4 Side-bending . . . . . . . . . . . . 4.7.5 Rotation . . . . . . . . . . . . . . .
112 113 113 114 114
4.8 Examination of the ribs . . . . . . . . . . 115
4.8.1 Screening examination . . . . . . 115 4.8.2 Examination of the first rib . . . . 116 4.9 Examination of the cervical spine . . . . 116
4.9.1 Screening examination . . . . . . 116 4.9.2 Examination of passive mobility . . . . . . . . . . . . . . . 117 4.9.3 Examination of the motion segments . . . . . . . . . . . . . . 118
Manipulative Therapy
4.9.4 Testing of mobility between occiput and atlas . . . . . . . . . . 122 4.10 Examination of the limb joints . . . . . 124
4.10.1 The shoulder . . . . . . . . . . . 4.10.2 The elbow . . . . . . . . . . . . 4.10.3 The wrist . . . . . . . . . . . . . 4.10.4 The hip . . . . . . . . . . . . . . 4.10.5 The knee . . . . . . . . . . . . . 4.10.6 The foot . . . . . . . . . . . . .
124 126 127 127 128 129
4.11 Examination of the temporomandibular joint . . . . . . . . 130 4.12 Examination of disturbances of balance . . . . . . . . . . . . . . . . . 130 4.13 Examination of muscle function . . . . 132
4.13.1 General principles . . . . . . . . 132 4.13.2 Examination of muscles with a tendency to weakness . . . . . 133 4.13.3 Examination of muscles with a tendency to shortening . . . . . 136 4.14 Examination of hypermobility . . . . . . 140
4.14.1 The spinal column . . . . . . . . 140 4.14.2 The joints of the upper limb . . 143 4.14.3 The joints of the lower limb . . . 144 4.15 Examination of coordinated movements (motor stereotypes) . . . . . . . . . . . 145
4.15.1 Examination with the patient sitting . . . . . . . . . . . . . . . 145 4.15.2 Examination with the patient standing erect . . . . . . . . . . 149 4.15.3 Movement patterns of respiration . . . . . . . . . . . . 150 4.16 Syndromes . . . . . . . . . . . . . . . . 151
4.16.1 The lower crossed syndrome . . 151 4.16.2 The upper crossed syndrome . 152 4.16.3 Stratification syndrome (according to Janda) . . . . . . 152 4.17 Retesting . . . . . . . . . . . . . . . . . 153 4.18 Dysfunctions and the course of examination . . . . . . . . . . . . . . . 153 4.19 Adjusting our thinking to the functional approach . . . . . . . . . . . 154 4.20 Chain reactions of dysfunctions and motor programs . . . . . . . . . . . . . 155
4.20.1 Function and chain reactions . . 155 4.20.2 Chain reactions in the light of developmental kinesiology . . . 157 88
4.20.3 The pathomechanisms of chain reactions . . . . . . . . . 4.20.4 Causes of chain reactions . . . 4.20.5 The role of the diaphragm . . . 4.20.6 Rotation of the trunk . . . . . . 4.20.7 Unilateral chains of dysfunction 4.20.8 Analysis of chain reactions . . .
159 160 160 161 161 161
4.21 Differential diagnosis . . . . . . . . . . 162
4.21.1 Problems . . . . . . . . . . . . . 4.21.2 Case studies . . . . . . . . . . . 4.21.3 Common differential diagnoses 4.21.4 Conclusions . . . . . . . . . . .
162 163 164 165
As in every other field of medicine, examination starts with taking the patient history. The model we shall take here is the diagnosis of vertebrogenic disturbances, which are among the most frequent type of dysfunction. Dysfunctions should not simply be diagnosed by a process of elimination; if we approach the task by ruling out all other possible causes of the lesions (especially pathomorphology) we cannot expect to arrive at helpful findings. Instead, diagnosis should be based on characteristic symptoms. Precise criteria for the patient history have been laid down by Gutzeit (1951). Following the patient history, the next step is the physical examination. There is no clinical field in the whole of our experience in which the purely clinical examination plays such a decisive role; nor does any other make such high demands as the examination of motor function. The examination begins the moment the patient enters – the very first steps into the room, the way the patient sits down, even the way the patient undresses. It is important that patients should undress for the first examination (to their underwear, since most patients feel more at ease if they can keep their undergarments on, and so move more naturally). Present-day knowledge of functional inter-relationships shows it to be essential to study the entire locomotor system at the initial examination.
4.1 Patient history 4.1.1 Course of the disease Unless we are dealing with a young patient, symptoms will usually have been present for some time;
Diagnosis of dysfunctions of the locomotor system
in most cases for years or decades, though sometimes in mild form, interspersed with periods of complete absence of pain. The frequency, duration, and intensity of the individual episodes are all relevant, but such details can often only be discovered by careful, specific questioning. For example, female patients will tend not to recall or mention low-back pain during menstruation unless specifically asked, because they consider this irrelevant. In contrast to this pattern, a short, progressive course should give rise to concern, especially if the patient is advanced in age.
4.1.2 Localization Over the course of years, pain may occur in various different parts of the spine and locomotor system; it is exceptional for dysfunctions to remain confined to a single region. Again, specific questioning is usually needed to elicit this information. Patients presenting with headache will have little idea that there might be a connection between this and their low-back pain, any more than patients with lumbago will associate this with vertigo originating from the spinal column. Patients may suffer from a number of complaints that might, if taken individually, be seen as having a variety of different causes, yet all have a common denominator in the spinal column or locomotor system. The greater the number of complaints a patient has – all of which, however different, could have a vertebral origin – the greater the likelihood that these are indeed vertebrogenic dysfunctions. This serves to confirm Gutzeit’s (1951) view that the spinal column is the link that runs like a bright red thread through a thoroughly varied list of different complaints. Vertebrogenic pain is typically asymmetrical as between sides and often unilateral. This applies both to radicular pain and to reflex, referred pain such as headache or pseudovisceral pain. The asymmetry usually increases as a patient’s condition deteriorates, and decreases as it improves. If (in the case of dysfunctions) a unilateral pain spreads to become bilateral, this does not usually indicate deterioration.
4.1.3 Trauma As has already been emphasized (in the discussion of pathogenesis), trauma is a significant factor in the etiology of vertebrogenic disturbances. If an accident features in the previous history it becomes all the more likely that the presenting complaint has a vertebral origin. Almost any kind of trauma, even if
Chapter 4
it ‘only’ affects the limbs, affects the spinal column. This is particularly so in the case of head injury. Nevertheless, it is well known that many patients tend to forget ‘minor’ injuries, serious as the consequences often turn out to be. Children who wrench their neck in an awkwardly performed somersault in a gymnastics lesson at school, or fall and sit down heavily, seldom suffer any painful consequences at the time; if they do, they compensate quickly. However there can be consequences, but they often appear very much later. It is therefore advisable not to accept straight away an answer that your patient cannot remember ever having had any accident. Instead, it should become a routine question to ask patients what sports they practice. To give a typical example: a patient who answered a direct question about injury by saying that he ‘never suffered any trauma’ replied to one about sport by saying that he had been a boxer!
4.1.4 Load, posture, and position Function and its disturbances in the locomotor system are influenced by movement, load, posture, and position, especially if the position maintained is stressful. Therefore one of the most important points in recording the case history is to discover under what conditions the pain occurs. This is not only useful in arriving at a diagnosis, but also important from the point of view of prevention. Details in the history such as these are essential, but often very difficult to discover from the patient. It does little good to ask what happened just before the onset of symptoms, because patients will give an answer based on all sorts of theories they have heard or formed for themselves. What we need to know are the circumstances in which pain was initially felt and which cause it to recur on a regular basis. Patients often find this very difficult to recall, thinking that it would not help to say, for example: ‘when I got up from my chair …’; ‘I was shaving, and when I tried to look more closely in the mirror …’; ‘… getting out of bed in the morning …’; ‘I was going to pick up a piece of paper from the floor …’; yet these are significant details. It is also important to ask which position or movement gives relief. It is important to know whether pain is provoked by sudden movements, by an extended period of sustained, strenuous effort, or by an enforced position. Even apparently irrelevant details can be important. The point that has 89
Manipulative Therapy
to be identified is whether a particular pain symptom occurs on bending slightly forward, as when working at a desk, or on maximum flexion, as when stooping to wipe a floor, or while straightening up from a stooping position. The mechanism behind the problem is very different in each case. In this context too it is necessary to find out about patients’ work and sporting activities.
4.1.5 Non-mechanical factors Dysfunctions of the locomotor system are not simply a mechanical problem, but involve every aspect that affects the reactive capacity of the body. The nervous system in particular plays a role, as can be seen in susceptibility to changes in the weather, to chills, and infectious diseases. This is especially so if these cause raised body temperature. Hormonal disturbances, the clearest effects of which are those experienced by women during menstruation, can also be important; allergy can likewise have an effect.
4.1.6 Psychological factors Since, as we know, the locomotor system is subject to human will, and pain is the most frequent symptom of dysfunction, it is hardly surprising that psychological factors play an important part. Psychological involvement in no way excludes, but rather corroborates, the diagnosis of vertebrogenic dysfunction. It must be stressed that appropriate treatment of the dysfunction is the best means of easing the pain. It also provides the practitioner with the best means of dealing with the psychological problems. It is ultimately the course of the illness that indicates how significant the psychological factor is in the particular case. The psychological problems may ease when the patient’s pain is relieved, or may persist; they may even cause relapse as a result of increased muscle tension, and an inability to relax. This is particularly the case in masked depression. One general principle needs to be stressed: we should guard against categorizing pain as psychological if patients are able to localize it accurately and if they give the same account of the symptoms each time they describe them. The conclusion we should draw in this case, assuming that no pathomorphological lesion is found, is that there is a dysfunction 90
of the locomotor system. Signs that a problem is caused by purely psychological factors are these: if the patients are unable to localize the pain, if they constantly change their account, or if they cannot describe the pain. They are often confusing their psychological suffering with the pain.
4.1.7 Paroxysmal character Gutzeit (1951) is entirely right when he describes the paroxysmal character of vertebrogenic complaints, especially if the symptoms involved are autonomic and vasomotor in nature: examples are headache, vertigo, pseudocardiac or other pseudovisceral problems. If the pain has the same, sustained intensity, for example headache, this tends to suggest another cause rather than a vertebral one. At the same time it should be pointed out that patients often speak of pain as being ‘constant’ when they are never completely free of it, although its intensity rises and falls paroxysmally with a certain frequency.
4.1.8 The significance of patient age For differential diagnosis it is important to bear in mind that the age of the patient plays an important role. In adolescents we might expect to find ‘ordinary’ restrictions or juvenile osteochondrosis, and in slightly older patients, ankylosing spondylitis. In the middle-age group, the most common serious conditions are herniated disc and ‘ordinary’ dysfunctions. In older age groups, osteoporosis is the most important, especially in women; also osteoarthritis, especially of the hip and knee joints. In this older age group, malignant disease must also be considered, especially if the patient is over 50 years of age and the disease has followed a progressive course. True vertebrogenic disease tends to decrease after the age of 60, accompanied by a rise in the incidence of osteoarthritis of the limb joints.
4.2 The inspection: posture The inspection usually begins with the dorsal aspect. The plumb line is positioned so as to fall between the heels. This is followed by the lateral and finally the frontal aspects. If possible the
Diagnosis of dysfunctions of the locomotor system
patient should also be assessed in the sitting position, again from all sides.
The inspection is the quickest way of gaining an overall impression so that the manual stage can be carried out in as targeted and economical a way as possible.
4.2.1 The dorsal aspect The inspection begins with an assessment of overall posture, looking for any deviation from the plumb line and any asymmetries. The next stage is the systematic inspection. Working upward from the feet, the specific points to examine are: • the shape (roundness) and position of the heels • the shape of the foot • the shape and thickness of the Achilles tendons and the calves, observing their medial and lateral contours • the position of the knees • the shape of the thighs • the height of the gluteal folds • the tone of the gluteal muscles • the course of the intergluteal cleft • the shape of the hips: whether symmetrical or projecting to one side • the waist • the distance of the pendant arms from the trunk on either side. Further details to examine are: • the rhomboid of Michaelis between the dimples situated at the posterior superior iliac spines (PSIS), and further craniad, the prominence of the erector spinae muscles. Between these lie the spinous processes, set within a groove between these muscles. This may follow a vertical course, or may be found to deviate from the vertical • the apex of the lordosis and the transition to kyphosis • the position of the shoulder blades: how high, and, if prominent, how symmetrical • the relative height and shape of the shoulders • the quadratus lumborum and latissimus dorsi muscles; these form the lateral contour of the
Chapter 4
trunk up to the axilla. The superior border of the shoulders is formed by the deltoid and superior portion of the trapezius, and medially to these by the levator scapulae. The inspection should note whether the superior contour takes a concave or convex (hypertonic) course and observe whether there is symmetry • the neck: note whether the neck deviates to one side or the other, and observe whether it is long, slim, or stocky • the hair line: note whether this is well above the shoulders or low down as in basilar impression • the head: look for any deviation. Does it deviate to the same side as the neck, or to the opposite side?
4.2.2 The lateral aspect Inspection of the lateral aspect also begins with an assessment of posture as a whole. The center of gravity of the head should normally be above the shoulder girdle; more precisely the external auditory meatus should be vertically above the pelvic girdle and this in turn above the feet, so that a plumb line from the external auditory meatus falls approximately 2 cm in front of the ankles and touches the scaphoid of the foot (navicular bone). During this inspection the patient’s gaze should be directed at an object at eye level. It is extremely important to register a forwarddrawn position, in which the head is in front of the shoulder girdle, and this in front of the pelvic girdle, with the pelvis above the anterior part of the foot. It is important for diagnosis to note any tension of the muscles of the back, and especially of the back of the neck, which disappears on sitting. When carrying out the systematic inspection, the examiner again works upward from the feet. Points to assess are: • the shape of the lower leg and especially the knee: genu recurvatum is a sign of laxity • the shape of the buttocks • the lumbar curvature: note whether the apex of the lordosis is located at or above the lumbosacral junction. In cases of increased lordosis with flabby posture, the abdomen is seen to protrude; this is not always a sign of adiposity. This protrusion may be at its maximum at the navel; however, if there is a drooping belly the level may be much lower 91
Manipulative Therapy
• the level of the transition from lumbar lordosis
to thoracic kyphosis: note whether the patient has a flat or round back; if the thoracic spine is flat there is frequently increased kyphosis at the cervicothoracic junction • the shape of the spinal column • the position of the shoulders: whether drawn forward or protruding. Cervical lordosis largely depends on the shape of the thoracic spine. If the thoracic spine is flat, cervical lordosis may be completely absent. This is particularly seen in individuals of the athletic type with broad shoulders and a flat thoracic cage; similarly in ballet dancers. If the back is round, on the other hand, the thoracic kyphosis often continues into the lower cervical spine, with only the upper part of the cervical spine
