This book is dedicated to my wife and to those of my pupils from whom I have learnt most of all.
For Elsevier Publisher: Sarena Wolfaard Development Editor: Sally Davies Project Managers: Anne Dickie and Sukanthi Sukumar Designer: Kirsteen Wright Translators: Elaine Richards and David Beattie Illustration Manager: Bruce Hogarth Illustrators: Gerda Istlerová, Prague, Henriette Rintelen and Velbert Photographs: Jitka Fabianová, Prague
First edition published in English © 2010, Elsevier Limited. All rights reserved. First published in Czech (original Czech title Manipulacˇní lécˇba v myoskeletální medicíneˇ) and subsequent other editions in Swedish, Dutch, Bulgarian, Polish, English (under the title Manipulative Therapy in Rehabilitation of the Locomotor System, 1985), Italian, Spanish, Russian, German and Japanese Eighth Edition published in German under the title Manuelle Medizin 8. Auflage © 2007 Elsevier GmBH, Urban & Fischer Urban & Fischer is an imprint of Elsevier GmBH No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Rights Department: phone: (+1) 215 239 3804 (US) or (+44) 1865 843830 (UK); fax: (+44) 1865 853333; e-mail:
[email protected]. You may also complete your request online via the Elsevier website at http://www.elsevier.com/permissions. ISBN: 978-0-7020-3056-7 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging in Publication Data A catalog record for this book is available from the Library of Congress Notice Neither the Publisher nor the Author assume any responsibility for any loss or injury and/or damage to persons or property arising out of or related to any use of the material contained in this book. It is the responsibility of the treating practitioner, relying on independent expertise and knowledge of the patient, to determine the best treatment and method of application for the patient. The Publisher
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Foreword My professional life has been enormously enhanced by Karel Lewit’s teaching and I am so pleased that he has continued to enhance his book, for this latest edition, by adding his further distillation of how recent research should refine our management of locomotor pain. If you liked a previous edition, you will definitely want this one. Although many would consider this a textbook, Professor Lewit has said that it is not one; he has always wanted to make us think, and to enable us to work out our puzzles and problems with the aid of the principles and approaches which he outlines in this book. I can remember, as a medical student, how my teachers gave me the impression that I was learning, at that hospital, all that could be learnt about humankind’s suffering, illnesses and diseases. How wrong they were! Karel Lewit’s teaching has certainly ‘shone light where there was darkness’ on my understanding of musculoskeletal pain. Even after many years it remains a source of pleasure and even excitement that our ‘clinical experience in the use of manipulation for diagnosis and treatment constantly reaffirms, in countless patients, the principle that treatment, if technically successful, brings normalization of restricted mobility in the joint or motion segment. Normalization of function also brings relief of pain.’ But we must take it further than being proud of technique. ‘It is as important – and still more difficult – to adjust our thinking to the functional approach as to master the technical aspect of manual medicine.’ Following this statement Lewit gives important differences between the usual, pathomorphological understanding and the functional approach. The fourteenth of these is, ‘When treating dysfunction, the practitioner is lost – or
rather his patient is – if he treats it at the point where pain is felt’. I can remember being so confused when Philip Greenman said this same thing. This book helps us understand more deeply about how the motor system works and how dysfunction causes pain, and why that statement is true: compared to doctors with our ‘structural’ training, you chiropractors, osteopaths and physiotherapists are fortunate! It is wonderful to see how manipulative therapy and musculoskeletal medicine have developed during Karel Lewit’s lifetime – not least through his own research and that of his younger colleague Vladimir Janda, and then Vojta and Kolárˇ. I remember John Mennell in his later years insisting that it is the muscles that are important’ but not quite being able to explain why. Mitchell, Greenman and others had of course shown, with the muscleenergy technique, that the patient’s own muscles can achieve reversal of dysfunction. But one cannot underestimate the influence of Karel Lewit in stimulating the Czech school and many others to show the underlying neuromuscular causative mechanisms of dysfunction. And nowhere have the clinical manifestations and treatment implications of this newer understanding been better explained than in this book. Karel Lewit can sift the pearls of wisdom from the side-issues, misunderstandings and downright wrong very effectively, as we know (sometimes to our cost!) at meetings of the multidisciplinary International Academy of Manual and Musculoskeletal Medicine (formerly the FIMM Academy). So, he has done all the hard work for you: read on, and give the benefit to your patients. Richard Ellis
vii
Preface The first Czech edition of this book was published in 1967 out of the necessity of providing instructional material. There was a need to teach physicians and, later, physical therapists a new specialty – the diagnosis and treatment of dysfunction of the locomotor system. A way of teaching both theory and practical skills was required that did not involve spending too much time in lectures. There was no comprehensive textbook to teach fundamental theory, functional anatomy, clinical aspects of dysfunction of the locomotor system, relevant treatment indications and appropriate preventive measures based on the findings. Nor is there any such textbook to this day, apart from an increasing number of technical manuals representing various schools of manual medicine. This is probably the reason that translations of this book have appeared in numerous languages: German, Swedish, Dutch, Bulgarian, Polish, English, Italian, Spanish, Russian and Japanese. The first English edition was published by Butterworth in 1985. This was a shortened and therefore more concise version of the original Czech and the seven German editions. The second and third English editions were published by Butterworth-Heinemann. The last two Czech and the eighth German editions were restructured according to the English editions. This eighth (2006) German edition has been translated and updated for the present English version. The starting point was initially manual therapy, but it soon became evident that the true object of ‘manual medicine’ is dysfunction of the locomotor system; such dysfunctions account for 90% of the vast number of patients suffering from painful conditions of the locomotor system. Despite this, afflictions of this nature are termed ‘unspecific,’ hence without diagnosis and consequently inadequately treated. Nevertheless, these complaints are specific disturbances of function: they can be precisely diagnosed by clinical means, requiring in the first place specific physiological methods of treatment. Knowledge about this largely unexplored field grew rapidly, and Professor Janda and I decided to use the term ‘functional pathology of the motor system’. As our knowledge kept increasing, it became
necessary to revise each new edition, which was the main source of the truly dramatic development of what was originally called manual medicine – for which we are in no small degree responsible. The main interest at first was clearly in joints and therefore in manipulative techniques. However, the function and the physiology of the joints were unthinkable without the muscles, controlled by the nervous system. Since (passive) manipulation appeared from the outset to be untenable without (active) rehabilitation to obtain lasting results, our interest in the musculature became obvious. Through their ‘muscle energy technique,’ the osteopathic school of Fred Mitchell senior showed convincingly that the patient’s own musculature does have an effective role to play in manipulative therapy. This prompted us to develop techniques facilitating and inhibiting muscles, which had to be as simple as possible, so as to bring into play the patient’s own muscles, since using the patient’s own muscles is a more physiological approach than that of even the best practitioners. For this reason, selftreatment is of great importance. Soon it became obvious that joint movement restriction was regularly released when muscle relaxation was complete. This promoted the con clusion that a tense musculature and myofas cial trigger points play a predominant role in joint restriction. This point was made in 1975 by the great physiologist of osteopathy, Irwin Korr. We now devote out attention as much to the diagnosis and treatment of trigger points as to that of joint restriction. A further significant step was that it became obvious that trigger points and joint restriction do not occur in an isolated and haphazard manner, but appear according to certain fundamental rules. The practical importance of this principle is that if the most important link of the chain is treated, the entire clinical picture could be normalized. This does not only make treatment more economical, it makes it possible to plan further treatment and rehabilitation, and is the basis of a rational holistic approach. ix
Preface
The next question to be pursued was to find the most important causes of these chain reactions. These were closely related to the role of the musculature maintaining the human upright posture, which is very labile. A crucial role is played by the recently discovered deep stabilization system – of the feet, the trunk, the shoulder blades, and the craniocervical junction. This is closely linked, via the diaphragm, to respiration. Dysfunction of these mostly short muscles must be compensated by movement restriction due to trigger points in the long muscles which, by co-contractions of flexors and extensors, stabilize the upright posture with the spinal column in the sagittal plane. Activation is training the deep stabilization system and diaphragmatic respiration, thus normalizes chains of trigger points and joint restriction, without passive mobilization and even relaxation. Only well localized dysfunctions, frequently found
x
at the extremities, remain to be mobilized. This is also true of the soft tissues and the internal organs, which have to move in harmony with the motor system even during respiration. Manual diagnosis and therapy of these tissues often play a dominant role, particularly with scars. What then remains of manual medicine? It is clinical diagnosis with our palpating hands, without which no chains of trigger points, movement restriction or soft tissue change can be diagnosed. The object of treatment is, however, solving dysfunction of the motor system and all the methods of treatment have to serve this purpose. Analysis of the findings and problem-solving are thus our main tasks. This book has therefore gradually changed into a textbook not just of manipulation, but of ‘musculoskeletal’ or ‘neuromusculoskeletal’ medicine. Prof. Karel Lewit
Acknowledgments The first English edition would have been impossible without the devoted care and critical help of my English wife. To deal with such a vast, in many ways new, field made it necessary to work in a team, one in which we were simultaneously both teachers and students. It was Professor Henner’s Neurological Clinic that made this possible. Thus it was that my first students were my neuroradiology teacher, Professor Jirout, Professor Janda, to whom I gave instruction in neurology and who did pioneering work on dysfunction of the musculature, and the ˇihák, to whom I explained anatomist Professor C functional radiology and who was my constant advisor in questions of anatomy. It is to Dr Véle that I owe what little I understand of EMG and a more sophisticated way to examine reflexes. My thanks are due to Dr Zbojan for the use of gravity for the relaxation of many muscles, to Dr Rosina for the reliable diagnosis of sacroiliac restriction, to Dr Kubis for the diagnosis of restriction of the upper ribs, and to Dr Sachse for the accurate diagnosis of hypermobility. In the scientific field, I learned in particular from the histologist, Professor Wolf, from Professor Berger and Professor Ivanichev. I learned also a great deal from the physical therapists who were my students: from Mrs Hermach I learned about exteroceptive stimulation, and got much practical advice from Mrs Kafková and Klierovám Verchozinová; in recent years in particular from Professor Kolárˇ about developmental kinesionology and stabilization. Others from whom I learned were Professor Starý, Professor Macek, Dr Strˇeda, Dr Gutmann, Dr Biedermann, Dr Wolff, Dr Gaymans, Professor Greenman, Professor Ward, and finally,
indeed most of all, from Professor Simons. Many of those I named are no longer alive. I should like to express my thanks to the Central Railway Health Institute, where I was able to pursue the work in my field from 1973 to 1990, and to Dr Sereghy, who made it possible for me to return to the neurological clinic, which I was forced to leave in 1972. When Dr Sereghy ceased to head the clinic, it was thanks to Professor Kucˇera and Professor Bojar that I was able to move to the rehabilitation clinic in Prague – Motol. This clinic offers at present the most favorable conditions for the further development of musculoskeletal medicine, under the leadership of Professor Kolárˇ, and not only in the Czech Republic. It was a particular honor that the last Czech edition, which was translated for Elsevier into German and now into English, was published under the name of the Czech J E Purkynje Medical Associations, for which I express my special thanks to Professor J Blahoš. My thanks for the quality of the illustrations are due to Mrs Istlerová and Mrs Fabianová. My thanks are also due to Elsevier who pleasantly surprised me in 2004 by requesting a new edition of Manuelle Medizin, and in particular to the translators, Mr Beattie and Miss Richards, who put up with all my suggestions, corrections, even criticisms, to Ms S Davies, who took the responsibility for the editorial development, and to Ms S Wolfaard, who initiated it all. Prof. Karel Lewit Dobrˇichovice
xi
Abbreviations ASIS CT DC DO EMG HAZ MET
Anterior superior iliac spine Computerized tomography Doctor of Chiropractic Doctor of Osteopathy Electromyography Hyperalgesic (skin) zone Muscle-energy technique
MRI PIR PSIS RI TeP TrP
Magnetic resonance imaging Post-isometric relaxation Posterior superior iliac spine Reciprocal inhibition Tender point Trigger point
xiii
Chapter One
1
History and fundamental principles
Chapter contents 1.1 The history of manipulative therapy . . . . . 1 1.2 Fundamental principles of reflex therapy . . . . . . . . . . . . . . . . . 4
1.2.1 Nociceptive stimulation . . . . . . . . 4 1.3 Reflex therapy . . . . . . . . . . . . . . . . 6
1.3.1 Indications and methods . . . . . . . 1.3.2 Choice of method . . . . . . . . . . . 1.3.3 Structural and functional changes . . 1.3.4 The place of reflex therapy . . . . . .
6 6 7 7
1.1 The history of manipulative therapy To begin with a chapter giving a brief outline of the history of manipulative therapy is helpful for several reasons; not least because it is hard to appreciate its unique place in medicine without such an introduc tion. It is also important for the avoidance of mistakes and a correct appraisal of its further development. Manipulative therapy is probably as old as the history of humankind. Throughout that history there have been healers who knew how to reposi tion or ‘set’ joints, including the spine. Among some peoples it was the custom for children to run bare foot over the backs of their weary parents following heavy work. Importantly in this history, in the fifth century bc, Hippocrates, founder of European medicine, listed rachiotherapy as a further fundamental ele ment of medicine alongside surgery and medicinal
therapy. In his treatise on joints, he speaks of parathremata, a concept which corresponded to what chiropractors would recognize as slight disloca tion or subluxation. Waerland expresses it in these words: ‘the vertebrae are not displaced by very much; only to a very small extent.’ Hippocrates goes on to say that ‘it is necessary to have a good knowledge of the spine, because many disorders are associated with the spine, and a knowledge of it is therefore necessary for healing a number of dis orders.’ He also describes how to treat the spine: ‘This is an ancient art. I have the greatest respect for those who first discovered it, and also for their successors, whose discoveries will contribute to the further development of the art of healing in a natu ral way. Nothing should escape the eye and hands of the skillful physician, so that he can reposition the displaced vertebrae on the treatment table without harm to the patient. No damage can occur as long as the treatment is undertaken in the correct way.’ According to Hippocrates, the list of disorders caused by displacement of vertebrae includes phar yngitis, laryngitis, bronchial asthma, tuberculosis of the lungs, nephritis and cystitis, inadequate gonadal development, constipation, enuresis, etc. Manipulation therapy in ancient classical times can be seen on many reliefs. Patients would lie prone on a bed specially constructed for the pur pose, while longitudinal traction to the head and legs was carried out. The physician performed manipulation of a particular vertebra. This type of therapy was evidently practiced throughout antiquity; Galen knew that the peripheral nerves emerged from the spinal cord and that they were susceptible to damage at this point, as is clear from
Manipulative Therapy
his account of the treatment of the Greek Sophist Pausanias. Over the course of time – particularly in the last two centuries – development took place in the primi tive medicinal (herbal) therapy and the surgery of the Ancients, giving rise to modern pharmacotherapy and surgery; however, manipulation therapy continued in the same state as when the ancient classical civiliza tions had received it from the peoples of earlier antiq uity. Consequently the successes of modern medicine completely eclipsed primitive manipulation therapy, causing it to slip to a great extent into oblivion. The medical press, which enjoys generous support from the pharmaceutical industry, contributed to this pro cess. What we now see, therefore, is unequal develop ment in the field of medicine, leading to a situation in which one discipline, failing to keep pace with the progress in the other specialisms, became almost for gotten. All that persisted, as far as we can tell, was a group of lay persons – to some degree established – called ‘bone setters’ who practiced manipulation therapy. This remained the situation until into the second half of the nineteenth century. It was Andrew Taylor Still (born 1828), who practiced as a doctor in the American Civil War, who rediscovered the importance of manipulation of the spine. In 1874 he founded a school on a pro fessional basis in Kirksville, USA, with 17 students. From the outset he also provided training to lay persons. At first the courses lasted two years; later they were extended to four years. At the present day, the length of training for a doctor of osteopa thy (DO) in the United States is the same as that for medical students and permits them both to exercise their profession in general practice and to progress to specialization. Around the year 1895, DD Palmer founded the chiropractic school in Davenport. Until then he had worked as a grocer and in magnetic healing. According to his own account, he wit nessed manipulation being practiced by a phy sician by the name of Atkinson. Other sources say that he himself received treatment from Still. At first, the courses he provided lasted only around two weeks, and cost 500 dollars. By 1911 the courses lasted a year. At present, the training consists of four years of universitylevel study in the United States. Graduates obtain the title DC (doctor of chiropractic), which enables them to practice as primary care physicians. Differences between osteopathy and chiropractic persist to this day. The training given to osteopaths 2
in the United States endeavors to provide a com plete body of medical knowledge, whereas schools of chiropractic will not teach pharmacotherapy and sur gery. Among chiropractors, there is a substantial diff erence between those of the older and the younger generation. The older generation adheres dogmati cally to the outdated theoretical and technical tradi tion; the younger rejects the traditional dogmas – it strives for a rational, scientific method and strongly desires to cooperate at the professional level with medical practitioners. From the technical point of view, chiropractors confine their approach for the most part to highvelocity, low-amplitude (HVLA) treatment using short-lever techniques, taking very little interest in soft-tissue techniques. They are increasingly inter ested in rehabilitation and lifestyle (dietetics). Osteopaths, in contrast, place emphasis on soft mobilization and soft-tissue techniques as well as HVLA treatments; however, they show a pre ference for long-lever techniques, using indirect (unlatching) techniques to be able to work in a targeted way. Neuromuscular techniques – muscleenergy techniques (MET) – derive from the school of Fred Mitchell, sen, Greenman and Mitchell, jun. Although physicians in Europe initially knew little of manipulative therapy, even completely rejecting the concept, here too they gradually began to take an interest in spinal manipulation. The dis covery of a mechanical disorder, the herniated intervertebral disk, was partly responsible for this interest. Attempts were made to provide relief by means of traction, and even to perform manipula tion under anesthetic. While, on the one hand, osteopaths and chiro practors were regarded as charlatans, on the other, attempts at manipulation by physicians of tradi tional (allopathic) medicine were rough and ready. Nevertheless, physicians in Europe were beginning to concern themselves with maneuvers applied to the spinal column. As long ago as 1903, the Swiss physician O Naegeli published his book on neu rological complaints, Nervenleiden und Nervenschmerzen. Ihre Behandlung und Heilung durch Handgriffe. The most important proponent of manipulation therapy in Europe was the British professor of physiotherapy, JA Mennell. He made no secret of having received instruction from osteopaths. His many publications (including manuals) remain to this day exemplary models of their kind. How ever, he mainly trained physiotherapists (physical
History and fundamental principles
therapists). His successor, J Cyriax, was a passion ate proponent of manipulation therapy as well as an outstanding clinician and diagnostician. His Textbook of Orthopaedic Medicine remains to this day a classical textbook of the locomotor system. However, the techniques he describes and teaches do not measure up to comparison with those of Mennell. Another individual deserving of mention is A Stoddard. He was originally an osteopath, and later studied medicine. His Manual of Osteopathic Techniques can be regarded as a classical textbook of manipulative techniques for the spine. The London College of Osteopathic Medicine was the first institution to provide instruction in osteopathic techniques to physicians trained in traditional medicine, and these individuals played a role in the further development that took place in Europe. The French physician, R Maigne, is one example; he also studied under the neurologist and rheuma tologist, de Sèze, who was long the most influen tial proponent and teacher of manual medicine in France. He systematically held courses for phy sicians at the medical faculty in Paris and wrote textbooks. Despite the leading role played by Maigne, there are many splinter groups in France. In Britain, on the other hand, the British Institute of Musculoskeletal Medicine (BIMM, and its pred ecessor the BAMM) is organized in a unified way, holds courses and, under Dr Richard Ellis, pub lishes probably the most important medical journal in the field, International Musculoskeletal Medicine (formerly entitled the Journal of Orthopaedic Medicine). The development that has occurred in the German-speaking countries is also of particular interest. After the end of the war, a number of German physicians began, out of necessity, to take an interest in manipulation therapy. Soon they began to found specialist scientific associations concerned both with the critical study of the issue and with courses of instruction. In Germany there were two groups involved at this time, the Forschungsgemeinschaft für Arthrologie und Chirotherapie (FAC), initially based in Hamm but later in Boppard, whose leading figures were G Gutmann, F Biedermann, A Cramer, and HD Wolff, and the Gesellschaft für manuelle Wirbelsäulen-und Extremitätengelenkstherapie (MWE) under K Sell, which was based in Neutrauchburg. Physicians from the former German Democratic Republic of East Germany also took part in these
Chapter 1
courses up until the beginning of the 1960s. After 1961 this was no longer possible. Students of the FAC were therefore commissioned to organize courses in East Germany, which were to be on the same lines as the FAC, and at the Charité in Berlin, under Professor H Krauss and K Lewit from Prague. This task was more than could be done by just one person, so it was necessary to train instructors who would later take over the leadership of the Associa tion. The most important of these were E Kubis, J Sachse, K Schildt-Rutlow, and H Tlustek. After the reunification of Germany this group became established as the Ärzteseminar Berlin (ÄMM). Today the FAC, MWE and ÄMM together make up the Deutsche Gesellschaft für Manuelle Medizin (DGMM). The development in former Czechoslovakia is also of great interest, as a result of the profoundly different political situation and especially in view of the fundamental role it served as a model for other then-communist countries (including East Ger many). At the end of 1951 the Ministry of Health commissioned the university hospitals to undertake a review of the methods used by lay practitioners and practitioners of complementary medicine. To this end a chiropractor with a practice in Prague was reviewed at the neurological clinic (under Professor Henner). It was an ideal moment, when interest was focused on the intervertebral disk problem, and also on exploring the feasibility of reflex therapy. An additional factor there was the position of neurology in Czechoslovakia in Professor Henner’s time: there was an interest in problems of pain and the locomotor system, and neuro logy also had a leading role in the development of rehabilitation. This made it possible for the technique of manipulation therapy to be reviewed in a clinical domain. Later there came the provision of instruc tion too, emanating from a prominent university hospital and later also provided by the Institute of Postgraduate Medical Training (under Professor Z Macek). Instruction was given in the form of a series of three two-week courses. Later, physi otherapists began increasingly to be trained in neu romuscular mobilization techniques. This is done in association with their university training. This model was then taken up in East Germany, Poland, the former Soviet Union, and to some extent in Hungary and Bulgaria. Professional bodies for physicians working in manual medicine were founded in most of the 3
Manipulative Therapy
countries of Europe, beginning in Switzerland, as well as in Australia and New Zealand; a body was also set up in cooperation with osteopaths in the United States. The International Federation for Manual Medicine (FIMM) was founded in 1965 in London, with the Swiss physician JC Terrier as its first president. His son, B Terrier, has held this post since 2004. A world congress is held every five years. In this way manual therapy has become a medical discipline. A professional body whose name refers merely to a method is not entirely satisfactory to physicians, however, given that the object concerned is the locomotor system and especially its dysfunctions. A number of bodies therefore decided to reinterpret the initials FIMM to represent the name Fédération Internationale de Médecine Musculosquelettale (International Federation for Musculoskeletal Medicine). Despite considerable activity in scientific work, manipulation has continued to be regarded by a great number of traditional physicians as an outsid er’s method; dysfunctions are little understood and, in matters at the practical level, physicians find it difficult to keep pace with physiotherapists, osteo paths, and chiropractors.
1.2 Fundamental principles of reflex therapy Pain – both in general and in disorders of the loco motor system – is a curse that humanity has always suffered. The constant search for relief has led to a great range of treatments of all kinds. The tradi tional approach has regarded bed rest and – to an extent and with some reserve – pharmacotherapy as the only reliable answer. From another standpoint there are many other methods that belong mainly, although not exclusively, to the realm of physical therapy, and these all have their eager proponents. These include massage, various kinds of electro therapy, laser and magnet therapies, acupuncture, neural therapy, manipulation, local cold or hot applications, cupping, wheal therapy, remedial exer cise, and movement therapy. The common feature of all these methods is their reflex effect. We may ask why, when treating essentially the same disorders, preference is given sometimes to one method and sometimes to another. This some times gives the impression that the choice of method 4
depends on which treatment the practitioner is best able to perform, irrespective of actual suitability. The pathomechanism underlying most of these methods is the reflex effect; they act on sensory receptors to produce a reflex response in the region where the pain originates. They can therefore be termed methods of reflex therapy. We must next ask which receptors are activated and which struc tures they supply. The route by which the control by the nervous system operates is primarily that of reflex reac tion; it would be helpful to proceed from this to an understanding of where, how, and why we should apply one or the other method. The better we com prehend the various methods, the more effective the treatment we can deliver. Since these methods are most frequently applied in painful conditions, there follows a description of nociceptive (pain) stimulation.
1.2.1 Nociceptive stimulation Any localized pain stimulation begins by provok ing a reflex in the segment to which the stimulated structure belongs. In this segment we usually find a hyperalgesic zone (HAZ) in the skin, muscle hardening, trigger points (TrPs), painful periosteal points, movement restriction of the corresponding segment of the spinal column, and (perhaps) some dysfunction of a visceral organ (see Figure 1.1). This enables us to diagnose the changes present and use whichever method is appropriate to exert an effect on the skin, soft tissues, muscles, peri osteum, motion segment of the spinal column, or visceral organ involved. Working in this way and on a case by case basis, we can decide in each case which structure is the location of the most intense changes, and which is the probable source of the pain.
Figure 1.1 • Reflex relations within the segment.
History and fundamental principles
Figure 1.2 • Schematic overview of afferent and efferent connections between the periphery and central nervous system.
These reflex changes are not confined to a single motion segment. For example, visceral disturbances are accompanied by viscerovisceral reflexes: pain in the region of the gall bladder produces nausea; pain in the region of the heart produces a sense of oppression, etc. This kind of effect is still more strikingly seen in the locomotor system: an acute disturbance in one segment of the spinal column produces muscle spasm in substantial sections of the erector spinae; any local movement restriction produces effects in distant segments of the spinal column, after the manner of a chain reaction. Any serious lesion at the periphery also brings about a central response: the motor pattern, or stereotype, will change in order to spare the affected structure. In this way altered patterns of movement are formed, and can sometimes persist after the peripheral lesion has disappeared (see Figure 1.2).
Reflex relations between the periphery and the central nervous system Pain stimuli produce both somatic and autonomic responses at all levels. The somatic response to the stimulus consists mainly of muscle hardening or the opposite response of hypotension (inhibition of the muscle). The expression of pain is found in the form of trigger points both in hypertonic muscles and in (otherwise) hypotonic ones. The autonomic response takes the form of reac tions in HAZs and soft tissues, and of a vasomotor reaction (mainly vasoconstriction) within the seg ment. At the level of the central nervous system, these reactions may occur as stress affecting respi ration, the cardiovascular or the digestive system. At this level there can also be changes in motor pat terns, the stereotypes of muscle action.
Chapter 1
Once we know the source of nociceptive stimu lation, for example movement restriction of a spinal segment, and can assess its severity, then the inten sity of these reflex changes can provide information about the reaction of the patient and of the particu lar segment. We can use the subjective assessment of the pain to evaluate the nociceptive stimulus, the reflex reaction, and the central (psychological) susceptibility of the patient to pain. These somewhat schematic guidelines indicate some possible lines of action to take in painful dis orders, using essentially the same approach as a neurologist would employ in disturbances of mobil ity. This approach is essential if we are to act in a targeted way, that is if we are to know why, when, and where we should use one or other of the meth ods of reflex therapy. First, therefore, we need to distinguish the source of pain and the reflex effects in the segment, at the suprasegmental level and at the level of the central nervous system.
As a rule a nociceptive stimulus produces somatic and autonomic changes. It is necessary to understand these changes in order to arrive at a rational, targeted course of treatment.
The key to this difficult task lies in the functions, or the dysfunctions, of the locomotor system. Since this subject is the main theme of the present book, no more need be said at this stage than to point out that the locomotor system is by far the most frequent source of pain in the body. This is readily understandable, because not only does the locomotor system constitute about three-quarters of our body weight, but it is under the control of our will – consequently even at the mercy of our whims – and has no other way of protecting itself against misuse than by causing pain. First and fore most, then, pain warns us of harmful function or malfunction. Conversely dysfunction is the most common cause of pain originating in the locomotor system. Movement restriction in a segment and disturbed motor patterns or stereotypes at the central level are typical examples. It is no coincidence that pain from a wide variety of causes (e.g. visceral pain) is accompanied by muscular trigger points and is usu ally felt in the locomotor system; (for example the heart causes pain in the left arm, the shoulder, and 5
Manipulative Therapy
the chest wall; the gall bladder causes pain in the shoulder blade, etc.).
Dysfunctions of the locomotor system are the most frequent cause of pain, and pain is the most frequent symptom of dysfunction of the locomotor system.
A sound knowledge of the dysfunctions of the loco motor system is therefore essential for successful therapy.
1.3 Reflex therapy 1.3.1 Indications and methods Clearly the chosen therapy and method must depend on the structure upon which we wish to act. In our approach to the skin, for example, a great variety of methods are available, as the recep tors in the skin are easy to access (e.g. by mas sage, electrotherapy, wheal therapy, or simple skin stretching). Muscle hardness (myogelosis; TrP) can be treated by massage, and more effectively by post-isometric relaxation (PIR), reciprocal inhibition (RI), pressure and needling. Manipulation and mobilization are mainly used to treat functional, reversible movement restrictions of joints or segments of the spinal column. Painful periosteal points can be treated by mas sage, soft tissue techniques, needling, or, if they are the insertion points of muscles, by PIR and RI of the muscles concerned. The most appropriate treatment for disturbed motor patterns is remedial exercise.
1.3.2 Choice of method The next step is to decide which of the affected structures is most important and which less so; which change is probably primary and which sec ondary. The severity of the disturbance is also significant. Even at the segmental level, there is a kind of hierarchy: in general, visceral disorders and abnormal motor patterns tend to be primary. The 6
significance of disturbances in muscles, joints, and soft tissues can only be decided based on an analy sis of the pathogenesis. The particular importance of the fasciae and active scars should be emphasized in this connection. In the locomotor system and in the spinal column, there are regions of greater and of lesser importance. There are some sections in which primary lesions occur more frequently than in others. It is vital to recognize those faulty motor patterns which are regularly found to cause relapses if left untreated. In this connection psychological factors play a major part, because motor patterns are in part expressions of the state of mind: anxiety, depres sion, and an inability to relax exert a considerable influence on motor function; no less important is the subject’s psychological attitude to pain, since pain is the most frequent symptom in our patients. In addition to issues of pathogenesis, there are certain practical aspects of technique to be consid ered, since not all methods are equally effective or ‘economical.’ For example, needling or soft-tissue techniques are usually more economical for the treatment of periosteal pain points than periosteal massage, but wherever possible (i.e. if the perio steal point is a point of muscle insertion) we pre fer to use PIR with RI of the muscle, because these techniques are painless and usually suitable for selftreatment. The attractiveness of manipulation tech niques lies mainly in the fact that they are effective and quick to perform. We can see from this that there is a wide range of possible treatments from which to select the most suitable. The decision as to which to use is reached by making as accurate a diagnosis as possible of the individual changes, and from this make what is known as the ‘present relevance’ diagnosis – what Gutmann (1975) calls the pathogenetische Aktualitätsdiagnose. This aims to identify the change that is the most important link in the chain of pathology at a given moment. All too frequently methods are applied which, for example, stimulate the skin when no signs of a HAZ have been found, or relax a muscle when no tension has been diagnosed (no TrPs found); we even find manipulations being performed when no restriction was present. Clearly, too, it is a waste of time to prescribe remedial exercise when there is no diagnosis of faulty muscle control. Naturally, in order to produce an accurate ‘present relevance’ diagnosis of pathogenesis as explained above, we need to have identified the
History and fundamental principles
individual links in the chain of pathology and ana lyzed their significance. We must proceed in a sys tematic fashion, starting at the peripheral level and working up to the central, applying treatment according to our findings.
The ‘present relevance’ diagnosis according to Gutmann enables us to identify the most significant link in the chain of pathogenesis.
Nevertheless, at times the results of treatment fail to meet expectations. One of the reasons for this is the presence of a lesion which causes intense nociceptive stimulation and dominates the clinical picture without the patient being aware of it. This may be referred to as a field of disturbance. Most commonly the source of this is an ‘active scar,’ the expression of which is a HAZ, increased resistance to shifting, and, in the abdominal cavity, a resist ance that is tender on examination. If the usual methods of therapy are unsuccessful, it is essential to treat the scar. Another cause of repeated failure is masked depression. This should always be consid ered in patients presenting with chronic pain, and needs to be treated.
The dysfunctions of the locomotor system that are described here, together with the reflex changes they produce, may aptly be called the ‘functional pathology of the locomotor system.’
1.3.3 Structural and functional changes In this connection the unfortunate but frequent use of the term ‘functional’ as a euphemism for ‘psy chological’ is most regrettable – it implies a grave underestimation of the importance of function and its role in pathogenesis. In rehabilitation we are primarily concerned with function, and seek at the very least to improve it when dealing with conditions where there is underlying pathomor phological, structural change. This is readily under standable; dysfunction is the form in which any relevant structural lesion is clinically expressed. It
Chapter 1
is fundamentally important to distinguish structural disturbances from functional ones. Where the disturbance is functional, it would be a mistake to think of the dysfunction as being exclusively a matter of reflex changes and reflex control. What we are dealing with here is more than just ‘reflexes’; these are rather ‘programs,’ having memory and capable of being elicited. They affect the entire locomotor system and its disturbances. The most common disturbances, which are also the object of manipulation therapy, concern the spinal column. The term ‘vertebrogenic’ is often used for these, although it is not entirely applica ble, since vertebrogenic disorders often include diseases with a pathomorphological definition, such as ankylosing spondylitis, osteoporosis, neoplasms, etc. Those which interest us, on the other hand, are mainly dysfunctions. They are not confined to the spinal column but also affect the limbs, soft tissues and, most of all, the musculature, which is control led by the nervous system. In view of this it is more appropriate to speak of dysfunctions of the locomo tor system, rather than vertebrogenic disturbances.
1.3.4 The place of reflex therapy The question as to the place of reflex therapy is as difficult to answer as that of the importance of pharmacotherapy. Whereas pharmacotherapy has developed into a significant science, methods of reflex therapy for some time remained empirical, and the indications for their use are ill-defined. The indication for a given treatment is not gov erned by the particular disease (diagnosis), but rather is based on the findings that are significant in terms of the pathogenesis. If, for example, head ache is due to muscular tension, then muscle relax ation is most important. If this muscular tension is associated with joint restriction, then manipulation (mobilization) is indicated; if faulty posture is the cause, it is this that has to be corrected. The advantages of this type of therapy over pharmacotherapy are that the methods used are entirely physiological and (usually) incur no side effects; further – because of their reflex nature – their effectiveness can generally be checked at once. It is worth saying a few words here about the role of pharmacotherapy in dysfunctions of the locomotor system. It would be difficult to conceive 7
Manipulative Therapy
of a drug that could restore a specific motor func tion, although it is possible to alleviate muscle ten sion, ease pain, and damp down some of the reflex effects involved, all of which can facilitate the res toration of function. Additionally, they are a neces sary means of treating depression and anxiety. To sum up, neither the diagnosis nor individual clinical findings in themselves suffice as the basis for deciding the most appropriate therapy. An analysis of pathogenesis is the only means of iden tifying the disturbance that is the most important at a given moment.
8
After treatment the patient must be re-examined to assess the effect, and from this we can make further judgments about the appropriateness of the approach taken. If treatment has been effec tive, the follow-up examination will show a change in the patient’s condition (short term evidence). The task then begins again to decide which distur bance is now the most important. Therapy is therefore never a monotonous rou tine; at the same time the success of treatment is always verifiable, and this aids the practitioner in applying a reasoned, scientific approach.
Chapter Two
2
Etiology and pathogenesis
Chapter contents 2.1 The significance of morphological changes . . . . . . . . . . . . . . . . . . . 9 2.2 Theoretical aspects of manipulation therapy . . . . . . . . . . . . . . . . . . . 10 2.3 The significance of functional disturbances . . . . . . . . . . . . . . . . 12 2.4 Motion segment and joint dysfunctions . . 13
2.4.1 The barrier . . . . . . . . . . . . . . 13 2.4.2 Joint play and restriction . . . . . . 14 2.4.3 Reflex changes in joint restriction . 15 2.4.4 Is restriction an articular phenomenon? . . . . . . . . . . . . 16 2.4.5 The possible mechanism of restriction and manipulation . . . . 16 2.4.6 The effect of manipulation . . . . . 17 2.4.7 The pathogenesis of restriction . . . 17 2.5 The spinal column as a functional unit . . 19
2.5.1 The spinal column and balance . . 20 2.5.2 Key regions of the spinal column in dysfunctions . . . . . . . . . . . 20 2.5.3 The importance of nervous control . . . . . . . . . . . . . . . . 21 2.6 Dysfunctions of the spinal column in childhood . . . . . . . . . . . . . . . . . . 24 2.7 Restrictions and their sequelae . . . . . . 26 2.8 The significance of disturbed motor patterns (stereotypes) . . . . . . . . . . . 27 2.9 Sequelae of disturbed movement patterns . . . . . . . . . . . . . . . . . . . 29
2.9.1 Walking and standing . . . . . . . . 29
2.9.2 Straightening up from a forward-flexed position . . . . . . . 29 2.9.3 Raising the arms . . . . . . . . . . . 30 2.9.4 Weight carrying . . . . . . . . . . . 30 2.9.5 The effect of respiration on the locomotor system . . . . . . . . . . 30 2.10 The significance of constitutional hypermobility . . . . . . . . . . . . . . . 33 2.11 Reflex processes in vertebrogenic dysfunctions . . . . . . . . . . . . . . . 34 2.12 Radicular pain . . . . . . . . . . . . . . . 36 2.13 The term ‘vertebrogenic’ . . . . . . . . . 37 2.14 Conclusions . . . . . . . . . . . . . . . . 38
2.1 The significance of morphological changes Chapter 1 indicated the great range of application of manipulative therapy and most methods of reflex therapy, which can be used for many different cases of pain in the locomotor system; these often involve pain whose cause and therefore treatment remain controversial. For a long time they were generally considered to be of inflammatory origin, for the simple reason that this provided the easiest explanation for the pain. Indeed we still speak of rheumatic diseases, for example ‘soft tissue rheumatism,’ and many terms ending in ‘-itis’ bear witness to this attitude (spondylitis, arthritis, radiculitis, neuritis, fibrositis, myositis, and panniculitis, for example). Since, however, inflammation is a well-defined pathological condition which
Manipulative Therapy
can be demonstrated or disproved, the inflammation theory became untenable and had to be abandoned for lack of evidence. Pathological anatomy and the use of radiology to examine pathology in living patients (X-rays) played their part by demonstrating degenerative changes. In place of terms ending in ‘-itis’ we speak of spondylosis, arthroses, and ‘diskopathy.’ This approach offers the possibility of explaining the changes in tissues that are sometimes bradytrophic. Vascularization of the intervertebral disk becomes reduced at quite a young age and the nucleus pulposus dries out: the water content decreases from 90% in the first decade of life to 70% in the third decade. According to Schmorl, 60% of women and 80% of men at age 50 show evidence of degenerative changes of the spinal column, while by the age of 70 the figure is 95% for both sexes. The very abundance of degenerative changes makes it difficult to define their pathogenetic significance. Whereas the number of degenerative changes increases with age, back pain occurs most often between the fourth and sixth decade, to become less common in old age. Subjects with considerable degenerative changes may be completely without clinical symptoms; alternatively they may suffer an attack of acute pain which subsides after a time (while the degenerative changes remain the same) to leave them once more symptom free. There can even be severe pain in young patients with no degenerative changes at all. The main difficulty is the fact that the term ‘degenerative’ is so poorly defined. It is used on the one hand for destructive lesions typically only found in the hip and knee, and on the other hand for changes of little clinical significance, and which are better described as normal ‘wear and tear.’ Often the change is a compensatory process or adaptation – as in scolioses, in hypermobility, or even instability (for example in spondylolisthesis) which can thus be stabilized. It is often difficult to distinguish between changes resulting from trauma and degenerative ones. When we find degenerative changes, we should begin by asking about their clinical relevance. It is a mistake to draw clinical conclusions without good reason from the mere existence of non-destructive degenerative changes seen on X-ray; they do not in themselves justify speaking of ‘degenerative disease.’ There is certainly some correlation between degenerative changes and herniated disk; with a few exceptions, herniation occurs mainly in disks already showing some degenerative change. The 10
discovery that disk herniation can be a cause of pain was an important step historically, but the success of surgical treatment was often so striking that disk lesions came to be held responsible for most of the many instances of pain related to the spinal column. The principles that applied to radicular syndromes, mainly in the lumbosacral region, were uncritically applied to a whole range of complaints in all parts of the spinal column. ‘Diskopathy’ became the fashionable word for what we now refer to as vertebrogenic (or spondylogenic) disease. Everyday practice contradicts this view and serves to correct it. Although disk surgery is a routine procedure for radicular syndromes of the lower limbs, it is rarely performed for low-back pain or radicular syndromes of the upper limbs, and not at all for simple neck pain or vertebrogenic headache. Nor is disk herniation the only possible cause of pain in radicular syndromes of the lower limbs: in operation statistics no disk herniation is found in about 10% of the cases; many radicular syndromes resolve without operation, and this is true even of cases in which medical imaging had found a herniated disk. Disk herniation can sometimes persist after the symptoms have disappeared, although resorption is also possible. Not only that; computerized tomography (CT) or magnetic resonance imaging (MRI) examination frequently reveals a herniated disk in healthy individuals in whom it is of little relevance. It is only significant when it correlates with clinical findings. To conclude, in the overwhelming majority of cases of back pain and associated clinical symptoms the morphological changes discussed above do not provide an explanation. For this reason this type of pain is referred to as ‘nonspecific’ (Jayson 1970) or ‘idiopathic’ (without any morphological diagnosis).
The vast majority of cases of pain are not associated with demonstrable morphological changes in the locomotor system. In effect, therefore, these are patients with ‘no diagnosis.’
2.2 Theoretical aspects of manipulation therapy Successful manipulative treatment usually results in relief of pain. We may conclude from this that an
Etiology and pathogenesis
understanding of how this therapy works will give us a better insight into what causes pain in the locomotor system, especially in cases where no pathological changes are present. The explanation originally given for the effect of manipulative therapy was that it involved ‘repositioning’; the understanding was that what was being treated was an incomplete dislocation, for which ‘subluxation’ became the accepted term. This was what Hippocrates believed, and probably also Still and most practitioners providing manipulative treatment down the ages. Indeed, the sight of a patient with acute lumbago or wry neck, unable to straighten up, who receives successful manipulation treatment and becomes able to stand erect, makes it little wonder that they did see this as the likely explanation. The reason that physicians have had to abandon the subluxation theory lies in the radiographic findings, since X-rays show no change for the individual segments before and after manipulation. The only change is in the abnormal posture, whose cause is muscular. It has been shown by M Berger (personal communication) by means of cineradiography that when the head moves to an extreme position and back, it does not return to the same neutral position as before. We were able to confirm this by means of transoral radiography (see Figure 2.1). An analogous effect was demonstrated by Jirout (1979a) for synkineses of the cervical spine in the sagittal plane on side-bending; when images were taken in the neutral position before and after
Chapter 2
maximum side-bending, the position of the spinous processes was generally found to be changed. The conclusion that can be drawn from these observations is that in a structure consisting of such a number of mobile elements there can be no absolute, fixed neutral position. The same applies to any changes there may be following manipulation. It will be shown below that manipulation operates only on disturbed function, that is mobility in the affected motion segment. If, however, there is no absolute neutral position, it follows that manipulation enables the motion segments of the spinal column to adopt the position that is most favorable in the particular circumstances.
If the mobility of the motion segments of the spinal column is normal, the spinal column itself knows far better than the person giving treatment which position it should adopt for each particular posture or load.
According to the literature, some authors, such as Cyriax, Maigne, and Stoddard, believe that manipulation exerts some kind of effect on the disks. However, it is difficult to see how manipulation could achieve repositioning of a herniated disk when its exact position can never be known. Another point to consider is that manipulation is also effective in treating other locations, where
Figure 2.1 • (A) Almost symmetrical position of C2 in the neutral position. (B) On returning to the same neutral position immediately after maximum rotation of the head to the left there is marked rotation of C2 to the left.
11
Manipulative Therapy
there are no disks, such as the limb joints, the atlanto-occipital and atlantoaxial joints and the pelvis. Clinical experience supports this: manipulation is most effective in situations where there is no disk herniation, and often fails precisely in cases where there is. The precise examination techniques used by osteopaths have also provided a clearer idea of the effect of manipulation therapies; these are indicated when we find movement restriction in a joint or a vertebral motion segment, and if manipulation is successful, normal mobility is restored. In other words, manipulation does not achieve a change of structure, as Still thought, but normalization of mobility; that is of function. This is also true in cases of acute lumbago or acute wry neck: the position of the neck or the back in such cases is not in fact abnormal in itself; it is only the fact that the patient is unable to straighten from a position, such as flexion, or rotation plus inclination, that is pathological. Manipulation (mobilization) simply frees mobility and thus enables the patient to return to the neutral position. Acute lumbago and wry neck are in fact an exception in this regard; in the vast majority of cases the position observed is normal and the finding is simply one of movement restriction in the joint (or vertebral motion segment).
Manipulative techniques are used to diagnose and treat only functional movement restrictions in a joint or vertebral motion segment. The purpose of manipulation techniques is simply to normalize disturbed function.
2.3 The significance of functional disturbances As the above makes clear, it is above all clinical experience in the use of manipulation for diagnosis and treatment that constantly reaffirms, in countless patients, the principle that treatment, if technically successful, brings normalization of restricted mobility in the joint or motion segment. Normalization goes hand in hand with the restoration of function (bending or rotation to the left or right; in the case of the limbs, symmetrical findings in the left and right limb). Normalization of function also brings relief of pain. 12
A similar principle applies not only to the passive mobility of joints, but also to active muscle function. Janda in particular demonstrated the significance of muscular stereotypes and showed that faulty movement patterns (disturbances of these stereotypes) produce abnormal stress on passive structures, especially joints. Closely associated with movement patterns is the matter of body statics. In fact, static overload and its consequences have become an extremely important issue in our modern technologically developed society with its general lack of mobility. Here too we find that correction of faulty posture frequently relieves pain. The contribution made by Brügger is particularly helpful in this connection, since he has made a special study of the hunched sitting posture and its treatment. Manual functional diagnosis thus served as a model for many other dysfunctions of the locomotor system. The muscle trigger point (TrP) most clearly demonstrates the close connection with pain. In saying so we should stress that morphological lesions are also associated with disturbances of function. This is most clearly the case for herniated disks and may explain spontaneous recovery and recovery after conservative treatment (including manipulation). A similar situation applies to rehabilitation in traumatology, where our primary aim is to improve function despite the presence of irreversible structural changes, where the aim of rehabilitation is to achieve functional compensation. As will be shown in more detail later, function and its disturbances are rarely confined to one site or structure. Diagnosis must therefore take in the locomotor system as a whole, and consequently the terms ‘vertebrogenic’ or ‘spondylogenic’ will no longer suffice. Even in back pain, muscle function and its nervous control play an important role, as do the functions of the pelvis and lower limbs. Since ‘vertebrogenic’ diseases or lesions include such well-defined pathological conditions as ankylosing spondylitis and osteoporosis, the decisive criterion for the use of manipulation and other measures aimed at restoring function is whether the patient’s complaint is due (mainly or exclusively) to dysfunction, or to structural (pathomorphological) changes. The solution is not simple, and the problem lies in the fact that the method of examination has not yet been precisely defined. It is the great weakness of important methods of treatment – such as manipulative therapy, remedial exercise, and other methods concerned with improving the functioning
Etiology and pathogenesis
of the motor system – that they are often more concerned with the method than with its object or its potential for diagnosis. In many fields of medicine the significance of findings relating primarily to function is now well recognized. In the locomotor system, however, where function is paramount, this aspect finds least acceptance. Yet the functioning of the locomotor system is extremely complex, and diagnosis of disturbed function is correspondingly difficult. Nor is there a specific medical specialty responsible for this area; functional disturbances seem to be the realm of everyone and of no one. There is an additional disadvantage in that, for the most part, the only means of investigating dysfunctions of the locomotor system is by inspection and palpation. Today these are often regarded as ‘subjective’ and dismissed, while instrumental and laboratory methods are regarded as objective.
2.4 Motion segment and joint dysfunctions Dysfunctions of joints and vertebral motion segments (see Figure 2.2) fall into two categories: hypermobility and restricted mobility; manipulative therapy is concerned only with restricted mobility.
Chapter 2
Clinical criteria are the decisive factor in identifying such restriction, and are judged from the qualitative point of view as well as quantitatively. A reduced range of motion is easy to recognize and measure in a joint, but much more difficult in motion segments of the spinal column. Qualitative changes are therefore of considerable diagnostic value when dealing with the spinal column. This is the case when the finding is one of increased resistance, and especially a lack of ‘springing’ at the end of the range of motion, with abrupt resistance encountered in the end position of the joint or motion segment. In a normal joint the extreme position is never reached abruptly, and a slight increase of pressure can always increase the range of motion. In a joint with functionally restricted mobility, this springing or giving way has been lost and we abruptly encounter a hard barrier. This, termed joint ‘restriction’ (sometimes ‘blocking’ or ‘blockage’), is perhaps the most significant sign in diagnosis.
2.4.1 The barrier The concept of the ‘barrier’ is a familiar one in the osteopathic literature. Three kinds of barrier can be identified: 1. The anatomical barrier, created by the bony structures. 2. The physiological barrier, which is clinically significant and is found at that point in the examination where the first, minute degree of resistance is felt; the barrier yields slightly with a sense of ‘springing.’ 3. The pathological barrier, which restricts motion and is felt as a hard, abrupt stop, lacking the sense of spring. In addition there is often a change in the neutral position; for example in rotation of the head or trunk, so that this becomes asymmetrical (see Figure 2.3).
Figure 2.3 • The barrier phenomenon. A–A: the anatomical Figure 2.2 • The motion segment (after Junghanns).
barrier; Ph–Ph: the physiological barrier; Path: the pathological barrier; N0: neutral position; N1: shifted neutral position when a pathological barrier is present.
13
Manipulative Therapy
The barrier as a phenomenon was originally defined with reference to joints, but is also useful in relation to the elasticity and mobility of soft tissues, including muscles. The barrier is therefore relevant for all mobile structures; it has a protective function. The definition of the physiological barrier given above is not universally accepted. It is defined in an osteopathic publication (Kuchera 1997) as the limit of active motion. We consider this definition to be of no practical use on the grounds that passive examination of the barrier is used to investigate movement restrictions, both for motion segments and for joint play. The objection applies all the more to soft tissue diagnosis. In chiropractic, this barrier is defined as the limit of maximum passive motion, the important point being that passive motion has a greater range than active motion. If manipulation were to be performed on a barrier defined in such terms, it would elicit an intense stretch reflex. This would rule out any gentle techniques, let alone relaxation on the part of the patient. Perhaps there is an explanation here for the harshness of technique used by some chiropractors. The definition we have given above for the physiological barrier must therefore stand. It is useful both in diagnosis and as a principle that underlies our treatment, which produces release. We recognize fully that this does involve subjective evaluation. The first, minute resistance is found by means of palpation, which of course depends on the experience of the practitioner.
only be sensed by palpation, but can be demonstrated radiographically (see Figures 2.4 and 2.5). Joint play is by no means only a matter of theoretical interest: its practical clinical importance lies in the fact that joint play reveals restriction at a stage when functional mobility is still normal, and – as can be seen from Figures 2.5 and 2.6 – translational
2.4.2 Joint play and restriction There are two types of joint movement, both of which are affected by restriction: 1. Functional movement: movement that can also be performed actively. 2. Joint play (according to Mennell 1964): movement of the joint which can only be brought about passively. This comprises a translatory (sliding) movement of one joint surface against the other, sometimes also rotation, and also distraction of the joint facets. To give an example, actively we can flex, extend, or side-bend a finger, whereas passively it can be shifted against the metacarpal in any direction, rotated, or distracted by axial pull. These movements can not 14
Figure 2.4 • Lateral and medial gapping of the knee joint, visualized radiographically.
Etiology and pathogenesis
Chapter 2
Figure 2.7 • Direction of joint mobilization according to
Kaltenborn. With fixation of the concave partner of the joint, mobilization is performed in the opposite direction to that of functional movement. With fixation of the convex partner, mobilization is performed in the same direction.
Figure 2.5 • Distraction of the metacarpophalangeal joint, visualized radiographically.
Joint play can be likened to a drawer that has stuck: any attempt to open it forcefully could damage it, but if we shift it slightly to and fro in the sideways direction, we can then open it easily. The diagram according to Kaltenborn (1989) (see Figure 2.7) shows the direction in which joint play is freest.
2.4.3 Reflex changes in joint restriction Figure 2.6 • Joint play according to Mennell. (A) Normal
gliding motion during joint flexion. (B) Where there is a dysfunction of gliding motion, passive functional movement can injure the joint.
movements and distraction provide a much more gentle method of treatment than passive functional movement.
Normal joint play is necessary for normal joint movement.
Restriction in a joint and particularly in a vertebral motion segment produces reflex changes, mainly in the segment concerned, affecting the cutaneous and subcutaneous tissue and muscles. Korr (1975) speaks of ‘facilitation’ in the segment. The movement restriction itself is associated with muscular tension (TrP or spasm); this can similarly be said of the straight-leg raising test and of the antalgic posture in lumbago or acute wry neck. Korr, a physiologist who worked on the problem of manipulative therapy, said of the role of the muscles: ‘While usually thinking of muscles as the motors of the body, producing motion by their 15
Manipulative Therapy
contraction, it is important to remember that the same contractile forces are also used to oppose motion’ (Korr 1975). From this we can conclude that, in their role as a brake, muscles act as a considerable and highly variable impediment to mobility in a dysfunctional joint. Korr continues: ‘The high-gain hypothesis is consistent with, and offers an explanation for, the steeply rising resistance to motion (‘bind’) in one direction and the equally precipitous collapse of resistance (increasing ‘ease’) in the opposite direction … They [the muscles] would also be provoked into stronger and stronger contraction by the exaggerated spindle discharges as motions that tend to lengthen the affected muscles occur’ (Korr 1975). This would also explain the hard ‘feel’ in the end position. All the clinical findings encountered in restriction might therefore be explained as the result of muscle activity and not as a disturbance of the joint itself. That is why osteopaths prefer to speak of ‘somatic dysfunction’ (Greenman), a term that includes the dysfunction of the joint, the muscles, and the soft tissues. The role of shortened muscles in movement restriction is emphasized by Janda. Muscle relaxation techniques are used with much success in order to mobilize joints. It is therefore appropriate at this point to consider the actual role of the joint in restriction.
2.4.4 Is restriction an articular phenomenon? Clearly the view that passive movement is exclusively the expression of articular function is not one that can be maintained. In fact, as Korr has shown, most clinical findings in joint restriction can be explained by muscle activity controlled by the gamma system. If this is the case, what role is played by the joint itself? If we are dealing with a reflex response, what is the origin of the stimulus that evokes it? It must surely be more than mere coincidence that techniques which have been found in a purely empirical manner to be effective in manipulation correspond to joint anatomy. The importance of joint play is also consistent with this, as is the fact that the popping sound, or ‘click,’ that is heard on successful manipulation comes from the joint. The hypotonus regularly observed following such manipulation is however a muscular phenomenon. 16
There are some joints that are not under the direct control of a particular muscle; obvious examples are the sacroiliac, the acromioclavicular and the tibiofibular joints. Yet muscular fixation of these joints (other than the acromioclavicular joint) is regularly found. In the case of the sacroiliac joint, for example, this is caused by the pelvic floor, the ischiocrural muscles, or the piriformis; in the tibiofibular joint by the biceps femoris. In order to investigate further the role of the joint, we undertook the following experiments: in patients who were about to undergo operation under anesthetic with artificial respiration, the cervical spine was examined shortly before operation. Restrictions were found in ten patients, and the exact location and direction determined. The patients were re-examined under anesthesia, which used mainly thiopental, nitrous oxide and 100 g succinylcholine iodide, the patients being in a state of complete muscle relaxation. This involved brief interruption of the intubation. In all cases the movement restriction remained unchanged during narcosis.
2.4.5 The possible mechanism of restriction and manipulation The importance of the experiment just referred to lies first in demonstrating that the joint does also play a part in restriction; and second in showing that there is (also) a mechanical resistance. It was Emminger (1967) who first suggested that this might be attributed to a trapping of the meniscoids as previously described by Töndury and others. Kos & Wolf (1972) showed in addition that these meniscoids do also exist in the limb joints. The physiological role of the meniscoids is to fill the changing joint space as it alters during movement, since they are a highly mobile structure. Most joints have very incongruous facets; without the meniscoids to perform this role, gapping of the joint would occur during movement. The meniscoid is intimately connected with the joint capsule. Clearly such wellnigh chaotic-seeming motion must be prone to disturbance. However, Cihák (1981) points out that the deep layers of the multifidus muscles are linked with the joint capsule and so control this mechanism. This theory has been further elaborated by Kos & Wolf (1972). They describe the following hypothetical pathogenetic mechanism:
Etiology and pathogenesis
Chapter 2
Figure 2.8 • The entrapment of a meniscoid and its
emergence, according to Wolf & Kos (1972). The meniscoid normally lying in position a has moved between the joint facets, b; following treatment, the meniscoid overcomes the slight resistance offered by the constriction from c to d.
• The main body of the meniscoid is soft,
connected with the joint capsule. It has a hard free edge, which cannot easily be compressed and projects into the joint space. • Joint cartilage is hard and elastic only if the force that acts on it does so briefly. If, however, we subject the cartilage to constant pressure, it adapts to the material exerting that pressure as though it were fluid. If, therefore, the meniscoid is caught between the gliding surfaces of the joint facets, the cartilage adapts to the hard meniscoid, embedding it (viscoelasticity) (Figure 2.8). This diagram clearly illustrates the mechanism of manipulative techniques. High-velocity, low-amplitude (HVLA) techniques cause gapping of the joint capsule, as a result of which the meniscoid has only a short constricted area to overcome (Figure 2.9). In repetitive mobilization, the meniscoid is freed during the back-and-forth movement of the joint facets, and all that is apparently needed as we wait for release to occur is the relaxation of the muscles, which widens the joint space.
2.4.6 The effect of manipulation The effect of successful manipulation is two-fold: 1. It restores mobility, including joint play. 2. It produces an intense reflex reaction in all structures where changes had been present before manipulation. This occurs most strongly in the musculature, where a previous state of increased tension (TrPs; occasionally spasm) is replaced following manipulation by hypotonia. The skin, too, becomes easier to fold and stretch, and soft tissues easier to shift against each other. Tension is thus reduced in all tissues, especially in the corresponding segment. Depending on
Figure 2.9 • The effect of therapy. (A) High-velocity, low-
amplitude thrust. (B) Repetitive mobilization. (C) Widening of the joint space by release technique.
the significance of the vertebral motion segment or the joint concerned, the effect of the manipulation also extends to distant segments; this will be discussed later. The effects referred to here can not only be observed clinically, but can also be objectively demonstrated by physiological methods (see Figures 2.10–2.13).
2.4.7 The pathogenesis of restriction Overload and abnormal load In the case of the most minor restrictions, we know from our own experience how these come about: sitting or working for a long period in an unfavorable position, we sense a need to stretch 17
Manipulative Therapy
Figure 2.10 • Changes in skin temperature after root infiltration in root compression syndromes. (A) Temperature reaction. (B) (Slow) course of reaction: the ‘overall mean temperature change’ curve also includes decreases in temperature. The changes in temperature pursue a much slower course than occurs in traction therapy (see Figure 2.11).
Figure 2.11 • Changes in skin temperature following traction therapy of the spinal column in root compression syndrome of the upper and lower limbs. (A) Temperature reaction. (B) (Rapid) course of this reaction; ‘overall mean temperature change’ curve also includes decreases in temperature. The changes in temperature pursue a much more rapid course than occurs in root infiltration (See Figure 2.10).
Figure 2.12 • Summation electromyogram showing the
increase in muscle activity (force) in the triceps brachii during cervical traction.
18
Figure 2.13 • Summation electromyogram of the triceps brachii taken from three leads in a C8 root compression syndrome (A) before and (B) after cervical manipulation.
Etiology and pathogenesis
and move, that is to ease such minor inhibitions of movement. This is the stiffness that causes us to stretch ourselves on getting up in the morning. Minor restrictions can therefore arise even in physiological situations and in healthy individuals; and these resolve spontaneously. There is a fluid transition between such minor restrictions following physiological stress, and persistent restrictions following pathogenic, harmful stress. Both the stress itself and the neuromuscular system of the patient play a role here. One pathogenic factor is overload; another, more frequent cause is a disturbed movement pattern (motor stereotype) on the part of the patient, consisting of an imbalance of muscle function which impairs the joint (Janda). Modern civilization brings with it very one-sided, unvaried posture and movement, causing muscular imbalance. Lack of movement together with static or postural overload are a characteristic feature of modern life. Disturbed movement patterns and static overload are probably the most frequent causes of reversible restrictions and of their occurrence and recurrence.
Trauma Trauma is a further potential cause. It is important to point out that the borderline between patient groups suffering from overload and those suffering the effects of trauma can in fact be very fluid, because it is not always easy to say what should and should not be interpreted as trauma. It is usually defined as a force acting on the body and capable of damaging structure or function. However, even under normal conditions the forces acting on the spinal column are considerable. If these forces are suddenly increased because of sudden, unexpected movement, especially if this involves contraction of the powerful muscles of the back, it becomes extremely difficult to distinguish between overload and trauma. The somewhat vague term ‘microtrauma’ is then used.
Reflex processes A further complex of causes involves reflex processes within the segment. As has been stated already, the spinal column is routinely involved in disease processes in the body. Vertebral restrictions can therefore occur following – and also as a result of – disease elsewhere in the body. The primary
Chapter 2
condition creates a stimulus in the segment, which in turn produces a spasm (TrP) in the corresponding region of the erector spinae muscle, in particular in the deep layer. The effect is muscular fixation of the vertebral motion segment: a restriction. This is the same mechanism that, according to Hansen & Schliack (1962), leads to scoliosis in visceral disease. Today it is possible to distinguish a number of characteristic patterns related to visceral disease (see Chapter 7) which points to certain pathogenetic rules. Another characteristic feature of this type of restriction is its recurrence if the internal disease relapses or exacerbates. Admittedly, however, we know more about visceral influence upon the spinal column than about the influence of the spinal column on visceral organs.
2.5 The spinal column as a functional unit The most important functions performed by the spinal column are: • giving support and protection to neural structures • being the axis of motion for the body • helping to maintain the balance of the body. As we can see from the first two functions listed, these roles are contradictory; Gutmann (1965) expressed this succinctly when he said: ‘the spinal column should be as mobile as possible and as firm as necessary.’ The implications of this become clear when we consider the remarkable range of movement of the atlanto-occipital and atlantoaxial joints, and the fact that vital centers of the medulla oblongata are located at this level; these twin facts explain why disturbances of these two basic functions are linked. If a dysfunction produces a pain stimulus, a muscular defense reaction blocks the damaging movement. A spinal column with restricted mobility is no longer properly able to carry out its protective function. The effects extend to the structures of the nervous system, which in turn exerts an effect on the spinal column that is causing the damage to them. Sobotka (1956) demonstrated that damage to a nerve root causes trophic changes of the intervertebral disks. The function of the spinal column affects not only the structures inside the spinal canal, but also the entire locomotor system, including the limbs, and probably also internal organs. 19
Manipulative Therapy
The existence of all these functional interconnections means that the spinal column should always also be considered when the object of concern is the pelvis, limbs, or especially the muscles under central nervous system control.
2.5.1 The spinal column and balance The importance of the spinal column in the maintenance of balance is usually underestimated. This applies in particular to the craniocervical junction. It is often forgotten that the labyrinth is not absolutely essential for the maintenance of balance and posture, whereas proprioception is, especially in the spinal column. Clinical evidence confirms this (see Chapter 7). The experiments carried out by Norré and coworkers (1976), using Greiner and coworkers’ (1967) flexible-support chair, are particularly valuable in this respect. The method they used involves keeping the subject’s head fixed in position while turning the trunk from side to side with a pendular motion. They were able in this way to produce nystagmus, purely by stimulation of the cervical proprioceptors (Greiner et al 1967, Hülse 1983, Moser et al 1974, Norré et al 1976, Simon & Moser 1976). The effects are not limited to the cervical spine. Komendantov (1945, 1948) demonstrated in rabbits that tonic reflexes can originate not only from the neck but also from the lumbar spine. He distinguishes the lumbosacral-eyes and lumbosacral-head reflexes. On side-bending of the animal’s trunk in the lumbar region around a dorsoventral axis, with the upper body and head fixed, the eyes move in the opposite direction to the trunk. If the head is not held fixed, there is an additional slight turning of the head, also in the opposite direction. Leads from the muscles of the nictitating membrane and the rectus muscles (of the eye) showed this to be a tonic reflex. Komendantov’s experimental design enabled him to make neck and lumbosacral reflexes compete, with the neck reflexes usually proving stronger. However, the effect was dependent on the extent of side-bending; the greater the side-bending, the stronger the effect. Interestingly in the course over time, it was seen that immediately following the effect of a neck reflex, even a relatively weak lumbosacral reflex can also assert itself. This mechanism apparently enables the animal to keep the visual field constant during locomotion, despite the motion of the head 20
and trunk. The reflexes therefore have very short transmission times; changes were still being registered in the activity of the muscles investigated, even at a side-bending frequency of 200 side-bends per minute. These experiments demonstrate that the spinal column is a functional unit governed by reflex response; if certain changes in position or function occur at one end of the spinal column, these exert an instant reflex effect along the entire spine. It should be stressed that, in humans, both ends of the spinal column are held relatively constant: in the case of the pelvis this is achieved because of the length of the legs; in the case of the head, through reflex fixation of the plane of the eyes and labyrinth in space. This preservation of the head position is strongly maintained as a movement pattern (motor stereotype). Ushio and coworkers (1973) demonstrated the deleterious effect of low-back pain on vertigo and the beneficial effect of immobilizing the lumbar spine in lumbago.
2.5.2 Key regions of the spinal column in dysfunctions So far we have considered restriction and its origins without reference to its effects on the rest of the spinal column. This, however, would be to ignore one of the most frequent causes of restrictions: a restriction or trigger point in another section of the spinal column. These bring about a compensatory increase in mobility in the neighboring segment, which leads to overload and ultimately a further restriction. Chain reactions therefore come about, which explains why vertebrogenic disturbances tend over time to involve the entire locomotor system. Therefore we should always examine the entire spinal column, at least in terms of screening assessment. It is important to realize, not least in this respect, that not all vertebral segments have the same importance for the overall function. When performing a brief assessment we should therefore focus on ‘key regions.’ In most cases these are transition zones from one type of movement to another: • The craniocervical junction: the delicate vertebrae of the upper cervical spine bear the heavy weight of the human head and also enable extensive mobility in all directions. Dysfunctions here affect muscle tone in the postural musculature and lead to disturbances of balance. Restrictions of the atlanto-occipital and atlantoaxial joints impair the mobility of the
Etiology and pathogenesis
rest of the cervical spine. The most important type of motion between the atlas and the axis is rotation; the rest of the cervical spine is less well adapted for this, and so suffers if forced to compensate for a craniocervical rotation dysfunction. The vertebral artery runs through the atlanto-occipital and atlantoaxial joints, and can also be affected by dysfunctions in this region. • The cervicothoracic junction: this is the region in which the most mobile section of the spinal column meets the relatively rigid upper thoracic spine. It is also the place where the powerful muscles of the shoulder girdle have their attachment, providing the main connection with the upper limbs and explaining why this region is particularly susceptible to dysfunctions. • The middle thoracic spine is to some extent the ‘weak point’ of the muscles of the back, since the lumbar and cervical parts of the erector spinae muscles end here, and kyphosis is usually greatest at this point. • One of the reasons for the considerable load borne by the thoracolumbar junction is that here the mechanism of motion typical of the thoracic spine changes within a short distance (at vertebra T12) to the lumbar pattern. This can be seen from the difference in shape of the upper and lower articular processes. If during walking the pelvis tilts from one side to the other, the lumbar spine side-bends so that the vertex of the scoliotic curve lies at the level of L3, the thoracolumbar junction remaining vertically in line with the sacrum; the thoracic spine then forms a scoliotic curve in the opposite direction. Consequently the thoracolumbar junction does indeed represent a junction. • The lumbosacroiliac joint region forms the base of the spinal column and is therefore extremely important to spinal column statics. At the same time the sacroiliac joints transmit movement from the legs to the spinal column and act as shock absorbers. • In humans the feet are the body’s actual base; also the greatest density of proprioceptive, exteroceptive, and nociceptive receptors is found there. Dysfunctions in this region consequently have an effect on the whole of the locomotor system; they should not be overlooked.
Chapter 2
2.5.3 The importance of nervous control The spinal column could not act as a functional unit unless all its reactions were coordinated, under control of the nervous system. Certain kinds of posture and movement sequences play the major role in this respect; these, following the proposal of Janda, are termed ‘motor patterns.’ These motor stereotypes are so characteristic of an individual that we can recognize people by their gait. There is considerable variation in the quality of these patterns, and this goes hand in hand with the susceptibility to disturbance of the locomotor system in the individual case. Any disturbance of function in a single motion segment will have its repercussions throughout the spinal column and must be compensated. The decisive role in this is played by the nervous system, which is similarly important in the matter of pain, for it is the nervous system that determines how intensely the segment will react, and where the threshold of pain lies. In other words, it is the nervous system that determines whether the dysfunction will manifest itself clinically. If the reaction to the nociceptive stimulus is intense, dysfunction in one motion segment will produce an antalgic response and alter the normal movement pattern, causing the dysfunction to become fixed, so that the condition becomes chronic. It is, therefore, no coincidence that dysfunctions of the motor system are more likely to be found in subjects with labile nervous regulation, and this tends to be evidenced psychologically as well. The point was emphasized by Gutzeit (1951), who saw the psychological factor as being characteristic for patients presenting with vertebrogenic disturbances. Kunc and coworkers (1955) showed that the psychological condition of patients plays a major part in recovery after disk operation. They demonstrated by means of experiment that these patients very easily formed conditioned reflexes to other pain stimuli, and that these reflexes were more difficult to extinguish than in healthy controls. Šrácek & Škrabal (1975) observed two groups of psychiatric patients: 50 cases of neurosis with symptoms of anxiety and depression, and 25 schizophrenics with blunted affect. Restriction, most frequently in the cervical spine, was absent in only 5 neurotic patients and in 16 schizophrenic patients. This difference is statistically highly significant (p < 0.01). Buran & Novák (1984), studying a group of 105 21
Manipulative Therapy
chronic patients, distinguished constitutionally neurotic and psychopathic patients from those who were psychologically normal. They found a preponderance of the fatigue reaction in the electromyogram (EMG) in the neurotic patients, and more frequent occurrence of positive F-waves, indicating a correspondence between psychological lability and labile nervous regulation. Lisý (1983) found similar results in EMG studies of patients with cervical syndrome. The clinical findings made by Janda (1978) are also worthy of note: in 100 patients with poor motor patterns, he found: • minor neurological signs of ‘microspasticity,’ in which movements were not fully coordinated, appearing as clumsiness • slight sensory impairment, especially of proprioception • poor adaptation to stress situations and inadequate, ‘uncoordinated’ behavior. All these clinical signs correspond to ‘minimal brain damage’ (MBD). Found in 10–15% of the child population, this is quietly assumed to disappear without trace in adulthood. However, Janda’s findings suggest that this brain dysfunction is in fact manifested in adult patients in the form of vertebrogenic disorders, poor motor patterns, and a considerable degree of labile nervous and emotional regulation. Despite the role played by muscular imbalance and faulty neural control, these should not be equated with joint dysfunction or restriction of a vertebral motion segment. Dysfunctions of the joints or vertebral segments do occasionally appear even in subjects with good motor patterns, yet may be absent in patients with neurological disease. Tilscher and coworkers (1979) found that of 27 spastic subjects, only 18.5% complained of backache. In our experience, most patients with Parkinson’s disease complain of backache; this is clearly associated with the muscle rigidity, which also affects the spinal column.
Faulty neurological and psychological control are among the factors involved in the pathogenesis and clinical signs and symptoms of locomotor dysfunctions. However, they are not identical with them.
22
The importance of developmental kinesiology It is no coincidence that Janda associates disturbances of motor pattern in adults with disturbances of the central nervous system in infants. Developmental kinesiology can indeed help us better understand the pathogenesis of dysfunctions, especially the effects that a structure belonging to the locomotor system can exert on distant regions; in other words, on the entire system. In this context we shall attempt to present the essential thinking of Vojta & Peters (1992) and Kolárˇ (1996, 1999, 2006) on the present subject. Neurophysiology today has no explanation for the effects exerted on each other by parts of the locomotor system that are situated far apart, which are found as a matter of everyday experience in manipulative therapy; nor can it explain the chains of trigger points. The principles governing these can however be explained by developmental kinesiology. The first reflexes in the newborn (stepping reflex, crossed extension reflex) are spinal cord reflexes. They offer no stability and do not enable posture of any kind. The first postural reflexes arise when the infant begins to observe its surroundings, raising and holding up its head. This is the point when the flexion posture of the newborn (see Figure 2.14) is brought into balance with the developing extensors. This development is complete roughly at the end of the third month (see Figure 2.15). The difference observed in the limbs is that the flexion posture gives way to a balanced, neutral posture with slight abduction, external rotation, and extension. It should be stressed that this posture can be achieved shortly after birth, according to Vojta & Peters (1992), who states that this can be done by
Figure 2.14 • Posture of the newborn in the prone position.
Etiology and pathogenesis
Figure 2.15 • Posture of the infant in the prone position at the end of the third month of life. The infant is able to support itself on forearms, pubic symphysis, and knees.
stimulating points where there is an abundance of proprioceptors. These points are structures on which we support ourselves; as soon as we rest on one of these points (forearm, elbow, or knee) for support, our posture changes automatically, remaining balanced in each case. This enables us to achieve the most favorable position (centering) of our joints. The extensor system is therefore younger in developmental terms than the ‘tonic’ flexor system, and therefore more susceptible to disturbance. This explains why the tonic system always predominates in pathological states, pain, and even in mere fatigue. Both systems are involved in upright posture; it is therefore inappropriate to use the term ‘postural muscles’ for the tonic system alone. The decisive issue is which system is older or younger in developmental terms. This course of development gives rise to the coactivity of antagonists, which enables balanced, upright posture and can be seen at two levels. As an example, the erector spinae is the antagonist that corresponds to the pectoralis major muscle. The relationship is so specific that certain bundles of fibers of the pectoralis major correspond only to certain bundles of fibers of the erector spinae. The same kind of correspondence applies to adductors and abductors in the limbs, for instance. Clinically this is seen in the localization of trigger points. However, this antagonism applies not only to individual muscles, but to the entire system. This fact is extremely important: stimulation of a muscle that belongs to the extensor system inhibits the whole of the flexor system. The effect can most clearly be seen when stimulation is applied to one of the points where most receptors are located, such as the fingers and toes. To give an example, stimulation of the finger extensors can produce inhibition in the straight-leg raising test.
Chapter 2
The coactivity pattern relates to upright posture as a whole. Muscles that maintain the position of the head over the shoulders have their fixed point of attachment in the region of the shoulder girdle, the muscles of the thorax and scapula in the pelvic region, and the muscles of the pelvis in the region of the lower limb, down as far as the foot. As soon as the position of one of these superposed sections changes, the entire system has to react. Control of these reflex processes in the maintenance of human upright posture is located above the brainstem; it has been little researched experimentally. The long chains of antagonists which subserve upright posture act on the spinal column like ropes stabilizing a mast. However, unlike a stiff mast, the spinal column is formed by 24 vertebrae and the sacrum which, according to Panjabi (1992a, 1992b), are unstable and would buckle under the strain. This is prevented by what is called the ‘deep stabilization system.’ Another system that is developed only in humans is that of the ‘deep stabilizers,’ which serves to maintain the upright posture of the spinal column. It consists of the deep layers of the erector spinae and transversus abdominis muscles, the diaphragm, and the pelvic floor. The last three of these support the abdominal wall. The abdominal cavity and its internal pressure provide the anterior support of the lumbar spine. In humans, the diaphragm plays a significant role as a postural muscle; only in humans is there a close link between respiration and posture, with the diaphragm lying horizontally. A further function, which develops relatively late in infants (after the sixth month) and which is therefore also susceptible to disturbance, is (active) rotation of the trunk. This plays a particularly important role in humans, since the most forceful movements, such as throwing a discus or boxing, proceed from a rotation of the trunk. At every step the shoulder girdle rotates in the opposite direction to the pelvis. The significance of this movement can be seen in the rehabilitation of leg amputees and paraplegic patients, because it is this mechanism that enables them to learn to walk. According to Farfan et al (1996), however, the spinal column is less well adapted to rotation movements in terms of its constituent parts; this applies especially to the intervertebral disks. In practical terms, both for the facilitation of muscle activity and in mobilization, it makes sense to utilize the posture that most closely matches development. In the model of the three-monthold infant, the limbs are brought into the optimum 23
Manipulative Therapy
Figure 2.16 • Weight-lifter’s posture.
(centered) position and the muscles activated. This posture also corresponds to that of a weight-lifter (see Figure 2.16).
Vojta’s developmental kinesiology offers an explanation for the physiological principles governing the upright posture of humans.
2.6 Dysfunctions of the spinal column in childhood From what has been said it follows that dysfunctions are regarded as primary phenomena in the pathogenesis of vertebrogenic disorders. Hence studies try to investigate them in their pure form, that is in the absence of degenerative changes, which can be done by studying them in children and young people. Schön (1956), and later Gutmann & Wolff (1959), have shown the average age at which the first symptoms appear to be much earlier than the age when they become evident 24
radiographically. Dysfunctions, however, appear at the same time as clinical symptoms. The most typical clinical condition in children is cervical myalgia (acute wry neck). Although this usually remits spontaneously, traction and gentle mobilization techniques, if well applied, should give immediate relief. This is particularly true for neuromuscular techniques. In children with headache, the cervical spine plays an important role. This is true of various types of headache, including migraine. In a group of 30 children suffering from vasomotor headache, manipulation produced improvement in 28 cases. Janda (1959) reported similar success following traction of the cervical spine. In a group of 27 children suffering from migraine, only 3 failed to respond to manipulation treatment (Lewit 1959). Similar results were reported by Kabátníková & Kabátník (1966). A particularly important type of headache in children, known as ‘school headache’ and generally believed to be of psychological origin, was proved by Gutmann (1968) to be due to head anteflexion during school hours, when the children were reading and writing at horizontal desks. This was confirmed by Lewit & Kuncová (1971). One clinical manifestation of disturbed function in the lumbosacral and pelvic region frequently found in young girls is dysmenorrhea with negative gynecological findings; this can frequently start as early as the menarche. Patients complain not only of pain in the lower abdomen; they also experience low-back pain. Manipulative therapy is the treatment of choice in such cases. The point should be made here that dysmenorrhea at an early age is frequently the first sign of dysfunction of the spinal column in women. True lumbago is much less frequent in childhood, but there are rare cases of true disk herniation as early as puberty. With the exception of acute wry neck, dysfunctions in the spinal column tend to be manifested indirectly in the form of referred pain, as headache, and in girls as dysmenorrhea. We were interested to see how frequently dysfunctions could be found in healthy children of different age groups. The most striking finding in children and adolescents is pelvic distortion which is dealt with in detail in later chapters. In serial studies we found this in 11 of 80 children (aged 14–41 months) examined in crèches, in 81 out of 181 children (aged 3–6 years) in nursery school and in 199 out of 459 schoolchildren aged 9–15 years. Statistical evaluation showed no significant difference between the incidence in boys and girls.
Etiology and pathogenesis
Movement restriction in the cervical spine (mainly at the atlanto-occipital and atlantoaxial joints) was found in none of the infants in crèches, in only 8 out of 181 nursery school children examined, and in 73 of the 459 schoolchildren. These investigations were carried out over 40 years ago, when the technique of examination for the upper cervical spine was much less sophisticated than it is today. It has since been found that pelvic distortion in children is generally associated with craniocervical joint restriction, mainly in the C0/C1 segment; there is normalization of the pelvic findings after the C0/C1 joint has been treated. In 1982 we therefore examined a group of 75 nursery school children (aged 3–6 years). We found pelvic distortion in 24, of whom 23 had movement restriction of C0/C1. In 12 of these children manipulation of the craniocervical joints was carried out, following which there was normalization of the pelvic distortion in all cases. There is thus good reason to believe that most of the children in whom we found pelvic distortion in the examination we performed over 40 years ago also suffered from restriction at the craniocervical junction. We also found slight scolioses in 175 of the 459 schoolchildren examined at that time, and in 15 out of the 181 nursery school children. Among the children in crèches, this finding was made in only 1 out of 80 children. The overwhelming importance of the craniocervical (atlanto-occipital and atlantoaxial) joints
Chapter 2
in infants was pointed out by Seifert (1975). In children in whom function is normal, they found that, on turning the head to one side, the pelvis turns to the opposite side. This reaction was absent in 298 of the 1093 infants examined. Over a period of 4–9 months restriction of the atlantooccipital and atlantoaxial joints was found in 58% of this group. Biedermann (1993) described what he termed ‘KISS syndrome,’ characterized by a forced attitude of the head in the side-bending position, often found in association with considerable somatic and autonomic disturbances. These he treated by manipulation. In a study group of 76 children suffering from chronic tonsillitis, Lewit & Abrahamovicˇ (1976), found restriction of the atlanto-occipital and atlantoaxial joints in 70 (92%) of the subjects, mainly in the C0/C1 segment. In evaluating these results we needed to discover whether they were chance findings or represented continuing, constant dysfunctions. In collaboration with Janda we therefore followed up a group of 72 children who started school attendance in 1960, carrying out regular examinations over a period of eight years. Half the number with dysfunctions of the spinal column were treated, and the other half left untreated as controls. In addition to the spinal column, the rest of the locomotor system and particularly the musculature were tested. The results are summarized in Figure 2.17.
Figure 2.17 • Follow-up study of 72 schoolchildren of various class age groups over a period of eight years to find the incidence of pelvic distortion, scoliosis, difference in leg length, and cervical restriction.
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Manipulative Therapy
The most important finding for our conclusions was that dysfunctions in the regions of the pelvis and cervical spine remained constant and seldom showed spontaneous improvement. The tendency to remain constant was greater for these than for scolioses or differences in leg length. There were only a few relapses after treatment.
Dysfunctions of the spinal column can be found even at a very young age, and even in subjects who are clinically healthy. However, they can be clinically manifested, usually as acute wry neck, headache and, in girls, as dysmenorrhea. These symptoms can occur in the absence of any degenerative changes.
2.7 Restrictions and their sequelae If a restriction occurs in the intact terrain of the spinal column of a child or an adolescent, for example, the consequences may seem at first sight to be minor: there may be some transitory pain, which usually disappears quickly as tends to be the case with acute wry neck. The dysfunction is compensated. Of course, a restriction occurring in the rest of the locomotor system, particularly the limbs, becomes clinically evident immediately. In the spinal column, consisting as it does of complex parts (54 intervertebral joints, including the atlantooccipital and atlantoaxial joints and the sacroiliac joints), the lack of mobility of a single joint or motion segment can go unnoticed. There is, however, a price to be paid for this capacity of compensation: increased demands or abnormal stress on the compensating structures. This becomes especially evident when the restriction occurs in a key region (see Section 2.5.2), because neighboring regions cannot easily compensate. As mentioned previously, restriction of rotation between the atlas and the axis means that their role in the rotation of the head has to be taken on by the rest of the cervical spine, which is far less suited to the task. This may help explain why osteochondrosis of the lower cervical spine is so commonly found. As a general principle, then, movement restriction in one segment produces hypermobility in its 26
neighbor, and this is most marked in the case of restrictions in key regions. The most frequent consequence of chronic overload is the formation of osteophytes to stabilize the motion segment. The lack of motion in the restricted segment often leads to disturbances of trophicity, which particularly affects bradytrophic tissues such as ligaments and disks. This is confirmed by radiographic evidence, which shows osteophyte formation in temporarily hypermobile segments (above block vertebrae). The usual findings in restricted segments are that two adjacent vertebrae form a block with the narrowed disk showing degenerative changes. Müller (1960) have shown how the hypermobile segment, initially created to compensate for a hypomobile one, stiffens in its turn as a result of osteophyte formation, so that the osteochondrosis spreads from one vertebral segment to the next. The stabilizing role of the osteophytes, which are plate-like in shape, can best be seen in chronic spondylolisthesis. Degenerative changes in themselves need not produce clinical symptoms. They do, however, make the spinal column more susceptible to disturbance, and the same applies to dysfunctions. Even patients with degenerative changes experience no symptoms as long as function remains compensated, but there is a risk of decompensation. This explains why the sequelae of trauma are usually more severe when degenerative changes are already present. Frequently, what are called degenerative changes are better described as adaptive ones, or an attempt to compensate dysfunction. One important sequela of degenerative changes can be a herniated disk. Here too there is a close relationship between structural change and dysfunction. With modern imaging techniques we find that disk herniation revealed by CT or MRI need not be accompanied by any symptoms; also that, in cases where the herniated disk does produce pain, the clinical symptoms may disappear despite the fact that the herniation continues to be evident on CT or MRI examination. The relationship between function and structural pathology is clearly very complicated here. Nevertheless, in cases of disk herniation, dysfunction can be treated at joints and trigger points, in soft tissue and in the stabilization system, to produce clinical compensation. The close association of structural and functional changes is clearly seen in carpal tunnel syndrome, which involves compression of the median nerve. On close examination we regularly find increased
Etiology and pathogenesis
resistance to the translatory displacement of neighboring carpal bones. When mobility is restored in the early stages, the symptoms of paresthesia disappear. In other words, it is only when there is free mobility between the bones forming the tunnel that the walls can adapt themselves to the contents of the tunnel in all the movements of the wrist. We should remember that one wall of the carpal tunnel is formed by the flexor retinaculum.
The dynamic role – usually also the primary role – in the interrelation between dysfunction and morphological change is that of function.
2.8 The significance of disturbed motor patterns (stereotypes) Disturbed motor stereotypes are perhaps the most important factor in the etiology of functional, reversible restrictions. This would make remedial exercise the treatment of choice and especially the best means of prevention. It is less clear what the actual content of such therapy should be when treating – usually painful – dysfunctions of the locomotor system, since remedial exercise expects to deal with a well-defined lesion (for example paresis), and that is not what we are dealing with here. It was Janda who first addressed this problem. The main object of remedial exercise in dysfunctions of the locomotor system is the correction of faulty motor patterning (disturbed movement patterns or stereotypes), that is faulty coordination of muscle function due to disturbed central nervous control. The problem here lies in defining what is the norm, since these movement patterns are very different and highly individual, consisting of programs built up by each subject in the course of life on the basis of chains of unconditioned and acquired (conditioned) reflexes. The way each individual moves is so characteristic that we can recognize people by their gait, their gestures, or their handwriting. Ideally, motor patterns should allow movement to be as economical as possible, that is to consume the smallest possible quantity of energy. As in many other situations, it makes sense for our purposes to take the dysfunction as the
Chapter 2
starting point. Even a layman will recognize awkwardness of movement, and, more often than not, such movement is uneconomical in energy expenditure; therefore the layman is also able to correct the most obvious aspects – just as sports trainers, for instance, correct the movements of sportsmen and women. In patients with vertebrogenic pain, Janda systematically applied the classic muscle test to the individual muscles involved in particular movements. His results revealed that the simple movements used to examine muscle function in fact study a (fairly simple) movement pattern, involving a number of muscles, rather than a particular individual muscle. Examining hip extension by polyelectromyography, Janda showed that it is not only the gluteus maximus muscle which contracts in hip extension, as had been thought, but that the ischiocrural muscles are the first to contract, followed shortly afterwards by the erector spinae. The typical disturbance of movement pattern found in hip extension is the belated and inadequate activity of the gluteus maximus (see Figure 2.18).
Figure 2.18 • EMG study during extension of the right hip:
contraction of the right gluteus maximus is slight and occurs at a late stage. There is increased activity of the ischiocrural muscles and erector spinae bilaterally. (By kind permission of Janda.)
27
Manipulative Therapy
We learned over time to recognize in clinical examination which muscles actually take part in simple test movements, by means of palpation. This enables us to assess not only muscle force, but also quality of performance. This quality may be considerably altered while force remains normal. The strength of hip extension may remain normal, even if it is carried out only by contraction of the ischiocrural muscles and the erector spinae. In this case there is considerable disturbance of the movement pattern, with important consequences for locomotor function, as will be explained later. Regular testing of simple movements using the muscle test revealed a surprisingly constant pattern: certain muscle groups repeatedly showed a tendency to lesser activity (weakness) and hypotonia, whereas others equally regularly tended to hyperactivity and tension. This resulted in characteristic patterns of imbalance which are so constant and typical that we can identify them as syndromes with a clinical significance. They are each characteristic of a particular clinical picture: in some cases there is a preponderance of weakness, flabbiness going hand in hand with hypermobility, whereas in others there is increased muscle tension and stiffness. Table 2.1 sets out those muscles with a tendency to hyperactivity and those that tend to hypoactivity. This difference in the behavior of these two muscle groups can be seen under various clinical conditions and is regularly found in painful states: in a painful hip it is always the flexors and adductors that are tense and the glutei weak; in shoulder pain the pectoralis and subscapularis muscles and the superior part of the trapezius are taut whereas the supraspinatus, infraspinatus, and deltoid muscles are weak; in chronic painful conditions of the knee the vasti are atrophic while the rectus femoris is like a tight band. The findings are similar for fatigue: again the same muscles will be inhibited and their activity frequently taken over by those with a tendency to hyperactivity. This behavior continues to be found in central paresis, when again we find that muscles with a tendency to hyperactivity become spastic, and those with a tendency to hypoactivity become flabby. Neurologically, this kind of muscle imbalance can be termed ‘microspasticity.’ Janda referred to those muscles with a tendency to hypoactivity as predominantly ‘phasic,’ and muscles with a tendency to hyperactivity as predominantly ‘postural.’ In terms of develop28
Table 2.1 Muscle groups exhibiting a tendency to hyperactivity or hypoactivity
Hyperactivity
Hypoactivity
On the dorsal aspect of the body Triceps surae
Gluteal muscles
Ischiocrural muscles
Inferior part of trapezius
Lumbar section of the erector spinae
Serratus anterior
Quadratus lumborum
Supraspinatus
Superior part of trapezius
Infraspinatus
Cervical extensors
Deltoid
On the ventral aspect of the body Thigh adductors
Tibialis anterior
Rectus femoris
Extensors of the toes
Tensor fasciae latae
Peronei
Iliopsoas
Vasti
Obliquus externus
Rectus abdominis
Pectoralis major and minor
Deep neck flexors
Subscapularis
Digastric
Scalenes Sternocleidomastoid Masticatory
Upper limbs Flexors
Extensors
mental kinesiology (see Section 2.5.3), those of the first group belong to the younger system and the second group to the older one. It should be stressed that there is no substantial difference between the types of muscle fiber or the biochemistry of these two groups; the physiological reason for the difference between them rests on the developmental kinesiology. Both systems evidently have a postural function. Examination of simple movements by applying the muscle test is no more than the first step in investigating muscle function; our habitual movements are individually acquired patterns or stereotypes.
Etiology and pathogenesis
The concept of patterning is clearly illustrated by looking at antagonists. For example, the ischiocrural muscles and the quadriceps femoris can be considered as antagonists if we are thinking of the movement of knee flexion and extension. However, during walking both these muscle groups are acting primarily to stabilize the leg. A similar principle applies to the abdominal and back muscles, and to the flexors and extensors of the cervical spine. In fact, in well-coordinated straightening up from a stooping position it is mainly the deep abdominal muscles that provide stability, a point to be remembered in remedial exercise. It should be stressed here that when treating muscle imbalance involving a predominance of the muscles that regularly tend to hyperactivity, the effect of strengthening the weakened (hypoactive) muscle is not only experienced in the particular segment but also influences the overall balance between ‘phasic’ and ‘postural’ muscles. This is particularly important where there is a greater density of afferent nerve receptors, so that afferent stimuli are more strongly felt; it is the case at the fingers and toes, as Brügger has shown. He found that, following stimulation of the extensors of the fingers and toes, the patient finds it easier to resume upright posture; one of the other consequences is improvement in the straight-leg raising test. The training of different movement patterns involves the interplay of a number of muscles reacting in sequence, whose reaction can be triggered if specific stimuli are employed. For movements of the limbs, stimulation of the periphery is most effective, since receptors are numerous here. To facilitate walking, lifting the big toe is helpful: the patient will then find it easier to dorsiflex the foot; that in turn helps the flexion of the knee and hip. Similarly, flexion of the fingers helps anteversion of the elbow and shoulder. What the fingers and toes are for the function of the limbs, the eyes are for the trunk: looking up facilitates straightening of the body, looking down facilitates bending forward, while looking to the side facilitates rotation. Furthermore, as straightening of the body is connected with inhalation, and bending forward with exhalation, it is enough for the patient to look up to facilitate inhalation (as when sighing). Similarly, directing the gaze downward assists exhalation. Returning to the question of imbalance between those muscle groups which are older and those which are younger in developmental terms, the problem here is a form of defective coordination.
Chapter 2
This is particularly so in the interrelationship of antagonists, where the hyperactive muscle generally has an inhibitory effect on its weak antagonist. For example, hyperactive lumbar erector spinae muscles inhibit the abdominal muscles, and hyperactive adductors the glutei. This disturbs the centering of the joints involved, imposing excessive stress on them.
2.9 Sequelae of disturbed movement patterns Having looked in detail at the nature of disturbed movement patterns, we now turn to the mechanisms by which they impair the locomotor system.
2.9.1 Walking and standing The most frequent findings here are an imbalance between weak gluteal muscles and hyperactive hip flexors, between hyperactive lumbar erectores spinae and weak abdominal muscles, and between hyperactive adductors and weak abductors of the hip. In standing we see increased pelvic tilt, a protruding abdomen, and lumbar hyperlordosis. The actual pathogenic mechanism in standing is overload of the lumbar spine as a result of increased tension of the erector spinae muscles; in walking, overload results mainly from the fact that pelvic tilt places the hip joints in extension, and also from the weak gluteus maximus. As a result, the extension of the patient’s legs in walking is mainly achieved by extending the lumbar spine still more. This produces hypermobility of the lumbar spine in the sagittal plane. Hyperactivity of the adductor muscles and above all the weak gluteus medius causes instability in the frontal plane, especially when the patient is standing on one leg. The result is increased swaying of the pelvis from side to side while walking; causing, in other words, hypermobility and overload of the lumbar spine in the frontal plane.
2.9.2 Straightening up from a forward-flexed position If the trunk is imagined as a straight lever with the L5–S1 disk as the fulcrum, calculation of the 29
Manipulative Therapy
stress involved during weight-lifting has produced values of 1000 kg and above (Matthiasch 1956, Morris 1973). Such a force is more than the disk could bear. Measuring intradiskal pressure, Nachemson (1959) found that the pressure during weight-lifting from a sitting position was 275% of that when standing upright. The reason, according to Gracovetsky (1988), lies in the role of the lumbodorsal fascia, into which the erector spinae, the glutei, and the ischiocrural muscles fan out. The tension from the ischiocrural muscles enables the spinal column to ‘hook in’ to this fascia, as it were, so that the lever effect is eliminated. This mechanism is further supported by the abdominal muscles, which also fan out into this fascia and in addition draw the thorax toward the pelvis and maintain intraabdominal pressure. The effect is that the correct movement pattern assists this ‘unreeling’ mechanism and avoids the lever effect.
2.9.3 Raising the arms Here the decisive factor is correct fixation of the shoulder girdle; this is the function of the superior part of the trapezius and the levator scapulae from above, and of the inferior part of the trapezius and the serratus anterior, the first two muscles being attached to the cervical spine and the last two to the thoracic spine. The faulty movement pattern typically found here is tension in the muscles providing fixation superiorly and weakness of those providing stabilization inferiorly. The effect is to lift the shoulder blades and place excessive load on the cervical spine.
2.9.4 Weight carrying The key factor here from the point of view of the biomechanics is the position of the shoulder joint: if the shoulder of the weight-bearing arm is behind the line of gravity of the body, the shoulder girdle is fixed at the thorax by the serratus anterior, the inferior part of the trapezius, the rhomboid major and rhomboid minor. If the shoulder is in a raised and forward position, then the muscles providing fixation are the superior part of the trapezius and the levator scapulae, placing undue load on the cervical spine and at the same time to destabilize the lumbar spine. It is the upright positioning of the head that ensures the correct position of the shoulder. 30
The muscular imbalance involved here is a hyperactive pectoralis major, in particular the clavicular head of the muscle, hypoactivity of the weak rhomboid and serratus muscles and the inferior part of the trapezius, and increased activity of the superior part of the trapezius and the levator scapulae. The hyperactivity of the pectoralis major causes kyphosis in the lower part and hyperlordosis in the upper part of the cervical spine. These examples illustrate the pathogenic effects of faulty movement patterns on the locomotor system and spinal column. The motor stereotype which leads to the most marked consequences, however, is faulty breathing.
2.9.5 The effect of respiration on the locomotor system When we think of respiration, we tend to focus almost entirely on the organs of the respiratory system. In doing so, however, we forget that the thorax and diaphragm are essential to the function of the lungs. The locomotor system has to coordinate the specific function of respiratory movement with the function of locomotor activity. This task is so complex that it would be a miracle if disturbances did not occur. The most important issue here is the close link between respiration and the postural function. Skládal et al (1970) observed on radiographic images that the diaphragm became flatter and contracted when the patient stood on tiptoe during the exposure. They interpreted this as being a postural reaction, and drew the further conclusion that: ‘The diaphragm is a respiratory muscle with a postural function, and the abdominal muscles are postural muscles with a respiratory function.’ The way this is understood today is as follows: the diaphragm attaches dorsally to the spinal column and laterally to the inferior costal arch, while ventrally the fixed point is provided by the abdominal wall. Here, the co-contraction of the deep layer of the abdominal muscles has a key role. Kolárˇ (2006) showed radiographically that the diaphragm was angled downward in the ventral to dorsal direction if the abdominal muscles were weak. If the abdominal muscles are functioning normally, contraction of the diaphragm during inhalation is accompanied by eccentric contraction of the deep abdominal muscles. This can be clearly palpated laterally above the iliac crest. The effect is not only to
Etiology and pathogenesis
enable the diaphragm to function in the most efficient way and, as shown by Kapandji (1974), to expand the thorax, but also to fix the thorax to the pelvis and so stabilize the lumbar spine. The activation of the abdominal muscles during inhalation was also described by Campbell (1978) and Basmajian (1978). Holding the breath (the Valsalva maneuver) reinforces this postural function. Morris et al (1961) showed that the spinal column is supported on the diaphragm when bending forward (see Figure 2.19). Experience does indeed show that when we are about to lift a heavy weight using maximum force, or to perform a heavy blow or vigorous throw, we hold our breath. This is such an important mechanism that athletes hold their breath during demanding activity such as sprinting over short distances, sacrificing the respiratory to the postural function. The most important faulty respiratory stereotype, seen from the point of view of the locomotor system, is that in which the thorax is lifted during inhalation (Parow 1954). In this pattern the thorax is lifted in the cranial direction by the scalene and sternocleidomastoid muscles and the superior fixator muscles of the shoulder girdle, but without expansion of the chest. Termed ‘clavicular breathing,’ it involves a reversal of the normal
Chapter 2
respiratory mechanism, since the scalene muscles, which normally only fix the thorax, raise the lung; resistance is offered by the diaphragm. This is inefficient, not only from the respiratory point of view, in that the volume of the chest increases very little, but also for the locomotor system, because of the chronic overload that this causes to the cervical spine. A further effect is that fixation of the thorax to the pelvis no longer occurs, causing instability of the lumbar spine. The pattern of lifting the thorax during inhalation, or clavicular breathing, can be asymmetric, if one shoulder is raised more than the other. The stress on the cervical spine is then greater on this side. Clavicular breathing is the disturbance that typically occurs when sitting but not maintaining a straight posture, because this makes expansion of the thorax difficult. An extreme form of this breathing pattern is paradoxical breathing, in which the patient draws in the abdomen during inspiration. ‘Passive’ exhalation is brought about mainly through the elasticity of the lung. Active exhalation, including that against resistance, is brought about mainly by the abdominal muscles as well as the erector spinae, which contract strongly when exhaling deeply in a lordotic posture (Lewit, Janda, Veverkova 1998). Here too the facilitation of
Figure 2.19 • The stress on the lumbosacral junction (A) without and (B) with simultaneous contraction of the abdominal wall (Diagram after Kapandji).
31
Manipulative Therapy
postural activity is important. The shouts uttered by attacking soldiers and weight-lifters serve a practical purpose. The effect of respiration is significant above all for the spinal column, which means that it can be employed to outstanding effect in neuromuscular techniques. As a general rule, muscle activity is facilitated during inhalation, and exhalation produces relaxation. The actual situation is a little more complicated: the abdominal muscles are facilitated during active exhalation, especially against resistance, and, as mentioned previously, raising the gaze of the eyes is associated with inhalation and lowering the gaze with exhalation. It is appropriate at this point to explain the concept of ‘respiratory synkinesis,’ in which movement in one direction is linked with inhalation and in the other with exhalation. Where this is the case, it is difficult to do the reverse. Typical respiratory synkinesis can be observed during forward flexion of the trunk, and when straightening up from forward flexion. The fact that straightening up is usually associated with looking up, and forward flexion with looking down, makes clear why the initial act of looking up facilitates inhalation, and looking down, exhalation. Inhalation facilitates straightening up, not only from forward flexion, but also from side-bending. Side-bending itself is facilitated by looking down while exhaling. Another very important example of respiratory synkinesis is the opening of the mouth during inhalation, and the closing of the mouth during exhalation. This facilitates first the masticatory muscles, and then in particular the digastric muscle. Inhalation facilitates kyphosis of the thoracic spine, and active exhalation lordosis of the thoracolumbar spine, especially in lordotic posture (Lewit, Janda, Veverkova 2000). Resistance to traction of the cervical spine increases during inhalation; also during distraction of the hip. The resistance decreases during exhalation. Conversely, resistance increases in the lumbar spine on traction in the prone position, and decreases during inhalation. Clearly, then, these respiratory synkineses are extremely effective in mobilization and relaxation techniques for the spinal column. One especially remarkable example of synkinesis is that described by Gaymans (1980) in the cervical and thoracic spine. He found that, during side-bending, resistance increases in the even segments (in C0, C2, C4, and C6 and in T2, T4, T6, T8, and T10) during inhalation; it disappears 32
during exhalation. Conversely, resistance increases in the odd segments (C1, C3, and C5 and T3, T5, T7, and T9) during exhalation, and disappears during inhalation. At the cervicothoracic junction, and only here, in the region between C6 and T2, resistance always increases during inhalation and decreases during exhalation. This synkinesis is so effective that during side-bending all that is needed is to take up the slack to the point of initial tension, then (in the case of an even-numbered segment) to ask the patient to inhale, and then to wait during the period of exhalation for mobilization to take place automatically. An exception to this rule is found in the atlanto-occipital segment; here this synkinesis operates not only in sidebending but in all directions. The phenomenon described here is so reliable that it can be used to correct the diagnosis as to the level of the vertebral segment. It is most marked at the cranial end of the spinal column and decreases somewhat in a caudal direction; in particular, the relaxation that accompanies exhalation diminishes in the lower thoracic spine. The reason for this may be connected with the fact that the thorax is stabilized during inhalation, and the diaphragm and quadratus lumborum as well as the deep layer of the abdominal muscles contract. We can therefore refer to inhalation–exhalation segments and exhalation–inhalation segments. Marked respiratory synkinesis can also be found in trunk rotation; in the upright position, rotation of the trunk (including active rotation) increases during inhalation, while considerable resistance appears on exhalation. In a kyphotic sitting position, in contrast, resistance increases on inhalation and mobilization is therefore performed on exhalation. Too little attention is paid to the effect of respiration on the locomotor system and vice versa. There is little awareness of the respiratory synkineses, and too little use is made of them by manual therapists, despite the fact that they are physiological methods. Empirically, many of these effects are employed in yoga; these include not only the effects on motor functions but also those on autonomic ones. This is understandable when we remember that respiration is the only ‘autonomic’ function on which we are able to exert any degree of direct influence voluntarily, that is using the voluntary muscles. In this section we have attempted to show the importance of faulty movement patterns for the
Etiology and pathogenesis
pathogenesis of dysfunctions and to explain the processes involved. It seems all the more important to do so since modern civilization is guilty not only of chemically polluting the environment, but also of causing extensive changes to the human locomotor system. We move around too little, but suffer static overload, creating conditions that produce muscular imbalance, among them that of faulty breathing while sitting in a hunched posture. Rehabilitation focuses on faulty movement patterns, and their diagnosis and therapy will be explored in more detail in the relevant sections of this book. As we come to understand them, it becomes clear that the methods used in manual medicine, which are predominantly passive ones, are usually only lastingly effective if accompanied by the active participation of the patient.
Faulty muscle control originating from the central nervous system plays a significant part in the pathogenesis of dysfunctions of the locomotor system. Often, however, they are also a consequence of disturbances involving chronic pain. They, in turn, can then perpetuate and intensify the basic disturbance.
2.10 The significance of constitutional hypermobility Movement restrictions, dealt with in the foregoing sections, are the true focus of manipulation therapy; however, the experienced clinician is well aware that hypermobility is frequently an even more difficult problem. The contributions made by Sachse (1984, Sachse et al 2004) have been fundamental in this area. The following categories can be distinguished: • Localized pathological hypermobility. This may be primary or secondary (it is usually compensatory, occurring in the neighboring segment to a restricted joint). As such it is most frequently found in the spinal column. • Generalized pathological hypermobility. This is most often found in certain congenital neurological conditions.
Chapter 2
• Constitutional hypermobility. This type is
of the greatest interest to us. In essence it is a variant of the norm, but under certain conditions it can be significant for pathogenesis. As a general rule, mobility is greater in childhood than in adulthood, is greater in women than in men and, in the limbs, tends to be greater on the non-dominant side (Sachse et al 2004). There are conditions in which hypermobility may be an advantage, for instance in certain sports and in employment where mobility is a requirement. However, it involves the risk of decreased stability, and given the predominance of static load and overload in most occupations today, hypermobility is inappropriate. Individuals with constitutional hypermobility are at a particular disadvantage when working at a computer, as a driver, or in the majority of sedentary occupations, especially if the hypermobility is accompanied by laxity of the ligaments and weakness of the muscles. The situation is still more unfavorable if the hypermobility is accompanied by poor coordination and qualitatively poor movement patterns (Sachse 1984). The problem may even cross the boundary into minimal brain damage (MBD) as described by Janda (1978). In a study of 100 cases in which rehabilitation proved difficult, he distinguishes three types: 1. The first is ‘microspasticity,’ showing mild signs of first motor neuron lesion which is often asymmetrical. 2. The second is characterized by hypotonicity, with asymmetrical tendon and periosteal reflexes, signs of instability and restlessness, and – consistently with the account given by Sachse – severe hypermobility. 3. The third type shows disturbances of proprioception, which become more evident with eyes closed. This is expressed as a certain marked ‘clumsiness’ and accompanied by poor psychological adaptability, which makes rehabilitation more difficult. Hypermobility in itself is no more than a constitutional characteristic; however, there is a tendency toward instability that is pathological. The most important role here is that played by the deep stabilization system. 33
Manipulative Therapy
Figure 2.20 • Causes and sequelae of restrictions and dysfunctions of the spinal column.
So far we have dealt mainly with the locomotor system and dysfunctions of that system, in particular mechanical disturbances (Figure 2.20).
The dynamic role – usually also the primary role – in the interplay between dysfunction and morphological change is that of function.
2.11 Reflex processes in vertebrogenic dysfunctions Despite the importance of the mechanical factor for pathogenesis, it is not identical with clinical disease. Patients do not generally tend to complain of disturbances of mobility, but rather of pain, whether in the back, limbs, head, or viscera. They may even be suffering from considerable movement restrictions, yet they do not notice these. Examination may sometimes even reveal signs of nociceptive irritation (latent trigger points or hyperalgesic zones on the skin), yet the patient does not feel pain. The explanation lies in the capacity of the nervous system to react. We now need to know how it is that dysfunction produces pain. 34
Before presenting an explanation I should stress that it is not the purpose of this book to deal with the purely theoretical aspects of the pathogenesis of pain; we do however need to deal with the theoretical inferences that can be drawn from clinical diagnosis and therapy. Examination before and after therapy enables us to arrive at certain theoretical conclusions, as we might from an experiment, and the findings that are made after therapy not only show a normalization of mobility, but also a reduction of tension in the affected muscles, and that of the soft tissues. The effect is observed after manipulation, local anesthesia, needling, relaxation of trigger points, and massage. In each case, pain too is relieved. If the pain arises as a result of having to maintain an uncomfortable forced position, correction of the position is often enough to bring relief. The same is true of strenuous work; when we work beyond our strength we hardly notice it at first, but eventually pain forces it to our attention and we suspend the activity. After a short while the pain subsides. The common denominator in all this is the close connection between tension and pain in the locomotor system. Daily evidence of this is seen in the post-isometric relaxation of tense muscles; as the tension reduces, so the pain subsides, not only in the muscle itself but also in its attachments (see Chapter 6). This experience is in fact a general principle: any disturbance of function is bound to produce
Etiology and pathogenesis
increased tension: when there is a restriction, there will be increased tension when the patient tries to move in the restricted direction; hypermobility will produce tension in the end position as a result of excessive range of movement; static overload, strenuous movements, or any faulty motor pattern must also lead eventually to increased tension. The muscular TrPs provide direct evidence of this, since these involve a close association between tension and pain. This is in keeping with the biological role of pain as a warning sign: increased tension constitutes a threat, and it is pain that delivers the warning. The nociceptive stimulus – in the form of overload – warns us at the stage when the disturbance is still functional and reversible. As soon as we correct the posture or cease the activity causing the pain, and as soon as we treat the restriction or muscular TrP, the tension is eased and the pain subsides. If pain made its appearance only when morphological (pathological) changes had occurred, it would fail to fulfill its biological function. Since the locomotor system is controlled by our will – and whim – it has no way of protecting itself other than by causing pain. In this way the voluntary activity of the locomotor system is kept within due bounds by pain. The locomotor system is therefore by far the most frequent source of pain in the human body; it is more than mere coincidence that referred pain from other organs or systems is perceived in the locomotor system, and that pain receptors are located in those places where tension in the locomotor system is expressed: in muscles, joint capsules, the attachments of tendons and ligaments, root sheaths, and the anulus fibrosus of intervertebral disks.
Pain is the most common symptom of dysfunction, and functional disturbances of the locomotor system are the most common cause of pain.
The close connection between physical and psychological factors in the production of pain is easy to understand: pain itself is both a physical and a psychological phenomenon. The same is true of tension and also, especially, of relaxation: it would be difficult to imagine psychological relaxation without relaxed muscles, or to imagine relaxing the muscles without being mentally relaxed. This close interrelationship is true for the locomotor system in
Chapter 2
general, since movement is the effect of voluntary motion that originates in the psyche.
Since movement is an outward effect of psychological activity, it is also true that psychological activity is a factor in motor function.
The nociceptive stimulus produces a reaction in the segment, and the intensity of the reaction can vary enormously. This is clinically significant, because it allows us to estimate the capacity for reaction in the individual case. This applies not only to autonomic reactions, but also to those of the muscles, whose response may take the form of TrPs or spasm. Korr’s concept of ‘segment facilitation’ is therefore appropriate here. There may be considerable differences between patients, and reactions may also vary considerably in the same individual under different circumstances. If, for instance, acute pain has been provoked by a draught, it should not simply be ascribed to the cold air alone, for in such patients we find restrictions in at least one segment, with severe muscle spasm. The restrictions are clinically latent, but produce a skin hyperalgesic zone (HAZ) in the segment. The cold draught striking this HAZ is an additional stimulus which intensifies the patient’s reaction and causes muscle spasm which makes the clinically latent lesions manifest. It is a mistake to explain the pain as due to mechanical irritation of nerve fibers, as is frequently suggested. It would be a peculiar concept of the nervous system (a system whose purpose is to process information) that would have it reacting, not to stimulation of its receptors, but to mechanical damage to its own structures. Referred pain from the viscera is the typical model, or experimentally-induced referred pain from the infiltration of hypertonic saline solution into ligamentous structures of the spinal column, as performed by Kellgren (1939) and later by Feinstein et al (1954) and by Hockaday & Whitty (1967), and in the zygapophysial cervical joints by Pi’tha & Drobný (1972). Just as in these model experiments, pain arising from deep structures (joints, muscles, ligaments, and internal organs) is referred, especially within the affected segment, and also gives rise to corresponding HAZs, sometimes even paresthesia, imitating radicular pain and so leading Brügger (1962) to refer to it as ‘pseudoradicular.’ Other terms often used, 35
Manipulative Therapy
where there is a combination of pain in the muscles, tendons, and insertions, are ‘myotendinosis’ (Brügger 1962) or ‘myofascial pain’ (Travell & Simons 1999). The soft-tissue changes, such as HAZs in the skin and subcutaneous tissue, have mainly been described as reflex changes or as secondary phenomena. This is usually true in acute cases where there is no long history, and these changes are generally found to subside when the joints and spinal column are treated. However, in the later, chronic stage, these changes – especially in fasciae and muscles – can become chronic; resistance is found in the fasciae, muscles become shortened, and chronic TrPs form. Some authors call this the ‘dystrophic stage’ (Popelyanski 1983, Popelyanski 1984). Pathological barriers are also present in such cases, however, and it is possible to achieve release. When dealing with chronic TrPs, this can be done by means of needling. In such cases, even these changes may turn out to be functional and reversible. Nevertheless it is important to note that where there are ‘sticky’ fasciae (which do not shift), shortened muscles, or chronic TrPs, these do not subside following manipulative treatment of joint restrictions. On the contrary, if they do not receive specific treatment, they can cause chronic recurrent restrictions. The model described here has been that of characteristic painful disturbances within the segment. However, it should not be forgotten that the pain threshold, which is under central nervous control, is only crossed when the nociceptive stimulus has reached a particular intensity. Only then is it actually experienced as pain. So it is that, on careful examination, very frequently we find clinical changes when patients have no sense of pain at all. It can therefore be seen that dysfunctions of the locomotor system produce nociceptive stimulation whose effects are felt both suprasegmentally and also at the level of the central nervous system. The entire complex of function-related disturbance can be called the ‘functional pathology of the locomotor system.’
kind of excuse for ignorance of the true causes or the true pathology in most cases of pain affecting the locomotor system and spinal column. Yet what other explanation is there for the fact that, following manipulation, not only does the pain cease, but mobility is restored to clinical normality and muscle TrPs and HAZs instantly disappear? These are not mere coincidence; careful clinical examination can predict the rapid appearance of the effect. If these were pathomorphological changes they would need to heal, and this requires time. The situation can best be explained by comparing it to the working of a car: it may break down because of a burst cylinder or a damaged ball bearing (a pathomorphological change), but another reason for it to fail may be that the ignition is out of order, or the carburetor needs adjusting; the structure is intact, and the disorder is a functional, reversible one. Following a simple adjustment, the problem is instantly resolved. One of the reasons for the failure to recognize that dysfunction is the most frequent cause of pain in the locomotor system is that the evidence is simply based on clinical findings, often relying on palpation, and this is rejected as ‘subjective.’ Connected to this we see a systematical underestimation of clinical diagnosis as a scientific discipline, and neglect accorded to it in practice. Much the same applies to the solving of the ‘puzzle of pain’ in dysfunctions of the locomotor system: pain is closely linked to tension and the release of tension to relief of pain, and the key to understanding this lies in palpation. In differential diagnosis of conditions affecting the locomotor system, the fundamental distinction to be made is therefore between conditions due primarily to pathomorphological changes and those caused by dysfunction. Yet even where a morphological lesion is present, dysfunctions may still play a significant role and should be treated accordingly; rehabilitation is included here.
2.12 Radicular pain The complex of predominantly mechanical dysfunctions and reflex changes can be termed ‘functional pathology of the locomotor system.’
Unfortunately, so widespread is the lack of knowledge, often combined with skepticism, that the concept of ‘functional pathology’ is viewed as a 36
The point having clearly been made that pain in the locomotor system is due to nociceptive stimulation of pain receptors, we must proceed to look at how and why pain arises in cases of root compression. The mechanical compression of a nerve does not itself cause pain but anesthesia, paresthesia, and paresis. However, we should bear in mind that the herniated disk causing the compression
Etiology and pathogenesis
cannot impinge on the nerve fibers until after it has affected the dura and the dural sheaths, which are richly supplied with pain receptors (Wyke 1980), and that with every movement of the legs and trunk the dura is being rubbed against the disk. Nor should it be forgotten that Lasègue’s sign indicates meningeal involvement, even in root compression syndromes. This is in keeping with the clinical course: first of all there is usually severe pain, and the signs of neurological deficit appear later. Other clinical observations support this. Cerný (1948), using autodermography to study patients with radicular pain, found that this method was more reliable in localizing the disk herniation to the particular segment than the typical signs of neurological deficit. This can be understood anatomically in that spinal nerves do not contain fibers from one segment only; they also carry many transitory fibers from neighboring segments. As a result, the failure of a single spinal nerve does not usually lead to signs of deficit. There is an overlap of the areas of nerve roots. Hanraets (1959), however, demonstrated that this is not always the case. He frequently found, during neurological surgery, that spinal nerves vary considerably in thickness: if one is very thick, its neighbor is likely to be much thinner, because of the number of transitory fibers in individual spinal nerves. If a thin spinal nerve is compressed or even severed, deficit will not be observed, because the transitory fibers in the neighboring nerve roots are able to compensate sufficiently, but if a thick root is severed, the consequences are quite different. Most thin neighboring roots have very few transitory fibers that can provide compensation. When Hanraets (1959) stimulated such a spinal nerve during operation (at that time his operations were still being performed under local anesthetic), his patients also felt paresthesia in the neighboring segments. Our own findings (1958), working together with Starý, are also consistent with this. We examined patients following intervertebral disk operations. At that time, in cases where no disk herniation was found, the neurosurgeon cut the sensory spinal nerve. Most of these patients experienced little effect, but some complained of permanent numbness and especially disturbances of proprioception following the procedure. In these cases a thick nerve root had evidently been cut, as described by Hanraets (1959). The pain resulting from irritation of dural receptors is referred pain, which corresponds precisely to the segment affected. It is this projection pain that is shown by Cerný’s autodermography. We
Chapter 2
can conclude that radicular pain is a combination of referred pain originating from dural receptors, and signs of neurological deficit. This explains why autodermography, in which patients themselves draw their projection pain, produces the most accurate clinical localization of a herniated disk. There is yet another observation that points to a functional factor in root compression: this is the frequent immediate improvement of muscle strength in weak muscles and sometimes even of tendon reflexes, immediately after manipulation and even after traction. This has been demonstrated by electromyography (see Figures 2.12 and 2.13), and also shown by the work of Drechsler (1970) and Hanák et al (1970). They showed that, even in true radicular syndromes with muscle weakness, the speed of nerve conduction may be normal. In the light of this they interpreted the weakness as reflex inhibition. Drechsler also concluded that decreased conduction speed indicates a poor clinical prognosis.
Radicular compression syndrome is a mixture of root compression and reflex phenomena. The decisive factor for localizing the cause of pain is referred pain produced by stimulation of receptors.
2.13 The term ‘vertebrogenic’ Once the terms ‘degenerative disease’ and ‘diskopathy’ had been abandoned as inappropriate, ‘vertebrogenic’ became widely adopted as a concept. It too is not quite appropriate: it includes pathological conditions such as ankylosing spondylitis, and does not cover dysfunctions that lie outside the spinal column. The term is therefore acceptable only if it is used as a pars pro toto. So long as it is used for back pain and very closely related disorders, there can be little objection to it; the term becomes controversial if the attempt is made to apply it to pain deriving from the internal organs, as might particularly tend to happen if treatment of the pain is successful. A correct understanding of referred pain, or pseudoradicular pain (to use a less accurate term), leaves little room for controversy. We see from the publications of Melzack & Wall (1965), Bonica & Albefessard (1976) and Milne et al (1981) that impulses from nociceptive stimuli arriving from all structures in a segment converge to spinal cord cells in the lamina V 37
Manipulative Therapy
of the dorsal horn. This also applies to stimuli from receptors in the joint capsules of zygapophysial joints, from the anulus fibrosus, or from internal organs. So it is easy to see how the locomotor system (the spinal column) can readily simulate visceral pain, or how pain from an internal organ might simulate that from the locomotor system. Therefore we must constantly take this problem into account in differential diagnosis. The therapeutic consequences are clear. We should not forget, however, that many instances of pain described as ‘functional’ in fact have their origin in the locomotor system. As will be seen in further chapters, vertebrovisceral relations are very complex; the term ‘vertebrogenic’ should therefore be applied with caution. In many cases pathogenesis is due to more than one factor, and it is then better to speak of disease with a vertebrogenic factor. Migraine is a good example, since the true cause is unknown, although it is usually accompanied by findings in the locomotor system that do cause significant pain. We should reserve the term vertebrogenic for those conditions in which the spinal column (the locomotor system) is the decisive factor, for example when we describe a case of vertigo as vertebrogenic. As Junghanns (1957) has pointed out, the role of the vertebrogenic factor may change over the course of time. It may trigger the disease process, but once this has started it may develop independently. Gutzeit (1953) very aptly characterized the spinal column as being sometimes the ‘initiator,’ sometimes the ‘provoker,’ and in yet a third way as being the ‘multiplier’ of a disease state.
We should speak of vertebrogenic disturbance only when we wish to say that the spinal column is the primary and decisive factor in pathogenesis in a given case of disease.
2.14 Conclusions • Morphological changes cannot explain
pathogenesis in the great majority of painful conditions of the locomotor system. These changes often have the role of a locus minoris resistentiae. • The most frequent cause of pain in the locomotor system is dysfunction, in a joint, 38
muscle, soft tissue, body statics, or dynamics (the movement patterns or motor stereotypes). • The most important cause of dysfunction is overload caused by overexertion, faulty movement patterns or body statics, trauma, or visceral disease. This includes joint restrictions, muscle TrPs, and soft tissue lesions, especially of fasciae and active scars. All these cause an increase in tension. • When dysfunctions in the segment persist for a long time they eventually lead to degenerative (adaptive) changes, and do not remain confined to the segment concerned but affect the entire system. • The locomotor system and the spinal column together make up a functional unit which has to compensate for any dysfunction, so that equilibrium is always maintained. In other words, the ‘motor program’ is reprogrammed. This gives rise to compensatory movement patterns, often designed to reduce pain. These can persist even when the primary cause is no longer present. • Mechanical disturbance of function alone is insufficient to cause pain. However, it does represent a nociceptive stimulus which produces reflex changes, especially within the segment. If these are of sufficient intensity to pass the pain threshold, they are experienced as pain. The specific nociceptive stimulus in the case of dysfunctions is understood to be increased tension. • Pain in the locomotor system is primarily a warning signal of harmful functioning, which should cause us to correct this before it causes permanent morphological damage. It is the type of pain that occurs most frequently in the human body. • If the patient is able to describe and localize the pain, and if on clinical examination we find corresponding changes, above all reflex signs, then the diagnosis (once we have excluded gross pathology) must be the relevant dysfunction. Undiagnosed dysfunctions are the most frequent cause of pain in the locomotor system, and treatment which is directed only at the symptom of pain, without a thorough understanding and analysis of the dysfunction causing that pain, will be frustrating and ineffective. • The complex of changes in function of the locomotor system and the reflex effects caused by these changes constitute what may be called the ‘functional pathology of the locomotor system.’
Chapter Three
3
Functional anatomy and radiology of the spinal column
Chapter contents 3.1 General principles . . . . . . . . . . . . . 39
3.1.1 Structural diagnosis . . . . . . . . . 39 3.1.2 Functional diagnosis of spinal column mobility (kinematics) . . . . 40 3.1.3 Functional diagnosis of body statics . . . . . . . . . . . . . 40 3.2 Technique in functional diagnosis . . . . . 40 3.3 The lumbar spine and pelvis . . . . . . . . 41
3.3.1 X-ray of the lumbar spine and the pelvis . . . . . . . . . . . . . . . 41 3.3.2 X-ray evaluation of lumbar spinal statics . . . . . . . . . . . . . 43 3.3.3 The pelvis . . . . . . . . . . . . . . 49 3.3.4 The lumbar spine . . . . . . . . . . 54 3.4 The thoracic spine . . . . . . . . . . . . . 58
3.4.1 Functional anatomy . . . . . . . . . 58 3.4.2 X-ray anatomy of the thoracic spine . . . . . . . . . . . . 59 3.4.3 Evaluating functional aspects . . . 60 3.5 The cervical spine . . . . . . . . . . . . . 62
3.5.1 X-ray technique . . . . . . . . . . . 62 3.5.2 Assessment of X-ray films . . . . . 63 3.5.3 Functional anatomy of the cervical spine . . . . . . . . . . . . 65 3.5.4 X-ray anatomy of the cervical spine . . . . . . . . . . . . 71 3.5.5 Evaluation with respect to functional implications . . . . . . . 74 3.5.6 Movement studies . . . . . . . . . . 77 3.5.7 Morphological changes . . . . . . . 82
Manual techniques call for an accurate understanding of anatomy, especially when treating the spinal column. Textbooks of radiology are interested mainly in morphology, while our concern is mainly with function, the consistent focus of the present book. The use of radiology for functional studies can greatly improve our understanding in manual diagnosis. However, if we are to be able to interpret radiographic images from the functional point of view, we need a good knowledge of X-ray anatomy, such as we present here, as well as certain requirements as regards technique.
3.1 General principles For our purposes, X-ray diagnosis fulfills three basic tasks: 1. Structural diagnosis. 2. Functional diagnosis of spinal column mobility (kinematics). 3. Functional diagnosis of body statics (interpretation of curvatures of the spinal column).
3.1.1 Structural diagnosis Structural diagnosis provides information about the morphology of the bony structures. This is the essential focus of classic X-ray diagnosis, which is mainly concerned with form and structure and constitutes the basis of our knowledge. This type of diagnosis is very important for manual therapy in
Manipulative Therapy
that it alerts us to potential serious errors of diagnosis, providing a warning against manual therapy where inflammation, tumors, fractures, or other contraindications are present. It also reveals abnormalities and changes in structure, such as asymmetries, which can be significant for function. Diagnosis of structure can be found in the classic textbooks of radiology, so we shall deal here only with those morphological changes that are important for an understanding of dysfunctions.
3.1.2 Functional diagnosis of spinal column mobility (kinematics) Functional diagnosis in the narrower sense involves movement studies of the spinal column in which X-rays are taken in end of range positions, in anteand retroflexion (extension), side-bending and, less frequently, rotation. Examination of this kind is the only approach that can provide direct information about dysfunctions in the motion segment. It can also be used before and after treatment. It is of value for documentation and assessment, but is too time-consuming and uneconomical and the radiation exposure is too great for use as a routine procedure. Since manual therapy examination gives good information on mobility and disturbances of mobility, it is generally possible to dispense with movement studies. They do have an important role to play in research, however, and provide an understanding of the biomechanics of movement processes.
3.1.3 Functional diagnosis of body statics Although movement studies come first to mind when we think of functional diagnosis, it is no less important to diagnose disturbances of body statics. The images used to assess this must be taken standing (or, for the cervical spine, sitting), under static loading and under standard conditions. The curvatures of the spine, as explained below, should mainly be assessed from the point of view of static function. This applies not only to the sagittal but also the frontal plane, in which every obliquity (e.g. of the pelvis during walking) produces a corresponding scoliotic curvature and rotation. Curvature may be regular or irregular, so that a marked 40
deviation may be observed in one particular segment. This may be scoliotic, increased lordosis or kyphosis, rotation, or lateral shift (‘offset’). The significance of these signs of irregularities in the position of neighboring vertebrae (relational diagnosis) is highly controversial, and closely connected with the discredited subluxation theory. It is also closely linked to the problem of asymmetry, bearing in mind the fact that a degree of asymmetry is the rule rather than the exception. Jirout (1978) has shown that asymmetry of the position of the atlas in relation to the axis is present in the majority of adults. In a study to compare children of various ages, he found that its incidence increases with age. This can be shown particularly easily by observing the position of the spinous processes. He concluded that these asymmetries were the result of asymmetrical pull of the muscles due to the dominance of one cerebral hemisphere. From this we can conclude that asymmetry and other kinds of irregularity are not in themselves pathological, although they can be the expression of functional asymmetries. We know, for example, that if the axis is asymmetrically rotated in neutral position, the entire cervical spine will rotate asymmetrically during side-bending. In general it is advisable to be cautious when drawing conclusions about examples of asymmetry observed on an X-ray film, and always to take the clinical findings into account when interpreting the radiographic findings. One advantage of static functional diagnosis is that the examination is economical: only two X-rays are required, two projections, which must correspond to each other vertically. Standard conditions must be observed as regards static loading. As individual posture is highly characteristic, it also remains fairly constant. Gutmann & Véle (1978) said of static function: ‘The dominating principle of the spinal column is body statics. All other functions are subordinate to the requirements of upright posture on two legs. The human body is more ready to accept loss of mobility or painful impingement of nerve roots than to sacrifice erect posture.’
3.2 Technique in functional diagnosis Functional diagnosis of the spinal column makes considerable demands as to technique. The following criteria must be observed: the X-rays should be
Functional anatomy and radiology of the spinal column
taken in a position that corresponds as closely as possible to the patient’s natural posture, normally either standing or sitting (with the exception of the anteroposterior (AP) view of the cervical spine, which is taken with the patient supine). In general, then, any slight inclination or rotation in the patient’s posture ought not to be corrected. However, it may become necessary to do so in order to achieve: • assessability of the X-ray films • reproducibility and comparability. Reliable criteria for comparability are therefore necessary. Assessability is, of course, absolutely essential in order to be able to evaluate the films, so it is important to avoid distortion through errors of projection. To achieve this, it will sometimes be necessary to correct side-bending (in the lateral projection) or rotation (in both projections). As to the format, it is essential to visualize a sufficiently large area to provide landmarks as means of comparison. In the lateral projection of the cervical spine in the sitting position, the hard palate must be visible to enable you to assess the posture of the head, and the mandible needs to be visible so as to indicate any side-bending or distortion. The lumbar AP projection must include the coccyx and the pubic symphysis, to enable you to assess correct positioning. As long as these requirements are observed, it will be possible to evaluate and compare the films successfully, even if there are very minor errors of centering. Since the spinal column is a functional unit, the most appropriate format for the X-ray examination is to show the entire spinal column on a single film. An AP and a lateral view with the patient standing are required, with the feet placed in a standardized position. If this cannot be done, the sections of the spinal column that have been imaged need to be assessed in the light of the clinical findings. These can then make good whatever is missing in the X-ray.
3.3 The lumbar spine and pelvis 3.3.1 X-ray of the lumbar spine and the pelvis The imaging projections needed for routine examination of the static function and morphological changes of the spinal column are simply one AP and one lateral view with the patient standing.
Chapter 3
This is done using a device described by Gutmann (1970), in which a plumb line indicates the vertical line from the head. The procedure is illustrated in Figure 3.1A–D and is as follows: A line which corresponds to the center of the cassette is drawn on the floor in front of the middle of the stand. For the AP view the patient places one foot symmetrically on each side of the line, and is requested to distribute the weight of standing equally between both feet, with legs straight, so as to rest on a base that is in line with the center of the cassette. A plumb line extended downward from the center of the cassette will therefore meet the floor at the mid point between the patient’s heels, setting the base line. A movable plumb line of metal wire (so as to create contrast) is attached to the screen. The cassette is first raised to the level of the patient’s occiput and this metal wire plumb line moved to a point precisely below the middle of the occipital squama, where the external occipital protuberance can be palpated. This sets the plumb line that marks the head position. The cassette is then adjusted (taking care not to displace it to the side) to the height required to take a view of the lumbar region and the pelvis (with the central ray of the X-ray beam and the center of the cassette roughly at the height of the navel). By setting up the AP view in this way, the shadow of the metal wire marks the plumb line representing the head position, and the center of the film represents that of the base line. The same procedure is used for the lateral view of the lumbar spine, except that this time the patient stands with feet across the line on the floor that represents the center of the cassette, with ankles one finger’s breadth behind the line. The plumb line for the head is positioned at a point in line with the external acoustic meatus. Here – as in the procedure described for the cervical spine – it is helpful to align the central ray below rather than on the center of the cassette, directing the beam off-center to focus approximately on the lumbosacral junction, midway between the iliac crest and the greater trochanter. This technique has two great advantages: 1. There is considerably greater absorption of radiation at the lumbosacral junction (on which the pelvis is superimposed) than in the lumbar spine. If the central ray is aligned as usual on the middle of the lumbar spine, the result is either under-exposure of the lumbosacral junction, while the rest of the lumbar spine is correctly exposed, or 41
Manipulative Therapy
Figure 3.1 • X-ray technique for the lumbar spine after Gutmann (1970). (A) Positioning of the plumb line for the head and (B) patient position during radiography, as prepared for the AP view. (C) Positioning of the plumb line for the head and (D) patient position during radiography, as prepared for the lateral view.
42
Functional anatomy and radiology of the spinal column
Chapter 3
arms folded in front of the chest (see Figure 3.1D). The final step, once the apparatus and the patient’s position have been set up, is to tape the wire to the cassette so that it cannot be displaced, and then instruct the patient to lean against the screen so as to remain steady during the long film exposure.
3.3.2 X-ray evaluation of lumbar spinal statics
Figure 3.2 • Lateral view of the lumbar spine with perfect demonstration of the entire pelvis, including the iliac crests and femoral heads.
over-exposure of the lumbar spine while exposure of the lumbosacral junction is good. Aligning the beam on the lumbosacral junction evens out the exposure, and has the additional advantage of providing good imaging of the hip joints (see Figure 3.2). 2. If the beam is aligned to the center of the cassette (middle of the lumbar spine), the effect is to project the iliac crests away from each other, lying well apart as they do, although they are very important for body statics. The projection error produced at the much slimmer lumbar spine, on the other hand, is only slight. For both projections the focus-film distance should be as great as possible, depending on the power of the apparatus and the corpulence of the patient, the ideal distance being at least 2 m (78 inches). For technical reasons, the patient needs to stand with
The purpose of the films taken in the standing position is mainly to study body statics. The only structures in the frontal plane that can be assessed by clinical examination are the occipital protuberance, spinous processes, iliac crests, intergluteal cleft, and the midpoint between the heels. In the sagittal plane, clinical examination can show the posture of the head, position of the shoulders, the trochanters and the heels in relation to the plumb line, which takes the line from a fixed point at the external auditory meatus. Clinical examination cannot provide information about the position and inclination of the sacrum and the most caudal vertebrae (which mark the true base of the spinal column), information which is essential for a full understanding and evaluation of spinal statics. This may explain why clinicians interested in body statics have devoted their attention mainly to the question of body equilibrium as a whole, studying deviation of the head and deviation from the line of gravity by means of statovectography. However, Rash & Burke (1971) pointed out that with static load each body segment should be vertically above the center of the segment on which it rests. The principle is violated if tension of the ligaments or excessive muscular contraction are required to maintain balance. X-ray examination under static conditions provides information on precisely this type of static disturbance. The mechanism of body statics differs considerably in the frontal and the sagittal planes. One way to appreciate this is to observe the effect of a heel insert, a pad or block placed under one foot. A healthy subject experiences a height difference of as little as 1 cm as uncomfortable, whereas if a heel insert of 1 cm is placed under both feet it is hardly noticed. This is because in the frontal plane the center of gravity lies over both feet, such that body equilibrium is (relatively) stable. As a result, any mechanical change (the insert under the foot) has an immediate effect. In the sagittal plane, in contrast, body equilibrium is labile, over the two 43
Manipulative Therapy
Figure 3.3 • Normal body statics: (A) with the subject standing with his weight equally on both feet; (B) with support to raise the right foot; (C) with weight shifted onto the right leg.
44
Functional anatomy and radiology of the spinal column
Chapter 3
perfectly round surfaces of the hip joints. A slight mechanical change has little effect, because it is dynamic muscle function that is maintaining balance in this plane. The muscular force required should, however, be minimal.
Lumbar spinal statics in the frontal plane In the ‘ideal’ case the pelvis and spinal column lie symmetrically in a straight line in the AP view. The external occipital protuberance, spinous processes, pubic symphysis, and coccyx lie in the midline. Such a spinal column is the exception in real life; people simply do not place their weight symmetrically on both feet, but stand in a relaxed posture in which the weight is taken mainly on one leg. During walking, the pelvis constantly swings from one side to the other. The result is the constant creation of oblique planes. The main concern in assessing these is to discover how the spinal column reacts to obliquity in the frontal plane. The physiological reaction to obliquity can be seen by performing a test in healthy subjects: the subject must first relax, stand with legs straight, and rest the weight of the body on both feet; a block of wood is then placed under one foot. The subject’s pelvis then shifts to the higher side (see Figure 3.3). The radiographic image shows not only the shift to the side, but also scoliosis and rotation to the lower side. The summit of the scoliotic curve is usually at the mid-lumbar region, with the thoracolumbar junction vertically above the sacrum. The degree of rotation depends on the degree of lordosis of the lumbar spine. If there is no lordosis – as is often the case in acute lumbago – there is also no rotation. If there is kyphosis, there may even be rotation to the same side as the concavity. Reaction by the spinal column to an oblique plane is normal if: • scoliosis to the lower side results • there is rotation to the same side (when there is lordosis) • the thoracolumbar junction is vertically above the sacrum • the pelvis shifts to the higher side (see Figure 3.4). Slight thoracic scoliosis occurs in the opposite direction.
Figure 3.4 • Normal reaction of the lumbar spine and pelvis to standing on an unlevel plane.
These features reflect normal spinal statics and are closely associated with the problem of difference in leg length. From the point of view of body statics, a difference in leg length becomes significant only when accompanied by obliquity of the base of the spinal column (see Figure 3.5). In the light of this fact, the age-old dispute over how to measure a difference in leg length is beside the point. While it is possible clinically to establish the presence of pelvic tilt, we cannot determine the position of the sacrum relative to the sacral promontory and the lumbar vertebrae that constitute the base of the spinal column proper, as the pelvis may be straight while the sacrum is tilted, or vice versa. The determining factor in spinal column and body statics is the base of the spinal column. The only way to establish the position of these, and find how the spinal column reacts to an oblique base, is by X-ray examination with the patient standing (see Figure 3.6). 45
Manipulative Therapy
Figure 3.5 • (A) Pelvic obliquity with level promontory and straight spinal column. (B) Following placement of a support to raise the foot, straightening of the pelvis but oblique promontory and deviation of the lumbar spine from the plumb line.
Figure 3.6 • (A) Pelvic obliquity with oblique sacrum, which is lower on the left. Left scoliosis with deviation of the head and
neck to the left. (B) Straightening of the lumbar spine and head position following placement of a support to raise the right foot.
46
Functional anatomy and radiology of the spinal column
The most important findings where there is a disturbance of body statics are: • obliquity of the base of the spine without scoliosis or with inadequate scoliosis, so that the thoracolumbar junction is not vertically above the lumbosacral • no lateral pelvic shift to the higher side • no rotation when there is scoliosis together with lordotic posture of the lumbar spine or even rotation in the direction of the concavity. The practical decision to be made is whether to order a corrective heel insert. This is primarily a clinical decision, although the X-ray can provide useful clues. The following radiological criteria show when a heel insert can be helpful in the case of obliquity of the base of the spine: • If scoliosis is not sufficient to bring the thoracolumbar junction into a position vertically above the lumbosacral, or if scoliosis is absent. Use of a heel insert to raise one heel should bring the thoracolumbar junction to the vertical, or at least nearly so.
Chapter 3
• If the pelvis is shifted, usually toward the higher side, it should then return to the midline.
• If the scoliosis was statically balanced, it should decrease.
These criteria should all be checked again by X-ray. The spinal column may react positively or negatively to the heel insert, either ‘accepting’ or ‘rejecting’ the correction. If the response is negative it would be wrong to force correction upon the patient, because this would only worsen the situation at the base (see Figure 3.7). The typical reaction to obliquity as seen radiographically has been studied by Illi (1954) and Edinger & Biedermann (1957), with the subject walking on the spot. At each step, oblique planes appeared together with corresponding scoliosis to the side concerned; the summit of the scoliotic curve appeared at L3. The thoracolumbar junction remained vertically above the sacrum. Above T12 there was a scoliosis of the thoracic spine to the opposite side, but it was shallow. According to Edinger & Biedermann (1957), the thoracolumbar junction forms a kind of point of interchange, and
Figure 3.7 • (A) Pelvic obliquity with oblique sacrum, which is lower on the left, and uncompensated left scoliosis.
(B) Following placement of a support to raise the left foot, the pelvis and sacrum are more horizontal, but not L5. No change can be seen in the rest of the spinal column. The displacement of the pelvis and plumb line to the left indicates that the patient is placing more weight on the left leg. Positioning from L5 to S1 is exacerbated.
47
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should not swing more than 4 cm from one side to the other. The relation of the scoliosis to rotation and its dependence on the presence of curvature in the sagittal plane was studied by Lovett (1907), who found that rotation of the lumbar spine (in the sense of scoliosis) occurs if lordosis is present, but not in kyphosis. The explanation for this lies in the fact that, whereas the vertebral bodies have good mobility during side-bending, the joints of the vertebral arches are forced together in lordosis and so resist movement. In contrast, in kyphosis there is less close contact between the joints of the vertebral arches; but the vertebral bodies are pressed more firmly against each other, so that these are less free to side-bend. As a result, either there is no rotation at all or rotation occurs in the opposite direction. This is sometimes the case in patients with acute lumbago or in radicular compression syndrome (see Figure 3.8). The situation can also be found clinically in healthy subjects. On passive side-bending of a subject in lordosis, the spinous processes remain in the midline, and the vertebrae rotate in the sense of scoliosis. If the same is done in kyphosis, the spinous processes form a scoliotic curve: in other words, they move in parallel with the vertebral bodies.
Lumbar spinal statics in the sagittal plane In the sagittal plane, we often speak of ‘normal’ curvatures; these are generally held to be the convex cervical curve (lordosis), concave thoracic curve (kyphosis), convex lumbar curve (lordosis), and concave sacral curve (kyphosis). Sollmann & Breitenbach (1961) demonstrated on the basis of 1000 X-ray films in the sagittal plane that there is no such thing as a general norm; at best we can speak of an ‘individual norm.’ They do not, however, lay down any criteria for this kind of norm. Cramer (1958) showed, on the basis of 150 measurements of the lumbar spine with the subject standing, that there is a constant correlation between the tilt of L5 and that of T12, and more important still, that the T12 vertebra lies an average of 4 cm dorsally to L5. The results of our own study (Lewit 1973) gave complete confirmation of Cramer’s findings and also showed that the plumb line for the head follows a line down from the external acoustic meatus exactly to the navicular bone. We found that the sacral promontory lay an average of 4 mm 48
Figure 3.8 • Typical relief position in lumbago or radicular
compression syndrome (‘paradoxical scoliosis’). Level pelvis, uncompensated right scoliosis with left rotation and deviation of the thorax and head to the left; lumbar lordosis absent.
Functional anatomy and radiology of the spinal column
Figure 3.9 • Lateral view of the lumbar spine with forwardthrust position of the thoracolumbar junction.
anterior to this plumb line, and the transverse axis of the hip joints 12 mm anterior to the plumb line. Deviations from this norm indicate a disturbance of body statics as a result of lack of muscle coordination. This is most evident in muscle spasm due to acute lumbago or radicular pain, when there is forward-thrust posture (see Figure 3.9), in which the thoracolumbar junction lies exactly over or ventral to the lumbosacral junction. The reverse is found in ‘flabby’ posture, in which the sacral promontory lies well forward of the plumb line for the head, and T12 lies dorsal to L5 by some distance (see Figure 3.10). ‘Flabby’ posture is the expression of imbalance of the muscles of the pelvic girdle; it may be the result of weakened abdominal and gluteal muscles, but equally well of hyperactive hip flexors. The curvature of the lumbar spine is of course also dependent on pelvic tilt which, in turn, varies according to the ‘type’ of pelvis, as is shown in the following section. One further point to note is that a slight curvature (a ‘flat’ spine) goes hand in hand with hypermobility and lack of stability, while greater curvature (in both the sagittal and the coronal plane) corresponds to stability and less mobility.
Chapter 3
Figure 3.10 • Lateral view of the lumbar spine with anteposition due to ‘flabby’ posture.
The curvatures of the spine are an expression of static function, and should therefore be interpreted in terms of whether they fulfill this function. In the frontal plane, balance is relatively stable; in the sagittal plane, muscle activity is the determining factor. Curvature of the lumbar spine in the sagittal plane is normal if the thoracolumbar junction is dorsal to the lumbosacral, if there is no forward shifting of the sacral promontory (no more than 8 cm in front of the center of the cassette, which is double the average). The position of the thoracolumbar junction vertically above the lumbosacral is also the most important criterion in the frontal plane. If there is obliquity at the base, the normal reaction is scoliosis and rotation of the spinal column (if lordosis is present) and a shift of the pelvis to the higher side.
3.3.3 The pelvis The pelvis and the spinal column together constitute a functional unity, in which the pelvis serves 49
Manipulative Therapy
both as the base of the column and at the same time as the connection with the lower limbs. The pelvis transmits motion from the lower limbs, at the same time acting as a shock-absorber. The spinal column rests on the pelvis much as the mast of a boat rests securely on the firm base of the mast step (Benninghoff, 1944). The sacroiliac joints and the pubic symphysis allow for a degree of mobility with enough spring to act as a buffer while also providing adequate stability.
Pelvic types The function of the pelvis and its influence on body statics depend largely on its type; we owe the recognition of this relationship to Erdmann & Gutmann (1965). The variability observed here is evidence of the phylogenetic instability of this region; evidence of this variability can be seen in our description of the last lumbar vertebra as a ‘transitional’ vertebra; it is difficult here to speak of any such thing as a ‘norm.’ If the variations are asymmetrical as between the two sides, this results in obliquity at the base of the spinal column, and the effects on spinal statics are considerable. If the variations are symmetrical, this affects the length of the sacrum, which is closely associated with its position and inclination. Erdmann & Gutmann (1965) distinguish the following pelvic types with respect to the associated mechanism of pathology (see Figure 3.11 and Table 3.1). The authors call these Hohes Assimiliationsbecken (high promontory assimilation pelvis), Normalbecken (normal pelvis) and Überlastungsbecken (overload pelvis): • High promontory: the ‘assimilation’ type presents a long sacrum and high sacral promontory, with a tendency to hypermobility (see Figure 3.17) • Normal type: this is of average length, with a tendency to restrictions. • Low promontory: the ‘overload’ type has a low promontory and marked inclination of the sacrum. All the points summarized in Table 3.1 should be borne in mind when evaluating X-ray films; it will be seen that the type of pelvis affects the spinal curvatures, the height of the last intervertebral disk, and the shape of the vertebral bodies, and therefore also the mobility of the most caudal motion segments. The assessment to be made when 50
hyperlordosis is found will therefore be different in the case of a high promontory (assimilation) type and in that of a low promontory (overload) type. Similarly, a low L5/S1 intervertebral disk will be differently assessed.
Identification of pelvic type (see Figure 3.11 and Table 3.1) is extremely important for the assessment of dysfunctions, especially in the lumbar and pelvic region.
The sacroiliac joints There is some mobility of the otherwise firm pelvic girdle, due to the role of the sacroiliac joints and the pubic symphysis. The major role is that of the sacroiliac joints. The sacrum is wedge shaped in two directions; first the whole structure tapers in the caudal direction. A double contour is usually seen in the AP view, since there is another wedge in the ventrodorsal direction; the sacrum is somewhat broader ventrally, at least in its craniad part, although in this respect too there are considerable variations. It is helpful to note that the greater the distance between the two contours of the joint, the narrower the joint space appears. If on the other hand we see only one contour, the joint space appears to be wide and clearly defined. This is often the case with the high promontory type, and is a further sign of hypermobility. It is important to point out that, despite its unusual shape and limited mobility and the fact that there are no muscles to move the sacrum against the ilium, the sacroiliac joint is a true synovial joint (Colachis et al 1963; Duckworth 1970; Mennell 1952; Weisl 1954). According to Duckworth, the sacrum rotates relative to the ilia around an axis corresponding to the shortest sacroiliac ligaments, at the level of S2. This movement is one of nutation; with each step taken during walking, the weight of the spinal column produces a forward nodding motion of the sacrum, together with the sacral promontory, acting as a shockabsorber. This mobility of the sacrum within the pelvic girdle is easily palpated and is familiar to gynecologists in the management of labor. Perpendicular to this ‘functional’ motion, the joint play consists in a springing, wing-like motion about a
Functional anatomy and radiology of the spinal column
Chapter 3
Figure 3.11 • The pelvic types. Angle a = angle of inclination of sacral promontory; angle d = angle of inclination of sacrum. 1, Head and base plumb line; 2, plumb line of promontory. (A) High promontory. (B) Normal type. (C) Low promontory.
craniocaudal axis, the effect of which is a distraction of the joint.
The degree of mobility in the sacroiliac joint should be as little as possible, yet never to the point of restriction, just as a shock-absorber is firm but never immobile.
It is appropriate at this point to deal with a condition described as pelvic distortion, which requires explanation from the functional anatomical point of view. The finding on palpation is that the posterior superior iliac spine (PSIS) is lower on one side than the other. The finding is the same if the finding is made at the posterior border of the iliac crests at the point where they can be palpated in the vertebral region. Ventrally the opposite is found: on the side where the PSIS is lower, the anterior superior iliac spine (ASIS) is 51
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Table 3.1 Pelvic types
High promontory (assimilation)
Normal
Low promontory (overload)
Inclination of sacrum
50˚–70˚
35˚–50˚
15˚–30˚
Inclination of end-plate of S1
15˚–30˚
30˚–50˚
50˚–70˚
Position of L4 disk
Above the line of the iliac crests
At the height of the iliac crests
Below the line of the iliac crests
Position of the promontory in the pelvic girdle
Eccentric (dorsal)
At the center
At the center or ventral
Shape of L5 vertebra
Rectangular
Trapeze shaped
Trapeze shaped
Shape of L5 disk
Rectangular and higher than L4
Wedge shaped and thinner than L4
Wedge shaped and thinner than L4
Segment with maximum mobility
L5/S1
L4/L5
L4/L5
Effect of iliolumbar ligament
Slight fixation of L5
Good fixation of L5
Good fixation of L4 and L5
Weight-bearing structure
End-plate of S1
End-plate of S1
L5/S1 joints and sacroiliac joint
Spinal curvature
Flat
Average
Considerable
X-ray statics
Promontory and hip joints lie in front of plumb line for head
Promontory and hip joints almost on line of plumb line for head
Promontory and hip joints lie behind plumb line for head
Clinical signs
Hypermobility, pathological changes of L5 disk; ligament pain
Restrictions, pathological changes of L4 disk
Arthroses of L5/S1, sacroiliac joint and hip
found to be higher than on the contralateral side, and vice versa. The ventral parts of the iliac crests behave in the same way as the anterior iliac spines. The middle portion of the iliac crests may be symmetrical, although this need not be so. On first impression it seems as if one ilium is twisted relative to the other about a frontal transverse axis, although this is in fact impossible if the pubic symphysis is intact. The functional anatomy involved can best be illustrated anatomically by Cramer’s diagram (1965) (Figure 3.12). This shows a one-sided nutation of the sacrum brought about by its rotation between the ilia around its longitudinal axis. This in turn results in rotation of one ilium about a horizontal axis and of the other about a vertical one. All attempts to visualize these changes radiographically have remained without success as far as we know. However, we have been successful in 52
Figure 3.12 • The mechanism of pelvic distortion (after Cramer 1965).
Functional anatomy and radiology of the spinal column
showing X-ray evidence of a disturbance of body statics in the presence of pelvic distortion (see Figure 3.13). The pelvis was found to be shifted toward the higher side, and there was deviation
Chapter 3
of the angle between the sacrum and the lumbar spine. This disappeared following treatment of the atlanto-occipital and atlantoaxial joints. Lewit & Rosina (1999) were able to induce pelvic distortion
Figure 3.13 • Disturbed statics in pelvic distortion. (A) With deviation between the lumbar spine and the sacrum. (B) No
improvement after insertion of support to raise the left foot. (C) Normal findings following treatment of atlanto-occipital and atlantoaxial joints.
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by rotating the head to one side and then the other, but radiographic examination showed this effect to have been a palpatory illusion.
3.3.4 The lumbar spine Although only a little shorter than the thoracic spine, the lumbar spine consists of only five vertebrae. However, in ante- and retroflexion as well as in side-bending, the corresponding motion segments play a significant part in ensuring the mobility of the trunk. Meanwhile the inferior part of the lumbar spine also carries the weight of the trunk, so the vertebral bodies and articular processes of the lumbar spine are the most robust. The joints of the vertebral arches form massive gliding surfaces that can enable considerable excursion and also provide stability. The greater part of the articular facets runs vertically, almost in the sagittal plane. Ventrally, the smaller part is turned almost at a right angle to point medially, in the frontal plane. Frequently, however, the articular facets simply form an arc, whose concave aspect faces dorsally. If the two parts do stand at right angles to each other, the joint spaces can be easily visualized by X-ray; if they form an arc, this cannot be done. Given that the joints of the vertebral arches only develop their final shape after birth, during the first years of life there is considerable variation in this respect.
The shape of the joints determines the function of the lumbar spine; it mainly allows for anteand retroflexion and tends to inhibit side-bending, which occurs in combination with rotation. The joints inhibit rotation about a sagittal axis. Just as side-bending happens in combination with rotation, so rotation of the trunk produces the effect of lateral flexion. If the joints of the vertebral arches determine the quality of the movements of the lumbar spine, its great mobility depends on the thickness of the lumbar intervertebral disks. Their thickness usually increases from L1 down to L4; consequently maximum mobility is usually found at the L4/5 segment. Only in the ‘high promontory’ pelvic type is maximum thickness and mobility found at L5/S1. Retroflexion, however, is usually most extensive in the L5/S1 segment.
X-ray anatomy of the lumbar spine The oval shadow of the pedicles of the vertebral arches are the most striking feature in the AP views of the lumbar spine (see Figures 3.14 and 3.15). The last pedicles (only) are projected onto the lateral edge of the fifth lumbar vertebra; they are also less distinct. This is partly owing to the triangular shape of the spinal canal in the inferior lumbar spine. Taking the pedicle as a starting point, it is
Figure 3.14 • Anatomical structures of the lumbar spine. (A) Dorsal aspect of the lumbar spine and sacrum. (B) X-ray: AP
projection. (C) Ventral aspect of the lumbar spine and sacrum. 1, Spinous process; 2, superior articular process; 3, lamina of the vertebral arch; 4, pars interarticularis; 5, joint space; 6, inferior articular process; 7, glimpse into the spinal canal; 8, posterior superior iliac spine; 9, dorsal part of the sacroiliac joint; 10, intervertebral disk; 11, transverse process; 12, vertebral body; 13, pedicle; 14, ventral part of the sacroiliac joint.
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Figure 3.15 • Schematic drawing of the AP X-ray view of a lumbar vertebra (after de Sèze et al 1969).
Chapter 3
possible to identify the lamina of the vertebral arch and trace it along to the spinous process. Lateral to and above the pedicle we find the superior articular processes; from the vertebral arch downwards and below the pedicle, the inferior articular processes can be traced in a caudal and lateral direction toward the superior articular processes of the next vertebra below. The two inferior articular processes form an arch; this, together with the spinous process of the caudal neighboring vertebra, forms a frame around a lucency which offers a glimpse into the spinal canal. At this point the canal is not covered by bone, and this is the location where lumbar puncture can be performed. Where both articular processes meet is the joint space. It is possible to see into the joint space if part of it is aligned in the sagittal plane. The lateral view (see Figure 3.16) also shows the thick pedicles, situated immediately behind
Figure 3.16 • Anatomical structures of the lumbar spine. (A) Lateral view. (B) Lateral view (X-ray). 1, Pedicle; 2, pars interarticularis; 3, inferior articular process; 4, superior articular process; 5, joint space; 6, intervertebral foramen; 7, transverse process.
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the bodies of the vertebrae. The superior and inferior articular processes arise from the pedicles. It is often also possible to see the joint space if the medial part of the joint lies in the frontal plane. Between the superior and inferior articular processes is the pars interarticularis (pars isthmica), which tends to be the site of spondylolysis in true spondylolisthesis. Between the pedicles of adjacent vertebrae can be seen the intervertebral foramen, dorsal to the vertebral bodies and intervertebral disk and bordered dorsally by the articular processes. It lies almost exactly in the frontal plane, and its width is almost that of the spinal canal. The lamina is covered by the articular processes, and dorsal to these can be seen the massive spinous processes. The transverse processes are projected onto the articular processes, appearing as a thick shadow. The fifth (last) lumbar vertebra occupies a special position in that it serves a transitional function between the mobile lumbar spine and the rigid pelvis. In terms of its shape, it is therefore adapted to the base (craniad end) of the sacrum. In the lateral view, the vertebral body of L5 is trapezoid. An important point to note is that the powerfully developed transverse processes of L5 – often resembling the pars lateralis of the sacrum – provide attachment to the iliolumbar ligaments, which stabilize the last lumbar vertebra in the pelvis. L5 therefore plays a part in the shock-absorbing function of the pelvis. The intervertebral foramen of L5 is usually narrower than the others of the lumbar spine, despite the generally powerfully developed pedicle of L5. This vertebra is usually considerably inclined, so the L5/S1 joints usually lie in the frontal plane, to prevent forward gliding. The most important anomalies of the lumbosacral junction have already been dealt with under ‘pelvic types’ (see Section 3.3.3). When there is a transitional vertebra, it can be difficult to decide whether this is a sacralized L5 or a lumbarized S1. It is especially difficult if the image shows six vertebrae with lumbar characteristics and the task is to decide whether the last is indeed a lumbar vertebra or a lumbarized sacral vertebra. In cases where a neurosurgical intervention is to be carried out, this decision can be very important. The most reliable criterion to use is an imaginary line drawn between the two iliac crests: this line usually corresponds to the fourth intervertebral disk (see Figure 3.17). If, however, this line projects across the middle of a vertebral body, the 56
Figure 3.17 • High promontory pelvic type with obliquity at
L4, left scoliosis, and rotation. Here the line between the two iliac crests runs level with the L5/S1 disk.
identification becomes well-nigh impossible, unless an X-ray of the thoracic spine is also available. Sometimes, instead of the massive transverse process of L5, a transitional lumbosacral vertebra may have a pars lateralis which forms a pseudarthrosis with the pars lateralis of S1, and may even cause clinical symptoms. The most serious anomaly, clinically, is probably spinal canal stenosis. In the lateral view the usual finding shows massive vertebral bodies with short, stubby pedicles and markedly narrow intervertebral foramina. The line of the inferior articular processes is noticeably steep. In the AP view the massive appearance of the articular processes is striking, it is possible to see clearly into the joint space, and the lucency between the inferior articular processes below the spinous process is particularly narrow. The effect is to give the spinal canal a trefoil shape. CT offers the best insight into the anatomical relations in the spinal canal; it can also visualize the narrow lateral recesses and the narrowed, trefoilshaped spinal canal. A narrow spinal canal adversely affects root compression and is often accompanied by radicular claudication. It is of course important to be able to assess the thickness of the intervertebral disks correctly. Straightforward disk hypoplasia is a quite common anomaly, and should not be confused with disk
Functional anatomy and radiology of the spinal column
Figure 3.18 • The anterior inferior border of the vertebral
body of L5 is lower (arrow) in relation to the sacrum on the left side than on the right. The L5/S1 disk is therefore narrower on the left. There is compensatory lumbar scoliosis with marked rotation.
degeneration. This is especially true in the case of an L5 transitional disk. If this vertebra shows no signs of degenerative changes and no shift that might indicate laxity, the practitioner should not be too hasty in diagnosing a narrow disk as degeneration. A useful sign of disk hypoplasia is a finding that shows abbreviated end-plates either side of a narrow disk. Although we usually rely on lateral views for the assessment of disks, marked asymmetry in the AP view can be a useful sign, particularly for the L5/S1 disk, where anomalies are frequently found (asymmetrical L5/S1 disk, see Figure 3.18).
Evaluation of function from X-rays In order to evaluate radiographic films from the point of view of function, they must be taken under standard conditions. The film must be taken with the patient standing erect, and if possible using the technique described in Section 3.3.1. A functional evaluation of the lumbar spine can only be done if the pelvis, hip joints and pubic symphysis are included on the film. A 30 × 40 format is therefore recommended for both projections, so that the entire sacrum and hip joints can also be seen
Chapter 3
in the lateral projection. A focus-film distance of at least 1.5 meters is needed to keep distortion to a minimum. Careful assessment of rotation can be important, because rotation is to some extent related to scoliosis and the degree of lordosis; if the relationship is disproportionate, this can be a sign of dysfunction. Rotation of a vertebra is recognized by a deviation of the spinous process and the pedicles in the direction opposite to that of rotation. On the side of rotation the pedicle appears wider and it is easier to see into the joint space; the transverse process is slightly shorter (because it is nearer the cassette). Deviation of the spinous process alone should never be taken to be a sign of rotation; absence of the other criteria, especially the corresponding asymmetry of the pedicles and the row of transverse processes, etc., indicates that the deviation observed is simply asymmetry and not rotation. Scoliosis should always be assessed according to the principles of body statics. The lateral view is used to assess lordosis, kyphosis and ventral or dorsal shift. If an apparently blocked position is found, this can also be significant. Slight shifting (ventrally or dorsally) is a sign of instability. This may become more marked during ante- or retroflexion. However, very slight, proportional shifts in ante- or retroflexion, especially in young patients, may be normal. There are two potential pitfalls to beware of: 1. Incongruence of the end-plates of two adjacent vertebrae, most frequently observed between L5 and S1 in the lateral view. In such cases the superior end-plate of S1 is usually slightly longer than the inferior endplate of L5, and the shift that is observed can be seen either only at the dorsal or ventral edge of the adjacent vertebra. 2. Slight rotation in patient positioning: here the shadows of the anterior and posterior borders form a double contour which can be mistaken for a shift. Slight shifts due to hypermobility or slight instability need to be distinguished from true spondylolisthesis (with spondylolysis) and from degenerative ‘pseudospondylolisthesis or spondylotic listhesis’ as described by Junghanns (1930), in which the superior articular process of the adjacent vertebra below (most frequently L5) is bent in the ventral direction, so that the vertebra above it (usually L4) glides ventrally over it. 57
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Radiographic movement studies Films taken in erect posture may not always provide any clues to disturbed function, which only becomes evident in movement studies. These are usually performed to study ante- and retroflexion and side-bending. In the normal case, movement is fluid and all segments of the lumbar spine participate. Where there is disturbed function, it is possible to distinguish segments of reduced or increased mobility. We find a sign of reduced mobility at a block vertebra position, and the segment concerned does not participate in the movement. Where there is increased mobility, local ventral or dorsal shifts may be observed in ante- and retroflexion. In young and hypermobile subjects, slight step-like shifting of vertebrae and shifting that occurs to an equal degree in all segments may be considered normal (Jirout 1956). Even the formation of an exaggerated sharp bend is a sign of local hypermobility. However, if this sharp bend is accompanied by a ventral narrowing of the disk in anteflexion, without a corresponding dorsal widening, this is indicative of a disk lesion. The same can be said if it is accompanied by dorsal narrowing of the disk without a corresponding widening ventrally (Jirout 1965). In the lumbosacral segment a ‘paradoxical’ shift sometimes occurs; instead of the ventral shift in anteflexion and dorsal shift in retroflexion that is observed in the other segments, there is a ventral shift during retroflexion and dorsal shift during anteflexion (Jirout 1957). This presumably occurs as a kind of leverage mechanism. Movement studies are mainly indicated where there is a clinical reason for doing so; usually where particular movements give rise to symptoms. These studies are particularly important in order to find out whether or not spondylolisthesis is already fixed. In side-bending, the main object is to look for asymmetry and to assess the relationship between flexion and rotation.
3.4 The thoracic spine 3.4.1 Functional anatomy The thoracic spine is the longest section of the spinal column, but also the one with the least mobi lity. The main reason for this is its firm, though 58
jointed, connection to the relatively rigid thoracic cage. The narrowness of the intervertebral disks is the morphological expression of this minimal mobility. In the frontal plane the joint spaces are almost vertical, but laterally they fall away anteriorly, as if on the periphery of a circle (cylinder) whose center is ventral to the vertebral body. This arrangement would allow for considerable rotation in the thoracic region were it not for the ribs and the intervertebral disks. Side-bending, and to some degree also anteflexion, are similarly limited by the thoracic cage. Anteflexion is also held in check by the tension of the inter- and supraspinal ligaments. Retroflexion is limited mainly by the articular and the spinous processes, which overlie each other in the manner of tiles on a roof. At a certain point in retroflexion this arrangement therefore obstructs bending in this direction.
Transitional regions One important reason for the significance of the thoracolumbar junction is that there is a sudden change in joint structure occurring in the region of a single vertebra (T12): whereas the articular processes above this point are those of the thoracic spine, those below it have the form and mechanical features of the lumbar spine. During walking on the spot, the thoracolumbar junction acts as a fixed point, where scoliosis of the lumbar spine to one side changes to scoliosis of the thoracic spine to the opposite side. The anatomists’ view that trunk rotation takes place mainly in the thoracolumbar junction was refuted by Singer & Giles (1990). They demonstrated directly by means of CT during trunk rotation that the rotation occurring in this segment was hardly any greater than that in the neighboring thoracic and lumbar motion segments. We confirmed these findings using AP films of trunk rotation taken in the sitting position with fixed pelvis. We demonstrated that scoliosis with rotation occurs in the entire lumbar spine (see Figure 3.19).
Just as side-bending (scoliosis) of the trunk is combined with rotation, so rotation of the trunk is accompanied by side-bending. In principle, movement of the spine occurs by coupled movements in all three planes.
Functional anatomy and radiology of the spinal column
Chapter 3
The ribs
Figure 3.19 • Right rotation with right lumbar scoliosis
during right rotation of the trunk in the sitting position, with fixed pelvis.
Another transition region which is commonly the site of dysfunctions is the cervicothoracic junction down to T3/T4; this is where movements of the head and neck end, as is most clearly seen in ante- and retroflexion. The same is true for sidebending and rotation, though it is evident only in erect posture. One possible reason for the frequency of dysfunctions in this region may be that it is the point of transition between the most mobile section of the spine and the least mobile section. Another is that this is the site where the powerful muscles and tendons of the upper limbs have their origin. The middle thoracic spine is an important transitional region, because this is where the cervical erector spinae muscle ends and the lumbar portion of the muscle begins. Around T5, therefore, the apex of the thoracic curvature of the spine, is the weakest point of the muscles of the back. All transitional regions are rich in anomalies. There may be rudimentary ribs at T12 or lumbar ribs at L1; cervical ribs at C7 or enlarged transverse processes at C7 are quite common. It is rare, on the other hand, for the first rib at T1 to be absent. The uncinate process at C7 may sometimes be absent on one or both sides.
The ribs articulate with the vertebrae at the costovertebral and costotransverse joints. The head of the rib articulates with the superior border of the body of the corresponding vertebra and with the inferior border of the next vertebral body above. The tip of the head of the rib (crista capituli) is attached to the intervertebral disk by ligaments. The third rib therefore articulates with the bodies of T2 and T3, and is attached to the T2 intervertebral disk. Exceptions to this rule are the first rib, which articulates exclusively with the body of the first thoracic vertebra, and the last two floating ribs, which are attached simply by a syndesmosis to the rudimentary transverse processes of the corresponding last thoracic vertebrae. Rib movement occurs about an axis running from the head of the rib through the neck of the rib to the costotransverse joint. In the upper thoracic spine, this axis is horizontal in the frontal plane. The movement about this axis causes the thorax to rise and fall and the sternum to undergo a pumping motion. In the inferior thoracic spine, the axis runs in an oblique, laterodorsocaudal direction, and produces a wing-like movement. At the last floating ribs there is no joint, so there will be no motion restriction here. If pain occurs here it is due to muscle attachments, especially that of the quadratus lumborum. The articulation between the ribs and sternum is often painful; this too is usually due to muscle attachments with TrPs in the pectoralis and scalene muscles.
3.4.2 X-ray anatomy of the thoracic spine X-ray imaging of the thoracic spine demonstrates the structural details less clearly than imaging of the lumbar spine. In the AP view (see Figure 3.20) the vertebral bodies, pedicles, and spinous processes can be clearly seen. The joint spaces are not visible because they lie in the frontal plane; the laminae of the vertebral arches and the superior and inferior articular processes can also not be seen. The spinous processes are angled downward. As a result, from about T4 to T10 the tip of the spinous process is projected onto the body of the next vertebra below. The characteristic feature of the thoracic spine is the costovertebral joint. The head of the rib can 59
Manipulative Therapy
Figure 3.20 • Anatomical structures of the thoracic spine. (A) AP radiograph. (B) Dorsal aspect of the thoracic spine. 1, Spinous process; 2, pedicle; 3, rib; 4, transverse process; 5, costotransverse joint.
be seen in close contact with the intervertebral disk and, laterally to it, the neck and tubercle of the rib are superimposed on the transverse process. The costotransverse joint space usually runs at a steep angle from dorsocranial to ventrocaudal, so is difficult to visualize much or at all. Sometimes, especially in the lower thoracic region, the joint space runs more dorsoventrally and horizontally, and is then easily seen. In this case the superimposed rib lies approximately on the transverse process. The first rib articulates only with the first thoracic vertebra. The two last ribs only contact the rudimentary transverse processes of the last thoracic vertebrae. The sternum and sternocostal joints are not generally visualized when the usual technique is used. In the lateral view (see Figure 3.21) the ribs and structures of the lungs are superimposed on the vertebral bodies and disks. At the vertebral arches this superimposition is still more troublesome. Nevertheless, if the film is technically successful enough to give good visualization, the pedicles and intervertebral foramen are easily seen. The foramen opens ventrally at an angle of approximately 15° to the frontal plane, but there need be little distortion 60
if the lateral projection is set up accurately. The joint space and articular processes are clearly visualized. The ribs are superimposed on the laminae and the greater part of the spinous processes, although the tips of the spinous processes can be seen if the image is good. The superior portion of the thoracic spine (approximately above T3) is completely hidden in the lateral projection and can only be demonstrated using oblique views or by tomography. It can sometimes be difficult to identify which thoracic vertebra is which in the lateral view, as T1 cannot be seen and it is hard to be sure of identifying T12, because the last rib can sometimes be rudimentary. It is therefore useful to look for the inferior angle of the scapula (which is usually at the level of T7), the bifurcation of the trachea (approximately at T5), the arch of the aorta (level with T4), and the dome of the diaphragm (usually level with T10).
3.4.3 Evaluating functional aspects The curvatures of the spine are important here as they are in all sections of the spinal column.
Functional anatomy and radiology of the spinal column
Chapter 3
Figure 3.21 • Anatomical structures of the thoracic spine. (A) Lateral aspect of the thoracic spine. (B) Radiograph, lateral
view. 1, Inferior articular process; 2, joint space; 3, superior articular process; 4, intervertebral foramen; 5, pedicle; 6, rib; 7, transverse process.
Scoliosis and increased kyphosis are the most frequent findings. It is always useful to know whether the curvatures are in static equilibrium. For this, the films must be taken under static conditions. It is important to note that the greater the curvature, the less the mobility and the greater the stability. Conversely, if the curve is flat, this indicates hypermobility and a tendency to instability. Dysfunctions may be associated with rotation, in which a sudden deviation is found in the line of the spinous processes (see Figure 3.20). The asymmetrical position of the spinous process is insufficient on its own to enable a diagnosis of rotation to be made; for this, there must also be a shift in the position of the pedicles in the same direction (see Figure 3.22). In the lateral view of the thoracic spine it is rare to see shifts between two adjacent vertebrae, or a lordotic or kyphotic deviation between neighboring vertebrae in cases of simple dysfunction. Kyphotic deformity, on the other hand, whose cause is morphological, does frequently occur here in the
Figure 3.22 • Schematic drawing to illustrate rotation of a vertebra.
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context of juvenile osteochondrosis (Scheuermann’s disease), following a traumatic compression fracture, or as a consequence of osteoporosis. Dysfunctions of the ribs can be recognized by changes in the spaces between them.
3.5 The cervical spine The cervical spine is the most mobile section of the whole spinal column; it is also the most vulnerable. This region is the richest in afferent proprioceptive nerves, which exercise an effect on the entire locomotor system. Dysfunctions here are therefore particularly important, and their treatment is correspondingly rewarding.
3.5.1 X-ray technique A suitable and effective technique is essential in order to obtain pictures that can be evaluated for function. The usual technique, which usually produces very poor visualization of the upper portion of the cervical spine in the lateral view and does not visualize it at all in the AP one, is not even adequate for morphological diagnosis and is completely useless for the evaluation of function. The Sandberg–Gutmann technique (Sandberg 1955) (see Figure 3.23A) best meets the requirements for a successful image in the AP projection. For this,
the patient is supine. Positioning is done using the following technique, so as to represent the patient’s posture accurately: the patient begins by sitting on the X-ray table, intergluteal cleft exactly on the midline of the table and legs extended, symmetrically side by side. Only then is the patient requested to lie down. Ask your patient to do so without use of the arms, looking straight ahead and in a completely natural manner. To check that the finding is representative rather than chance, this procedure may be repeated. If the head regularly deviates to one side, this must not be corrected; instead you should adjust the cassette and the X-ray tube accordingly. If you correct the head position you might either correct or artificially produce cervical scoliosis and at the same time induce axis rotation and lateral deviation of the atlas. The film format used is either 18 × 24 cm or 15 × 40 cm; it can be helpful to include the upper thoracic spine as well. Position the cassette so as to be able to assess the upper margin of the foramen magnum, the front incisors and, caudally, at least T1. This is usually achieved when the upper edge of the cassette is aligned slightly craniad to the patient’s external ear. Ask the patient to open her mouth as wide as possible and place a cork between her front teeth. The patient should then draw in her chin until the forehead (glabella) and upper lip (filtrum) are on the same horizontal plane. For this, a pillow beneath the head is often necessary, except when the patient is a child.
Figure 3.23 • X-ray technique for the cervical spine according to Sandberg–Gutmann. (A) Alignment of the central ray for the AP projection with the aid of a string. (B) Alignment for the lateral view of the cervical spine.
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Now the X-ray tube can be centered. The central ray must be aligned through a point one finger’s breadth below the upper premolars to a point one finger’s breadth above the palpable inferior border of the occiput (posterior margin of the foramen magnum) in the midline. Either a light field indicator or a piece of string running from the center of the focal spot to the appropriate position on the patient’s face can be used for this alignment. The X-ray tube is then aligned so that the line of the central ray is an extension of that of the string (or light) (see Figure 3.23A). For edentulous patients, the central ray is aligned through a point one finger’s breadth below the maxilla to the border of the occipital squama, and in infants who do not yet have teeth, from the inferior border of the maxilla to the border of the occipital squama. Finally, correct any rotation of the patient’s head since this would make the film hard to evaluate. This projection can also be taken with the patient seated, aligning the beam in an analogous manner. This approach is slightly more difficult but has the advantage of being performed under static conditions. Nevertheless, there can be an advantage in having taken the AP projection with the patient supine and the lateral one with the patient seated, if the findings reveal discrepancies. It is always possible then to perform an additional AP view taken in the sitting position. One objection to the open-mouth technique is that the mandible is superimposed on the mid-cervical spine. This problem can be avoided if the patient rapidly opens and shuts her mouth while the film is being taken; in this way the shadow of the mandible is blurred. The risk in this case is that there will be slight associated movement of the head, which might cause blurring of the image at the craniocervical junction. For the lateral view the patient is seated relaxed in front of a vertical stand (see Figure 3.23B). The film may be 18 × 24 cm or 24 × 30 cm, and must be placed so that the image demonstrates the cranial base as far as the sella turcica, and the cervical spine down to the cervicothoracic junction. In subjects with very tapering shoulders it will also be possible to include the first thoracic vertebra. The patient’s gaze should be fixed on a distant object at eye level, maintaining the hard palate horizontal. Take care that there is no inclination or rotation of the patient’s head, so that the two mandibles are exactly superimposed. This is necessary for accurate assessment of the film. Do not align the central ray on the mid-cervical region as is usually done, but on the tip of the mastoid process. The light field indicator can be used for this. It is best to use a film-focus distance of
Chapter 3
1.5 meters or more. This produces an undistorted image of the cranial base and the entire cervical spine and also evens the exposure; the density of the cranial base means that it demands more irradiation than the cervical spine.
X-ray films of the cervical spine that do not provide good visualization of the atlanto-occipital and atlantoaxial joints and cranial base and of the cervicothoracic junction are inadequate for the evaluation of function.
3.5.2 Assessment of X-ray films The technique described here provides sufficient criteria to evaluate all the images and to repeat them for comparison, even if all structures are asymmetrical. In the AP projection (see Figure 3.24) the first task is to make sure that both
Figure 3.24 • Anatomical structures of the craniocervical
junction, anteroposterior view. 1, Inferior border of the clivus; 2, foramen magnum; 3, occipital condyle; 4, inferior border of the anterior arch of the atlas; 5, lateral triangle; 6, foramen transversarium of the axis; 7, inferior contour of the occipital squama; 8, medial lucency of the atlas; 9, transverse process of the atlas; 10, inferior border of the posterior arch of the atlas; 11, pedicle of the arch of the axis; 12, lamina of the axis (superior border).
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occipital condyles, the atlas, and the axis are well visualized, and whether it is possible to look into both foramina transversaria (which give passage to the vertebral artery). At the caudal end, ensure that at least the first thoracic vertebra is included in the image. Next the centering should be checked, to make sure that the image is straight. If the positioning is correct, the middle point between the incisors should be vertically in line with the middle of the dens of the axis and of the occipital squama. The tip of the chin will be projected onto the middle of the cervical spine, which must run symmetrically between the two rami of the mandible. The position of the mastoid processes should also be symmetrical. In order to evaluate the inferior part of the cervical spine, it is necessary to ensure that the superior thoracic spine is not rotated. In the lateral projection (see Figure 3.25), first ensure that the cranial base, including the sella turcica and hard palate, can all be seen. If possible the cervical spine should be shown as far down as C7, although this is often not possible in heavily built patients or those with high shoulders. Check that the alignment is perfect before beginning to evaluate the findings on the film. It is particularly
important that the line of the hard palate should be horizontal. Fineman et al (1963) showed that a difference of only 10° in inclination of the head is sufficient to change lordotic to linear posture, or even to change it to the extent that lordosis becomes kyphosis. It is important that the two halves of the mandible should overlie each other exactly. If the vertical borders of the rami appear projected side by side, the head is rotated to one side. Projection of the horizontal line of the mandible one above the other indicates that the head is inclined to one side. Another sign of rotation is if the shoulders are projected apart. The oblique projection (for which the patient adopts a position turned at an angle of 45°) gives the clearest imaging of the intervertebral foramina. This projection is indicated especially for radicular syndromes and vertebral artery syndrome. As recommended by Gutmann (1956), this projection should be taken with the patient’s head in retroflexion, because this more clearly displays any narrowing of the intervertebral foramen. It is also recommended to take it not with the patient’s back to the cassette, but with the patient facing toward it (see Figure 3.26).
Figure 3.25 • Lateral view of the cervical spine, indicating
the plane of the foramen magnum, of the atlas and of the axis. Dotted lines indicate the clivus and basion (white), and the posterior border of the spinal canal (black).
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Figure 3.26 • Oblique view of the cervical spine showing a narrowed intervertebral foramen of C5/6.
Functional anatomy and radiology of the spinal column
3.5.3 Functional anatomy of the cervical spine The cervical spine has two distinct sections: the atlanto-occipital and atlantoaxial joints, and the rest of the cervical spine from C3 to C7; nevertheless it is a functional unity, since all the movements it performs originate at the atlanto-occipital and atlantoaxial joints, these movements being anticipated by eye movements. The anatomical description will accordingly be treated in separate sections. The function of the cervical spine will then be dealt with as a whole.
Functional anatomy of C3–C7 As in other parts of the spinal column, the degree of mobility in the cervical spine corresponds to the thickness of the intervertebral disk, which is greatest in the segments C3/C4 and C4/C5. The characteristic feature of the cervical spine is the raised lateral margins of the vertebral bodies, the uncinate processes. The disk therefore thins laterally, with the consequence that thinning of the disk brings about contact in this lateral region. This is where early degenerative changes occur, tending to form unco vertebral joints (neoarthroses). The position of these is very close to the intervertebral foramen. The significance for cervical function is that the shape of the vertebrae with their lateral margins limits sidebending and favors ante- and retroflexion. The intervertebral joints are almost parallel, inclined at an angle of about 45° from ventrocranial to dorsocaudal. The angle is greatest at C2/C3. In this segment the joints are frequently not parallel but arranged as if on the circumference of a cylinder with its center behind the vertebra; it is therefore not pathological if the joint space at C2/C3 is less clearly delineated than in the other segments of the cervical spine in the lateral projection. As a general principle, laterally the joints in the lordotic section of the cervical spine are inclined slightly posteriorly and in the kyphotic section slightly anteriorly. According to Janda (2002) the transition from the one to the other occurs roughly at C3/ C4. The inclination of the intervertebral joints in the sagittal plane means that side-bending produces rotation, the two kinds of movement being coupled. Similarly, rotation brings about side-bending, always to the same side (see Figure 3.30A and B). During anteflexion, a slight ventral shift of the cranial partner vertebra relative to its caudal neighbor is
Chapter 3
often observed. In retroflexion there is a slight caudad shift. This too is associated with the inclination of the joints. Penning (1968) describes this motion as a rotation of the upper vertebra relative to the lower one, around a frontal axis in the dorsal part of the vertebral body. Experience shows this motion to be physiological, as long as it occurs evenly in the motion segments of the cervical spine. It is regularly seen in young subjects with good mobility. If it is not observed in less mobile, older patients, this absence is not pathological. The shift is greatest between C2/C3 (see Figure 3.32 B and D) where the range of motion is least in adulthood. It is also important to note that the cervical spinal canal lengthens considerably during anteflexion, shortening during retroflexion. This produces a significant movement of the meninges and dural sheaths of the nerve roots relative to the spinal cord, which becomes longer and thinner in anteflexion and shorter and thicker in retroflexion. The course of the vertebral artery also has an important role. This enters its bony canal at C6, passing upward through the intervertebral foramina in close contact with the intervertebral joints and uncinate processes almost at right angles to the course of the nerve roots. Therefore, as the intervertebral foramen (canal) narrows in retroflexion, this may affect both the nerve root and the vertebral artery.
Functional anatomy of the craniocervical junction In order to understand function it is important to look first at the anatomy of the individual articular structures and ligaments. The superior articular surfaces of the atlas run obliquely from dorsolateral to ventromedial. The facets are oval in shape, converging anteriorly like a section of the surface of a sphere with its center located above both articular surfaces. The most important movement of the atlanto-occipital joint is ante- and retroflexion of about 16° (see Figure 3.27). Gliding of the
Figure 3.27 • Diagram to illustrate ante- and retroflexion between the occipital condyles and the atlas.
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Figure 3.28 • AP X-rays of an isolated axis: (A) in neutral position and (B–H) in various positions of rotation. These images provide a suitable reference for evaluating X-ray films.
occipital condyles occurs in the dorsal direction during anteflexion and in the ventral direction during retroflexion. Very slight rotation is also possible, which Jirout (1981) was able to demonstrate as a synkinetic movement during side-bending of the head. Slight side-bending is also possible, coupled with rotation in the opposite direction. The atlantoaxial joint is made up of the articulation between the anterior arch of the atlas and the dens of the axis, between the dens and the transverse ligament of the atlas with its articular cartilage, and between the lateral mass of the atlas and the body of the axis. Its main function is that of rotation, and it also performs ante- and retroflexion. All these articulations participate in rotation. On one side the lateral mass of the atlas glides ventrally on the body of the axis, rising as it does so, while on the other side the lateral mass of the atlas glides dorsally and downward. The rotation is limited by the joint capsules and the strong alar ligaments, which have their attachment to the margins of the foramen magnum. The average range of motion of this rotation (our own results) is 25° in each direction, although we have found a range of motion up to as much as 40° (see Figure 3.28). Dvorák, using CT, even obtained average measurements of 41.1° to the right and 44° to the left. Huguenin, on the other hand, in measurements made using CT, obtained figures corresponding to our own. 66
Figure 3.29 • X-ray film of rotation between atlas and axis. With the subject erect and head fixed, the subject’s body was turned in maximum rotation counter to the sagittal beam (here at 40° axis rotation).
Ante- and retroflexion between atlas and axis is considerable, amounting on average to 15°. The anterior arch of the atlas slides up and down on the dens of the axis, while the atlas itself performs a tipping motion (see Figure 3.29).
Kinematics of the cervical spine Rotation Rotation begins between the atlas and the axis and the movement takes place mainly there until
Functional anatomy and radiology of the spinal column
the range of motion in this segment is exhausted, that is to about 25° to each side. Up to this point the head rotates about a vertical axis in the horizontal plane. From this point onwards the other segments participate in succession in the rotation movement, from C2/C3 to C6/C7, as long as the cervical spine is in a position of slight kyphosis. If the neck is completely upright the cervicothoracic junction also rotates, down to and including T3. In passive rotation there is still some slight additional rotation between the atlas and the occiput. The moment rotation below C2 begins, the inclined course of the intervertebral joints brings about simultaneous lateroflexion to the same side unless the subject deliberately resists this synkinesis.
Side-bending Side-bending can be studied only by X-ray, hence the decision to deal with it under functional radio graphic studies (see Figure 3.30). Like rotation, it begins at the atlanto-occipital and atlantoaxial joints. This can be demonstrated by looking at the craniocervical region in passive side-bending (‘side-nodding’). This shows that side-bending starts with rotation of the axis relative to the atlas. At the same time we find a synkinesis in which the atlas shifts relative to the occipital condyles and C2 in the direction of the side-bending (see Figure 3.30C). During this side-bending the cervical spine rotates, maximum rotation occurring at C2. Jirout (1968) demonstrated that this rotation is absent in the lower cervical spine during side-bending to the right, but during side-bending to the left it continues down into the upper thoracic spine. He explains this as being due to the stronger pull of the muscles of the shoulder girdle on the right side, whose attachment to the spinous processes exerts a pull to the right and so brings about left rotation. This combination of side-bending and rotation is consistent with the positioning of the intervertebral joints, although this cannot be the true cause, as is usually thought, because the side-bending originates at the axis. This rotates even with the slightest side-bending, followed by the other segments. If rotation of the axis does not take place, there is no rotation of the rest of the cervical spine (see Figure 3.47B) According to Jirout (1968), the forces that bring about axis rotation are the product of side-bending
Chapter 3
of the head (see Figure 3.31). Side-bending of the head involves rotation of the head about a sagittal axis at the level of the root of the nose. This creates a pull on the spinous process of the axis, which causes rotation of the axis with simultaneous tipping in the sagittal direction. This tipping motion in the sagittal plane, which takes place both in side-bending and in rotation, is, according to Jirout (1968), the joint play of the cervical spine. The sideways shift of the spinous process can easily be palpated, and occurs as soon as the subject’s head inclines to the side even to a slight degree. Interestingly, Gaymans (1973) demonstrated that a shifting of the spinous process of the axis (rotation of the axis) occurs even on mere leaning against slight resistance in the neutral position and with minimum pressure, thus simply through the pull of the muscles. He obtained radiological evidence of this.
Rotation of the axis on side-bending of the cervical spine is not simply the combined result of rotation movements of the individual vertebrae, due to the inclination of the zygapophysial joints of C7, C6, etc.; on the contrary it results from the inclination of the head itself, in which the head rotates about a sagittal axis and exerts a pull on C2. If there is no rotation of the axis, there is also no rotation of the other vertebrae of the cervical spine during side-bending. At the same time there is a tipping motion in the sagittal plane, so that the movement occurs in a coupled way in all three planes.
Anteflexion and retroflexion Two distinct kinds of anteflexion should be distinguished. The first is a nodding movement limited to the atlanto-occipital and atlantoaxial joints. The other is a forward flexion involving the entire cervical spine. This distinction does not exist for retroflexion. The two kinds of anteflexion of the head are to some extent mutually exclusive. If we draw the chin in toward the chest (forward nodding), this usually inhibits full anteflexion. If we drop the head far forward in anteflexion, this renders nodding more difficult except in hypermobile subjects. The explanation lies in the tipping mechanism of the atlas. 67
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Figure 3.30 • AP X-ray of the cervical spine of a healthy subject, to compare the (asymmetrical) neutral position, active
side-bending, and passive ‘side-nodding.’ (A) In neutral position the atlas is to the right in relation to the condyles and axis; the plane of the condyles and that of the axis therefore converge on the right, with the axis rotated about 5° to the left. (B) In active side-bending to the left the atlas is still slightly to the right, and the plane of the condyles and that of the axis still converge to some extent to the right, while the axis is now more markedly rotated (about 10°) to the left. (C) In passive ‘side-nodding’ to the left, the atlas is now clearly to the left of the condyles and the plane of the condyles and that of the axis are parallel. The axis is rotated about 10° to the left. Transmission of the axis rotation to the next vertebra below can clearly be seen. (D) Diagram to illustrate the rotation of C2.
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Chapter 3
spine according to Jirout (1968). During side-bending the head inclines about a sagittal axis (x) passing through the anterior cranial fossa. The diagram shows how the cranial base, together with the occipital condyles, shifts relative to the atlas in the opposite direction to the side-bending, and how the axis, together with the lower cervical vertebrae, is brought into rotation in the direction of the side-bending, while the axis is tilted ventrally by a cranial pull on the spinous process.
atlanto-occipital and atlantoaxial joints are in maximum anteflexion. • In maximum anteflexion (see Figure 3.32C), the cervical spine is almost horizontal; there is a proportional slight ventral shift of the individual cervical vertebrae up to C2. Anteflexion between C1 and C2 is at its maximum. In contrast to the situation in the erect posture and in forward nodding there is now retroflexion of the head relative to the atlas, which can be greater than in retroflexion with the subject seated. Anteflexion of the atlanto-occipital and atlantoaxial joints is thus reduced as compared to forward nodding, closer to the degree of anteflexion in the erect posture. Consequently the angle between the clivus and dens is usually the same with the head erect as during maximum anteflexion. There is also a forward shift of the clivus (basion), together with the atlas, relative to the tip of the dens. • In maximum retroflexion with the subject seated (see Figure 3.32D), there is maximum retroflexion of the atlas (relative to the axis). Retroflexion of the cranium, on the other hand, is seldom at its maximum (it is usually very little greater than during anteflexion of the head). Here, too, we see a proportional dorsal shift of the individual cervical vertebrae from C7 to C2 and of the clivus and atlas relative to the tip of the dens. • In passive retroflexion with the subject sidelying and so without the effect of gravity (see Figure 3.32E), there is now maximum retroflexion of the head relative to the atlas, while retroflexion of the atlas relative to C2 is even less than in the erect posture. There is no dorsal shift of the basion with the atlas.
The following changes can be observed in X-ray studies of anteflexion and retroflexion (see Figure 3.32): • In the erect posture (see Figure 3.32A), the atlas is already in a position of slight retroflexion with an average angle of about 5°. • During forward nodding (see Figure 3.32B), anteflexion of the atlas increases only slightly. This movement causes an anteflexion of the head (the plane of the foramen magnum); in the erect posture the head had been in a position of anteflexion relative to the atlas. In this position the
The mechanism underlying these processes, which appear paradoxical at first sight, has been termed the tipping of the atlas. It is based on the following (see Figure 3.33): in anteflexion with the subject sitting, as soon as the center of gravity of the head shifts ventrally, the occipital condyles exert pressure on the anterior, rising part of the concave articular surface of the atlas. This causes the atlas to tip forward and downward. There is an analogous process in retroflexion with the subject sitting: the atlas tips backward. This does not happen, however, with the subject lying on one side, which explains why in this case retroflexion of the occiput relative to the atlas attains its maximum.
Figure 3.31 • Mechanism of side-bending of the cervical
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Figure 3.32 • Ante- and retroflexion of the cervical spine. (A) Erect posture. (B) Forward nodding. (C) Maximum anteflexion. (D) Maximum retroflexion. (E) Passive retroflexion.
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Chapter 3
Figure 3.33 • Diagram to illustrate tipping of the atlas: 1, in erect posture; 2, in ‘forward nodding’; 3, in maximum anteflexion; 4, in maximum retroflexion; 5, in passive retroflexion.
3.5.4 X-ray anatomy of the cervical spine Anteroposterior view The AP view (see Figures 3.34 and 3.35) shows the arc of the anterior margin of the foramen magnum,
at the cranial end of the cervical spine. Its superior border is formed by the clivus and its lateral part by the occipital condyles. Beneath the condyles lie the two articulations of the atlanto-occipital joint, meeting at an angle of about 125–130°. Below the condyles, to either side of the dens of the axis, can be seen the lateral masses of the atlas. These are wedge shaped, tapering towards their medial
Figure 3.34 • The cervical spine (ventral aspect) to enable comparison of the anatomical structures. (A) Skeleton. (B) AP X-ray. 1, Anterior margin of the foramen magnum; 2, inferior border of the anterior arch of the atlas; 3, foramen transversarium; 4, intervertebral foramen; 5, course of the vertebral artery; 6, uncinate process; 7, pedicle of the vertebral arch.
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Figure 3.35 • The cervical spine (dorsal aspect) to enable comparison of the anatomical structures. (A) Skeleton. (B) AP
X-ray. 1, Foramen transversarium; 2, inferior border of the posterior arch of the atlas; 3, lateral mass of the atlas with lateral triangle, 4; 5, joint space; 6, spinous process.
border. Close to this border we often see a medial lucency which should be interpreted as a normal finding. Laterally to the lateral mass, the transverse processes can be seen. It is sometimes possible to see into the foramen transversarium, which gives passage to the vertebral artery. The spindle-like posterior arch (broadest in its medial portion) can be traced from one transverse process to the other. It separates the ‘lateral triangle’ from the lateral mass. Sometimes the anterior arch can also be seen, projected across the tip of the dens. The inferior contour of the lateral mass forms the superior articular surface of the joint between C1 and C2. At the medial border of the joint facet of the axis there is a tiny notch marking the border of the dens. The tip of the dens usually lies well below the superior border of the foramen magnum. Just below the lateral end of the superior joint facets of the axis is the foramen transversarium. Medial to this foramen, the point-like projection of the pedicles of the axis can be seen. From here can be traced the shadow of the arch of the axis on both sides, through to the spinous process. If there is hyperlordosis it is sometimes possible to see into the spinal canal above the arch of the axis. Below the axis can be seen the typical cervical vertebrae with their characteristic uncinate process either side. This causes the intervertebral disk to be 72
much higher medially than laterally. Beneath the unciform processes lies the shadow of the pointlike pedicles. The spinous processes can be seen in the midline and the lateral contour is formed by the transverse processes. The intervertebral foramen is visible, but less clearly. Rarely, the intervertebral joint space can be seen.
Lateral view The lateral view (see Figure 3.36) offers an undistorted image of the cranial base and the atlantooccipital and atlantoaxial joints. The clivus can be followed in its entirety down from the sella turcica to the anterior margin of the foramen magnum (basion) which is situated directly above the tip of the dens. The posterior margin of the foramen magnum (opisthion) cannot always be clearly distinguished from the squama of the occipital bone; it helps to follow the posterior margin of the cervical spinal canal from caudad to craniad. Where the arc-shaped prolongation of this margin meets the occiput is the opisthion. The mastoid process frequently overlaps the condyle and atlanto-occipital joint; therefore this joint is not always visualized in the lateral view, although it is often clearly seen (see Figure 3.37).
Functional anatomy and radiology of the spinal column
Chapter 3
Figure 3.36 • The cervical spine (lateral aspect) to enable comparison of the anatomical structures. (A) Skeleton.
(B) Lateral X-ray. 1, Transverse process; 2, width of the spinal canal; 3, joint space; 4, inferior articular process; 5, intervertebral foramen; 6, superior articular process.
The plane of the foramen magnum can be established by drawing a line from the basion to the opisthion on the posterior margin of the foramen magnum. The plane of the atlas corresponds to a straight line through the middle of the anterior and posterior arches of the atlas.
The plane of the axis lies on a straight line linking the inferior border of the transverse processes and the inferior border of the spinous process. These lines are used to determine the ante- or retroflexion of the occiput, atlas, and axis (see Figures 3.25 and 3.38).
Figure 3.37 • Atlanto-occipital joint, lateral view.
Figure 3.38 • Anteflexion of the atlas (relative to the axis).
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The dens of the axis is projected just behind the anterior arch of the atlas. The tip of the dens is usually at the same level as the superior border of the anterior arch of the atlas. It should not be much above the palato-occipital line; this is the case in basilar impression. In this section of the spinal column, unlike the others, the pedicles and transverse processes are projected onto the vertebral bodies in the lateral view but not in the AP view, because here the spinal canal is wider than the vertebral bodies. The superior border of the transverse processes lies slightly above the superior end-plate of the vertebral bodies, which can cause them to appear somewhat blurred. In the lower cervical spine the shadow of the transverse processes lies more in the dorsal direction and in the superior cervical spine more ventrally; at C2 the position of this shadow of the transverse process is such that its anterior border overlies the anterior border of the vertebral body. The shadows of the articular processes and joint spaces are projected behind the vertebral bodies. If the projection is well executed, all that can be seen is a lucency, showing that the joints are essentially parallel. This need not be so at C2/C3, where it can be quite normal to see some fuzziness of outline. The posterior margin of the spinal canal corresponds to a line linking the bases of the spinous processes (posterior border of the vertebral arch) – a rule that thus also applies to the atlas, which does not have a spinous process. If, however, this shadow is absent at the atlas, this is a sign of spina bifida atlantis, a frequently-found anomaly.
3.5.5 Evaluation with respect to functional implications The most characteristic disturbance of statics in the cervical region is the forward-drawn posture (see Figure 3.39). Even when statics are normal, the centre of gravity of the head is slightly in front of its support, so that electromyographic studies reveal a slight degree of muscular activity in the nuchal muscles even with the subject in normal erect posture. As soon as there is any forward inclination (not flexion!), whether of the entire body or of the neck alone, tension can immediately be palpated in the muscles of the back of the neck. The forwarddrawn position therefore creates overload of the cervical spine and compensatory hyperlordosis at 74
Figure 3.39 • Typical forward-drawn position of the head.
the atlanto-occipital and atlantoaxial joints, and tension in the short extensor muscles of the neck. In order to demonstrate the patient’s natural posture radiographically, lateral projections should be taken with the subject seated in a relaxed manner, in a backless chair, as described by Gaizler (1973). It is important to ensure that the patient remains relaxed, with gaze fixed on an object at eye level, so that there is no anteflexion of the head despite the natural posture. We took projections of a group of 50 patients with the patients in erect posture (kneeling), and sitting both upright and relaxed. Whereas with the subject sitting upright the external auditory meatus was projected almost exactly above the anterior border of C7, in the erect posture it was 7 mm in front of C7, and sitting relaxed it was projected forward by 16 mm; in individual cases even by 5 cm. This was particularly the case where a patient’s relaxed sitting position involved lumbar kyphosis. In addition to disturbances of statics, localized irregularities can be observed. Examples of these are slight relative shifts in neighboring vertebrae or local lordotic or kyphotic deviations. In the
Functional anatomy and radiology of the spinal column
craniocervical region the atlas may be in a position of ante- or retroflexion in relation to the axis. The older expressions ‘atlas superior’ or ‘atlas inferior,’ which were adopted by chiropractors, are less appropriate because they refer to the position of the atlas relative to the occiput rather than the axis, whereas the criterion being assessed in the rest of the spine is always the position of the upper of two vertebrae relative to the one below it. The tipping of the atlas means that the atlas is usually in a slightly retroflexed position if there is cervical lordosis, with the occiput in anteflexion; if the posture is kyphotic the atlas would be in anteflexion and the occiput in retroflexion (see Figures 3.33, 3.39 and 3.40). Other frequent findings are the rotation of several vertebrae (see Figure 3.46) and, in the region
Chapter 3
of the atlanto-occipital and atlantoaxial joints, lateral shifting, an asymmetrical position of the condyles relative to the atlas, and of the atlas in relation to the axis. This is often described as a shift of the atlas to one side relative to the condyles and to the axis, which is not quite appropriate: the description should always be given in terms of the upper element relative to the lower. The description in this case would not be of the atlas to the right relative to the condyles and axis, but of the atlas to the right relative to the axis, and the condyles to the left relative to the atlas (see Figures 3.41–3.43). Isolated rotation of the atlas in relation to both the occiput and the axis is fairly uncommon. The joint space between atlas and axis is narrower on the side of rotation, the lateral triangle of the lateral mass becomes larger, the center of the posterior arch is shifted in the opposite direction to the rotation, and the lateral mass becomes larger on the side opposite to rotation. Much more frequent than rotation of the atlas is axis rotation in neutral posture (see Figure 3.44). A 5° or occasionally even 10° rotation of the axis is not unusual. Interestingly, the rotation of the axis is caudally transmitted, down to the rest of the cervical vertebrae and even down as far as the cervicothoracic junction, particularly when rotation is to the left. This can happen even in the simple case of lateral deviation of the spinous process. The mechanism clearly seems to be the same as that discussed in connection with side-bending, which brings about left rotation of the lower cervical spine and cervicothoracic junction.
Figure 3.40 • Kyphotic posture of the mid-cervical spine
with balanced body statics: the external auditory meatus and the dens of the axis are not projected in front of the anterior border of C7. The position of C7 is consistent with a flat thoracic spine.
Figure 3.41 • Diagram to illustrate the asymmetrical position of the atlas relative to the occipital condyles and the axis.
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Figure 3.42 • (A) Asymmetrical position of the atlas relative to the occipital condyles and axis. (B) After manual therapy the position is symmetrical.
Figure 3.44 • Dextrorotation of the axis. (A) X-ray. (B) Diagram.
Figure 3.43 • Dextrorotation of the atlas. (A) X-ray. (B) Diagram.
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Figure 3.46 • Rotation of the cervical spine: X-ray, lateral view. The joint spaces, articular processes and transverse processes are projected apart.
Figure 3.45 • Schematic drawing to illustrate the rotation of a cervical vertebra in the AP view.
The characteristic features of axis rotation in the AP view are the deviation and position of the pedicles and the spinous process to that of rotation. The foramen transversarium widens on the side of rotation and the joint space narrows on the opposite side. Rotation of the other cervical vertebrae is characterized not only by the deviation of the spinous process and rotation of the pedicles to the opposite side, but also by distortion of the unciform processes (see Figure 3.45). In the lateral view, the structures that usually overlap are projected apart. This applies particularly to the joint spaces,
together with the articular processes and transverse processes. At C2 one transverse process is projected in front of the vertebral body (see Figure 3.46). An important sign of static disturbance is discrepancy between the AP view taken with the patient supine and the lateral view with the patient sitting, in particular if there is rotation in the view taken sitting and none at all in the AP view with the patient supine. The cause may be an oblique plane below the cervical spine.
3.5.6 Movement studies Radiographic movement studies are used to investigate restrictions and hypermobility. X-rays are taken in ante- and retroflexion and side-bending. Rotation is less studied by this method because interpretation is difficult. 77
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The physiological reaction of the cervical spine during side-bending has been described in Section 3.5.3. The study of side-bending is useful in the diagnosis of movement restrictions. We
find that if there is no rotation of the axis, there will be none in the rest of the cervical spine (see Figure 3.47). Even if, on side-bending, an asymmetrical spinous process of the axis fails to
Figure 3.47 • (A) Neutral position. (B) Side-bending with absence of axis rotation. Rotation of the other motion segments is also absent. (C) After treatment, rotation of the axis is restored and the other motion segments now also rotate. The extent of side-bending has also increased.
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Functional anatomy and radiology of the spinal column
Chapter 3
It is not usually difficult to demonstrate a restriction of side-bending between the atlas and axis. When this is done, rotation is (also) seen to be blocked (see Figures 3.47 and 3.49). The radiological evidence of restriction in the other motion segments of the cervical spine is much more difficult to achieve. According to Jirout (1971) side-bending is accompanied by slight synkineses in the sagittal plane, consisting of ante- and retroflexion movements that can be recognized by a change in the position of the spinous processes relative to the vertebral bodies. Comparison of the films taken before and after manipulation found a more marked reaction of these synkineses in restrictions than actual side-bending as seen radiographically. To summarize: Figure 3.48 • Schematic drawing to illustrate the effect
of asymmetry of the spinous process of C2 on the caudad vertebrae during side-bending. (A) Neutral posture with spinous process of the axis to the right of the midline. (B) On inclination to the right the axis rotates to the right in the normal way, but the asymmetrical spinous process travels no further than the midline. The vertebrae below therefore remain in the central position and do not rotate.
reach any further than the midline, the rest of the cervical spine will not rotate. This demonstrates that the rotation is transmitted through the spinous processes in a caudal direction. Lack of rotation in the lower cervical spine does not in any way impair rotation above the restriction (Jirout 1972) (Figure 3.48). Although lateral shifting of the atlas occurs in side-bending, this shifting can sometimes be absent without implying any movement restriction, especially if there is marked asymmetry. More importantly, the shifting may still be seen in the radiographic image even in cases where there is restriction. If there is restriction blocking axis rotation, no side-bending occurs at the atlanto-occipital and atlantoaxial joints (see Figure 3.49). This is in keeping with the fact that in cases of atlas assimilation, side-bending at the craniocervical junction occurs in the normal way. This raises the question as to whether restriction between occiput and atlas on side-bending can be demonstrated radiographically at all. We have shown this to be possible (Lewit & Krausová 1967) with the head rotated to the side, locking the atlas/ axis motion segment. This is necessary to obtain an accurate diagnosis.
• Lateroflexion of the head against the cervical
spine (side-bending; ‘side-nodding’) is mainly performed by means of rotation of the axis relative to the atlas. Normalization of sidebending at the atlanto-occipital and atlantoaxial joints also normalizes this rotation. • Lateroflexion between occiput and atlas can be established radiographically and clinically only if the more mobile segment (C1/C2) is locked, that is if the head and atlas are rotated by at least 45°. The movement restriction between occiput and atlas does not affect sidebending in the frontal plane or the synkinesis between occiput and atlas during side-bending in the sense of a lateral shift accompanied by simultaneous rotation of the axis. • Ante- and retroflexion is the movement most frequently examined by X-ray. The disadvantage of this examination from the point of view of manipulation therapy is that this is the movement most frequently and preferentially performed and so the least susceptible to dysfunction. Hypermobility, on the other hand, is more readily revealed here. This can reveal increased shift between neighboring vertebrae, increased lordosis or kyphosis between neighboring vertebrae, and the following signs of hypermobility at the craniocervical junction: - Laxity of the transverse ligament of the atlas and a widening of the joint space between the anterior arch of the atlas and the dens of the axis, especially the superior part (see Figure 3.50). As a consequence the basion also shifts anteriorly. During anteflexion the distance between the anterior arch of the atlas 79
Manipulative Therapy
Figure 3.49 • Restriction of side-bending between atlas and axis. (A) In the neutral posture the position of the atlas is
slightly asymmetrical, to the left relative to the condyles. (B) On attempted left lateroflexion there is almost no side-bending at the craniocervical junction, although the atlas has moved markedly to the left. (C) After manipulation, normal lateroflexion is restored, with (slight) rotation of the axis. (D) Spontaneous side-bending to the left; position analogous to (C) with acute cervical myalgia.
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Functional anatomy and radiology of the spinal column
Chapter 3
Figure 3.50 • Increased distance between the anterior
arch of the atlas and the dens of the axis, especially in the superior part, with anterior shift of the basion.
and the dens and the angle between the clivus and the dens decreases. This happens not only on forward-nodding, but also anteflexion (see Figure 3.51). - Hypermobility between the occipital condyles and the atlas without laxity of the transverse ligament of the atlas can be recognized by a shift of the basion and opisthion in relation to the dens of the axis (see Figure 3.52).
Figure 3.52 • Hypermobility between the occiput and
atlas during ante- and retroflexion of the head. (A) During anteflexion, the basion lies above the anterior arch of the atlas and the opisthion above the posterior arch. (B) On retroflexion the occiput is shifted posteriorly by about 2 cm.
Figure 3.51 • Hypermobility of the atlas on anteflexion of the head with slackening of the transverse ligament of the atlas.
(A) Neutral posture. The articular facet of the anterior arch of the atlas lies parallel to the dens of the axis. (B) On maximum anteflexion the anterior arch of the atlas and dens of the axis create a gap that is open cranially, the basion shifts anteriorly, and the angle between the clivus and dens (obtuse) becomes noticeably smaller than in the neutral posture.
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3.5.7 Morphological changes It is not the task of this book to deal in detail with morphological and structural changes; nor is it necessary to do so, since this field forms the subject of textbooks of radiology and orthopedics. Therefore only certain aspects, the limited number of those that are particularly important from the point of view of manual medicine, are touched on here.
Anomalies Block vertebrae Block vertebrae lead to a compensatory hypermobility in the neighboring segments. The coalescence may be complete or partial, or sometimes simply consist of a hypoplastic intervertebral disk, in which case the vertebral bodies adjacent to the hypoplastic disk are narrower (see Figure 3.53). This occurs because the adjacent end-plates – between which the hypoplastic disk lies – are also the zone of
growth. This anomaly could easily be confused with the consequences of childhood rheumatoid arthritis (Still’s disease). The difference lies in the obliteration of the joints, while the vertebral arches and spinous processes are normally developed.
Cervicothoracic transitional vertebra A transitional C7 cervicothoracic vertebra with a very large transverse process or with a cervical rib is another frequent anomaly. There may also be an absence of the unciform process on one or both sides. A transitional T1 vertebra is however rare.
Spinal canal stenosis A narrow spinal canal is particularly important clinically, because it is the most important cause of cervical myelopathy. From the practical point of view in diagnosis it is more helpful to look at the change in the proportions of the individual anatomical structures than to measure the sagittal diameter of the spinal canal; the proportions of the structures can be seen at first glance. Normally, in the cervical spine, the spinal canal is wider than the vertebral bodies. In spinal canal stenosis this is not so; also (if there is no rotation in the radiograph) the articular processes overlie the entire width of the spinal canal (see Figure 3.54).
Figure 3.53 • Incomplete block vertebra (congenital
coalesence) of C5/C6 with a hypoplastic intervertebral disk and narrowing of the vertebral bodies in the region of the narrowed disk. The articular processes and vertebral arches are normally developed.
82
Figure 3.54 • Spinal canal stenosis. The spinal canal
is markedly narrower than the vertebral bodies, and the articular processes cover its entire width.
Functional anatomy and radiology of the spinal column
Basilar impression As a region of transition, the craniocervical junction, the region of the atlanto-occipital and atlantoaxial joints, is the site of many anomalies. Probably the most important of these is basilar impression (see Figure 3.55), which is the result of hypoplasia of the basiocciput. In this condition the occipital part of the clivus is shortened and therefore the dens axis appears as if shifted into the foramen magnum, so as to lie above the palato-occipital line in the lateral view (see Figure 3.55A). In the AP view the dens can be above the occipital condyles, placing it
Chapter 3
well above the line between the mastoid processes and digastric muscles (see Figure 3.55B). At the same time the foramen magnum may be narrower than usual, unless there is also an Arnold–Chiari malformation, in which case displacement of the tonsils of the cerebellum below the foramen magnum has the effect of widening it. These changes can cause syndromes associated with compression of the medulla oblongata, similar to those of spinal canal stenosis in the cervical region. Frequently basilar impression is accompanied by hypoplasia or assimilation of the atlas to the occipital bone and its condyles. Less frequently there can
Figure 3.55 • Basilar impression. (A) The lateral view shows hypoplasia of the clivus, and the dens high in the foramen
magnum. (B) In the AP view the dens of the axis is again seen in a high position. (C) Diagram: a, sphenoid part of the clivus; b, occipital part of the clivus; c, palato-occipital line; d, distance (according to Klaus 1974) of the dens of the axis from a line joining the tuberculum sellae and the internal occipital protuberance; e, plane of the foramen magnum.
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be a block vertebra involving coalescence of the axis with a lateral mass of the atlas. All the anomalies listed here are frequently asymmetrical, so that lateral displacement of the atlas and also rotated positions of the axis can be found simultaneously. In addition there can also be hyperlordosis. It is therefore little wonder that these anomalies often also lead to dysfunctions which in turn cause pain.
Hypoplasia of the dens of the axis Hypoplasia of the dens or especially the os odontoideum leads to pathological instability (see Figure 3.56). Another anomaly deserving of mention is reclination of the dens (Gutmann 1981), which results in retroflexion of the atlas and therefore places increased strain on the transverse ligament of the atlas during head anteflexion.
Figure 3.56 • Os odontoideum, lateral view in neutral position (B). Pathological shift of the atlas relative to the axis (A) during retroflexion and (C) during anteflexion.
Figure 3.57 • Spondylarthrosis in a case with a horizontal course of the articular facets. (A) Joint spaces well visualized
in the AP projection as a result of the horizontal direction of the beam; also the condensation. (B) The lateral view provides clear evidence of the horizontal course; the condensation and extension of the articular processes can clearly be seen.
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Chapter 3
Degenerative changes Degenerative changes can be of clinical significance, especially if they affect the intervertebral foramen, if they are closely associated with the nerve root and the vertebral artery, or if they cause additional narrowing of an already narrow spinal canal. These changes mainly develop in the region of the uncinate processes when there is thinning of the disk, bringing the uncinate processes into close contact with the body of the vertebra above. This can lead to the formation of uncovertebral joints (neoarthroses) and osteophytes. Degeneration of the articular processes also has an effect on the intervertebral foramina. Arthroses of the zygapophysial joints often occur as a consequence of their horizontal position, whether this has come about as an anomaly or in the case of hyperlordosis. In such cases the joint facets, rather than the end-plates of the vertebral bodies, become the weight-bearing structures. This causes a broadening and condensation of these joints, and they can therefore be clearly seen in the AP view (see Figure 3.57) as well as the lateral view. Finally, the significance of a divergent course of the paired joints in the cervical spine needs to be highlighted. This change can clearly be seen in a well-centered lateral view. It causes rotation of the
Figure 3.58 • Difference in the inclination of the articular facets in the C3/C4 segment.
upper of two neighboring vertebrae, relative to the caudally adjacent one, during retroflexion, and consequent narrowing of the intervertebral foramen on the side of the rotation (see Figure 3.58).
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Chapter Four
4
Diagnosis of dysfunctions of the locomotor system
Chapter contents 4.1 Patient history . . . . . . . . . . . . . . . 88
4.1.1 Course of the disease . . . . . . . . 88 4.1.2 Localization . . . . . . . . . . . . . 89 4.1.3 Trauma . . . . . . . . . . . . . . . . 89 4.1.4 Load, posture, and position . . . . 89 4.1.5 Non-mechanical factors . . . . . . 90 4.1.6 Psychological factors . . . . . . . . 90 4.1.7 Paroxysmal character . . . . . . . . 90 4.1.8 The significance of patient age . . . 90 4.2 The inspection: posture . . . . . . . . . . 90
4.2.1 The dorsal aspect . . . . . . . . . . 91 4.2.2 The lateral aspect . . . . . . . . . . 91 4.2.3 The ventral aspect . . . . . . . . . . 92 4.2.4 Inspection of the seated patient . . 93 4.3 Palpation (soft-tissue examination) . . . . 93
4.3.1 Hyperalgesic zones . . . . . . . . . 93 4.3.2 Subcutaneous tissue and fasciae . 94 4.3.3 Trigger points . . . . . . . . . . . . 94 4.3.4 Periosteal pain points . . . . . . . . 96 4.3.5 Radicular syndromes . . . . . . . . 96 4.3.6 Conclusion . . . . . . . . . . . . . 100 4.4 Mobility testing . . . . . . . . . . . . . . 100
4.4.1 Active mobility . . . . . . . . . . . 100 4.4.2 Movement against resistance . . . 100 4.4.3 Passive mobility . . . . . . . . . . 100 4.5 Examination of the pelvis . . . . . . . . . 101
4.5.1 Screening examination . . . . . . 101 4.5.2 Pelvic obliquity . . . . . . . . . . . 102
4.5.3 Pelvic distortion . . . . . . . . . . 4.5.4 Pelvic tilt . . . . . . . . . . . . . . 4.5.5 Restriction of the sacroiliac joint . 4.5.6 Shear dysfunction (Greenman) (upslip and downslip) . . . . . . . 4.5.7 Outflare and inflare . . . . . . . . . 4.5.8 The pelvic floor and coccygeus muscle . . . . . . . . . . . . . . . 4.5.9 The painful coccyx . . . . . . . . . 4.5.10 Ligament pain . . . . . . . . . . .
102 103 103 106 106 106 107 107
4.6 Examination of the lumbar spine . . . . . 108
4.6.1 Screening examination of active movement . . . . . . . . . . . . . 108 4.6.2 Examination of individual motion segments . . . . . . . . . . . . . . 109 4.7 Examination of the thoracic spine . . . . 112
4.7.1 Screening examination of active movement . . . . . . . . . . . . . 4.7.2 Palpation of mobility . . . . . . . . 4.7.3 Anteflexion . . . . . . . . . . . . . 4.7.4 Side-bending . . . . . . . . . . . . 4.7.5 Rotation . . . . . . . . . . . . . . .
112 113 113 114 114
4.8 Examination of the ribs . . . . . . . . . . 115
4.8.1 Screening examination . . . . . . 115 4.8.2 Examination of the first rib . . . . 116 4.9 Examination of the cervical spine . . . . 116
4.9.1 Screening examination . . . . . . 116 4.9.2 Examination of passive mobility . . . . . . . . . . . . . . . 117 4.9.3 Examination of the motion segments . . . . . . . . . . . . . . 118
Manipulative Therapy
4.9.4 Testing of mobility between occiput and atlas . . . . . . . . . . 122 4.10 Examination of the limb joints . . . . . 124
4.10.1 The shoulder . . . . . . . . . . . 4.10.2 The elbow . . . . . . . . . . . . 4.10.3 The wrist . . . . . . . . . . . . . 4.10.4 The hip . . . . . . . . . . . . . . 4.10.5 The knee . . . . . . . . . . . . . 4.10.6 The foot . . . . . . . . . . . . .
124 126 127 127 128 129
4.11 Examination of the temporomandibular joint . . . . . . . . 130 4.12 Examination of disturbances of balance . . . . . . . . . . . . . . . . . 130 4.13 Examination of muscle function . . . . 132
4.13.1 General principles . . . . . . . . 132 4.13.2 Examination of muscles with a tendency to weakness . . . . . 133 4.13.3 Examination of muscles with a tendency to shortening . . . . . 136 4.14 Examination of hypermobility . . . . . . 140
4.14.1 The spinal column . . . . . . . . 140 4.14.2 The joints of the upper limb . . 143 4.14.3 The joints of the lower limb . . . 144 4.15 Examination of coordinated movements (motor stereotypes) . . . . . . . . . . . 145
4.15.1 Examination with the patient sitting . . . . . . . . . . . . . . . 145 4.15.2 Examination with the patient standing erect . . . . . . . . . . 149 4.15.3 Movement patterns of respiration . . . . . . . . . . . . 150 4.16 Syndromes . . . . . . . . . . . . . . . . 151
4.16.1 The lower crossed syndrome . . 151 4.16.2 The upper crossed syndrome . 152 4.16.3 Stratification syndrome (according to Janda) . . . . . . 152 4.17 Retesting . . . . . . . . . . . . . . . . . 153 4.18 Dysfunctions and the course of examination . . . . . . . . . . . . . . . 153 4.19 Adjusting our thinking to the functional approach . . . . . . . . . . . 154 4.20 Chain reactions of dysfunctions and motor programs . . . . . . . . . . . . . 155
4.20.1 Function and chain reactions . . 155 4.20.2 Chain reactions in the light of developmental kinesiology . . . 157 88
4.20.3 The pathomechanisms of chain reactions . . . . . . . . . 4.20.4 Causes of chain reactions . . . 4.20.5 The role of the diaphragm . . . 4.20.6 Rotation of the trunk . . . . . . 4.20.7 Unilateral chains of dysfunction 4.20.8 Analysis of chain reactions . . .
159 160 160 161 161 161
4.21 Differential diagnosis . . . . . . . . . . 162
4.21.1 Problems . . . . . . . . . . . . . 4.21.2 Case studies . . . . . . . . . . . 4.21.3 Common differential diagnoses 4.21.4 Conclusions . . . . . . . . . . .
162 163 164 165
As in every other field of medicine, examination starts with taking the patient history. The model we shall take here is the diagnosis of vertebrogenic disturbances, which are among the most frequent type of dysfunction. Dysfunctions should not simply be diagnosed by a process of elimination; if we approach the task by ruling out all other possible causes of the lesions (especially pathomorphology) we cannot expect to arrive at helpful findings. Instead, diagnosis should be based on characteristic symptoms. Precise criteria for the patient history have been laid down by Gutzeit (1951). Following the patient history, the next step is the physical examination. There is no clinical field in the whole of our experience in which the purely clinical examination plays such a decisive role; nor does any other make such high demands as the examination of motor function. The examination begins the moment the patient enters – the very first steps into the room, the way the patient sits down, even the way the patient undresses. It is important that patients should undress for the first examination (to their underwear, since most patients feel more at ease if they can keep their undergarments on, and so move more naturally). Present-day knowledge of functional inter-relationships shows it to be essential to study the entire locomotor system at the initial examination.
4.1 Patient history 4.1.1 Course of the disease Unless we are dealing with a young patient, symptoms will usually have been present for some time;
Diagnosis of dysfunctions of the locomotor system
in most cases for years or decades, though sometimes in mild form, interspersed with periods of complete absence of pain. The frequency, duration, and intensity of the individual episodes are all relevant, but such details can often only be discovered by careful, specific questioning. For example, female patients will tend not to recall or mention low-back pain during menstruation unless specifically asked, because they consider this irrelevant. In contrast to this pattern, a short, progressive course should give rise to concern, especially if the patient is advanced in age.
4.1.2 Localization Over the course of years, pain may occur in various different parts of the spine and locomotor system; it is exceptional for dysfunctions to remain confined to a single region. Again, specific questioning is usually needed to elicit this information. Patients presenting with headache will have little idea that there might be a connection between this and their low-back pain, any more than patients with lumbago will associate this with vertigo originating from the spinal column. Patients may suffer from a number of complaints that might, if taken individually, be seen as having a variety of different causes, yet all have a common denominator in the spinal column or locomotor system. The greater the number of complaints a patient has – all of which, however different, could have a vertebral origin – the greater the likelihood that these are indeed vertebrogenic dysfunctions. This serves to confirm Gutzeit’s (1951) view that the spinal column is the link that runs like a bright red thread through a thoroughly varied list of different complaints. Vertebrogenic pain is typically asymmetrical as between sides and often unilateral. This applies both to radicular pain and to reflex, referred pain such as headache or pseudovisceral pain. The asymmetry usually increases as a patient’s condition deteriorates, and decreases as it improves. If (in the case of dysfunctions) a unilateral pain spreads to become bilateral, this does not usually indicate deterioration.
4.1.3 Trauma As has already been emphasized (in the discussion of pathogenesis), trauma is a significant factor in the etiology of vertebrogenic disturbances. If an accident features in the previous history it becomes all the more likely that the presenting complaint has a vertebral origin. Almost any kind of trauma, even if
Chapter 4
it ‘only’ affects the limbs, affects the spinal column. This is particularly so in the case of head injury. Nevertheless, it is well known that many patients tend to forget ‘minor’ injuries, serious as the consequences often turn out to be. Children who wrench their neck in an awkwardly performed somersault in a gymnastics lesson at school, or fall and sit down heavily, seldom suffer any painful consequences at the time; if they do, they compensate quickly. However there can be consequences, but they often appear very much later. It is therefore advisable not to accept straight away an answer that your patient cannot remember ever having had any accident. Instead, it should become a routine question to ask patients what sports they practice. To give a typical example: a patient who answered a direct question about injury by saying that he ‘never suffered any trauma’ replied to one about sport by saying that he had been a boxer!
4.1.4 Load, posture, and position Function and its disturbances in the locomotor system are influenced by movement, load, posture, and position, especially if the position maintained is stressful. Therefore one of the most important points in recording the case history is to discover under what conditions the pain occurs. This is not only useful in arriving at a diagnosis, but also important from the point of view of prevention. Details in the history such as these are essential, but often very difficult to discover from the patient. It does little good to ask what happened just before the onset of symptoms, because patients will give an answer based on all sorts of theories they have heard or formed for themselves. What we need to know are the circumstances in which pain was initially felt and which cause it to recur on a regular basis. Patients often find this very difficult to recall, thinking that it would not help to say, for example: ‘when I got up from my chair …’; ‘I was shaving, and when I tried to look more closely in the mirror …’; ‘… getting out of bed in the morning …’; ‘I was going to pick up a piece of paper from the floor …’; yet these are significant details. It is also important to ask which position or movement gives relief. It is important to know whether pain is provoked by sudden movements, by an extended period of sustained, strenuous effort, or by an enforced position. Even apparently irrelevant details can be important. The point that has 89
Manipulative Therapy
to be identified is whether a particular pain symptom occurs on bending slightly forward, as when working at a desk, or on maximum flexion, as when stooping to wipe a floor, or while straightening up from a stooping position. The mechanism behind the problem is very different in each case. In this context too it is necessary to find out about patients’ work and sporting activities.
4.1.5 Non-mechanical factors Dysfunctions of the locomotor system are not simply a mechanical problem, but involve every aspect that affects the reactive capacity of the body. The nervous system in particular plays a role, as can be seen in susceptibility to changes in the weather, to chills, and infectious diseases. This is especially so if these cause raised body temperature. Hormonal disturbances, the clearest effects of which are those experienced by women during menstruation, can also be important; allergy can likewise have an effect.
4.1.6 Psychological factors Since, as we know, the locomotor system is subject to human will, and pain is the most frequent symptom of dysfunction, it is hardly surprising that psychological factors play an important part. Psychological involvement in no way excludes, but rather corroborates, the diagnosis of vertebrogenic dysfunction. It must be stressed that appropriate treatment of the dysfunction is the best means of easing the pain. It also provides the practitioner with the best means of dealing with the psychological problems. It is ultimately the course of the illness that indicates how significant the psychological factor is in the particular case. The psychological problems may ease when the patient’s pain is relieved, or may persist; they may even cause relapse as a result of increased muscle tension, and an inability to relax. This is particularly the case in masked depression. One general principle needs to be stressed: we should guard against categorizing pain as psychological if patients are able to localize it accurately and if they give the same account of the symptoms each time they describe them. The conclusion we should draw in this case, assuming that no pathomorphological lesion is found, is that there is a dysfunction 90
of the locomotor system. Signs that a problem is caused by purely psychological factors are these: if the patients are unable to localize the pain, if they constantly change their account, or if they cannot describe the pain. They are often confusing their psychological suffering with the pain.
4.1.7 Paroxysmal character Gutzeit (1951) is entirely right when he describes the paroxysmal character of vertebrogenic complaints, especially if the symptoms involved are autonomic and vasomotor in nature: examples are headache, vertigo, pseudocardiac or other pseudovisceral problems. If the pain has the same, sustained intensity, for example headache, this tends to suggest another cause rather than a vertebral one. At the same time it should be pointed out that patients often speak of pain as being ‘constant’ when they are never completely free of it, although its intensity rises and falls paroxysmally with a certain frequency.
4.1.8 The significance of patient age For differential diagnosis it is important to bear in mind that the age of the patient plays an important role. In adolescents we might expect to find ‘ordinary’ restrictions or juvenile osteochondrosis, and in slightly older patients, ankylosing spondylitis. In the middle-age group, the most common serious conditions are herniated disc and ‘ordinary’ dysfunctions. In older age groups, osteoporosis is the most important, especially in women; also osteoarthritis, especially of the hip and knee joints. In this older age group, malignant disease must also be considered, especially if the patient is over 50 years of age and the disease has followed a progressive course. True vertebrogenic disease tends to decrease after the age of 60, accompanied by a rise in the incidence of osteoarthritis of the limb joints.
4.2 The inspection: posture The inspection usually begins with the dorsal aspect. The plumb line is positioned so as to fall between the heels. This is followed by the lateral and finally the frontal aspects. If possible the
Diagnosis of dysfunctions of the locomotor system
patient should also be assessed in the sitting position, again from all sides.
The inspection is the quickest way of gaining an overall impression so that the manual stage can be carried out in as targeted and economical a way as possible.
4.2.1 The dorsal aspect The inspection begins with an assessment of overall posture, looking for any deviation from the plumb line and any asymmetries. The next stage is the systematic inspection. Working upward from the feet, the specific points to examine are: • the shape (roundness) and position of the heels • the shape of the foot • the shape and thickness of the Achilles tendons and the calves, observing their medial and lateral contours • the position of the knees • the shape of the thighs • the height of the gluteal folds • the tone of the gluteal muscles • the course of the intergluteal cleft • the shape of the hips: whether symmetrical or projecting to one side • the waist • the distance of the pendant arms from the trunk on either side. Further details to examine are: • the rhomboid of Michaelis between the dimples situated at the posterior superior iliac spines (PSIS), and further craniad, the prominence of the erector spinae muscles. Between these lie the spinous processes, set within a groove between these muscles. This may follow a vertical course, or may be found to deviate from the vertical • the apex of the lordosis and the transition to kyphosis • the position of the shoulder blades: how high, and, if prominent, how symmetrical • the relative height and shape of the shoulders • the quadratus lumborum and latissimus dorsi muscles; these form the lateral contour of the
Chapter 4
trunk up to the axilla. The superior border of the shoulders is formed by the deltoid and superior portion of the trapezius, and medially to these by the levator scapulae. The inspection should note whether the superior contour takes a concave or convex (hypertonic) course and observe whether there is symmetry • the neck: note whether the neck deviates to one side or the other, and observe whether it is long, slim, or stocky • the hair line: note whether this is well above the shoulders or low down as in basilar impression • the head: look for any deviation. Does it deviate to the same side as the neck, or to the opposite side?
4.2.2 The lateral aspect Inspection of the lateral aspect also begins with an assessment of posture as a whole. The center of gravity of the head should normally be above the shoulder girdle; more precisely the external auditory meatus should be vertically above the pelvic girdle and this in turn above the feet, so that a plumb line from the external auditory meatus falls approximately 2 cm in front of the ankles and touches the scaphoid of the foot (navicular bone). During this inspection the patient’s gaze should be directed at an object at eye level. It is extremely important to register a forwarddrawn position, in which the head is in front of the shoulder girdle, and this in front of the pelvic girdle, with the pelvis above the anterior part of the foot. It is important for diagnosis to note any tension of the muscles of the back, and especially of the back of the neck, which disappears on sitting. When carrying out the systematic inspection, the examiner again works upward from the feet. Points to assess are: • the shape of the lower leg and especially the knee: genu recurvatum is a sign of laxity • the shape of the buttocks • the lumbar curvature: note whether the apex of the lordosis is located at or above the lumbosacral junction. In cases of increased lordosis with flabby posture, the abdomen is seen to protrude; this is not always a sign of adiposity. This protrusion may be at its maximum at the navel; however, if there is a drooping belly the level may be much lower 91
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• the level of the transition from lumbar lordosis
to thoracic kyphosis: note whether the patient has a flat or round back; if the thoracic spine is flat there is frequently increased kyphosis at the cervicothoracic junction • the shape of the spinal column • the position of the shoulders: whether drawn forward or protruding. Cervical lordosis largely depends on the shape of the thoracic spine. If the thoracic spine is flat, cervical lordosis may be completely absent. This is particularly seen in individuals of the athletic type with broad shoulders and a flat thoracic cage; similarly in ballet dancers. If the back is round, on the other hand, the thoracic kyphosis often continues into the lower cervical spine, with only the upper part of the cervical spine showing lordosis. In flabby posture, exaggerated cervical lordosis is sometimes seen; the thyroid cartilage (and trachea) may protrude, giving the impression of an enlarged thyroid gland. This, however, disappears in the supine position. In a forward-drawn posture there is frequently hyperlordosis in the craniocervical region.
4.2.3 The ventral aspect At inspection of the ventral aspect the most striking features are asymmetries between one side and the other, especially those that fall into the category of hemihypertrophy. Working from caudal to cranial, the points to observe are: • the position of the feet and their transverse and longitudinal arching • the knees: varus or valgus alignment • the thighs • the lower abdomen. Note a protruding abdomen and also the navel; the position of the navel is important. Specific points to note are whether it is central, and whether it lies on the surface or at some depth. If the patient has a large abdominal circumference and the navel is deep-lying, this indicates corpulence, but if the abdomen is enlarged and the navel ‘floats’ in a superficial position, it is indicative of muscle weakness. The lateral contours of the abdominal wall are normally concave, but if the abdominal muscles are weak, the contour is convex bulging • the epigastric angle: this may be obtuse or acute 92
• the sternum and pectoral muscles. It is mainly in male patients that these are easily seen
• the clavicles, noting how they move during
inhalation and exhalation and the extent to which they participate in the movements of respiration (markedly or little). The depth of the supraclavicular fossae is important; these are deeper when the thoracic cage remains in an inspiratory position, as happens in emphysema, for example, or where there is a functional problem of faulty breathing. In this case there is also hypertonus of all the other upper fixators of the shoulder girdle, which is manifested as a ‘Gothic shoulders’ posture • the position of the shoulders: asymmetry is almost the general rule • the jugular fossa in the neck region between the medial ends of the clavicles, and the sternoclavicular joint: one joint is often found to be more prominent than the other, although this need not be clinically significant. The sternocleidomastoids can be seen either side of the jugular fossa; the lateral attachment of this muscle on the clavicle is usually less distinct. Between the sternocleidomastoids and the trapezius, some bundles of the scaleni may be visible in slim patients • the thyroid cartilage: this can be seen more distinctly in males. Any lateral shift in its position is clinically very significant, since this indicates tension in one of the digastric muscles, drawing the hyoid to one side along with the thyroid cartilage. This observation is accompanied by distortion and asymmetry of the floor of the mouth, which is shallower on one side and deeper on the other • hyperactivity of the masticatory muscles: this can often also be seen at rest. Another manifestation is that the patient’s mouth hardly opens during speech. • the face: facial asymmetry is very frequent, and can be combined with asymmetry of bite and even ‘facial scoliosis.’ This in turn can be associated with scoliosis of the spinal column and hemiatrophy.
To summarize: inspection of the dorsal and ventral aspects enables the practitioner to detect asymmetries, either in the sense of relative
Diagnosis of dysfunctions of the locomotor system
weakness of one side (hemihypogenesis), or simply of the marked dominance of one side. Dominance is clearly recognized by the arm that is more powerful. In the lower limbs, the stance leg is more powerful and solid, though it is the swing leg that is dominant.
4.2.4 Inspection of the seated patient Examination of the patient in the relaxed, sitting position can produce very different results from those obtained with the patient standing. This is particularly so with hypermobile subjects, in whom lumbar hyperlordosis standing changes to a kyphotic posture when seated and relaxed. This is accompanied by a forwarddrawn neck and hyperlordosis at the atlanto-occipital and atlantoaxial joints. This is particularly important in subjects whose profession is mainly sedentary. Inspection from above would reveal rotation of the shoulder girdle in relation to the pelvic girdle and the feet.
4.3 Palpation (soft-tissue examination) Palpation is extremely important in the diagnosis of painful structures of the locomotor system and essential for all manipulative techniques. This examination therefore follows next, immediately after the inspection. The first step in palpation is to place a hand (finger) onto the surface of the patient’s body, and then to focus one’s attention on the aspect to be tested: warmth, moisture, consistency (whether the surface is rough or smooth), mechanical properties (resistance, mobility, stretch capacity), and whether the examination causes the patient to feel pain. Given that palpation is associated with touch, and this in turn with pressure, we might think that an objective way to perform it would be to use a pressure gauge. Sadly this idea is misleading; palpation is never a matter of mere (static) pressure, but a process that involves movement of the hands (fingers). Whether attempting to penetrate down from the surface to underlying layers, or to examine some aspect of the tissue by feel, we are constantly moving tissue aside or drawing it apart. Palpation therefore involves a combination of alternating pressure
Chapter 4
and movement. It is registered using not only our pressure receptors but also, simultaneously, our proprioceptors. Further, touch constantly evokes a reaction from the patient, and this reaction must also be registered. Feedback operates between the examiner and the patient, and is extremely important in diagnosis; a non-reproducible process of feedback is taking place between two systems. Palpation is a method that reveals a great deal to the experienced examiner; a host of information that a technological instrument is incapable of providing. The fact that it is not reproducible frequently leads to its rejection as too subjective: however this is not only absurd on practical grounds but also theoretically untenable; computers that process information are in essence no more than imperfect copies of the nervous system. The information that we obtain from them is uncritically accepted as ‘objective’ while the original, the human brain and the hands that provide the sensory input of information, are rejected as unreliable. Yet there is already radiological evidence to demonstrate ‘palpatory illusions’ (see Figure 4.11).
The palpating hand has receptors to sense heat and cold, to distinguish pressure, motion, position, and tissue quality. No technological instrument is able to detect and integrate all these factors simultaneously. There is also a feedback process between practitioner and patient, both during diagnosis and during treatment.
4.3.1 Hyperalgesic zones The quickest, most elegant method of finding a hyperalgesic zone (HAZ) is to run one’s fingers very lightly over the surface of the skin: heightened friction is felt at an HAZ on account of increased sweat production. The lighter the touch of the fingers, the more readily this is detected. The ‘barrier’ phenomenon is used when examining all the tissues of the locomotor system other than bones (see Figure 2.3). The points to note are: • the point at which the first resistance is felt on moving away from the neutral position: on stretching or folding the skin, stretching a subcutaneous fold, or displacing muscles relative to the bone 93
Manipulative Therapy
• in the movement of a joint, the point at which
the barrier is reached • whether the barrier is normal or pathological. A small area of skin can be examined by stretching it between the fingertips (the interdigital folds are an example) – a larger area is examined between the thumbs and the palms of the hands – always taking up the slack until the point where the barrier is engaged, and always comparing one side with the other (see Figure 6.56).
4.3.2 Subcutaneous tissue and fasciae To examine – and also treat – subcutaneous connective tissue, including that in scar tissue and shortened muscles, the practitioner should create a fold (see Figure 6.57) and stretch (not squeeze) it until the barrier is reached. If it is not possible to create a fold, slight pressure alone is enough to arrive at this barrier. In examining fasciae, the most useful characteristic to look for is their mobility against the underlying layer, that is mobility of the subcutaneous layer against the muscle and especially of the muscle against the bone. This mobility is examined as follows: • The muscles of the back in the cranial or caudal direction, with the patient prone. • The gluteal muscles in the cranial direction. • The muscles around the thorax in the dorsoventral direction. • The muscles of the neck around the longitudinal axis of the neck. • The muscles of the limbs around their longitudinal axis (pp. 232–234). The scalp also behaves in the same way as a fascia relative to the skull. Resistance (pathological barrier) is often discovered at periosteal pain points when trying to shift the subperiosteal tissue in various directions, and an easing of the pain is achieved when mobility is restored. This applies particularly at the attachments of tendons and ligaments. Bones that are linked not by joints but by connective tissue also move relative to one another. Examples are the metacarpal and metatarsal bones, and the fibula relative to the tibia. Testing of their mobility relative to each other often reveals pathological barriers, which are treated in analogous 94
ways. Everything that has been said about softtissue lesions applies to active scars.
The soft tissues surround the muscular and articular structures everywhere, and need to move in harmony with them. The same principle also applies to the internal organs. For this reason, dysfunctions that are closely associated with the function of joints and muscles can be diagnosed in the soft tissue. It is the mobility and elasticity of the soft tissues that enable them to move, and there is a harmonious interplay between these and movement. This mobility has been little studied, but if it is disturbed, the neuromusculoskeletal system cannot function normally.
4.3.3 Trigger points Palpation is the means of diagnosing the most characteristic change, the myofascial trigger point (TrP). Various terms for this exist in the literature; it is known, for example, under the names myogelosis, fibrositis, or local hypertonus. Here we shall apply the definition and terminology given by Travell &
Figure 4.1 • Flat palpation of TrPs. (A) Taut muscle bundle (detected by palpation). (B) Local twitch response.
Diagnosis of dysfunctions of the locomotor system
Simons (1999), who describe the TrP as a hyperirritative spot in skeletal muscle, which is associated with a hypersensitive palpable nodule in a taut band. A twitch reaction can be elicited by snapping palpation which can be registered by electromyography. At the same time the patient feels characteristic pain, which is accompanied by signs from the autonomic nervous system (see Figures 4.1 and 4.2). A muscle bundle in which there are TrPs contains some muscle fibers that are in a state of contraction, alongside others that are uncontracted (relaxed). If we succeed in relaxing the contracted fibers, using post-isometric relaxation, reciprocal
Chapter 4
inhibition, ‘spray and stretch’ or simple pressure, the problem usually disappears instantly, showing it to be a functional, reversible disturbance. Recent studies show that the hardening derives from the part of the muscle fiber that is stretched, and that the nodule of contracted muscle is the actual myogelosis. These changes have also been demonstrated histologically (Windisch et al 2001), findings which indicate that there are also TrPs that are chronic and irreversible. These respond little to the reflex methods mentioned above, requiring instead aggressive therapy such as needling (see Chapter 6, p. 248).
Figure 4.2 • Examination of myofascial TrPs. (A) Flat snapping palpation. (B) Palpation using pincer grip.
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Myofascial TrPs can also be studied objectively by means of electromyography (EMG) using monopolar needle electrodes. This method has successfully been used (Hong & Yu 1998; Hubbard & Berkoff 1993; Simons 2003) to show that what they were observing were end-plate potentials originating in TrPs. Two kinds of TrP can be distinguished: active and latent. Active TrPs are those that give rise to pain, especially referred pain. Latent TrPs do not give rise to spontaneous pain, but are painful on palpation and participate, often decisively, in chain-reaction patterns. Myofascial TrPs are not the only pain points that can be palpated; points of tenderness can also be found at the periosteum, in joint capsules, at attachment points of tendons and ligaments, and within muscles in the absence of any area of hardness. Since the hardened area forms part of the definition of a ‘TrP’ the term cannot strictly be applied in this case and instead it is best to use the term ‘tender point’ (TeP). These can also be the point of origin of referred pain. If the TeP is the attachment of a tendon, this is usually closely associated with the TrP of the corresponding muscle, the actual cause of the pain at the tendon attachment. Characteristic muscular pain points are also present in system-wide disease, as for instance in fibromyalgia syndrome, but a particular feature of these is that there are no areas of hardness. There is also no twitch response, and these pain points do not respond to reflex relaxation. Table 4.1 lists some muscle TrPs that are important for their diagnostic implications.
4.3.4 Periosteal pain points Numerous pain points on the periosteum are also found in most cases of dysfunctions of the locomotor system. The appearance and resolution of these pain points – as well as their treatment – play an important role in the course of the dysfunction. Many periosteal pain points are sites of attachment of tendons or ligaments closely associated with TrPs in the muscles, and have the effect of producing increased tension there. This is called enthesopathy. On examination, mobility testing of the subperiosteal tissue against the underlying bone reveals characteristic resistance in one or more directions on the affected side as compared with the healthy side. 96
Pain points can also be found in the region of the vertebral and limb joints wherever these are accessible to palpation. At the spinal column this is particularly so in the cervical region. They are also found at the sternocostal joints and at the temporomandibular joint. Table 4.2 lists the most important periosteal points and their clinical significance.
4.3.5 Radicular syndromes As already stressed, radiating pain alone (even mere paresthesia) are not sufficient for the diagnosis of a radicular syndrome. Conclusive evidence of radicular syndrome is provided by neurological deficit, the main signs being: • hypesthesia • localized hypotonia and/or atrophy • muscle weakness • decreased tendon and periosteal reflexes • increased idiomuscular excitability. Unless these signs are present we may suspect root lesion, but this requires further proof. There are certain signs, however, which strongly suggest radicular syndrome, without being positive proof. These are if the pain and paresthesia radiate down to the fingers (or toes), especially if objective examination also finds increased resistance to stretching at the interdigital fold, and difficulty in the mobility relative to each other of the metacarpals (metatarsals) in the corresponding segment. If the straight-leg raising test produces a finding below 45°, this also raises suspicion. Another sign is when the patient reports that control of the limb feels different from usual. The individual radicular syndromes are dealt with in Section 7.8.2. There is disagreement as to the dermatomes, and some individual variation has to be expected. The scheme we observe, particularly for the trunk, is that of Hansen & Schliack (1962) (see Figure 4.3A–C and E); for the lower limbs, that of Keegan (1944) (see Figure 4.3D). In radicular syndromes and herpes zoster, the authors work on the basis of Head zones (referred pain) findings. There is very credible evidence to support the existence of the cervicothoracic and the lumbosacral hiatus; this term describes the fact that segments C5–T1 are only found on the upper limbs and segments L2–S2 only on the lower limbs. This means that on the trunk, segment C4 is followed immediately by T2,
Diagnosis of dysfunctions of the locomotor system
Chapter 4
Table 4.1 Muscular trigger points
Muscle
Clinical significance
Soleus
Pain at the Achilles tendon
Quadriceps femoris
Lesion in L4 segment; pain at the upper edge of the patella; ‘pseudo hip and/or knee pain’
Tensor fasciae latae
Pain at the hip and at the superior border of the patella
Thigh adductors
Lesion in the hip joint; TrP in pelvic region
Iliacus
Lesion in S1 segment; coccyx; pseudovisceral pain
Piriformis
Lesion in L5 segment; ‘hip pain’
Ischiocrural muscles
Lesion in segments L5, S1 (straight-leg raising test positive); pain at the ischial tuberosity and head of the fibula
Levator ani
Pain at the coccyx
Coccygeus
Low back pain; many chain reactions due to pelvic floor dysfunction
Erector spinae
Back pain in the corresponding segment
Psoas major
Pseudovisceral pain; restricted rotation of trunk
Quadratus lumborum
Acute lumbago; restricted rotation of trunk
Rectus abdominis
Tenderness at xiphoid process and pubic symphysis; pseudovisceral pain
Pectoralis major
Pain at chest wall; pseudocardiac pain
Pectoralis minor
Tender coracoid process, sternocostal joints, and superior thoracic aperture
Diaphragm
Chest pain; cervical syndrome
Transverse (middle) part of trapezius
Cervicobrachial and radicular syndromes
Subscapularis
Pain in the shoulder; in the arm; at the lesser tubercle; pseudocardiac pain
Supraspinatus, infraspinatus
Pain in the shoulder; in the arm; at the greater tubercle
Supinator, biceps brachii, forearm extensors
Radial (lateral) epicondylopathy
Triceps brachii
Pain in the axilla; epicondylopathy
Finger flexors
Ulnar (medial) epicondylopathy
Descending (superior) part of trapezius
Neck pain; headache and shoulder pain
Levator scapulae
Shoulder pain; headache; neck pain
Scalene muscles
Pain at Erb’s (supraclavicular) point; at the superior thoracic aperture
Craniocervical extensors
Upper cervical syndrome
Sternocleidomastoid
All cervical syndromes
Masticatory muscles
Earache; upper cervical syndrome
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Table 4.2 Clinically important periosteal points
Periosteal point
Clinical significance
Head of metatarsals
Metatarsalgia in the case of splay foot; also in the case of tarso-metatarsal restriction
Calcaneal spur
TrP of deep plantar flexors
Head of fibula
TrP in biceps femoris, tibialis posterior; restriction of fibular head; forward-drawn posture
Pes anserinus (tendinous expansions of muscles at medial border of tuberosity of tibia)
TrP in the hip adductors; osteoarthritis of hip joint
Insertion of collateral ligament
Lesion of a meniscus in the knee
Superior border of patella
TrP in quadriceps femoris and tensor fasciae latae
Ischial tuberosity
TrP in the ischiocrural muscles
Posterior superior iliac spine (PSIS)
Frequent but not specific
Lateral border of the pubic symphysis
TrP in the hip adductors; hip
Superior border of the pubic symphysis
TrP in the rectus abdominis; forward-drawn posture
Coccyx
TrP in the levator ani, tension in the gluteus maximus
Iliac crest
TrP in the gluteus medius and quadratus lumborum
Pain at spinous process
Hypermobility with TrP in the erector spinae muscles
Spinous process T4—T6
Weakest region of erector spinae with TrP
Spinous process of C2
Lesion in segments C2—C4; TrP in levator scapulae
Xiphoid process
TrP in rectus abdominis
Ribs in the medioclavicular line
TrP in pectoralis minor
Ribs in the axillary line
TrP in the serratus anterior
Sternoclavicular joint
TrP in the scalene muscles and superior parts of the pectoralis muscles
Sternum just below 1st rib
Sternocostal joint of 1st rib
Angle of ribs
TrP in subscapularis; restriction of ribs
Sternal end of clavicle
TrP in sternocleidomastoid
Pain at Erb’s point
TrP in scalene muscles; radicular syndromes
Transverse processes of atlas
TrP in sternocleidomastoid
Posterior margin of foramen magnum
Restriction of retroflexion at C0/C1; headache; migraine
Nuchal line
Referred pain from the short craniocervical extensors, insertion of splenii capitis muscles
Condylar process of mandible
TrP in masticatory muscles
Hyoid
TrP in digastric and mylohyoid muscles
Styloid process of radius
Lesion of the radioulnar joint
Radial (lateral) epicondyle
TrP in biceps, supinator, extensor muscles of the fingers
Ulnar (medial) epicondyle
TrP in flexor muscles of the fingers
Attachment of deltoid
TrP in deltoid; frozen shoulder
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Chapter 4
Figure 4.3 • The dermatomes. (A) Ventral aspect. (B) Dorsal aspect. (C) Lateral aspect of the trunk (after Hansen &
Schliack 1962). (D) Lateral aspect of the lower limb (after Keegan 1944). (E) The perineum (after Hansen & Schliack 1962).
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patient. The muscle contraction is then described as concentric, isometric, or eccentric. If testing is not performed isometrically, the movement against resistance can be performed isotonically (i.e. maintaining the same force) or isokinetically (i.e. at constant speed). The object of testing is to examine not only the force produced by the muscle but also the provocation of pain, and coordination. Figure 4.3 • (Continued).
and L2 by S2. These dermatome charts regularly show a ‘step’ on the trunk, approximately on the axillary line, which marks the boundary of the area supplied by the dorsal ramus and ventral ramus of the spinal nerve, and which is usually clearly observable in herpes zoster (see Figure 4.3).
4.3.6 Conclusion There are many functional and reflex changes that correspond to nociceptive stimulation of the skin, subcutaneous tissues, and muscles, at the periosteum and the points of attachment of tendons and ligaments. These changes can be diagnosed clinically and can also be registered instrumentally, by means of thermography, measurement of electrical resistance, and EMG. These present a means of precise diagnosis by straightforward methods, so enabling targeted treatment.
4.4 Mobility testing This section will deal with general principles only. The regular procedure should be to examine active and passive mobility and movement against resistance.
4.4.3 Passive mobility First and most obviously, the testing of passive movement examines joint function. Very considerable changes in joint function may be found, however, as a result of muscle tension. Findings fall into three categories: normal mobility, movement restriction, and hypermobility; this relates both to functional movement and to joint play (see Chapter 2). The following changes should be looked for during examination: • Restriction of the movement of a joint as compared with the contralateral joint or the neighboring spinal segment. • Increased resistance during movement, particularly during the examination of joint play. • Resistance to springing in the end-of-range position (i.e. at the barrier). Note whether this resistance is physiological or pathological, or whether it is found during functional movement or on testing of joint play. Figar & Krausová (1975) were able to measure the resistance to springing using a resistance transducer. This was done in a restricted cervical segment before treatment, during manipulation, and after treatment (see Figure 4.4).
4.4.1 Active mobility Active movement includes muscle activity and joint mobility in the absence of any influence on the part of the examiner. This corresponds to voluntary movement.
4.4.2 Movement against resistance The force applied by the examiner may be less than, equal to, or greater than that used by the 100
Figure 4.4 • Measurement of force during the examination
of side-bending of the cervical spine: increased resistance in the restricted segment (left); resistance during manipulation of the restricted segment (center); equal resistance after manipulation (right). The peak preceding each curve is the gauge of 400 g (after Figar & Krausová 1975).
Diagnosis of dysfunctions of the locomotor system
The spinal column It is important when examining the spinal column to discover which of two neighboring segments is restricted. The question as to which of the paired joints is restricted is less important because the determining factor is the direction in which the treatment is applied.
The lumbar spine It helps to picture the joints as positioned with the articular facets fully covering each other in retroflexion, but as being in their end position in anteflexion. If anteflexion of a spinal joint is restricted, the spine deviates to the restricted side in anteflexion. If retroflexion is restricted, then also the spine deviates to the restricted side during retroflexion (see Figure 4.5). However, the deviation to one side that is observed is frequently the result of antalgic posture in order to relieve reflex pain, for example in radicular syndromes.
The cervical and thoracic spine In the cervical and thoracic spine, it is (in theory) possible to discover on which side the restricted joint is by examining side-bending first in retroflexion and then in anteflexion. If side-bending is more restricted in retroflexion, then the joint on the side to which the patient is bending is affected; if side-bending is more restricted on the opposite side, then it is the joint on the opposite side that is restricted.
Figure 4.5 • Schematic drawing of side-bending of two lumbar vertebrae.
Chapter 4
4.5 Examination of the pelvis Examination of the pelvis is usually preceded by screening assessment of the lower limbs, in particular since problems there can be the cause of pelvic obliquity.
4.5.1 Screening examination Inspection Points to observe are: • deviation to one side • unilateral prominence • height of the buttocks • irregularities of the rhomboid of Michaelis, which is formed by the dimples above the PSISs, the spinous process of L5, and the uppermost point of the intergluteal cleft. Deviation of the upper end of the intergluteal cleft to one side is the result of asymmetrical positioning of the inferior end of the sacrum and coccyx.
Palpation Palpation begins at the iliac crest, which the examiner can find by sliding the edge of his forefinger downward from the patient’s ribs. The reason this is important is that the iliac crest is often considerably higher than might be expected from the localization of the contours of the buttocks (often it is even just below the costal arch). A spirit level can be used to confirm the horizontal position of the pelvis (see Figure 4.6).
Figure 4.6 • Comparison of the level of the iliac crests using a spirit level.
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If the pelvis deviates to one side, this creates the impression that it is higher on the side toward which it deviates. This is because the examiner can easily contact the top of the iliac crest on the side to which the pelvis deviates, whereas on the other side the superior border of the iliac crest is hidden under the costal arch and has to be searched for. Working in a medioparavertebral direction, the examiner can then locate the PSISs. The most reliable way to perform the palpation of the PSIS is from laterally and below, since this corresponds to the shape of the spines. The same approach is suited to the palpation of the anterior iliac spines. If both the anterior and posterior iliac spines are at the same level on both sides, the pelvis is horizontal in the neutral position. A point worth mentioning here is that the rise in obesity has made palpation more difficult in many cases, and this is especially true when palpating the posterior iliac spines. Deviation of the pelvis to one side can be the result of a difference in leg length; in this case the pelvis deviates to the higher side. More frequently it is the result of (usually minor) scolioses, the pelvis being horizontal. In the case of true pelvic obliquity the iliac crest and anterior and posterior iliac spines are lower on one side.
4.5.2 Pelvic obliquity Measurement of leg length is more difficult than might be thought, because the head and neck of the femur are not externally evident. Pelvic obliquity is therefore the most reliable clinical sign of difference in leg length, unless there is a measurable difference in the length of the lower leg. However, this may be compensated by the length of the thigh. Where there is a difference in leg length the pelvis is generally seen to deviate to the higher side if the patient stands with weight equally distributed on both legs. The shoulder is typically seen to be lower on the side where the pelvis is higher. The findings can be tested clinically by placing a block or heel insert under the shorter leg. When this is done the pelvis becomes horizontal and no longer deviates to one side, and the shoulders level out. However, this effect only takes place if any significant movement restrictions have already been resolved. 102
A check can be made at the same time by placing each of the patient’s feet separately onto a balance scale, and placing a heel insert under the shorter leg to equalize the length. This produces one of three possible results: 1. The difference remains the same. 2. The difference is equalized. 3. The difference increases. The patient should be asked each time whether it is more comfortable with the heel insert, or whether it feels awkward. If the patient finds at the very least that the (unaccustomed!) heel insert does not feel awkward, the effect is seen to be favorable. Equalization of length can then be recommended, unless of course the patient has one flat foot. An X-ray check (with patient standing) is recommended to confirm the difference in leg length.
4.5.3 Pelvic distortion This is a curious phenomenon which must be distinguished from pelvic obliquity. The dorsal inspection usually shows the pelvis to deviate to the right, with the appearance of being slightly rotated to the left. Palpation of the iliac crests may show their height to be symmetrical laterally, but as the examiner’s palpating fingers (the edge of the forefingers) advance medially and approach the PSISs, they do not meet: one of the iliac spines (usually the right) lies higher than the other. This can be confirmed by direct palpation of the PSIS (from below). The finding for the anterior iliac spines is the converse: here the right anterior superior iliac spine (ASIS) is usually lower than the left. The two ilia seem to be twisted relative to each other. There is always a discrepancy when the position of the ASIS, PSIS, and the iliac crests are compared. However, the difference at the anterior or posterior iliac spines, and at the iliac crests, can vary, so that it is not always easy to distinguish pelvic distortion from pelvic obliquity, especially if both changes are simultaneously present. In such cases it is advisable to begin by treating the pelvic distortion and then to repeat the process of measurement. Another feature of pelvic distortion is the overtake phenomenon. On anteflexion the PSIS that is lower (usually the left) momentarily ‘overtakes’ the right. After 10–20 seconds the finding reverts to what it was before. Cramer’s (1965) analysis of the
Diagnosis of dysfunctions of the locomotor system
Chapter 4
mechanism involved (see Figure 3.12) appears best to match our understanding of what is happening. This also leads us to expect findings such as external rotation of the leg on the side of the ilium that is tilted so as to be lower posteriorly. The aspect that now seems to us to be more significant is that of muscular dysfunctions which are associated with pelvic distortion and accompanied by asymmetrical muscle function. Pelvic distortion is always secondary, and the cause is usually located in the atlanto-occipital and atlantoaxial joints (see Chapter 2); the findings at the muscles are inconsistent.
Testing for ‘overtake’
4.5.4 Pelvic tilt
The spine sign test
A third condition can be distinguished in addition to pelvic obliquity and pelvic distortion; this is pelvic tilt. To examine for this it is necessary to palpate the anterior and posterior superior iliac spines. The line between them is normally horizontal. In patients with a drooping belly the pelvis is usually tilted forward, and in patients with tension of the gluteal and ischiocrural muscles it is tilted backward.
The ‘spine sign’ is a more successful test to use with non-adipose patients, following the method devised by Dejung (2003) (see Figure 4.7). The examiner sits behind the standing patient, placing one thumb on the posterior inferior iliac spine and the other on the spinous process of L5. The patient is then told to bend the knee and lower the hip on the side being
Testing for the overtake phenomenon, as described above in connection with pelvic distortion, is more difficult to assess in patients with a degree of adiposity. The changes observed in overtake, unlike those in pelvic distortion, are not transitory, but remain during anteflexion. Bear in mind that it is not possible to retain hold of the posterior iliac spine, since it disappears under the skin during anteflexion; it does not present the same surface in anteflexion, and of course, if the restriction is bilateral the test fails completely to reveal it.
4.5.5 Restriction of the sacroiliac joint There is still a frequent tendency to overestimate the importance of restriction of the sacroiliac joint. One reason for this is the fact that there are no muscles between the sacrum and ilium, yet despite this, restrictions here were a relatively frequent finding, and this led to the assumption that this was a ‘pure’ joint restriction, with no involvement of muscle spasm or TrPs. However, this view has proved untenable, because it is often possible to release ‘indirect’ restrictions in the case of TrPs in the biceps femoris (head of the fibula), pelvic floor, piriformis muscle, and elsewhere, after which it is usually found that restrictions of the sacroiliac joint are also resolved. Such chain reactions indicate that most restrictions of the sacroiliac joint are secondary. There is also a practical problem: diagnosis usually relies on palpation of the mobility of bony structures, which often lie under a considerable layer of fat and connective tissue. This reduces the reliability of comparative examination.
Figure 4.7 • The ‘spine sign.’
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Figure 4.9 • Springing test of the ilium against the sacrum Figure 4.8 • Springing test of the ilium against the sacrum
with the patient in the side-lying position.
with the patient supine, one leg flexed.
examined. The normal finding is that the distance between the examiner’s two thumbs increases: the thumb on the iliac spine moves caudad and laterally while the thumb on the spinous process of L5 remains still. If there is restriction, the distance does not increase and the examiner can feel the laterally directed pressure of the spinous process of L5.
Springing test with patient supine The remaining examination methods are all ‘springing’ tests. The springing test with the patient supine (see Figure 4.8) is much used. The examiner stands by the table and grasps the patient’s contralateral leg (which is bent, while the other remains extended) and adducts her leg until the pelvis begins to follow. This engages the barrier and sets up the position from which the test is performed. With the hand that is guiding the patient’s knee, the examiner exerts pressure in the longitudinal axis of the thigh in the direction of the PSIS, to take up the slack. The examiner then exerts springing pressure. The springing is palpated with the hand under the posterior iliac spine. Adduction (to the barrier) is usually measurably restricted on the affected side. This is a useful test to use as a screening examination and is simple to perform.
Springing test with patient in the side-lying position This test produces a springing response of gapping (distraction) of the joint, so that the technique is also suitable for use in therapy (see Figure 4.9). 104
The patient is side-lying with the uppermost leg bent, knee resting on the treatment table. The examiner’s caudad arm should be placed so that his forearm lies gently on the region of the ASIS and iliac crest, and is angled to point ventrally, medially, and cranially. Gliding pressure with a springing movement is then exerted on the ala of the ilium in the same direction. This has the effect of producing a dorsal gapping (distraction) of the sacroiliac joint. The thumb of the examiner’s other hand senses the springing motion between the PSIS and sacrum.
Springing test with patient prone The superior portion of the sacroiliac joint is examined with the patient lying prone. The practitioner takes hold of the patient’s ASIS from the ventral side by curling the fingers of one hand around it, then lifts it slightly on taking up the slack, and shakes it upward with a springing movement. The thumb of his other hand is meanwhile used to palpate the sacrum, to sense whether it moves together with the ASIS. It will only do so if the joint is restricted (see Figure 4.10). The inferior portion of the sacroiliac joint is examined by applying pressure with a springing movement to the inferior apex of the sacrum with the patient prone. Mobilization techniques, which are described in Chapter 6, can also be used for examination.
Test technique according to Rosina The ‘traditional’ tests described so far all involve some degree of unreliability in view of the great number of obese patients. Lewit & Rosina (1999)
Diagnosis of dysfunctions of the locomotor system
Figure 4.10 • Springing test with the patient prone, to examine the superior part of the sacroiliac joint.
has developed a technique that is also reliable when examining such patients. Lewit & Rosina (1999) observed that, when the subject’s head is turned, the ASIS is displaced caudally on the side toward which the head turns. Following this observation we found that the opposite happens at the posterior iliac spines; in other words, that pelvic distortion occurs. On the side to which the head turns, the posterior border of the iliac crest also rises at the same time as the posterior iliac spine. For this test the patient is standing. The examiner places the edges of the forefingers of both hands on the iliac crests, approaching them from the lateral aspect of the iliac crests in a medial direction just above the PSIS. The patient is then asked to rotate her head to the side. After a few seconds’ latency, in a normal subject the examiner finds that the forefinger rises on the
Chapter 4
side to which the head is turned. Only very slight pressure from above is required in this test. The layer of fat on the iliac crest does not influence the result (Lewit & Rosina 1999). The effect is absent if there is restriction of the sacroiliac joint. The mechanism involved in this test is unknown. Although the difference in height of the two iliac crests is very noticeable, no difference in their position can be demonstrated radiologically. The effect must therefore be due to a shifting of soft tissues, producing a palpatory illusion (see Figure 4.11). On anteflexion with head turned, it is even possible to observe a transitory overtake phenomenon on the side that lies lower. There is no movement if the sacroiliac joint is restricted. (No explanation for this has been found.)
Pain points There may be pain points at the upper margin of the sacroiliac joint, at the lower end of the joint, and also, more rarely, in the iliacus muscle, at the attachment point of the adductors at the symphysis (slightly positive Patrick’s sign) and above the posterior iliac spine, although these findings need not be present.
The position of the pelvis is usually normal in cases of restriction of the sacroiliac joint. The relevant factor is simply the movement restriction, the sign of which is the poor springing of the joint.
Figure 4.11 • Palpatory illusion. (A) The ischia and ischial tuberosities are seen to be symmetrical, but to palpation
they seem extremely asymmetrical. (B) The bones of the pelvis are unchanged; what has changed is the position of the examiner’s thumbs.
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4.5.6 Shear dysfunction (Greenman) (upslip and downslip) When there is tenderness at the superior border of the pubic symphysis and tenderness to pressure at the ischial tuberosities, the usual finding on palpation is that the medial end of the pubic bone is higher on the side that is painful, and that the ischial tuberosity is lower on the side where the gluteus maximus is tense. Clinically we have found these to be signs of a syndrome associated with tension (TrPs) of the rectus abdominis muscles, forwarddrawn posture, tension of the erector spinae and neck extensors, gluteal muscles, and biceps femoris. The sacroiliac joints do not themselves play any significant role in our experience. Curiously, the position of the symphysis and ischial tuberosities appears to be symmetrical when the patient is standing. Still more remarkably, after treatment the palpatory finding had normalized but the X-ray showed no evidence of change even though palpation had found changes of up to 2 cm at the ischial tuberosities. To try to find an explanation for this, X-rays were taken showing the examiner’s thumbs as they palpated before and after treatment. The result was clear: what had changed was not the position of the bones, but that of the examiner’s palpating thumbs (see Figure 4.11). In this way we were able to obtain evidence to document a ‘palpatory illusion.’ It must be remembered that bones are often overlain by a layer of soft tissues, including muscles, and this may sometimes be considerable. If painful disorders produce a change in tension in these tissues, that must exert an effect on the position of the fingers palpating the site. In the particular case described here, this would be taking place at the attachment of the rectus abdominis on the pubic symphysis and that of the biceps femoris at the ischial tuberosity. The general principle to be drawn is that if there is asymmetry of tension in the soft tissues, a deviation in the position of the underlying bone (e.g. spinous processes) can generally be palpated; these are then found to be ‘repositioned’ once tension has been balanced. The same effect can be observed if cotton wool or foam rubber of varying thickness is wrapped around the corners of a matchbox and the object is then palpated with eyes closed: the shape of the matchbox is felt to be distorted. 106
4.5.7 Outflare and inflare Greenman and Tait (1986) described an apparently isolated change in the position of the ASISs, which caused a distortion of the triangle formed by these iliac spines and the navel (see Figure 7.3). Our experience shows this change to be clinically important, and it is discussed in more detail in Chapter 7 (see Section 7.1.8). One iliac spine (usually the right) is usually found to be flatter and its distance from the navel to be greater (‘outflare’) than the other (usually the left), which is more prominent and closer to the navel (‘inflare’). At the same time, palpation shows tonus in the lower part of the abdomen on the flattened side to be (relatively) decreased, as compared with the other side. In this case the finding is certainly not a palpatory illusion, because the tissue layer over the anterior iliac spine is very thin, and the asymmetrical positioning is clearly visible in slim patients. In adipose patients it is necessary to palpate it, since otherwise a clinically important lesion would be missed; one that is easy to treat. The clinical significance (i.e. the effect of treatment) was for a long time a mystery, but we have recently been able to establish (Lewit & Olšanská, 2005) that this change is always associated with an asymmetrical internal rotation of the hip joint. This rotation is restricted on the side of the inflare and instantly becomes normal following treatment.
4.5.8 The pelvic floor and coccygeus muscle Examination of the pelvis also includes palpation of the pelvic floor, the coccygeus muscle. In 1989, Silverstolpe described a syndrome which he called ‘pelvic dysfunction.’ He performed the examination by exerting pressure next to the coccyx, in the direction of the sacrotuberous ligament, and this had the effect of provoking intense pain. The types of pain reported by the patients usually varied considerably and included visceral pain. In these patients he found extremely painful TrPs in the region of the thoracolumbar erector spinae muscles, and snapping palpation of the prone patient produced dorsiflexion of the lumbar spine and pelvis. By maintaining the (painful) pressure in the direction of the sacrotuberous ligament he was able to resolve most of the symptoms these patients were experiencing (see Figure 4.12).
Diagnosis of dysfunctions of the locomotor system
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misleading; only pain experienced at the tip of the coccyx is diagnostically useful. Patients often report pain at the coccyx when what they are experiencing is in fact referred pain from other pelvic structures, in which case pain points will also be found laterally (pelvic floor, lower sacroiliac joint, etc.). In addition, a HAZ is often found in the sacral region, resembling a cushion of fat. There are often concomitant findings in the straight-leg raising test and Patrick’s test and a TrP in the iliacus muscle. In the history, the patient may report pain on sitting.
4.5.10 Ligament pain Figure 4.12 • Palpation of the coccygeus muscle from a
paracoccygeal position in the direction of the sacrotuberous ligament.
If this palpation provokes pain, the examiner will sense distinct resistance; if the pressure is maintained, the resistance resolves. What this palpation has found is a TrP in the coccygeus muscle, the pelvic floor. The great significance of this finding is that the pelvic floor forms part of the deep stabilization system which gives rise to effects in the form of chain reactions in the entire locomotor system. This explains the importance of finding this TrP.
A condition known as ‘ligament pain’ (Barbor 1964, Hackett 1956) tends to be found where there is sustained static load; this may be associated with sacroiliac restriction, especially if there is hypermobility. It particularly involves the iliolumbar and the sacroiliac ligaments. The key to diagnosis is the ability to provoke pain, and the following technique is used. The patient lies supine on the table with one leg bent at the hip and knee. The examiner should stand beside the table. He grasps the patient’s bent leg at the knee and adducts the thigh, at the same time exerting pressure along the axis of the thigh to take up the slack (see Figure 4.13).
4.5.9 The painful coccyx A coccyx that is tender to pressure should never be ignored, because it is a considerably more frequent contributory cause of low-back pain than coccygodynia. Palpation of the coccyx should therefore be carried out when diagnosing low-back pain. Palpation of a painful coccyx can be more difficult than might be expected. The problem here is one of myotendinosis (insertion tendopathy) resulting from tension of the gluteus maximus and a TrP in the levator ani, which can be palpated quite easily via the rectum. A tender coccyx is always ventrally curved. The pain point is typically on the ventral surface of the tip of the coccyx, so it is necessary to feel around for the ventrally curved coccyx, which produces resistance from the tense gluteus maximus. Mere touch is enough to provoke pain. Any strong pressure here is always painful and therefore
Figure 4.13 • Testing of ligament pain.
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At about 90° of hip flexion, the maintenance of adduction tests primarily the iliolumbar ligament, and the patient will feel pain in the groin. At a hip flexion of 60–70° it is mainly the sacroiliac ligaments that are tested. This time, as the examiner maintains the adduction, the pain radiates down the leg in the S1 segment. It is important to ensure before testing the ligaments that there is no sacroiliac joint or lumbosacral restriction. The localization of the provoked pain is the main criterion for diagnosis. Closer examination will show that in these patients adduction is restricted on the painful side. It is easy to measure this by looking at the distance between the adducted knee and the table. This degree of increased resistance cannot be due to ligaments alone. The fact that it is often resolved using post-isometric relaxation (PIR) suggests a muscular cause. The authors quoted above treat ligament pain with injections of hypertonic solutions at the attachments of the ligaments, and we have also treated this type of pain by means of straightforward needling. This we follow with PIR and reciprocal inhibition (RI), both of which are suitable methods for use in self-treatment.
If movement restriction is found on testing of the iliolumbar or sacroiliac ligaments, this is due to muscle tension, which can be treated by PIR and RI.
4.6 Examination of the lumbar spine 4.6.1 Screening examination of active movement Retroflexion Examination of the lumbar spine can properly be said to have begun with that of the pelvis. The examination starts with the patient standing, ideally in retroflexion, and the examiner should not only assess the overall range of motion but also observe whether the movement extends into the lumbosacral segment. In normal cases this is easily seen, because dorsiflexion is greatest in the lumbosacral segment, while the excursion in other directions of movement is greatest in the L4/L5 segment. The examiner can 108
not only identify movement restriction, but also local hypermobility, which is seen as a sharp lordotic bend on retroflexion, often in the inferior-most part of the lumbar spine or at the thoracolumbar junction. If retroflexion is painful and inhibited without actual restriction, this may be a sign of TrPs in the rectus abdominis muscle with tenderness to pressure at the pubic symphysis, or pain at the spinous processes.
Side-bending When examining side-bending, the examiner needs to ensure that the patient’s movement does not deviate in the forward or backward direction. He should then compare on both sides how far down the leg the patient’s arm extends when side-bending with arms and fingers extended. (Do the fingertips reach as far as a point above, or – more frequently – beyond the knee?) As the patient bends, the examiner notes whether the spinal column arches over in an even curve, or with a sharp bend at some point, or whether it remains stiff. A further aspect to look for is rotation synkinesis, in which the pelvis rotates in the opposite direction to the side-bending as soon as the side-bending movement reaches the thoracolumbar junction. This movement is evidently determined by the rotation of the lumbar spine during side-bending.
Anteflexion When examining anteflexion with the knees held straight, the examiner should test how close to the floor the patient’s fingertips reach with knees fully extended, and at the same time note the arch of the lumbar spine and the position of the pelvis; it is important to distinguish whether anteflexion happens mainly at the pelvis with minimal lumbar kyphosis, or whether the main action is flexion of the lumbar spine with shortened ischiocrural muscles. Certain kinds of flattening of the bend during anteflexion are common and can be normal variations. These occur at the thoracolumbar junction and at the lumbosacral junction. The examiner compares the prominence of the transverse processes as well as that of the erector spinae muscles that are stretched over them. This provides a sign of rotation as found in scoliosis, or possible deviation to one side such as happens in radicular syndromes. When measuring the distance between the reach of the fingertips and the floor it is important to note
Diagnosis of dysfunctions of the locomotor system
not only an increased fingertip–floor distance but also a negative measurement. If the patient is able to place the flat of her hand on the floor, this is a sign of hypermobility. The patient’s body proportions should be noted, looking at the length of the trunk, legs, and arms. Anteflexion can be painful, even when there is no restriction. One reason is the ‘painful arc’ described by Cyriax (1978): during anteflexion, often shortly after beginning to bend forward, the patient feels considerable pain. An evasive movement of the spinal column can often be seen, as if the patient is working around some obstacle, after which the action continues quite normally. On straightening again the pain reappears and there is an evasive reaction at the same point. This sign indicates disk herniation. It is also possible for the patient to carry out the anteflexion movement normally but experience the pain on straightening. This indicates joint restriction in retroflexion. If the fingertip–floor distance is increased, movement restriction of the lumbar spine is not the only possible cause, since this finding may also be linked to a positive straight-leg raising test. Therefore, if an increased fingertip–floor distance is found, the examiner should also test anteflexion in the sitting position with knees bent. If anteflexion is also restricted in sitting, and mobility of the hip joints is normal, this localizes the disturbance to the lumbar spine. Before testing the mobility of the individual motion segments of the lumbar spine it is advisable to examine muscles with TrPs that are characteristic for disturbances in particular motion segments (see Table 4.1).
Chapter 4
disks), so that it is important to avoid testing the spinous processes at the same time. The thenar and hypothenar eminences of one hand are placed on the transverse processes, ‘bridging’ over the spinous process. The examiner exerts very slight pressure with the extended arm to take up the slack, followed by ‘springing’ pressure (see Figure 4.14). Another method is to place the tips of the second and third fingers of one hand on the transverse processes from the caudal direction, then using the ulnar (medial) edge of the other hand to take up the contact, then taking up the slack and applying the springing pressure (see Figure 4.15). The springing test is not totally specific to a particular segment. If there is joint restriction, increased resistance (an absence of springing) is felt after the slack has been taken up, and the patient may also experience pain. However, if the patient feels pain when springing of the segment is normal, this is a sign of disk pain.
If the springing test produces pain in the lumbar spine and joint restriction is either absent or has been resolved, this indicates a disk lesion.
4.6.2 Examination of individual motion segments Palpation The examination can begin with palpation. The fingertips are used to provoke pain at the spinous processes. Although the spinous process lies in the midline, careful palpation will show that it is only truly tender to pressure on one side.
Springing test Following palpation, the springing test is applied. This examines resistance and also provokes pain in the deeper-lying structures (mainly the joints and
Figure 4.14 • Springing test, using the thenar and hypothenar eminences and with the arm extended.
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Figure 4.15 • Springing test, using the tips of the second and third fingers. (A) Position of the fingertips. (B) Position of the
fingertips, illustrated using a skeleton (schematic drawing). (C) The arm applying the springing pressure exerts this using the medial (ulnar) edge of the hand placed on top of the fingertips.
Palpation of mobility Carefully directed palpation of mobility serves to localize a hypomobile or hypermobile motion segment more precisely.
In a normal case this is sensed as a slight dorsal shifting of the lower of the two vertebrae against the upper one that is fixed. This movement is not felt if there is restriction, as long as the
Retroflexion Restricted retroflexion can be localized as follows to the segment affected: the patient is in the sidelying position on the treatment table, with hips and knees flexed at an angle of about 100°. The examiner stands facing the patient, and begins by fixing the upper vertebra of the segment to be examined. This is done by placing one finger of each hand, one on top of the other, on the spinous process. Using his thighs he should then exert pressure against the patient’s bent knees in the dorsal direction, toward the fingers that are holding the vertebra fixed (see Figure 4.16). Having taken up the slack, he applies springing pressure to the knees, taking up the impulse at his fingers. 110
Figure 4.16 • Examining retroflexion of individual lumbar segments by means of springing pressure.
Diagnosis of dysfunctions of the locomotor system
Chapter 4
Figure 4.18 • Examining anteflexion of individual lumbar segments by means of palpation.
Figure 4.17 • Examining retroflexion of individual lumbar segments by means of palpation.
examination is not being done forcefully. It has been shown radiologically that this is in fact a slight, localized dorsiflexion, not a shift. It is extremely important when carrying out this technique that the application of very slight pressure to the patient’s knees to take up the slack by the fingers should be done in absolute synchrony. The examiner can achieve this by straightening his trunk, which forces his thighs forward to deliver the push to the patient’s knees at the same time as bringing his arms backward. This technique is one of the very few that can localize the restriction to one single segment. In 35 patients examined at random independently by two examiners familiar with that technique there was full agreement in 30 cases and only 5 disagreements (see Figure 4.16). Retroflexion can also be examined with the patient in the side-lying position. The examiner should grasp the patient’s lower legs above the ankles and push them away from the neutral position in a dorsal direction, so flexing the lumbar spine dorsally. The fingers of the other hand palpate between the spinous processes as these approach one another. Resistance is felt if there is restriction (see Figure 4.17). It is important for the success of this technique to keep the patient’s ankles on the treatment table, and not to lift them, when exerting the push in the dorsal direction.
Anteflexion Anteflexion of the lumbar spine is examined with the patient in the side-lying position, with knees
flexed to the abdomen and positioned so to lie close to the edge of the treatment table. The examiner stands facing the patient and fixes her thoracic region by placing one elbow on it from above. With his thighs, he exerts a push against the patient’s knees so as to produce kyphosis of the lumbar spine and take up the slack. With the other hand, which is resting on the patient’s buttocks, he now applies a springing pressure designed to create further kyphosis. At the same time, the fingers of the hand fixing the upper thoracic spine palpate the mobility, sensing the separation of the spinous processes of two neighboring vertebrae, or sensing the resistance if there is restriction (see Figure 4.18). It is important for the practical success of this technique to ensure that the hand fixing the spinal column from above is used to take up the pressure delivered by the examiner’s other hand and thighs. If the patient is very tall and the examiner small, this will make it impossible to reach the spinous processes of the lower lumbar spine with the same hand while it continues to fix the patient’s shoulder region. In that case it will be necessary to use the fingers of the hand on the patient’s buttocks both to palpate and to deliver the pressure.
Side-bending The patient adopts the side-lying position for this examination. Her underneath leg should be bent at right angles both at the hip and at the knee, so that her lower legs lie parallel to the line of her trunk, knees protruding slightly over the edge of the table. The examiner stands facing the patient, and grasps the underneath leg just above the ankle. 111
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underneath leg, like a lever operating from a point of support resting against his thigh, using this to side-bend the lumbar spine (see Figure 4.19). The thumb of the other hand, which is on the spinous process of the upper vertebra in the segment being examined, is used to palpate movement (or resistance).
4.7 Examination of the thoracic spine 4.7.1 Screening examination of active movement
Figure 4.19 • Examining side-bending of the lumbar spine by means of palpation.
As he does so, her other leg becomes more flexed, so that her foot is now behind the thigh of the underneath leg. With the thumb of the other hand, the examiner fixes the upper vertebra of the segment being examined, from above. The examiner should now raise the lower part of the patient’s
Examination begins with active movement. The patient should sit astride the end of the treatment table and bend backwards and then forwards, easing out the body as she does so; she should then bend to each side, and rotate to each side with a slightly kyphotic posture. This enables the examiner to note the angle between her shoulder girdle and the table, and to see clearly any irregularities in the line of the spinous processes. A springing test is performed using the same technique as that described for the lumbar spine, with the patient lying prone (see Figures 4.14 and 4.15). The spinous processes are palpated; this is best done with the patient seated in a kyphotic position (see Figure 4.20).
Figure 4.20 • (A) Palpation of the spinous processes, patient sitting in a kyphotic posture. (B) Schematic drawing using a skeleton.
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Chapter 4
Mobility of the individual segments can be observed from the side with the patient prone, by means of deep inhalation and exhalation as described by Tesarová (1969). It is helpful if the patient is asked to inhale first into the abdomen and then into the chest. This enables the examiner to observe the rise and fall of the back and also the fan-like movement of the spinous processes as they expand and separate during inhalation and draw together during exhalation. If this movement is absent anywhere, this indicates joint restriction. This test cannot be applied in a case of pronounced clavicular breathing (in which the thorax is lifted during inhalation), because the chest wall is not being expanded.
4.7.2 Palpation of mobility For the specific palpation of mobility the examiner should stand to one side behind the patient. The patient sits on the table with arms clasped behind the back of her neck.
Figure 4.21 • Examining retroflexion of individual segments of the thoracic spine by means of palpation.
Retroflexion The patient’s elbows should be angled forward, and the examiner grasps them from below with one hand. With his other hand he should palpate with one finger between two spinous processes (see Figure 4.21). Then he should bring the patient’s thorax into retroflexion until the barrier is engaged, following this with a springing pressure. In those locations where the spinous processes do not move toward each other, the examiner will simultaneously sense resistance if there is joint restriction. It is important in this technique to guide the patient’s trunk in such a way that the apex of the retroflexion occurs at the position of his palpating hand. This can be done if the patient is made to lean against the examiner’s body and the two move in concert.
4.7.3 Anteflexion Figure 4.22 • Examining anteflexion of individual segments
To examine anteflexion, practitioner and patient adopt the same position as for retroflexion; this time, however, the practitioner grasps the patient’s elbows from above. He should anteflex the patient’s trunk in kyphosis to take up the slack, and apply a springing pressure (see Figure 4.22), palpating
of the thoracic spine by means of palpation.
between the spinous processes with the fingers of the other hand to sense the increase in tension during the springing pressure. No springing is felt if joint restriction is present. The hand which 113
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anteflexes the patient’s trunk also feels increased resistance, which makes the diagnosis easier. Again, in this examination it is important to move the patient’s trunk in such a way that the point of maximum kyphosis is the site of palpation by the examiner’s other hand.
4.7.4 Side-bending To examine side-bending the practitioner stands behind the patient, who is sitting. The practitioner should place one hand dorsally around the patient’s ribs at the level of the segment being examined, the thumb palpating between the spinous processes of the segment from laterally. He places his other hand at approximately shoulder height (according to the level of the segment being examined) on the other side, side-bending the patient’s upper body to engage the barrier (see Figure 4.23). With his palpating hand the practitioner stabilizes the patient’s thorax while the thumb palpates the resistance to the springing pressure delivered by his other hand. Resistance is greater if there is joint restriction. For this technique it is important for the fingers on the ribs to create a fulcrum as they support the patient’s trunk. At this point it seems as if the thumb will not be able to reach the spinous processes, but during the side-bending the thoracic spine rotates, which brings the spinous processes into contact with the palpating thumb.
Figure 4.24 • Palpation of the thoracic spine in sidebending with the patient sitting, in broad-shouldered patients.
If the patient has a very broad back (and the examiner has a very small hand), the following technique is more appropriate: the examiner should stand at the patient’s side, grasp her farther elbow, which is raised, and draw that elbow toward him. He uses the thumb of the other hand, from a lateral direction, to fix the spinous process of the lower vertebra in the segment being examined (see Figure 4.24).
4.7.5 Rotation
Figure 4.23 • Examining side-bending of individual
segments of the thoracic spine by means of palpation.
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For this examination the patient should sit astride the end of the treatment table, with her back toward the examiner, and actively turn her trunk from one side to the other. The examiner compares the extent of rotation and notes any asymmetry. On palpation (sometimes even on inspection) with the patient in slight kyphosis it is often found that the spinous processes in the region of the thoracolumbar junction do not move evenly to each side. In the past this was interpreted as a sign of restriction; however, this was disproved by Singer &
Diagnosis of dysfunctions of the locomotor system
Giles (1990) in a computerized tomography (CT) study during rotation. Further, clinically it was then found that the rotation restriction to one side is muscular in origin; it is produced by TrPs in the thoracolumbar erector spinae, psoas major, and quadratus lumborum muscles, especially those on the contralateral side to the rotation restriction. The treatment we give to our patients, therefore, consists almost entirely in relaxation of these contralateral muscles. Because of the way that these muscles are linked, to relax just one of them is enough to normalize rotation (see Chapter 6).
4.8 Examination of the ribs 4.8.1 Screening examination The examination continues with the thorax, including the ribs. Just as the spinous processes are palpated for tenderness when examining the thoracic spine, so it is the angle of the rib that is palpated when examining the ribs for pain points (Tilscher & Oblak 1974). The angle of the ribs is the most prominent part dorsally, situated laterally to the erector spinae muscles. It is accessed by abducting the scapula, which can be done by pressing the patient’s elbow against the thoracic cage on the same side. Pain points at the angle of the rib must be differentiated from a frequently-found TrP in the middle part of the trapezius, which tenses like a tendon medially to its attachment to the scapula when this is fully adducted, and is also tender to pressure. There is a pain point at the sternocostal joint that generally corresponds to pain points at the angle of the rib. (This is the point of attachment of the pectoralis minor muscle.) The respiratory excursion of the ribs is examined by comparing rib movement on both sides during inhalation and exhalation, with the patient lying down. This movement should be assessed visually and by palpation of the area between the ribs. The patient should be asked to inhale and exhale deeply. When the excursion of the ribs is at its maximum it is easiest to assess whether the inhalation (or exhalation) stops sooner on the affected side than on the healthy side. When the patient is supine, an overtake phenomenon is often observed in the region of the upper ribs. One rib is found to be slightly lower than its opposite number; during inhalation, the
Chapter 4
rib that had been lower ‘overtakes’ the other. This indicates joint restriction on the side that was ‘overtaken.’ The most useful method of examining the upper and middle ribs is the palpation of resistance during retroflexion as described by Kubis (1970). The patient is sitting. For this examination she should adopt the same position as was used to examine retroflexion of the thoracic spine, except that this time she should raise only the elbow on the side of the rib to be examined. This she raises to the maximum, placing her hand on the back of her head. The examiner stands on the other side, grasps the elbow from in front, and uses it to bend the patient’s trunk backwards. The pads of the fingers of his other hand take up contact with the angle of the rib under examination and offer resistance (see Figure 4.25). The examiner applies pressure in a dorsal direction to the raised elbow, toward the fingertips of the other hand, to take up the slack, followed by
Figure 4.25 • Palpation of resistance at the upper ribs during retroflexion, by the method according to Kubis (1970).
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springing pressure to test whether the springing of the joint at the end of range is normal. It is important to support the patient’s body, and to guide the elbow in such a way that movement occurs only in the sagittal plane and that there is no rotation of the patient’s trunk. When examining in the region of ribs 2–5 it is necessary to palpate through the shoulder blade, but this does not affect the quality of the palpation. Putting pressure on the lower arch of the thorax (mainly the 10th rib) between two fingers from inside and outside is diagnostic for a ‘slipping rib’.
Palpation of mobility is carried out by the following method. The patient is sitting. The examiner begins by drawing the patient toward him and placing the lateral edge of one forefinger on her clavicle, laterally to the neck, to create a fulcrum. The patient’s neck is rotated contralaterally and then inclined forward until resistance is felt (see Figure 4.26). If there is restriction of the first rib, this diagonal anteflexion will be markedly restricted as compared with the normal side. There is a close link between restrictions of the first rib and dysfunctions of the cervicothoracic junction.
4.8.2 Examination of the first rib
4.9 Examination of the cervical spine
The first rib occupies a special position, and dysfunction causes pain at the upper border of the shoulder and just below the clavicle, toward the sternal manubrium, where the first rib articulates with the sternum. Restriction of the first rib is common. The simplest method of testing for this is to apply springing pressure from above, which is done as follows: the examiner should stand behind the patient, place the radial (lateral) edge of one forefinger on the first rib from above and apply slight pressure to take up the slack. This is followed by springing pressure, and the examiner can then sense whether there is any springing at the first rib.
Figure 4.26 • Examination of restriction of the first rib.
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4.9.1 Screening examination This begins with inspection, concentrating in particular on head posture and symmetry, followed by palpation of the soft tissues and TrPs. The assessment of active movement looks at anteflexion, retroflexion, side-bending (inclining the ear toward the shoulder), and rotation to both sides. Examination against (isometric) resistance is also important in order to diagnose any muscular lesion, especially following an accident. Palpation is done with the patient supine, her head beyond the end of the treatment table, slightly raised and supported against the examiner’s thighs (see Figure 4.27). In this position all the muscles are relaxed and the examiner can palpate not only
Figure 4.27 • Palpation of the structures of the cervical spine, patient supine with the head raised.
Diagnosis of dysfunctions of the locomotor system
the spinous processes but also the transverse and articular processes. The supine position with head raised is necessary in order to palpate the short craniocervical extensors, posterior arch of the atlas, and posterior border of the foramen magnum, where important pain points are found. The pain points at the nuchal line are secondary. In order to palpate the site of important pain points on the lateral aspect of the spinous process of C2, the examiner should incline the patient’s head to the opposite side. As he does so, it rotates toward his fingers, which he uses to palpate from a lateral position. The patient can be either sitting or lying down. Palpation of the transverse process of the atlas is better carried out with the patient sitting, palpating from laterally and below, between the mastoid processes and the ascending ramus of the mandible. This transverse process is more prominent laterally than those of the other cervical vertebrae. Following this, the examiner should palpate TrPs in the two sternocleidomastoid muscles, between his thumb and forefinger. Accurate localization of the spinous process of C7 can sometimes be important for precise orientation, since the examiner has to ensure that the process found is that of C7 which is not always the vertebra prominens. This is best done during retroflexion, placing a finger on each of two neighboring spinous processes at the cervicothoracic junction. During retroflexion the spinous process of C6 moves deeper, while that of C7 remains in the same place.
4.9.2 Examination of passive mobility The assessment of passive mobility begins with a screening examination of the whole of the cervical spine. The patient is sitting and the examiner must fix (immobilize) the cervicothoracic junction so that any resistance, or indeed tenderness, can be detected.
Retroflexion and anteflexion Retroflexion is examined as follows: the examiner should stand beside the patient and ease her head backward, testing springing of the cervicothoracic junction. To test passive anteflexion the examiner should guide the patient’s chin toward the chest while
Chapter 4
holding the upper thoracic spine fixed from behind, and noting the tension. The most common cause of restriction here is shortened neck muscles. If pain is felt at the start of anteflexion, this may indicate restriction of the atlanto-occipital and atlantoaxial joints; meningeal or radicular pain is typically felt during the course of anteflexion, and pain felt at the barrier, after a period of latency, is most probably ligament pain (see Section 7.6.1, Anteflexion headache, p. 332).
Side-bending In order to test side-bending, the examiner should fix the shoulder from the side toward which the side-bending is performed and ease the patient’s ear down toward her shoulder, comparing mobility in both directions.
Rotation This test is the most important for diagnosis.
Examination with patient sitting The patient should be sitting erect. The examiner fixes her shoulder from in front, on the side away from that to which the patient’s head is to be turned, using his elbow to do so. As he turns her head, the examiner should note how close it is possible to bring the chin to the shoulder on either side (see Figure 4.28A). Care must be taken to rotate the head accurately about a vertical axis. An alternative method is to perform this test with hands crossed. To turn the patient’s head to the left, the examiner applies lateral pressure with the right hand to her chin, while his left hand guides the occiput to the right. The examiner should fix the patient’s right shoulder, using his forearm from behind (see Figure 4.28B).
With the head in maximum anteflexion To test rotation in maximum anteflexion the examiner stands behind the patient, who is sitting. With one hand on the occiput he should ease her head into maximum anteflexion, while using the fingers of the other hand to fix her chin. 117
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Figure 4.28 • Examination of rotation of the entire cervical spine. (A) Shoulder fixed by the examiner’s elbow, from in front. (B) Shoulder fixed using the forearm from behind, hands crossed.
In this position, rotation takes place almost entirely between the atlas and axis. It is particularly important in this case to ensure that the rotation takes place about the longitudinal axis of the cervical spine; the cervical spine will now be almost horizontal. This can only be achieved by ensuring that the main movement is that of the occiput from one side to the other, while the chin is held fixed as described (only the minutest amount of movement should be permitted). Because the examiner sees only the patient’s occiput, he only sees the movement there, and so tends to move the chin. A warning must be given: when carrying out rotation in maximum anteflexion it is a serious mistake to exceed an angle of 45° in either direction.
With maximum forward nutation of the head To test rotation with the patient’s chin drawn to its maximum extent towards the neck (forward nutation), the examiner stands behind the patient and eases her chin toward her neck, rotating her head as far as it will go to one side and then the other and at the same time applying slight traction. According to Jirout (1979b), rotation takes place almost exclusively in the C2/C3 motion segment. Again it is important to ensure that rotation takes place about the correct axis, and this is done by moving mainly the occiput, and permitting the minimum of movement at the chin. 118
In retroflexion In retroflexion the atlanto-occipital and atlantoaxial joints are locked and the examination looks at the region below C2/C3. The farther backward the cervical spine is inclined, the more the rotation takes place in the lower and cervicothoracic sections. Here, too, care has to be taken to ensure that rotation occurs about the longitudinal axis of the cervical spine. The crossed-hand hold shown in Figure 4.28B is helpful here. One hand simultaneously moves the chin to one side and raises it. Again, the chin should move only minimally, and it is mainly the occiput that is moved. Care should be taken not to permit any lateroflexion. Having completed these investigations, which are designed essentially as a screening examination, we proceed to the examination of the individual motion segments.
4.9.3 Examination of the motion segments Side-bending This can be performed with the patient sitting or lying down. For each segment, the examiner inclines the patient’s head to the side with one hand while the other creates a fulcrum at the lower vertebra of
Diagnosis of dysfunctions of the locomotor system
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Figure 4.29 • Examination of side-bending of individual motion segments of the cervical spine with the patient supine (A) between the atlas and axis; (B) between the vertebrae from C3 to C7.
the segment under examination; the examiner uses the edge of his forefinger to do this and the cervical spine is inclined over this fulcrum. With the hand that moves the patient’s head, the examiner then applies very slight pressure to take up the slack. Springing pressure is given to test springing at the end of range (resistance) as well as range of movement. The findings are compared with the other side and with neighboring segments.
With patient supine For the examination in the supine position the patient’s head extends beyond the end of the table and is cradled in the examiner’s hand, slightly raised and rotated gently toward the contralateral side. When examining C1/C2, the cervical spine up to C2 should remain as far as possible in the neutral position, with only the head nutated to one side: to be precise, the head is rotated about an axis at the level of the root of the nose (see Figure 4.29A). For the lower segments the index which forms the fulcrum is lowered to the examined segment and the head side bent accordingly to take up the slack and to sense resistance against springing in end position (see Figure 4.29B).
With patient sitting For side-bending at the cervicothoracic junction, the patient must be sitting as erect as possible. Using the ulnar (medial) fingers of one hand in the region of the zygomatic bone, the examiner should bend the patient’s head backward and to the side, at the same time rotating it in the opposite direction to that of the side-bending. While performing this rotation, the examiner uses the thenar eminence of the other hand to contact and fix the spinous process of the upper vertebra of the pair in the segment being examined. With the thumb of the other hand, he applies springing pressure from the side to the spinous process of the lower vertebra of that segment and senses the resistance (see Figure 4.30).
With patient in the side-lying position The examination is somewhat easier to perform with the patient in the side-lying position. The examiner should stand facing the patient, with his forearm under her head, his elbow supported on the table, and his hand cradling the patient’s occiput. The examiner should now push the supporting elbow forward on the table, so that his hand automatically produces a side-bending movement 119
Manipulative Therapy
Figure 4.30 • Examination of side-bending of the cervicothoracic junction with the patient seated: (A) as seen from the rear; (B) as seen from in front.
of the patient’s head combined with rotation to the opposite side. This is done until the barrier is engaged, when he applies springing pressure in the same direction. The thumb of his other hand meanwhile fixes the spinous process of the lower vertebra of the pair (see Figure 4.31).
Figure 4.31 • Examination of side-bending of the
cervicothoracic junction with the patient side-lying.
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The examiner will find it easier to perform this test with his knee supported on the treatment table.
Rotation The patient is sitting, and the examiner stands behind her. He fixes the vertebral arch of the lower vertebra of the segment, from one articular process to the other, between the thumb and forefinger of one hand. With his other hand, he should rotate the patient’s head to the side (usually guiding it by the chin) until he senses resistance at the thumb or forefinger of the hand fixing the vertebral arch. He can then deliver slight springing pressure (see Figure 4.32). The examination begins by fixing the axis and establishing the range of movement between atlas and axis; it then proceeds with C2/C3, and on down to C5/C6. The range of movement increases stepwise. If there is a restriction in a segment, this step increase is absent on one or both sides. This method can be used to register the movement found, which was successfully done by Berger (1990) by means of cervicomotography (see Figure 4.33). The following points are important in order to perform this technique accurately:
Diagnosis of dysfunctions of the locomotor system
Chapter 4
Figure 4.32 • Examination of rotation of individual motion segments of the cervical spine.
Figure 4.34 • Examination of rotation of the cervicothoracic junction.
Figure 4.33 • Step diagram produced using
cervicomotography according to Berger (1990). 1, Movement restriction between C1/C2 and C2/C3 (arrows), and hypermobility between C3/C4. 2, After mobilization, restriction between C2/C3 and hypermobility between C3/ C4. 3, Normal finding after further treatment.
forehead rests in the crook of his elbow. With the little finger of the same hand, he should then span the arch of the upper vertebra of the segment being examined. The thumb of his other hand fixes the spinous process of the lower vertebra from the contralateral side (see Figure 4.34). Next the examiner should turn the patient’s head to take up the slack, and exert gentle springing pressure.
Shifting techniques • The vertebra that is fixed during the investigation
must be held exactly in the neutral position. • Only the minimum of force should be used to fix the vertebra, because as soon as the finger that is fixing (palpating) the vertebra reaches the articular process, a reflex response by the patient causes it to stop, which has the effect of determining the range of motion. Another useful place to examine rotation is at the cervicothoracic junction. The examiner stands behind the patient, who is sitting erect on a low chair. The examiner takes hold of the patient’s head between his forearm and upper arm, so that her
These techniques are used to examine joint play in the cervical spine in the ventrodorsal and laterolateral directions. The patient should be sitting erect. The examiner stands at the side and takes hold of the patient’s head between his forearm and upper arm. The little finger of the same hand spans the vertebral arch of the upper vertebra of the segment to be tested. From this point, two methods are possible: 1. The examiner shifts the patient’s head backwards until the barrier is engaged, and then applies springing pressure. In this case he 121
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Figure 4.35 • Examination of dorsal shifting (springing) in the motion segments of the cervical spine with the exception of C1/C2 but including the occiput–atlas.
should fix the lower vertebra of the segment at the vertebral arch by holding it between thumb and forefinger. 2. The examiner side-shifts the patient’s head and that part of the cervical spine down as far as the upper vertebra of the segment, holding the lower vertebra of the pair fixed using either his thumb, working toward him, or his forefinger, away from him. Each time, on engaging the barrier he applies gentle springing pressure (see Figure 4.35). This technique can be used to examine the segments from C2/C3 down to C5/C6 backward and to the side. It can also be used successfully, in the backward direction only, to test the occiput–atlas segment. In this case slight anteflexion of the head is advisable. The fixing hand grasps around the arch of the axis, but shifting is only possible between the atlas and the occipital condyles, not between the atlas and axis. From C6 to T3, the shifting technique can be used successfully in the backward direction for diagnosis. The patient is sitting erect on a low chair. The examiner takes hold of the patient’s head between his forearm and upper arm, so that her forehead rests in the crook of his elbow. With the ipsilateral hand, he applies pressure in the dorsal direction to 122
Figure 4.36 • Examination of dorsal shifting (springing) at the cervicothoracic junction.
the patient’s trapezius muscle. The lower vertebra of the segment is fixed with the finger or the thumb of the other hand (see Figure 4.36). The backward pressure applied to the shoulder muscles has the effect of delivering a dorsal push to the spinal column while fixation of the lower vertebra of the segment localizes it.
4.9.4 Testing of mobility between occiput and atlas Anteflexion The patient is supine. The examiner should place his hand, palm uppermost and completely relaxed, on the treatment table, allowing the patient’s occiput to rest in the palm. He should rest his thumb and forefinger on the superior, posterior border of the transverse process of the atlas to fix the vertebra from the cranial direction. The other hand is placed on the patient’s forehead and she is asked to look down toward the chin to engage the barrier (see Figure 4.37). In this position, springing pressure is applied. This is done using the fingers on the transverse
Diagnosis of dysfunctions of the locomotor system
Chapter 4
Figure 4.37 • Examination of anteflexion between the occiput and atlas.
processes of the atlas, as the fingers release their hold, so that the examiner can verify how effective fixation of the atlas is. At that moment, anteflexion should increase.
Side-bending The patient lies supine, head beyond the edge of the table. The examiner should take hold of the patient’s head and rotate it so as to lock the atlas/ axis segment, then very gently carry out sidebending between the occiput and atlas sufficiently to engage the barrier, and apply springing pressure (see Figure 4.38). With older patients, head rotation need not exceed 50–60°.
Figure 4.38 • Examination of passive side-bending between the occiput and atlas.
This test is carried out once with the patient’s head rotated to the right, and once to the left.
Rotation The patient is sitting erect. The examiner should stand behind the patient, place one hand on the patient’s cheek and, with this hand, rotate the
Retroflexion The patient lies supine, head well beyond the edge of the table. The examiner should take hold of the patient’s head by the chin and at the occiput, well up toward the top of the skull, then raise the head a little and rotate it so as to lock the rest of the cervical spine. In this position, the examiner should incline the head backward sufficiently to engage the barrier, and apply springing pressure (see Figure 4.39). The hand on the occiput needs to be placed high enough up the skull so that it does not obstruct retroflexion (this also applies during the mobilization).
Figure 4.39 • Examination of passive retroflexion between the occiput and atlas.
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patient’s head to one side. It is stabilized against the body of the examiner. Care should be taken to ensure that the head rotates about a vertical axis. Using the very minimum of force, the examiner should take up the slack and gently apply springing pressure, again with the absolute minimum of force. Springing is sensed with a fingertip of the other hand, placed on the transverse process of the atlas. If there is joint restriction, no springing is felt, either at the chin or at the transverse process of the atlas.
4.10 Examination of the limb joints Dysfunctions of the locomotor system affect the limbs as much as they do the spinal column, and both are so closely linked that it is always hard to decide the location of the primary or more serious disturbance. As a result, the diagnosis and treatment of these disturbances are an important part of everyday practice. Examination always begins with inspection, followed by active movement, then passive movement and movement against resistance, so as to differentiate between a disturbance of the joint and one of the muscle. Weakness in a muscle need not be the result of paresis; it may be caused by pain. When examining passive movement, a distinction has to be made between functional movement and joint play. In disturbances of functional movement, we distinguish between a situation in which movement is affected within the joint itself, and one in which it is affected by an external obstruction (such as a disturbance of the subdeltoid bursa at the shoulder joint). In this case, mobility of the joint is restricted only in the direction in which the obstruction operates; for example abduction of the shoulder if there is a disturbance in the region of the subdeltoid bursa. In the other case, all the movements of the joint are affected; not to the same degree in every direction, but nevertheless a clear proportional relationship can be observed. This has been termed a ‘capsular pattern’ by Cyriax (1977). Every joint has its own characteristic capsular pattern, and it is this pattern that determines the diagnostic significance. Movement restriction of the joint itself usually also involves restriction of joint play. Therefore this should always be examined; joint play and the 124
re-establishment of joint play are fundamental to therapy. The technique used to examine joint play is identical to that used for joint mobilization performed for the purpose of therapy; it is therefore described in Chapter 6, in connection with therapy.
4.10.1 The shoulder Active movement Active movement can be further classified into the categories of abduction, adduction, internal rotation, anteflexion, and retroflexion. The most commonly found disturbance, and also the most painful, is that of abduction. Pain is felt on movement within a circumscribed range, which can be overcome (the ‘painful arc’): the patient feels pain during abduction at a particular angle of less than 90°, but if it is possible to pass this point, abduction continues quite normally to the full extent. The cause of this lies in the fact that the head of the humerus and rotator cuff slip under the acromioclavicular ligament during abduction. This is enabled by the subdeltoid bursa. If there is a disturbance of the subdeltoid bursa or in the rotator cuff, this initially results in a transitory constraint; however, if the change is more advanced it leads to a painful, absolute, isolated barrier to abduction. This is the interpretation given by Cyriax (1977) and is the basis of ‘impingement syndrome,’ and is widely accepted. Examination of patients with this clinical picture, that is impaired abduction but normal rotation with the arms in abduction, regularly presents lack of joint play as shown in Figure 4.42. After mobilization – restoring joint play – abduction is regularly restored (see Figure 6.13). The explanation lies in the biomechanics of the glenohumeral joint as given by Latarjet (Testut 1928). On page 592 we read: ‘If the distal part of the humerus is lifted, its proximal part or its head slips down in the fossa glenoidalis; on the other hand, if the same extremity moves upward in the glenoid cavity then the humerus which was previously raised returns to its position of rest in adduction’ (see Figure 4.42). ‘Whatever the role of tears in the rotator cuff and/or changes in the bursa subdeltoacromialis, once joint play is restored, that is the normal biomechanics of the glenohumeral joint, the patient can abduct (lift his arm) normally and without pain.’
Diagnosis of dysfunctions of the locomotor system
Chapter 4
Figure 4.40 • Provoked pain, tested by means of isometric tension, of the muscle attachments: (A) against isometric abduction, of the supraspinatus; (B) against isometric external rotation, of the infraspinatus; and (C) against isometric anteversion, of the long biceps tendon.
The most commonly found painful changes of muscle attachments in the region of the rotator cuff can be investigated by isometric contraction against resistance in the starting position. Pain produced by the tension of abduction with the arm fully adducted (see Figure 4.40A) indicates a lesion of the supraspinatus. Pain produced by the tension of external rotation (see Figure 4.40B) indicates a disturbance of the infraspinatus. The long biceps tendon can be palpated directly, but if the patient reports pain when this is done, it originates from the attachments at the crest of the greater or the lesser tubercle. A more reliable method is to provoke the pain by anteversion of the supinated arm, bent at the elbow, against resistance (see Figure 4.40C). The subscapularis, the most important internal rotator muscle, has to be palpated deep inside the axilla.
Figure 4.68) or from the side at the inferior angle of the scapula.
External rotation It is important when examining external rotation to ensure that the patient’s upper arm remains adducted and the elbow flexed at 90°. External rotation is usually examined on both sides at once (see Figure 4.41).
Passive movement If passive mobility is impaired at the shoulder joint itself (the scapulohumeral or glenohumeral joint), the characteristic capsular pattern observed is, according to Sachse (1995), the following: first and most commonly, abduction is restricted, followed by external rotation and then internal rotation. The starting position is with the arm adducted and elbow ventrally directed. The shoulder blade must be fixed, either from above (see
Figure 4.41 • Examination of external rotation with the arms in adduction and elbows flexed at right angles.
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Internal rotation
The acromioclavicular joint
Internal rotation is usually also examined on both sides at once, by drawing the patient’s thumbs upward behind her back and comparing the two sides. When this examination is performed, adduction produces a degree of retroflexion.
Two more joints frequently cause shoulder pain: the acromioclavicular and the sternoclavicular. Disturbance of the former is very frequent, although its involvement is seldom recognized; however diagnosis is not difficult: adduction of the arm in front of the thorax causes the patient to feel pain and is restricted in comparison with the normal side. This is done by passively moving the elbow of the affected side toward the opposite shoulder. Direct palpation of the joint itself is also painful.
Abduction In this case there is a characteristic disturbance of joint play: with the upper arm abducted at a right angle, the examiner applies slight pressure to the head of the humerus from above to engage the barrier, followed by springing pressure (see Figure 4.42). If there is a true capsular pattern and the patient is still able to abduct her arm to approximately 90°, joint play is normal, indicating that the frozen shoulder is not due to dysfunctional joint restriction but to reactive capsulitis. If abduction alone is restricted, there is generally also a disturbance of joint play. In this case the head of the humerus cannot glide down from the narrow, upper part of the glenoid cavity as it needs to in abduction. It is important when performing this test to ensure that the pressure is applied at the correct point: on the head of the humerus, which is lateral to the apex of the deltoid (see Figure 4.42).
The sternoclavicular joint Dysfunction of the sternoclavicular joint is a much less common condition. The patient experiences pain when moving the shoulder blades and on movements involving greater excursion of the shoulders; on palpation the joint is tender to pressure. The following points should be noted, however: tenderness of the medial end of the clavicle is also found in cases of myotendinosis of the sternocleidomastoid. Also, laterally below the clavicle is the joint between the first rib and the manubrium of the sternum, and this is tender to pressure in cases of restriction of the first rib.
The expression ‘periarthritis humeroscapularis’ or ‘shoulder periarthritis’ is still much used, but is meaningless and unhelpful as a description of frozen shoulder. Specific diagnosis of the disturbance is required.
4.10.2 The elbow
Figure 4.42 • Examination of joint play in the shoulder joint
by springing pressure applied from above to the head of the humerus, with the arm abducted at 90°.
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Disturbances of the elbow joint produce restriction in flexion and extension, with flexion being more markedly affected in accordance with the capsular pattern. The joint play here is a sideways (radial or ulnar) springing of the forearm, especially of the ulna relative to the upper arm. The elbow is also the location of the radioulnar joint, and it is here that pronation and supination take place. The most frequently found clinical condition is pain at the epicondyles. There is tenderness on palpation involving application of pressure. If the
Diagnosis of dysfunctions of the locomotor system
radial epicondyle is affected, pain is produced by shaking hands or lifting a chair with the arm pronated. Lifting with the arm supinated is painful if it is the ulnar (medial) epicondyle.
4.10.3 The wrist The wrist joint is complex, consisting of the radius and ulna, the carpal bones, and their articulations with the metacarpals. In order to localize findings anatomically it is useful to know that the skin fold on the dorsal aspect of the wrist in dorsiflexion corresponds to the radiocarpal joint, and that the fold on the palmar aspect in palmarflexion corresponds to the carpometacarpal joints. The general appearance of the wrist joint (articulatio radiocarpalis) is at first sight rather like an egg that is free to move around in every plane in the shallow joint socket of the radius. Its functional movements, in combination with the midcarpal joint (articulatio mediocarpalis), are in fact limited to dorsal extension and palmar flexion and radial and ulnar abduction. Rotation is entirely possible in terms of joint play, but as regards functional movement the muscles to perform active rotation are lacking. The wrist joint and midcarpal joint each have a distinct role to play in dorsal extension and palmar flexion. Palmar flexion takes place mainly in the wrist joint, the proximal row of the carpal bones gliding in a dorsal direction relative to the radius. Dorsal extension takes place mainly in the midcarpal joint, the distal row of the carpal bones gliding in a palmar direction relative to the proximal row. In ulnar abduction, the proximal row glides radially (laterally) relative to the radius. In ulnar abduction, the proximal row glides radially (laterally) relative to the radius. Radial abduction involves the most complicated mechanism. The proximal end of the first metacarpal draws closer to the radius, and as it does so the lateral end of the scaphoid tips in the palmar direction. The trapezium and trapezoid glide in the palmar direction, rather as they do in dorsal extension. This explains why it is possible to perform radial abduction at the same time as dorsal extension, but not simultaneously with palmar flexion. In dorsal extension, ulnar abduction is prevented. A further factor affecting ulnar abduction and, still more, radial abduction, is the mobility of the
Chapter 4
ulna relative to the radius. Radial abduction is accompanied by a synkinetic pronation of the forearm when the hand is kept in the same plane. Similarly, on ulnar abduction there is a corresponding slight supination. The radius also moves proximally relative to the ulna during radial abduction, and distally during ulnar abduction. Lateral movements in the wrist are therefore dependent on the mobility of the radius relative to the ulna. This is the main cause of certain frequently occurring painful conditions, such as pain at the radial styloid process or, less frequently, at the ulnar styloid process, tenosynovitis and persistent pain following fracture of the radius.
The cause of restricted abduction of the wrist in a radial (lateral) or ulnar (medial) direction is most frequently found in the radioulnar joints, most importantly at the elbow.
The metacarpophalangeal joints are in fact ball and socket joints, which permit movement in every plane, but the absence of rotator muscles means that only flexion, extension, and laterolateral movements are actively possible. The only exception is the saddle joint between the trapezium and first metacarpal. This joint permits movement in all three planes, whereas the first metacarpophalangeal joint only permits flexion and extension. The interphalangeal joints are hinge joints, which permit only flexion and extension. Joint play in the finger joints is dealt with in Section 6.2.1.
4.10.4 The hip Although the hip is a limb joint, clinically it is part of the pelvis, borne out by the fact that frequently the first symptom in lesions of the hip joint is lowback pain. In disorders of the hip joint, the hip – and therefore also the knee – is in flexion; it is also in external rotation, which often has the effect of increasing the lumbar lordosis. This makes it possible to distinguish hip pain from acute lumbago at first glance. The distinction is still clearer in retroflexion. 127
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Figure 4.43 • Patrick’s sign (‘frog-leg’ position). Figure 4.44 • Examination of internal rotation of the hip joint with the patient supine, hip and knee flexed at 90°.
The most constant sign to be looked for is Patrick’s sign (see Figure 4.43), and it is with this that the examination proper begins. The leg to be tested is flexed at hip and knee (‘frog-leg’ position). The test is positive if abduction of that leg is restricted. The capsular pattern in dysfunction is first and most markedly restriction of internal rotation. This is tested with the patient supine, with the knee and hip flexed (see Figure 4.44) or with the patient lying prone with the hip straight (examining both sides at the same time). This is followed by an examination of extension (with the patient prone), of maximum flexion (patient supine), and finally external rotation. In addition, active abduction of the leg with the patient in the side-lying position is painful. The range of motion may be normal at first, but springing in the end position is painful. The most important pain points are at the femoral head in the groin, the greater trochanter, and the attachment of the adductors on the pes anserinus of the tibia, which the patient experiences as pain in the knee. The articular head and socket being largely congruous, the only joint play is distraction. 128
4.10.5 The knee The inspection of the knee should note: • valgus or varus alignment • genu recurvatum (back-knee) • deterioration of fine structural features as in osteoarthritis • the height of the hollows of the knees. Again, asymmetry here can cause pelvic obliquity. The knee, like the elbow, consists of two joints: it is made up of the true knee joint, between the femur and the tibia, and the joint between the tibia and fibula (the tibiofibular joint). The movements that take place at the knee joint are flexion, extension, and, when the knee is flexed, rotation. There is considerable joint play, partly because the joint surfaces are incongruous, and partly on account of the articulation with the patella. The joint play consists of gliding in the ventrodorsal direction with the knee flexed, distraction, laterolateral shifting, and springing with the knee extended; also of craniocaudal and laterolateral shifting of the patella.
Diagnosis of dysfunctions of the locomotor system
The joint pattern of the knee means that the first and most common restriction is that of flexion. This must therefore be examined first, by bringing the heel toward the buttock as far as it will go. It will be necessary to guide the patient’s heel so as to deviate slightly medially or laterally, to avoid obstruction of the approach caused by the substantial belly of the calf and ischiocrural muscles. Rotation between the upper and lower leg can also be examined when the patient’s knees are flexed. The most important pain points are at the medial collateral ligament, in the hollow of the knee, at the superior border of the patella, and at the attachment of the patellar ligament (housemaid’s knee). The tibiofibular joint participates in the rotation of the lower leg on the thigh. Passive movement can most accurately be examined by comparing the internal and external rotation of the feet with the patient prone and the knees flexed. The joint play consists of dorsomedial and ventrolateral rotation of the fibular head, and is best examined with the patient supine and with knees flexed. Restriction of the head of the fibula is clinically very significant. The fibular head is the point of insertion of the biceps femoris, and restriction of the fibular head is regularly associated with a TrP in this muscle. This disturbs the fixation of the pelvis, affecting the abdominal and gluteal muscles and so overall posture (forward-drawn posture).
4.10.6 The foot Some aspects have already been dealt with when discussing the inspection. Assessment of flat foot can be carried out most accurately and with equivalence on both sides by inserting the tip of the finger under the longitudinal arch from medially, pushing the fingertip inward, and comparing findings. The finger meets resistance sooner on the side that is flattened. If asymmetry is found, this is often the cause of pelvic obliquity. The patient should be asked to stand supported on the lateral edges of the foot; both iliac crests then become horizontally level. Besides establishing the shape of the foot, a functional diagnosis is needed. For this, the examiner must observe the arch of the foot from medially, during walking. The point that needs to be checked is whether the arch of the foot is maintained or yields during the action of walking, irrespective of the degree of arching or flatness of the foot. In
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normal locomotion the heel strikes the ground first; the foot then uncurls, mainly along its lateral border, into pronation and pushes off with the aid of the toes. If the patient concentrates on the lateral border and tries to sense this during walking, this is often enough to restore the function of the foot. The function of the toes in pushing off often suffers restriction. This insufficiency of the toe flexors is closely associated with splay foot. Véle’s test (personal communication) examines this. If the patient, standing barefoot, transfers her weight forward without going on tiptoe, this automatically (as a reflex response) produces flexion of the toes, evidently as a defensive action to prevent falling. This reflex is frequently absent, especially when there is weakness of the short flexors of the foot in the case of splay foot or S1 radicular syndrome. Therefore, in the case of splay foot, this synkinesis needs to be practiced. The patient is asked to rock rhythmically to and fro. Hallux valgus is commonly found, representing a deviation of the great toe toward the lateral side of the foot as a result of wearing constricting shoes, and involving a weakness of the abductor hallucis. This muscle also supports the longitudinal arch of the foot, so that the patient has to learn (laboriously!) how to exercise the muscle. Shoes are a factor not only in hallux valgus, but also in causing the deficient function of the toes and so also for splay foot. The best method of screening all the joints of the foot is to test rotation about its longitudinal axis. The patient is supine, the examined leg flexed with the heel resting on the table. The examiner grasps the foot with one hand at the first metatarsal head and the other at the fifth, and rotates it around the longitudinal axis, which passes through the talar head. If there is dysfunction in any of the foot joints, this rotation is impaired: either the foot deviates from the axis before the end of the rotation, or increased resistance is found if the axis of rotation is maintained. The ankle joint (articulatio talocruralis) is a hinge joint which allows only the movements of dorsiflexion and plantarflexion. As a result of its joint pattern, the prime, most common restriction of this joint is dorsiflexion. This is generally examined with the patient’s knees flexed, because, with the knee extended, a short gastrocnemius muscle hinders dorsiflexion. Joint play consists of ventrodorsal shifting of the tibia and fibula against the talus, and distraction. It is important to realize 129
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that, when there is dysfunction of this joint, this is clearly shown by the joint play, while the range of functional movement often remains normal. The joints of the foot include the subtalar (talocalcaneal) and talocalcaneonavicular joints between the talus, the calcaneus and the navicular bone, the transverse tarsal (Chopart’s) joint, and the tarsometatarsal (Lisfranc’s) joints between the tarsals and metatarsals. They enable active pronation and supination combined with eversion and inversion. Joint play in particular should be examined, and this is used for mobilization (see Section 6.2.2). Examination of the toe joints is done in the same way as that of the finger joints. Although there is no articulation between the heads of the metatarsals, in the foot their free mobility one against the other is especially important. This mobility is often disturbed in painful splay foot and in radicular syndromes. The problem is due to a soft-tissue lesion between the metatarsals.
4.11 Examination of the temporomandibular joint The temporomandibular joint forms a functional unit together with the masticatory muscles and muscles of the floor of the mouth, and it is of great importance, as can be seen from the term ‘mandibulocranial syndrome.’ In fact, the mandibulocranial syndrome can cause symptoms that are difficult to distinguish from craniocervical syndrome, including headache and even vertigo. When the main symptom is pain in the face, differential diagnosis is important to exclude trigeminal neuralgia. Pain in the region of the ear, and dysphagia, sometimes also tinnitus, are also typical symptoms. An important diagnostic indication is tenderness to pressure of the capitulum in front of the tragus, on palpation from the direction of the external auditory meatus. This may intensify on opening and closing of the mouth. TrPs in the masticatory muscles are another important sign. The functional movements of this joint are the opening and closing of the mouth, shifting the mandible from anterior to posterior and also laterally. Dysfunction causes restriction of mouth opening. It is normally possible to insert the width of three finger knuckles between the upper and lower incisors. Joint play consists of distraction and side-toside movement. 130
TrPs can be found in the temporal region in the temporalis muscle, through the cheeks or from the mouth in the masseter muscle, behind the mandibular angle in the medial pterygoid muscle and, most frequently, in the lateral pterygoid in the mouth above the wisdom teeth; this TrP is most intensely painful. Tension in the floor of the mouth, caused by TrPs in the digastric and mylohyoid muscles, is also important. These are best diagnosed by palpation of resistance at the thyroid cartilage or at the hyoid, which is more difficult to perform. The tension on one side is often so considerable that lateral deviation of the thyroid cartilage is seen toward the side of the tension, as well as distortion of the floor of the mouth. The characteristic muscular imbalance is shortening of the masticatory muscles, with weakening of the muscles that govern the opening of the mouth. The main causes are a faulty bite, ill-fitting dentures, or trauma, or they may be functional and brought about by stress and grinding of the teeth (bruxism). Functional chain reactions are frequent, especially in the craniocervical region.
4.12 Examination of disturbances of balance As has already been made clear (see Section 2.5), the spinal column plays a significant part in maintaining or disturbing balance; and it is therefore important to have straightforward methods of clinical examination to assess dysfunctions of the spinal column in cases of disturbed balance. Hautant’s test seems the most suitable for this purpose. The patient is seated comfortably in a chair which supports her back, with eyes closed and both arms stretched forward. The examiner stands facing her, with his thumbs pointing at the patient’s fingertips (see Figure 4.45). This enables him to detect whether the patient’s arms deviate (not owing to rotation of the trunk) and then assess the role played by the cervical spine. The test is repeated with different positions of the head relative to the trunk and enables the examiner to recognize ‘pathogenic’ and also relief positions, by judging whether the deviation appears, increases, or disappears. Between each test, when the patient changes the position of her head, the examiner must hold her hands in neutral position to prevent deviation due to synkinesis of the arms. When testing each head position, the examiner should wait
Diagnosis of dysfunctions of the locomotor system
Chapter 4
Figure 4.45 • Hautant’s test to assess lateral deviation of the patient’s outstretched arms.
for about 5–10 seconds to see whether deviation sets in or is spontaneously corrected. This test has great advantages: being seated with the back supported, the patient feels safe even if dizziness occurs, and any deviation that is found is not caused by nervousness, as is often the case in Romberg’s test or Unterberger’s stepping test. The second advantage is that with the patient’s back leaning against a chair, the back is fixed and only side deviation of the arms is possible. There is no swaying to and fro as in disturbance of the labyrinth. If the patient is asked to turn her head when in the sitting position, this best enables the examiner to assess the role of the cervical spine. The reaction produced is so characteristic that it is possible to speak of a ‘cervical pattern’ (see Section 7.6.2). This examination is therefore indicated whenever the patient complains of disturbances of balance and also when the test standing on two scales produces a difference of more than 4 kg. Berger (1990) has constructed a simple technique to register this deviation: the patient is sitting with eyes closed; in one outstretched hand she holds a ballpoint pen and moves it from right to left and back for about 1 cm each time on paper that is moving forward at a constant speed. In this way
Figure 4.46 • Trace registering lateral deviation using
Berger’s recording apparatus: In the sections marked ‘g’ the patient’s head is in the neutral position, in section ‘r’ it is rotated to the right and in section ‘l’ it is rotated to the left. In that bottom section, the line on the left (marked ‘3’) can be seen to deviate toward the right. After treatment, the line on the right (marked ‘4’) shows no deviation.
deviation can be registered for various head positions (see Figure 4.46). The test can be performed before and after treatment for comparison. For the test using two scales, the patient is asked to stand with legs extended and to distribute her body weight equally on both, since otherwise it is natural to place more weight on the stance leg. What is tested is therefore the patient’s ability to estimate accurately the symmetrical distribution of body weight on the legs. It is of course essential to make a distinction between the position of the head relative to the trunk and the position in space of the head and trunk together, that is to diagnose positional vertigo. To do so we must change the position of the patient’s head and trunk simultaneously (e.g. sitting up and lying down are done with the patient’s head in a neutral or rotated position; turning to one side or the other supine is done by turning the head and 131
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the rest of the body simultaneously). The positional vertigo produced in this way is true labyrinthine rotatory vertigo. Although it lasts only a few seconds, it is usually very intense, as can be seen from the patient’s reaction. The patient tends to close her eyes, so that it is not usually possible to see the nystagmus, which lasts only very briefly. To determine the role of the vertebral artery in vertigo, the patient is examined in positions assumed to restrict blood flow in the artery on the contralateral side to the rotation. De Kleyn’s test is suitable for this. The patient is supine, with her head beyond the end of the treatment table. Rotation is examined in retroflexion. The examiner needs to wait to see whether the patient begins to experience vertigo; if her eyes are open, nystagmus will be seen. This test is particularly conclusive if there is no restriction in the position being tested, and all the symptoms can therefore be attributed to the disturbance of blood flow. If concomitant restriction is found, this should be treated and the test then repeated. If the result of the test is again positive, the cause must lie with the vertebral artery. In some instances de Kleyn’s test may provoke positional vertigo. If this is observed the examiner should recognize the fact and follow either of two options, the first being to repeat the test at short intervals. In positional vertigo, adaptation soon occurs so that no vertigo is provoked. No such adaptation takes place if there is insufficiency of the vertebral artery. The other option is to maintain the test position and wait. Positional vertigo never lasts more than a few seconds, whereas the patient’s condition gets worse if there is insufficiency of the vertebral artery; this situation involves some degree of risk.
Differential diagnosis of vertigo can be considerably refined by using manual techniques.
4.13 Examination of muscle function 4.13.1 General principles One fundamental difficulty of examination is undoubtedly the lack of established definitions as to what is to be considered normal. Diagnosis has to be 132
based almost exclusively on clinical examination, since the alternative, electromyography, is so cumbersome and time-consuming that it is seldom practicable.
Clinical kinesiological examination In addition to neurological screening, the examination should include: • muscle strength (muscle tests) • shortened muscles • hypermobility • overall tonus, mobility, and elasticity of the soft tissues including the fasciae • posture, standing and sitting • sensitivity, especially in the regions of the hands and feet • simple movements • gait, including tests of walking in unaccustomed posture such as on tiptoe or on the heels, or with arms raised or hanging down. In the neurological examination the signs of special interest are those characteristic of minimal brain damage, such as marked asymmetry, especially of the face and the limbs, restlessness, clumsiness, agitation, and also minor deficits such as slight paresis, hypesthesia, and paresthesia.
Evaluation of muscle function The muscle test was originally introduced to examine paresis of individual muscles or of muscle groups in such diseases as poliomyelitis. It essentially examines muscle strength during a simple coordinated movement. This enables the strength of one specific muscle or muscle group to be assessed. Standard conditions must be maintained, so that results are comparable. Results are graded as follows: • 0: No muscle activity. • 1: Muscle twitch without motor effect. • 2: Muscle contraction enabling movement without resistance, therefore in the horizontal plane. • 3: Movement against gravity. • 4: Movement against moderate resistance. • 5: Movement against maximum resistance. Our patients are for the most part seeking treatment for painful conditions, and none of them apart from those with radicular syndromes are suffering from true paresis; consequently the values
Diagnosis of dysfunctions of the locomotor system
we find range between grades 4 and 5, and only the abdominal muscles and deep neck flexors occasionally exhibit weakening to grade 3. As a result, the degree of distinction that can be made using grades 4 and 5 is not fine enough to be useful for the assessment of our patients. Without going into details, the examiner must bear in mind the following principles when performing the muscle test: • The position of the patient must be constant. • Resistance must remain constant throughout the movement. • The direction and speed of movement should remain as constant as possible. • The movement must above all be isotonic. • Isometric resistance can also assess the degree of force in the muscle but does not assess coordination. Some modification of the muscle function test therefore are helpful for our patients, who do not suffer from paresis. The most important techniques are described below. In the sections dealing with muscular stereotypes (see Sections 2.9 and 4.15),
Chapter 4
a distinction is made in line with the work of Janda between those muscles with a tendency to weakness and laxity and those with a tendency to hyperactivity and shortening.
4.13.2 Examination of muscles with a tendency to weakness The gluteus maximus Before performing the classic muscle test we begin by examining active retroflexion (hyperextension) of the hip, with the patient prone in order to identify the patient’s accustomed stereotype (movement pattern; see Figure 4.47). Electromyography has established that, far from simply being a function of the gluteus maximus alone, retroflexion of the hip is carried out by the coordinated action of the ischiocrural muscles (knee flexors), gluteus maximus, and erector spinae. The major role is performed by the ischiocrural muscles, rather
Figure 4.47 • Examination of the gluteus maximus by palpation of the gluteus maximus, the ischiocrural, and erector
spinae muscles (A) with the lower limb extended; (B) with the knee flexed; and (C) with the lower limb in external rotation.
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than the gluteus maximus. The action begins with contraction of the ischiocrural and gluteus maximus muscles, followed by the erector spinae on the contralateral and finally the ipsilateral side. It is therefore advisable to palpate the gluteus maximus and ischiocrural muscles with one hand, and the erectores spinae of both sides with the fingers of the other. In the frequent cases of an inhibited gluteus maximus, contraction is found to be retarded, so that it is passed over and the contraction of the ischiocrural muscles is immediately followed by an exaggerated contraction of the ipsilateral erector spinae. In the most severely disturbed movement patterns muscular contraction may start at the superior part of the trapezius. The muscle test proper is performed with the patient prone, face down and knee flexed. Resistance to the extension of the hip is applied above the knee (see Figure 4.47B). If we wish to facilitate the gluteus maximus, the best approach is to examine retroflexion of the hip with the leg in external rotation (see Figure 4.47C). If the patient’s leg, in extension, is allowed to hang down beyond the edge of the treatment table so that the extension of the hip begins from that position, the examiner will see that the gluteus maximus does not contract until the leg is horizontal, whereas the ischiocrural muscles are active from
the very beginning of the movement. The same applies in upright gait. On the other hand, when the person is getting up from a chair or climbing steps, the gluteus maximus contracts immediately.
The gluteus medius The gluteus medius is examined with the patient in the side-lying position, her underneath leg flexed slightly. She should be asked to raise the uppermost leg laterally (i.e. upward from the table), completely spontaneously. The examiner should make no intervention at this stage, but instead observe whether she makes a true abduction (see Figure 4.48A), or a combined movement, involving flexing of the hip and external rotation of the leg (see Figure 4.48B). Only the first is genuine abduction, employing the true abductor muscles (gluteus medius and minimus) at the same time as contracting the tensor fasciae latae. The second reveals incoordination, in which there is substitution by the tensor fasciae latae. It is therefore advisable to palpate both the gluteus medius and the tensor fasciae latae during the examination. In incoordination there is also premature contraction of the quadratus lumborum, producing side-bending of the trunk rather than hip abduction.
Figure 4.48 • Examination of hip abduction by contraction of the gluteus medius with the patient in the side-lying position.
(A) Pure abduction correctly carried out. (B) False abduction (incoordination) by substitution by the hip flexors, particularly by the tensor fasciae latae. (C) The ‘classic’ test for the abductors.
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The classic test is performed by applying resistance against the lower third of the thigh from laterally and above, at the same time fixing the pelvis in such a way as to prevent substitution by the quadratus lumborum (see Figure 4.48C). Meanwhile, with the thumb and forefinger of the other hand, the examiner should palpate the gluteus medius and tensor fasciae latae.
The rectus abdominis The classic test is performed with the patient supine, knees flexed, and arms clasped behind the back of her neck. The examiner fixes the patient’s lower limbs and pelvis. She is then asked to sit up, beginning by lifting her head, then her thorax, ‘curling up’ in the process. For our purposes it is better if the patient sits up unaided with arms stretched forward (see Figure 4.49). This can only be done if the abdominal muscles are sufficiently strong. Very strong patients will even be able to sit up with arms clasped behind the back of the neck. Although bending the knees inhibits the hip flexors to some degree, sitting up is always the result of coordinated action together with the hip flexors. To examine the abdominal muscles alone, excluding the hip flexors, the examiner should place his hands under and behind the patient’s heels, telling her to press down onto his hands with her heels. Then she is asked to lift her head and her thorax in succession. The moment the patient starts using the hip flexors, the pressure of her heels on the examiner’s hands ceases. The stronger the abdominal muscles, the higher the patient can lift her head and trunk without relaxing the pressure of her heels.
Chapter 4
The transversus abdominis The transversus abdominis cannot be tested by means of a particular movement; the examiner simply has to observe whether the patient’s flanks are drawn inward during sitting up or rotation of the trunk. If the patient’s flanks bulge outward, this is a reliable sign of insufficiency. Another indication of insufficiency is seen when the patient’s abdomen bulges on lifting an object from a position of anteflexion.
The inferior (ascending) part of the trapezius For this muscle test the patient should be prone, face down, and with the arm on the tested side stretched forward. With one hand, the examiner grasps the outstretched arm, and with the other he should grasp the inferior angle of the scapula, telling the patient to pull her arm and shoulder down in the caudal direction (see Figure 4.50). For our purposes, the best way to diagnose incoordination is simply inspection. The patient is face down, with her arm against her body. She is then asked to draw one shoulder down in the caudal direction (i.e. in line with the muscle fibers). If the trapezius is weak, the inferior scapular angle moves medially like a hook and protrudes under the skin, as it does in winged scapula (scapula alata). This movement, which is normally forceful, can in this case be prevented easily by the thumb and forefinger of the examiner’s hand. The patient should be able to move the scapula in a caudal (and slightly medial) direction against resistance.
Figure 4.49 • Examination of the rectus abdominis (see also Figure 6.139A).
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arms rather than putting the weight on her knees, and her shoulder blades should be abducted. She can flex her elbows slightly as she does this (see Figure 4.51). She must then maintain this position while the examiner waits and observes. If the muscle is weak, then after a period of latency the medial border of the scapula lifts, leading to the appearance of slight winged scapula.
The deep flexors of the neck
Figure 4.50 • Examination of the inferior part of the trapezius.
The serratus anterior This muscle is tested with the patient on all fours. She should distribute her weight forward onto her
The patient is supine and is told to lift her head in an arching movement, drawing her chin toward the jugular fossa. The examiner fixes the patient’s chest from above with one hand while the other, on her forehead, applies resistance (see Figure 4.52). If there is weakness of the deep neck flexors, a ventral shift of the head (incoordination) is seen, due to predominance of the sternocleidomastoid muscles. There is a useful ‘quantitative’ test that can be applied: the patient is asked to raise her head as if reading (without lifting the thorax). If strength is normal, this position can be maintained for half a minute or even longer, but if the muscles are weak, the patient’s head sinks back down onto the treatment table after a few seconds. To test the sternocleidomastoid muscles, the examiner should apply resistance to the ventral lifting of the head.
4.13.3 Examination of muscles with a tendency to shortening Figure 4.51 • Examination of the serratus anterior with the patient positioned on all fours.
Evaluation of those muscles that tend to hyperactivity and shortening – the ‘predominantly
Figure 4.52 • Examination of the deep neck flexors. (A) Head raised in an arc: good muscle function. (B) Head raised vertically: insufficiency; predominance of the sternocleidomastoid muscles.
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Chapter 4
Figure 4.53 • Test for shortening of the soleus. (A) Normal muscle stretch. (B) Raising of the heel from the floor on adopting a squatting position: this indicates shortening.
postural muscles’ identified by Janda (see Table 2.1, p. 28) – is essentially a matter of observing how far a muscle can be stretched without the use of force; as this is done in the same way as if taking up the slack in PIR, only those muscles for which the techniques differ are dealt with here.
The soleus If this muscle is shortened, dorsiflexion of the ankle joint is restricted. This can be tested by asking the patient to squat down without raising her heel from the floor. If she has to lift her heels from the floor, then it is primarily the soleus that is shortened (see Figure 4.53). If, as often happens, it is only the gastrocnemius that is shortened, dorsiflexion of the ankle joint is restricted with the knee extended but not with the
knee flexed, and this can be shown quite simply by comparing dorsiflexion with the knee extended and flexed (see Figure 4.54). For this reason the mobility of the ankle joint should never be tested with the knees extended. The foot must be guided precisely at the lateral border while applying traction at the heel.
The ischiocrural muscles The ischiocrural muscles are tested in the same way as in the straight-leg raising test. The patient is supine. The leg that is not being examined should be fixed on the table from above, and the other leg flexed at the hip, with the knee extended. The ischiocrural muscles are considered shortened if the extended leg cannot be flexed at the hip to an angle of 90°. All the patient feels in this case is tension in
Figure 4.54 • Examination of muscle stretch of the gastocnemius by dorsiflexing the foot (A) with the leg extended and (B) with the knee bent. A marked difference in dorsiflexion indicates that the gastrocnemius is shortened.
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the hollow of the knee and in the thigh, but (unlike in radicular syndrome) no real pain. Shortening of these muscles is the most frequent reason why a clinically healthy subject cannot touch the floor when bending forward with the arms and legs straight. This is most clearly evident when observed from the side: on anteflexion, considerable kyphosis of the lumbar spine is seen, but ventral inclination of the pelvis is inadequate.
The hip flexors These comprise the iliopsoas, the rectus femoris, and the tensor fasciae latae. They are examined in the position for Mennell’s test. The patient is supine with the buttocks at the end of the table, and draws one knee toward her chest, close enough to flatten lumbar lordosis (see Figure 4.55). The other leg (the one to be tested) is allowed to hang down over the edge of the table. In this position
some disturbances can be identified straight away by simple inspection: if the iliopsoas is shortened, the knee of the leg being tested will be raised. If the rectus femoris is shortened, the lower leg will not hang vertically; instead there will be an obtuse angle between the lower leg and thigh. If the tensor fasciae latae is shortened, the thigh will be slightly abducted and the patella will deviate slightly outward. To evaluate the individual muscles, the examiner should reinforce fixation of the flexed knee (the one not being examined) from above with one hand. With the other hand, the examiner then: • exerts pressure from above on the knee of the leg being tested in order to assess shortening of the iliopsoas • applies pressure to the lower leg to flex the knee: the knee of the leg being tested rises prematurely, even with knee flexion greater than 90°
Figure 4.55 • Examination of the hip flexors. (A) The examiner notes whether the thigh is raised above the horizontal,
and/or whether the lower leg is extended forward, or the thigh and patella deviate to the side. (B) By pressure from above, the examiner brings out the shortening of the iliopsoas; by pressure from the side, the examiner brings out the shortening of the tensor fasciae latae. (C) Flexion of the knee produces the avoidance reaction of hip flexion if the rectus femoris is short.
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Figure 4.56 • Examining for shortness of the lumbar erector spinae muscles. (A) Drawing the forehead to the knees.
(B) The patient fixes her pelvis with her hands. Restricted anteflexion in the lumbar spine due to short spinal erectors can now be easily diagnosed.
• applies lateral pressure to the slightly abducted
knee. Premature resistance is felt and the tension can be seen in the iliotibial tract, as if in a groove on the lateral aspect of the thigh.
The lumbar erector spinae Examination for a shortened lumbar erector spinae is carried out with the patient sitting, the knees flexed and the trunk in anteflexion. The patient’s hands should rest behind her body, palms uppermost and the back of her hands flat on the treatment table (see Figure 4.56A). She is asked to draw her forehead to her knees. This cannot be done if the erector spinae muscles are shortened. However, other factors are also capable of preventing this: for example it is impossible if the patient’s trunk is long and her thighs short. Conversely, however, if the patient has a short trunk and long thighs, it is possible to perform the movement even if the muscles of the back are shortened. A modified version of the test is therefore more reliable: the patient, seated, fixes her pelvis by placing her hands on the iliac crests, and humps her spine to create lumbar kyphosis. If the lumbar part of the erector spinae is shortened, lumbar lordosis remains unaltered (see Figure 4.56B).
The quadratus lumborum Shortening of the quadratus lumborum can be identified on side-bending, but scoliosis or a difference in leg length can give a false impression of shortening of this muscle. Examination with the patient
Figure 4.57 • Examination of the quadratus lumborum.
side-lying is more accurate; the patient should raise her upper body, supported on her elbow and forearm, so as to produce side-bending of the lumbar spine. The lower part of her trunk should remain on the table (see Figure 4.57); if necessary the examiner should fix the patient’s pelvis from above to prevent her from raising her trunk too far. If the quadratus lumborum is shortened, side-bending is reduced.
The muscles of the nuchal region The technique used to test for shortening of the superior (descending) part of the trapezius, pectorales, and levator scapulae muscles is identical to that used in PIR treatment to take up the slack, and is described in the section dealing with this (see Section 6.8). 139
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of hypermobility in pathogenesis has already been described (see Section 2.10); here we shall focus on diagnosis. The guidelines in this respect have been set out by Sachse (1969), and enable the examiner to make the distinction between normal mobility, hypomobility, and hypermobility, all within the range of the normal. It is nevertheless important to bear in mind the great variability between individuals, and also between age groups. What may be considered hypermobile in an adult male may be perfectly normal in a female or a child. With this proviso in mind, it will be helpful in what follows to present the results not in the form of a continuous scale of measurements, but of three levels of mobility, A, B and C: • A: hypomobile to normal • B: slightly hypermobile • C: marked hypermobility. I also compare Sachse’s criteria with the data given by Kapandji (1974) and describe the technique.
4.14.1 The spinal column Figure 4.58 • Overload of the upper fixators of the
shoulder girdle and superiorly convex ‘Gothic’ shoulders.
On inspection, shortening of the pectoralis is shown by increased thoracic kyphosis, shortening of the superior part of the muscle is shown by forward-drawn shoulders, and hypertonus of the superior part of the trapezius is revealed by the upwardly convex ‘Gothic’ shape of the shoulders (see Figure 4.58). For rapid screening assessment, the muscles of the nuchal region are examined as follows. The patient should draw her chin to her chest (with mouth closed). If the muscles are short, the patient will be unable to do this, and a gap remains, which the examiner can measure in terms of fingers’ breadth. Short nuchal muscles are the most frequent cause of inability to bring the chin down on to the chest.
4.14 Examination of hypermobility Not only weakness and tautness, but hypermobility, too, is mainly muscular in origin. The significance 140
The overall mobility of the spinal column on the basis of X-ray examination is 145° for anteflexion, 135° for retroflexion, 75° for side-bending, and 90–95° for rotation to each side, as found by Kapandji (1974). Clinically, each of these movements is measured separately. One sign of hypermobility of the lumbar spine which is of particular clinical importance is this: hyperlordosis is seen when the patient is standing, and changes to hyperkyphosis when the patient adopts a relaxed sitting position.
The lumbar spine Retroflexion The average range of retroflexion is 35° according to Kapandji (1974). Clinical examination may show the maximum angle of retroflexion to be either lumbosacral or thoracolumbar. According to Sachse (1969) the test is carried out with the patient prone so as to exclude synkineses of the pelvis. The patient’s hands should be placed underneath her as support, flat on the table, and positioned so that her fingertips are immediately under her shoulders (see Figure 4.59A). The examiner should fix her pelvis
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Figure 4.59 • (A) Testing the range of retroflexion of the trunk. (B) Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
from above. The patient is asked to direct her gaze at the floor and to lift her upper body by the pressure of her arms, raising it as far as her lumbar spine will allow without involving any movement of the pelvis. The degree of movement can be read indirectly by looking at the internal angle of the elbow. Range A is up to 60°, range B up to 90°, and range C in excess of 90° (see Figure 4.59B).
Anteflexion The average range of anteflexion is 60° according to Kapandji (1974). When this is tested by having the patient bend to touch the floor, hip flexion is also tested, and if done with legs extended, this also tests the muscle stretch of the ischiocrural muscles (see Figure 4.60). Range A covers a finger–floor distance through to 0 cm. Greater flexibility, through to the point where the patient is able to touch the floor with her knuckles, is classed as range B. Range C covers anything beyond this. The patient is sometimes even able to place the chest against the thighs. This examination has the disadvantage that it tests not only the kyphosis of the lumbar spine but also muscle stretch of the ischiocrural muscles. The following test can focus much more specifically on anteflexion of the trunk: for this the patient is in the sitting position and is asked to bend and try to touch her knees with her forehead. In this test, range A describes anteflexion that does not go beyond a forehead–knee distance of 10 cm, range B covers anteflexion to the point where the patient
Figure 4.60 • Testing the range of anteflexion of the
trunk. Evaluation: A, hypomobile; B, slight hypermobility; C, marked hypermobility.
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can touch the knees with her forehead, and in range C the patient can put her forehead between her knees.
Side-bending The lumbar spine allows side-bending of approximately 20° to each side; in the test devised by Sachse (1969) the patient stands with legs closely together and flexes to the side. The plumb line from the fold of the contralateral axilla reaches no further than the intergluteal cleft in range A. In B it reaches beyond this point as far as the middle of the buttock of the side toward which the patient is side-bending, while in C it reaches beyond the lateral aspect of the buttock (see Figure 4.61). When testing anteflexion and side-bending the examiner must take into account the mobility of the hips and, in particular, the body proportions of the patient: there may be ‘false’ hypermobility due to a long trunk and short legs. In anteflexion this impression can also be given if the patient has long arms.
Rotation The range of lumbar rotation is given by Kapandji (1974) as 5°, which is not capable of being clinically tested.
The thoracic spine Rotation The figure given by Kapandji (1974) for trunk rotation is 35° to each side. The patient sits astride the end of the treatment table and fixes her shoulder girdle with her hands, which are clasped behind the nape of her neck. She is asked to turn to the right and left in succession, while the examiner ensures that the pelvis remains fixed. Up to 50° to each side is defined as range A, from 50–70° as range B, and beyond 70° as range C (see Figure 4.62). We now know that rotation of the trunk produces simultaneous side-bending of the spinal column in a coupled movement, in which the lumbar spine also participates (see Section 3.4.1).
Anteflexion, retroflexion, and side-bending Testing of anteflexion, retroflexion, and side-bending of the trunk also involve the thoracic spine. The examination of these movements (with the patient in the standing position) has already been described above as tests for the assessment of the lumbar spine. Kapandji (1974) gives the range of movement for the thoracic spine as 45° in anteflexion, 25° in retroflexion, and 20° to each side in side-bending. If the examiner wishes to measure anteflexion and retroflexion of the thoracic spine clinically, this
Figure 4.61 • Testing the range of side-bending of the trunk. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
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Figure 4.62 • Testing the range of trunk rotation.
Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
Diagnosis of dysfunctions of the locomotor system
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Figure 4.63 • Testing the range of rotation of the head.
Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
should be done with the patient sitting, asking her to hump her back and straighten up.
The cervical spine Rotation In the cervical spine, rotation can be measured clinically. According to Kapandji (1974), this movement is 50° to each side. When tested with the patient’s head in perfectly erect posture (see Figure 4.63), the degree of movement is assessed as range A when it is up to 70° to each side, B from 70–90°, and C when it is over 90°. When examined in this way the rotation also involves the upper thoracic spine. If the head is held slightly bent forward, this synkinesis can be eliminated.
4.14.2 The joints of the upper limb The figures used in this section are those given by Sachse (1969).
The metacarpophalangeal joints In passive dorsal extension (in which the interphalangeal joints may be bent), an average range of movement of up to 45° is assessed as A, between 45° and 60° as B, and measurements beyond this as C (see Figure 4.64).
The elbow At the elbow joint, there is often a correlation between valgus alignment and hypermobility. The
Figure 4.64 • Testing the dorsal extension of the
metacarpophalangeal joints. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
following test is based on this fact. The patient is asked to bend her elbows and place her forearms and hands firmly together in front of her. She should then extend her arms as much as she can without separating her elbows (see Figure 4.65). If the internal angle at the elbows remains less than 110°, this is assessed as range A, an angle of 110– 135° is range B, and beyond this is range C.
The shoulder For this test the patient is asked to bring the horizontally raised upper arm towards the shoulder of the opposite side. Range A mobility enables the patient to bring the elbow to the midline at most, range B from there to a point half way between the midline and the contralateral shoulder, and range C beyond this. In extreme cases the elbow may even reach the contralateral shoulder (see Figure 4.66). Another test examines the patient’s ability to make both hands meet diagonally behind the back. The test is performed on both sides, and relates to the side of the hand approaching from below. The result is recorded as range A if the fingers do not touch or if the fingertips just come into contact, as range B if the patient’s fingers overlap, and as C if the fingers can be placed in the palm (see Figure 4.67). There must be no hyperlordosis of the spinal column. The best way to test the mobility of the glenohumeral joint specifically is by means of passive abduction. If the examiner fixes the shoulder blade 143
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Figure 4.65 • Testing elbow extension, forearms aligned and touching. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
precisely in position from above, abduction of 90° is assessed as range A, from 90° to 110° as range B, and beyond this as range C (see Figure 4.68).
4.14.3 The joints of the lower limb The knee
Figure 4.66 • Bringing the elbow towards the contralateral shoulder. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
The knee joint is best tested by means of hyperextension. This is assessed as range A when the limit of this extension movement is at 0°. Hyperextension of up to 10° is range B, and extension beyond this is assessed as range C (see Figure 4.69).
Figure 4.67 • Making both hands meet behind the shoulder. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
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variations on that test is followed by the study of more complex movements. We begin with assessment of posture (see Section 4.2).
Motor stereotypes are the result of conditioned and unconditioned reflexes and/or programs acquired in the course of ontogenesis.
Figure 4.68 • Testing the abduction of the glenohumeral
4.15.1 Examination with the patient sitting
The hip
The patient is examined sitting on a height-adjustable stool. The examiner notes the position of the feet and the level of the iliac crests, the posture of the lumbar spine, and the tonus of the abdominal, paravertebral, and gluteal muscles. In correct sitting posture, the feet are flat on the floor and the iliac crests level; the lumbar lordosis should be flattened, and muscles only slightly tensed with the tonus evenly distributed (see Figure 4.71).
joint, with shoulder blade fixed. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
To evaluate the hip joint, the most satisfactory method is to measure the combination of external and internal rotation with the hip flexed at 90°. Combined external and internal rotation of up to 90° is assessed as range A, between 90° and 120° as B, and more than 120° as C (see Figure 4.70).
4.15 Examination of Anteflexion: stooping and coordinated movements straightening (motor stereotypes) Examination of individual muscle groups by means of simple movements in the muscle test and the
For correct stooping, one leg moves forward in front of the other and the knee of that leg is bent. At the same time the trunk bends forward, the movement
Figure 4.69 • Testing hyperextension of the knee joint. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
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Figure 4.70 • Testing internal and external rotation of the hip joint. Evaluation: A, hypomobile to normal; B, slight hypermobility; C, marked hypermobility.
Figure 4.71 • Sitting on a stool. (A) Correct posture; (B) and (C) two types of faulty sitting posture.
starting with the head, the body then curling up from caudal to cranial as the abdominal and gluteal muscles contract slightly (see Figure 4.72A). The erector spinae contracts initially, but relaxes again at the point of maximum anteflexion. As the body straightens up again, the knees are extended and at the same time the trunk 146
uncurls, lifting first the lumbar spine, then the more cranial sections of the spine, and finally the head (see Figure 4.72A). This action is brought about by contraction of the abdominal and gluteal muscles. The whole of this movement is the result of coordinated activity by the muscles of the gluteal
Diagnosis of dysfunctions of the locomotor system
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Figure 4.72 • (A) Stooping and (B) lifting an object correctly.
Figure 4.73 • (A) Stooping and (B) lifting an object, performed incorrectly.
region, abdomen, and back. The knee of the forward leg is positioned under the thorax so that the center of gravity of the body constantly lies above this point of support. The trunk must never be
raised stiffly like a ramrod, because this acts as a long lever and places great stress on the lumbosacral junction (see Figure 4.73B). Nor must the abdomen be allowed to bulge. 147
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Trunk rotation, sitting This test mainly examines the thoracic spine and shoulder girdle. The patient is seated on a stool, holding a small book in her hands. Correct sitting posture is important. The shoulder girdle should be relaxed and posture erect, including the shoulders. The patient is now asked to place the book on a shelf behind her, at head height (see Figure 4.74). The examiner should observe the rotation of the trunk, which should be about a vertical axis, and check for coordinated activity of the back and abdominal muscles, fixation of the shoulder blades, and minimal tension in the superior part of the trapezius. If performed properly, the rotation is seen as a fluid movement in which the pelvis and legs do not participate. There is only moderate activity of the abdominal and back muscles, the inferior angles of the scapula do not diverge, and the superior part of the trapezius remains relaxed.
Figure 4.75 • Head rotation, sitting: (A) correct; (B) faulty
Rotation of the head and neck
Raising the arms
The examiner should begin by observing head posture with the patient standing and sitting. The normal posture is slightly lordotic, but this lordosis may be absent if the thoracic spine is flat. The angle between the mandible and neck should be about 90°. During head turning, the examiner observes neck rotation and also the cervical muscles and position
When raising the arms, the patient also raises her shoulders and shoulder blades. This activates the upper fixators of the shoulder girdle, in particular the superior part of the trapezius and the levator scapulae, especially if fixation of the shoulder blades from below by the inferior part of the trapezius is insufficient (see Figure 6.152).
posture.
of the shoulders (see Figure 4.75). If the movement is performed correctly, lordosis should not increase and there should be minimal side-bending. The sternocleidomastoid should not be overstrained, and neither shoulder should be drawn forward or lifted.
Figure 4.74 • Trunk rotation, with the patient sitting and holding an object in the hand: (A) correct; (B) faulty posture.
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causing tension in the upper fixators of the shoulder girdle and muscles of the upper limbs (see Figure 4.76). If a weight is to be carried correctly, the shoulders should be behind the center of gravity of the body and the head and neck remain erect. When this is so, the hand carrying the weight is also relaxed.
Standing on one leg
Figure 4.76 • Carrying weights: (A) correct; (B) faulty posture, with forward-drawn shoulders and neck.
4.15.2 Examination with the patient standing erect Weight carrying Here the typical fault is a forward-drawn position of the head and a drawing forward of the shoulders,
The examiner should observe all the joints of the stance leg, the line and center of gravity of the body, the pelvis and iliac crests, the spinal column and muscle tension, especially that of the hip stabilizers (the gluteus medius and minimus). In correct posture on one leg, all joints of the stance leg are in the line of gravity; the center of gravity moves forward as compared with stance on two legs, to the second and third metatarsal heads. The iliac crests remain horizontal, the physiological curvatures of the spine remain unchanged, and no scoliosis occurs. The hip stabilizers, in particular the abductors, contract on the side of the stance leg. The flexors and extensors of the lumbar spine (the abdominal and erector spinae muscles) and of the hip should contract evenly, as should the quadratus lumborum (see Figure 4.77A). If the abductors are weak, as is frequently found in patients with faulty posture, the patient raises the iliac crest on the side opposite to the stance leg (see Figure 4.77B). Trendelenburg’s sign, in
Figure 4.77 • Standing on one leg. Dorsal view: (A) correct; (B) faulty posture. Lateral view; (C) correct; (D) faulty posture.
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which the iliac crest is lowered, is mainly found in decompensated hip luxation and extreme muscle weakening.
Gait In normal gait the steps are even and the weight is placed equally on each leg in turn. Each foot strikes the ground heel first, the entire foot then uncurling along its lateral edge to end in pronation and propulsion by the toes. The examiner should note the extension of the knees and hips. The pelvis sways from side to side, remaining horizontal but rotating about a vertical axis; the excursion is more pronounced in women than in men. The spinal column curves from one side to the other in waves, the greatest excursion being at L3; there is some counter-excursion in the thoracic spine, the point of change occurring at the thoracolumbar junction, which remains vertically above the sacrum. The head should move very little and the arms should swing symmetrically (in right-handed individuals, slightly more on the left than the right). This movement comes from the shoulder, which rotates in the opposite direction to the pelvis. The shoulder blades are fixed against the back by the caudal fixator muscles. The body’s center of gravity shifts only slightly, from one side to the other and up and down; that is the person should neither waddle nor rock. Significant asymmetries of gait are also clearly audible, especially if the patient is walking quickly. Certain faults only become observable if the patient walks with eyes closed, on tiptoe, on the heels, or with upstretched arms. If it is possible to examine patients in their typical working position (lifting weights, at the computer, at a machine or instrument, etc.), this can provide important insights.
Respiration can be examined starting with the patient at rest, supine. In the supine position, abdominal respiration should predominate. In erect posture, standing or sitting, the abdominal muscles must also perform their postural function during respiration, and this occurs when the thoracic cage widens, beginning from the waist. To find whether this is happening, the examiner should place his hands on the patient’s lower ribs on each side, and sense whether his hands are moved apart as the patient breathes in, or whether they move upward with no widening of the thorax (lifting of the thorax during inhalation – clavicular breathing – see Figure 4.78). If this faulty breathing pattern is very pronounced, the thorax may remain permanently in the inhalation position and the lifting of the thorax during inhalation may be seen even at rest. In this case the sternocleidomastoid and scalene muscles and all the upper fixators of the shoulder girdle are found to be taut
4.15.3 Movement patterns of respiration Although the prime purpose of respiration is the exchange of gases, it is the function of the locomotor system that underlies it. The muscles involved in breathing are in their turn extremely important for the function of the locomotor system, so much so that breathing patterns are considered the most important of all motor stereotypes (see Section 2.9.5). 150
Figure 4.78 • Clavicular and paradoxical breathing: tension in the muscles that fix the shoulder girdle from above; deep supraclavicular fossae; the thorax in the inhalation position; the abdomen is drawn in at inhalation.
Diagnosis of dysfunctions of the locomotor system
and the supraclavicular fossae are deep. In the most severe cases the patient may draw the abdomen in during inhalation (paradoxical respiration, see Figure 4.78). In these cases clavicular breathing can be evident even when the patient is lying down. In less severe cases it is only observed when the patient inhales deeply. This lifting of the thorax can also be asymmetrical; the shoulders are each lifted to a different extent and there is often weakness of the inferior part of the trapezius on the side that rises more. Another consequence of the lifting of the thorax is that breathing is performed mainly by the contraction of the scalene muscles and the diaphragm is not sufficiently activated. The movement of the ventral wall of the thorax may even cause the diaphragm to be cranially angled; if this happens there will be no co-contraction of the diaphragm together with the abdominal muscles, and therefore no fixation of the thorax to the pelvis. As Figure 4.78 also shows, the effect is not only to overload the cervical spine, but to lift the thorax away from the pelvis, so that there is no fixation of the lumbar spine. The photograph also shows the hypotonus in the region of the waist and lateral abdominal wall (see Section 2.9.5). Therefore the tonus of the lateral abdominal wall should also be palpated and the patient asked to exert pressure against the examiner’s palpating fingers. The patient often finds this impossible to do. According to Kolárˇ (2006), the following tests can then be performed: • The patient lies supine with knees flexed. Resistance is applied to the knees and the patient asked to flex the knees further against the resistance; alternatively the patient, sitting erect, is asked to raise both knees against gravity. The examiner palpates the abdominal wall laterally at the waist. The lateral abdominal wall contracts (the patient can feel this by touch, and so can provide feedback), but the thorax should not rise as it does so. • The patient lies supine and slowly lifts the head and trunk while the examiner palpates the medioclavicular line. As the neck is flexed, the abdominal wall begins to contract, and when the thorax is lifted, the lateral part of the abdominal wall contracts. The equivalent method with the patient prone is used to examine the extension of the head and shoulders as the muscles at the waist contract. The close relationship between posture and respiration can be seen not least in the effect of a
Chapter 4
hunched sitting posture, which makes it difficult for the thoracic cage to expand and so leads to clavicular breathing. This kyphotic posture is associated with a forward-drawn position of the head, which is compensated by hyperlordosis of the cervical spine. This close relationship is also shown by holding the breath during muscular effort (Valsalva maneuver); the body achieves maximum stability at the expense of respiration, as is done, for example, when delivering a tennis serve. Holding the breath is even maintained for the period of a short sprint: the body temporarily reinforces postural function at the expense of respiratory function. Inhalation and exhalation have about the same duration; the patient should be able to extend that duration considerably, to at least 10 seconds. (Professional singers should be able to sustain a breath for much longer.) A quiet breathing sound is heard, the sound coming from the nose. The nostrils expand during deep inhalation and narrow during exhalation. In the prone position the progress of the respiratory wave can be observed traveling up from the lumbar spine to the upper part of the thoracic spine during deep breathing. This wave may be interrupted where there is a restriction. If there is a faulty breathing pattern the wave may be completely absent.
The close relationship between the locomotor system and breathing means that a faulty breathing pattern, especially clavicular breathing (in which the thorax is lifted during inhalation), is highly pathogenic. It should never be overlooked.
4.16 Syndromes 4.16.1 The lower crossed syndrome In this syndrome there is imbalance of the following muscle groups: • Weakness of the gluteus maximus; shortening of the hip flexors and tension of the ischiocrural muscles. • Weakness of the rectus abdominis and shortening of the lumbar and thoracolumbar part of the erector spinae. 151
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• Weakness of the gluteus medius, tension of the
tensor fasciae latae, adductors, and quadratus lumborum. There is also substitution for the weak gluteus maximus by the ischiocrural and erector spinae muscles, for the gluteus medius by the tensor fasciae latae and quadratus lumborum, and for the rectus abdominis by the hip flexors. Clearly this syndrome renders the curling of the spinal column on lying down from a sitting position impossible. The main visible result of imbalance between the rectus abdominis and the lumbar erector spinae is lumbar hyperlordosis; if there is imbalance between the gluteus maximus and hip flexors, the hyperlordosis occurs at the lumbosacral junction. The psoas major does not only flex the hip but also brings about lordosis of the lumbar spine (‘psoas paradox’). There is also increased pelvic tilt (see Figure 4.79).
4.16.2 The upper crossed syndrome There is imbalance in the following muscle groups: • Between the upper and lower fixators of the shoulder girdle. • Between the pectorales and the interscapular muscles. • Between the deep neck flexors (longus colli, longus capitis, omohyoid, and thyrohyoid) and the neck extensors. There may be shortening of the superior part of the ligamentum nuchae with fixed lordosis in the upper cervical region. The ascending part of the trapezius is extremely important for the fixation of the scapula. Activity of this muscle portion can produce reflex relaxation of the upper fixators. Tension of the pectoralis muscles leads to increased thoracic kyphosis and forward-drawn shoulders, as well as kyphosis of the lower part and hyperordosis of the upper part of the cervical spine. The correct movement of arched anteflexion from a supine position is only possible if there is coordinated activity of the scalenes and deep neck flexors. If these are weak and the sternocleidomastoids hyperactive, there is ventral shifting of the head (incoordination). The cause that leads to weakness of the deep neck flexors is often weakness of the deep stabilizers of the lumbar spine. This is because the longus colli has its point of attachment here.
4.16.3 Stratification syndrome (according to Janda)
Figure 4.79 • (A) Lumbosacral and (B) lumbar hyperlordosis.
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In this syndrome, alternating strata of hypertrophic and weak muscle groups are found: on the dorsal aspect, working in a caudocranial direction, we find fairly slim calves, but hypertrophic ischiocrural muscles; hypotrophic, lax gluteal muscles and underdeveloped lumbar erectores spinae, and above these the bulging hypertrophic, thoracolumbar erectores spinae; above these we find flabby interscapular muscles and hypertrophic, taut upper fixators of the shoulder girdle. On the ventral aspect the inferior part of the abdominal wall bulges, but lateral to the rectus abdominis muscles there is a hollow corresponding to the taut obliquus abdominis muscles; lateral to this the abdominal wall may bulge again in the region of the waist (‘pseudohernia’).
Diagnosis of dysfunctions of the locomotor system
The significance of the stratification syndrome lies in the alternation of sections marked by contraction and lax, hypermobile sections. Hypermobility in the region of the lumbosacral junction is especially pathogenic in its effect. Dysfunction of the feet appears to play an important part here. Minor variations in balance are normally absorbed by the toes; in fact by the muscles of the foot and especially the calf. The function of the toes is often inhibited by the shoes, and the muscles of the thighs then take over the task of managing static balance. There is a simple explanation for the fact that the interscapular muscles are often found to be weak, if we look at developmental kinesiology: in infants, the development of upright posture takes place in the form of two lordotic curvatures, and is brought about through the activity of the cervical and thoracolumbar erector spinae muscles. The weak point is at the place where the two meet, at T4 or T5.
4.17 Retesting Clinical examination routinely provides a wealth of data to give us the information we need about dysfunctions, and therefore also to compare findings before and after therapy. The effects of such treatment are often instantaneous, by reflex response. Immediate, post-treatment testing, or retesting, is therefore a means of feedback, and is indispensable for all practitioners who want to use solid criteria. This plays the role of short-term evidence. Yet – with a few exceptions – this kind of instant check is simply not possible for other modalities such as pharmacotherapy, for example. Given the great variation in the course of patients’ complaints, there is great value in this. Nevertheless, however good the immediate effect, this must not be confused with actual therapeutic success, because patients are rarely suffering from a single dysfunction; the therapeutic effect depends to a great extent on how relevant the lesion is that we have treated. If treatment of that lesion achieves only a partial effect, there is no reason why we should not continue by treating a further lesion and retesting once more. In principle, every abnormal finding at clinical examination can be compared by testing before and after treatment. Where the test involves actual measurement, such comparison can be especially useful; examples include the range of movement
Chapter 4
of joints or sections of the spinal column, and the straight-leg raising test. Side deviation in Hautant’s test can also be compared before and after. Even in radicular syndromes, an increase of strength in weakened muscles may be found on retesting (see Figures 2.12 and 2.13). Routine testing before and after treatment can also be carried out for reflex changes such as muscle TrPs, HAZs, and mobility of fasciae, for example following therapies such as mobilization, needling, PIR, RI, or local anesthesia. Instrumental methods such as thermography may also be used. Subjective statements by the patient are also valuable. Most patients seek treatment because they are suffering pain, so it matters that they should find relief after treatment. The practice of concluding treatment by letting patients palpate their pain points found during the examination is a helpful one; they can palpate them with their own hands and confirm for themselves that the symptoms have indeed improved or disappeared. Testing also gives a useful indication as to the most suitable further therapy. The practitioner can test the application of a particular treatment approach. For example, if we wish to find out whether traction or the treatment of an active scar is indicated, we can test whether the planned approach brings immediate relief. An immediate (reflex) result can be useful evidence-based medicine that indicates the effectiveness of a particular method, although this should not be equated with therapeutic success.
4.18 Dysfunctions and the course of examination The question to be answered is how to carry out a systematic examination of a patient suffering from dysfunctions. If we wish to draw up the medical report of a patient with functional disorders as described by Brügger (2001), what would this look like? Having described the various clinical examination techniques, the next issue is how to proceed in practice; how to obtain useful results and avoid errors as far as is humanly possible. The answer is not simple, as the object of examination – the locomotor system, including morphological changes and dysfunctions – is in fact the concern of many different fields of medicine. The locomotor system can in many ways be said to be 153
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a reflection of everything that is happening in the body. Some patients present with problems belonging to the field of internal medicine; others with neurological, orthopedic, or rheumatological complaints. Still others are in the fields of ear, nose, and throat, or gynecology. For some, the main problem lies in disturbed muscle function, for others, in disturbed joint mobility; yet others may be suffering from a great range of reflex changes. To examine each patient from all of these aspects would demand far more time than is practicable, especially given the outpatient nature of most consultations. The problem is essentially that our focus of interest lies in dysfunctions for which there is no specific, established medical field, since they relate to the locomotor system as a whole.
4.19 Adjusting our thinking to the functional approach The examination techniques described in detail so far deal with dysfunctions, as do the demanding techniques used in treatment. However, they can only be used effectively if we have a proper understanding of these disturbances of function. Practitioners need not only master the techniques but must adjust their thinking to understand in a functional way.
It is as important – and still more difficult – to adjust our thinking to the functional approach as to master the technical aspect of manual medicine.
The following points present in general terms the most important differences between the usual, pathomorphological understanding and the functional approach. • The first and fundamental task in classification and differential diagnosis is to decide whether the particular case is primarily pathomorphological or primarily one of dysfunction. • Function (physiology) is as real as is morphology (anatomy). • If a disorder is mainly pathomorpholological, the task is to localize it and decide what precisely is 154
affected. Function and dysfunction, on the other hand, are the result of the interplay of a whole chain of different structures which are variously located. • The clinical picture correlates far more with the functional disturbances than with the pathomorphological changes. Consequently, pathological processes often do not manifest themselves until they cause dysfunction. Dysfunctions, on the other hand, can cause very marked clinical symptoms, even in the absence of any morphological changes. • Thus: pathomorphological changes cause dysfunctions, which manifest themselves in clinical symptoms. • Consequently, even pronounced pathomorphological findings can often exist without causing any clinical symptoms, and may even be clinically irrelevant (e.g. disk herniation at CT, scoliosis, or spondylolisthesis). Concomitant dysfunction, on the other hand, can be of decisive importance clinically. • In such cases, if the pathomorphological changes are assumed to be the key to the disorder, therapy fails; on the other hand, even if the pathomorphological changes are clinically relevant, we still may improve the patient’s condition if we improve function – for example by rehabilitation. It is, however, necessary to be aware of the limits of what can be achieved. Compensation can occur, so should not be forgotten. • In pathomorphological diagnosis, the aim is to localize the lesion exactly and to identify its nature (principle of localization). • In diagnosing dysfunction, the aim is to identify the pathogenetic chain of reactions and to assess the interrelationships and relevance of the individual links (holistic principle). • In pathological processes, the cause of pain lies in the nature of the lesion; in dysfunction, the cause of pain is mainly pathological tension brought about by the dysfunction. • In pathomorphological conditions, if therapy is successful it is continued until healing is achieved. Alternatively a decision may be made to intervene surgically. • If therapy is successful in conditions due to dysfunction, the next step is usually to treat another link in the pathogenetic chain. If the
Diagnosis of dysfunctions of the locomotor system
same lesion needs to be treated again, we should consider whether there is another link in the chain that is more relevant and requires treatment. Change of approach in therapy is therefore the norm. • In pathomorphological conditions, success depends on drug treatment or surgery; success in dealing with dysfunctions depends on the relevance of the particular link in the pathogenetic chain we address at that moment. • When treating dysfunction, the practitioner is lost – or rather his patient is – if he treats it at the point where pain is felt. • Because dysfunctions are by definition reversible, the effect of treatment can be immediate, giving the impression of a miracle cure. This is by no means unusual; at times it is even what we would expect. • Modern technology achieves wonders in dealing with pathomorphological lesions, but often fails when it turns to the treatment of dysfunction, where it is at best cumbersome. Clinical skill is decisive in such cases, but is often undervalued as ‘subjective’ and too little put into practice. As a result, too much stress is often placed on morphological changes, which may in fact be of little relevance. • The psychological factor is important in all disease. In dysfunctions of the locomotor system, however, psychology is itself a link in the pathogenetic chain, because voluntary motor function is the effector of psychological activity. Here, too, pain is the main symptom, and tension and its relaxation play a very important role. Practitioners need to decide in each case how relevant the psychological factor is and how amenable it is to treatment. • In pathomorphological conditions, the relationship between cause and effect tends to be clear. In dysfunctions, what had been the cause can often turn into the consequence. Pain, whatever its origin, will produce changes in movement patterns or stereotypes; these in turn cause dysfunction which perpetuates pain. Chronic tension and joint restriction cause impaired mobility of the fasciae, and resistance in the fasciae in turn becomes the cause of recurring joint restrictions. • When dealing with pathomorphological conditions, it is easy to produce statistics,
Chapter 4
and such findings are indeed very important. The task is incomparably more difficult when dealing with dysfunctions. Even in diagnosis, the symptom can be the result of a long chain of various disturbances in various locations, and the relevance of each link can change. In therapy, if we have treated one link successfully, there would be no sense in repeating treatment there. If the symptoms continue, we treat another link in the chain, and so on. If at the end of the process the clinical symptoms have disappeared, there is no reason to conclude that the treatment of the first link contributed less to the success. • The functional approach is difficult. We may compare function to the ‘software’ and structure to the ‘hardware’ of the system.
4.20 Chain reactions of dysfunctions and motor programs 4.20.1 Function and chain reactions In view of the argument presented in the previous section, which emphasizes that dysfunctions normally affect the entire locomotor system, or at least the major part of it, we must turn to the question of how to approach the individual case. Experience has shown that if on examination we find ‘A’, we expect ‘B’, and must then test ‘C.’ What regularly occurring patterns or rules can we observe or expect? What can we take as our screening guidelines in the clinical situation? The first test is based on the premise that these regularly occurring patterns are associated with certain basic functions of the locomotor system. Basic functions or programs relate to the following: • Gait, and especially the lower limbs and pelvis. • Body statics, and especially the trunk, neck, and head. • Respiration, and especially the trunk and neck. • Prehension, and especially the upper limbs and shoulder girdle. • Eating and speaking, and especially the orofacial system, head, and neck. 155
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Table 4.3 Reaction chains of dysfunction
Lower limb — gait — swing phase – extension Tension
Flexors of toes and foot, soleus, ischiocrural muscles, glutei, piriformis, levator ani, erector spinae
Painful points of attachment
Calcaneal spur, Achilles tendon, fibular head, ischial tuberosity, coccyx, iliac crest, greater trochanter of femur, spinous processes of L4—S1
Joint dysfunction (restrictions)
Small joints of foot, ankle joint, fibular head, sacro-iliac joint, lower lumbar spine, (atlanto-occipital and atlanto-axial joints)
Lower limb — gait — stance phase — flexion Tension
Extensors of toes and foot, tibialis anterior, hip flexors, hip adductors, recti abdominis, thoracolumbar erector spinae
Painful points of attachment
Pes anserinus of tibia, patella, lesser trochanter of femur, superior border of pubic symphysis, xiphoid process
Joint dysfunction (restrictions)
Knee, hip, sacroiliac joint, superior lumbar spine, thoracolumbar junction (atlanto-occipital and atlanto-axial joints)
Trunk — body statics Tension in muscle pairs
Sternocleidomastoid and: short craniocervical extensors Scalenes + deep neck flexors + digastric and trapezius + levator scapulae + masticatory muscles Iliopsoas + recti abdominis and: erector spinae + quadratus lumborum
Painful points of attachment
Posterior arch of atlas, spinous process of C2, nuchal line, sternal end of clavicle, superior and medial border of scapula, xiphoid process, pubic symphysis, lower ribs, iliac crest
Joint dysfunction (restrictions)
Atlanto-occipital and atlanto-axial joints, cervicothoracic junction and upper ribs, thoracolumbar junction (trunk rotation), lumbosacral and sacroiliac junction, temporomandibular joint
Lifting the thorax during inhalation (clavicular breathing) Tension
Superior parts of abdominal muscles, pectoralis, scalene, diaphragm, sternocleidomastoid muscles, short craniocervical extensors, levator scapulae, superior part of trapezius
Painful points of attachment
Posterior arch and transverse processes of atlas, spinous process of C2, nuchal line, sternal end of clavicle, superior border of scapula, sternocostal joints and upper ribs
Joint dysfunction (restrictions)
Atlanto-occipital and atlanto-axial joints, cervicothoracic junction, upper ribs, thoracic spine
Upper limb — prehension — restricted flexion Tension
Extensors of fingers and wrist, thenar eminence, supinator, biceps brachii, triceps brachii, deltoid, supraspinatus, infraspinatus, upper fixators of scapula, interscapular muscles
Painful points of attachment
Radial styloid process, radial (lateral) epicondyle, attachment of supraspinatus and infraspinatus, attachment of levator scapulae, spinous process of C2
Joint dysfunction (restrictions)
Elbow, acromioclavicular joint, middle cervical spine, cervicothoracic junction, upper ribs
Upper limb — prehension — restricted extension Tension
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Flexors of fingers and wrist, pronators, subscapularis, pectoralis, sternocleidomastoid, scalene muscles
Diagnosis of dysfunctions of the locomotor system
Chapter 4
Table 4.3 (Continued). Painful points of attachment
Ulnar (medial) epicondyle, sternal end of clavicle, sternocostal joints, Erb’s point, transverse process of atlas
Joint dysfunction (restrictions)
Carpal bones, elbow, glenohumeral joint, cervicothoracic junction, atlanto–occipital and atlanto-axial joints
Head and neck — eating — speaking Tension
Masticatory, digastric, sternocleidomastoid muscles, craniocervical extensors, trapezius, levator scapulae, deep neck flexors, pectoralis muscles
Painful points of attachment
Hyoid, posterior arch and transverse processes of atlas, spinous process of C2, nuchal line, sternal end of clavicle, superior border of scapula, angle of upper ribs
Joint dysfunction (restrictions)
Temporomandibular joint, atlanto–occipital and atlanto-axial joints, cervicothoracic junction, upper ribs
The chain reactions of dysfunction envisaged here are given in Table 4.3. These do not claim to be complete; although these are the chains especially affected, the disturbance is not limited to the details listed. The intention is rather to provide some means of screening. Our understanding is further focused and extended by our insight into developmental kinesiology.
4.20.2 Chain reactions in the light of developmental kinesiology What is said here follows on from Section 2.5.3, which describes the development of the co-contraction pattern of flexors and extensors, adductors and abductors, and external and internal rotators. As a prerequisite for human upright posture, antagonists developed into synergists, a development that can most clearly be seen at joints such as the knee and individual segments of the spinal column. This pattern appears yet more fundamental in the craniocaudal direction, with the formation of muscle chains in the sagittal plane beginning at the feet, connected through their points of attachment and stabilizing the spinal column just as a mast is stayed. These muscles, as pointed out by Richardson et al. (2004), are long, most of them spanning two or more joints. This is the more important for the fact that the spinal column, unlike a mast, is jointed. Panjabi et al. (1992a) showed that the motion segments are unstable, and require the activity of the short, deep muscles of the back to stabilize them. If it were not for these muscles, the contraction of the long
muscles would cause individual motion segments to buckle. Therefore, in parallel with the co-contraction pattern, there developed the system of the deep stabilizers. This includes not only the multifidi, but also, ventrally, the abdominal cavity and its walls: the diaphragm, transversus abdominis, and pelvic floor, sustaining intra-abdominal pressure. The importance of this stabilization function is so great that, in the action of raising the arm, the diaphragm or transversus abdominis contract before the deltoid (see Figure 4.80). We even observed a patient who was unable to raise her arm if her pelvis was not fixed, on account of paralysis of the deep muscles of the back. If her pelvis was fixed, however (in the sitting position), she was able to carry out the action without difficulty (Lewit & Horácek 2003). The development discussed so far has been that of the postural program, which takes place automatically and is also associated with the optimal positioning (centering) of the limbs. This development is completed in overall terms in the fourth month of life, but only fully completed at four years of age. As indicated previously in Section 2.6, in a considerable proportion of children this development does not proceed straightforwardly. As soon as children learn movement, their own individual programming of movement patterns begins to take shape, in line with their particular interests and opportunities. The way this happens will become clearer if we use an example: playing tennis. On the basis of neurology we would expect the following: as soon as the player sees the ball, the image strikes the retina. From there, the stimulus travels to the diencephalon and is transmitted to the occipital lobe, from there to the parietal lobe, and finally to the motor cortex. From here, 157
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Figure 4.80 • EMG of the deltoid muscle and diaphragm on raising the arm: contraction of the diaphragm takes place in advance of contraction of the deltoid (modified after Richardson et al 2004). vdi, transdiaphragmatic pressure; Pga, intra-abdominal pressure; Poes, intrathoracic pressure.
the neurons of the central nervous system communicate with the spinal cord and peripheral neurons with the muscles. There is then feedback via the posterior horn and the cerebellum. Assuming a transmission speed of 100 m/s, the ball will be long since out of play. The only way to understand this problem is once more by looking at the developmental process: first, we place the ball firmly in the child’s hands. (The child has successfully passed through the stage of 158
postural development.) Then we carefully throw the ball to the child, who stands with hands ready to receive it. It takes some time before the child is actually able to catch the ball, first with both hands, then with just one. Only now do we give our child a tennis racquet for the next stage: learning to hit the ball. What has been happening during those years? The brain, that most accomplished computer of all, has constructed a program, and the moment the eye sees the ball, the program springs into action:
Diagnosis of dysfunctions of the locomotor system
the movements of eye, head, trunk, and limbs all take place automatically. This understanding is extremely important in determining our practical approach. It clearly shows that the program involves the entire system. If a disturbance appears somewhere along its course, we must reprogram it. It also follows that symptoms, in this case dysfunctions, can appear in many places, and it is our job to discover which is the most important dysfunction, the one that is the key link in the chain reaction. Understanding this development enables us to organize our approach in a rational way and draw up certain rules that describe how this system behaves as a whole. A good way to illustrate this ‘holistic’ approach is with reference to the programmed reaction of supporting oneself, for example with hand, elbow, or knee, in standing posture. As soon as we do this there is an instant change in our posture in every section of our locomotor system. This reaction must originate from the receptors of these points of support, which are also very important, according to Vojta & Peters (1992), as points of stimulation. The only way that a programmed function can be directed is by the nervous system, by means of the musculature. Therefore we must take the muscles as our starting point if we wish to understand and analyze the chains of reaction. The function of the muscles is closely linked with that of the joints: the earlier discussion of TrPs made clear that these are linked with movement restrictions; this is manifested in practical terms in the use of neuromuscular techniques of treatment. In this context it becomes evident that TrPs in fact have the function of establishing stability at the cost of mobility. They are found in antagonists in motion segments or limbs: adductors–abductors; extensors–flexors. In the case of fan-shaped muscles such as the pectoralis major, a section of the muscle corresponds to a particular section of the erector spinae. However, the antagonism is not limited to the particular segment: if, for example, an extensor is stimulated, this does not only inhibit its specific antagonist, but also the entire flexor system. As demonstrated by Brügger (2001), this effect is especially pronounced when the extensors of the fingers and toes are stimulated, since the density of receptors is particularly great in these locations. As an example, stimulation of the toe extensors can inhibit the activity of the ischiocrural muscles, with consequent weakening in the straight-leg raising test.
Chapter 4
The co-activation pattern applies not only within the segment; it also serves to maintain upright posture. From their anchor point at the feet, the muscles and their attachments work together to maintain upright posture just as a mast is stayed by the rigging. Dysfunctions often produce TrPs in the muscle chains that form these ‘mast stays.’
TrPs are markers that trace out chain reactions, and these chain reactions also involve joints and soft tissues.
4.20.3 The pathomechanisms of chain reactions A further principle can be drawn from developmental kinesiology: the developmentally older function is less susceptible to disturbance, and therefore predominates. In pain, exhaustion, aging, and the phenomena associated with paresis, the predominating model is that of the newborn. The same principle follows equally from the disturbances of movement pattern in the concept developed by Janda (see Table 2.1) and from Brügger’s (1971) ‘sterno-symphyseal syndrome.’ In both these cases it is possible to speak of a chain reaction in which the flexors predominate. In Janda’s terms these are the ‘primarily postural muscles’; in terms of current knowledge they are the developmentally older muscle groups. Brügger’s (1971) explanation of the round-shouldered sitting position, however, is not based on muscular imbalance, but on the position of the joints: in sitting with thighs adducted, the pelvis tips backward, and if the arms are folded in front of the chest, it becomes impossible to straighten the thorax. This situation also shows the close relationship between joint function and muscle activity. A further chain reaction in which the balance between flexors and extensors is disturbed is the forward-drawn posture when standing. On inclining forward, all the erector spinae muscles, including the nuchal muscles, become taut. Proof of this can be found by palpating one’s own neck muscles. If patients are found to have tense nuchal muscles in standing posture, and if restriction of the atlanto-occipital and atlantoaxial joints has been excluded, the following test is decisive: the patient 159
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whose nuchal (and back) muscles are tense when standing is asked to sit on a chair; the tension disappears on sitting excluding the role of the lower limbs. TrPs are generally found in the sternocleidomastoid and especially the rectus abdominis. There is often tenderness to pressure of the attachment points on the xiphoid process, inferior costal arch, and especially the superior border of the pubic symphysis, at least on one side. The chain usually continues on down to the ischiocrural muscles, especially the biceps femoris and its insertion at the fibular head, and there is generally restriction relative to the fibula. If the chain does not end here, there may be TrPs in the short toe flexors and short extensors with restrictions in Lisfranc’s (tarsometatarsal) joint. The most distal link in the chain is generally the decisive factor, and in many cases this is in the foot, which also belongs to the deep stabilization system. The pathogenesis of this chain lies in the important role played by the powerful ischiocrural muscles in the fixation of the pelvis. If there is a TrP here, the fixation of the pelvis is disturbed and has to be compensated by the rectus abdominis and the gluteus maximus. The consequence of this is tension of the rectus abdominis in particular, and this helps cause the forward-drawn posture. Often such patients complain of headache and pain in the nape of the neck; the cause, however, often lies in the region of the patient’s feet.
4.20.4 Causes of chain reactions The most frequent cause of chain reactions is dysfunction of the deep stabilizers. These form a chain in their own right, as was demonstrated by Richardson and coworkers (2004) in their electromyographic study of the contraction of the pelvic floor. The muscles involved are the diaphragm, the transversus abdominis, the pelvic floor, and the multifidi. TrPs can be palpated directly on the pelvic floor and diaphragm. In the case of disturbance here, the long muscles react with the emergence of TrPs in an attempt to compensate for the disturbed stability, a task to which they are little suited. In the trunk region, the longissimus, quadratus lumborum, and psoas major, and sometimes the rectus abdominis, are the muscles involved. The irritability of the erector spinae is sometimes so marked that snapping palpation of a TrP in the thoracic portion sometimes produces a twitch reaction in the lumbar portion as well. This causes strong 160
dorsiflexion of the pelvis, described by Silverstolpe (1989) hence called ‘S’ reflex. Working in the cranial direction, the next muscles are the pectoralis and subscapularis, the upper fixators of the shoulder girdle, scalenes, sternocleidomastoid, short craniocervical extensors, and the masticatory and digastric muscles. Working in the caudal direction, the next muscles are the hip adductors, the ischiocrural muscles, and quadriceps femoris; then in particular the soleus and painful Achilles tendon and the short muscles of the foot.
4.20.5 The role of the diaphragm The diaphragm clearly seems to play a special role because it combines a postural function with that of respiration. This means that disturbance of the deep stabilizers is associated with faulty breathing, or, conversely, that correct breathing and good stabilization of the lumbar spine depend on the coordinated contraction of the diaphragm and abdominal wall. According to Kolárˇ (2006), this can be examined by means of the following tests: the patient is supine or sitting, thorax caudalized in exhalation. The examiner should fix the thorax in the exhalation position, simultaneously palpating the lateral abdominal wall at the waist. The patient is asked to exert pressure against the examiner’s palpating fingers. To facilitate this, the patient’s knees should be bent and, if the patient is supine, resistance is applied to the flexed knees. If the patient is sitting, the only action necessary is for the patient to lift the bent knees slightly; the lateral abdominal wall tenses at that moment. This tension should be maintained during inhalation to prevent clavicular breathing (in which the thorax is lifted during inhalation) and oblique positioning of the diaphragm. Contraction of the diaphragm is then concentric, and this counters the eccentric contraction of the transversus abdominis in particular. The examiner should at the same time ensure that there is contraction of the muscles of the lower abdomen, and to a lesser degree the upper abdomen, so that the navel does not move in the cranial direction. If supine, the patient should slowly raise the head and to a slight degree also the trunk, and the examiner should palpate the lower ribs in the medioclavicular line. The raising of the patient’s head activates the abdominal muscles, so that the thorax remains caudalized. Further raising of the thorax
Diagnosis of dysfunctions of the locomotor system
causes activation of the lateral abdominal wall, even caudad to the navel. However, the abdomen should not bulge, either forward or laterally. If prone, the patient should be asked to lift the head and bend upward to create a slight lordosis of the back. This should cause the erector spinae muscles and lateral abdominal wall to contract. If there is insufficiency of the muscles, there will be no contraction of the lateral abdominal wall, and if there is excessive activity of the thoracolumbar erector spinae, the shoulder blades will move craniad.
4.20.6 Rotation of the trunk Trunk rotation is another function that is recent in developmental terms. As in the case of the deep stabilizers, a muscle chain is responsible for this movement. If trunk rotation is restricted, TrPs are found in the thoracolumbar erector spinae, quadratus lumborum, and psoas major, usually on the opposite side to the restricted rotation. Release of one of these three muscles is sufficient to remove the TrPs in the other two, whereupon trunk rotation becomes symmetrical again. This function is so important that, in cases where rotation of the cervical spine is also restricted, the treatment of trunk rotation frequently has the effect of normalizing findings at the cervical spine.
4.20.7 Unilateral chains of dysfunction In very painful conditions such as radicular syndrome, a unilateral chain pattern tends to be observed. This involves the sternocleidomastoid, short craniocervical extensors, trapezius, pectoralis muscles, subscapularis, and erector spinae, and sometimes the iliacus and quadratus lumborum, piriformis, glutei, hip adductors, rectus femoris, and soleus, down to the TrPs and restrictions of the foot, though it may not include the deep stabilizers. If this is the case, the disturbance derives from the ‘deep’ short stabilizers of the foot, which can similarly elude voluntary control; for example the abductor pollicis brevis. Another very important feature here is this: in such unilateral chains, sensitivity is noticeably asymmetrical, both overall and, in particular, on the soles of the feet. This is clearly evident from the involuntary reaction to exteroceptive stimulation of the sole of the foot. In
Chapter 4
such cases this test of exteroceptive stimulation is decisive, meaning that the afferent disturbance is the most relevant link in the chain. In addition there are shorter chains, which are of particular local significance. In the case of lateral (radial) epicondylopathies, these chains consist of TrPs of the extensors of the fingers and wrist, the supinator, the biceps brachii and tripceps brachii, all muscles with a point of attachment on the lateral epicondyle and with a role in prehension. Usually, however, these muscles are also linked with chains of dysfunction in the cervical spine. Even more important is insufficient fixation (stability) of the shoulder blade on the same side. The syndrome of the superior thoracic aperture represents a chain of muscular and joint dysfunctions in its own right. This chain consists of the cervical spine, the scalenes, the upper fixators of the shoulder girdle, the pectoralis minor and subscapularis muscles, and the uppermost ribs and cervicothoracic junction, as a rule associated with clavicular breathing and therefore also with the deep stabilizers. The soft tissues have for the most part been excluded from the discussion so far for the sake of clarity. However, fasciae that ‘stick,’ especially around the thorax, the back, and the scalp, can often play a decisive role in the chains. The most pathogenic soft tissue lesions are ‘active scars,’ which will be discussed in Chapter 5.
4.20.8 Analysis of chain reactions Chain reactions are not always complete, and sometimes there may be more than one chain. Diagnosis seeks to find the most relevant link in the chain, since treatment of this key link will often normalize the entire chain, enabling therapy to be given in the most efficient way. Equally importantly, the practitioner needs to know the direction in which to proceed when planning further treatment. What, then, are the criteria to be used in this analysis? • The patient history should give an indication as to which symptoms occurred early on and which later, and also which symptoms tend to recur and under what circumstances. • The intensity of a given finding can be important. • It is very important to identify whether the part affected is a key region, structure, or function. For example, the problem may affect the feet, 161
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the joints of the craniocervical region, structures of the deep stabilization system, faulty breathing, or an active scar; this is particularly important if the symptoms appeared shortly after trauma or an operation. • Having decided on the treatment, the practitioner should of course check the effectiveness of therapy by re-examining the patient immediately afterwards. • Therefore, diagnosis does not end until the first treatment procedure is given. If the expected effect is not achieved, the practitioner should turn to another link in the chain. The first treatment is often chosen with an eye to diagnosis, in order to establish the relevance of a particular link in the chain (i.e. that of a particular finding). In the case of active scars, this is the normal procedure. If these are found to be highly relevant, any other treatment would fail. • Even if the first therapeutic/diagnostic procedure proves successful, this does not necessarily mean that another might not also be successful. If the chain reaction runs in one direction, this does not necessarily mean that it might not run in the opposite direction; these chains are not ‘one-way streets’ (Hermach 2007).
An understanding of chains of dysfunction is fundamental to a holistic approach to their treatment.
4.21 Differential diagnosis 4.21.1 Problems As has already been mentioned, the locomotor system reacts to some degree to everything that happens in the body, and reflects it. As a result, clinical diagnosis is multifaceted and a highly responsible task. The problems essentially fall into two fundamentally different categories. The first concerns conditions which to varying degrees involve the spinal column and locomotor system: headache, vertigo, and a number of visceral symptoms in which vertebrogenic disturbances regularly play a part, such as chest pain, pain in the abdominal cavity, dysmenorrhea, etc. 162
In the case of these conditions the task is to decide the significance of the concomitant findings that usually exist in the locomotor system, and to determine whether they require treatment. This problem covers the whole field of medicine, and so can often only be solved with the collaboration of specialists in the relevant branches of medicine. The second problem is the differential diagnosis of disturbances of the locomotor system and the spinal column itself. Here the task is to decide whether the lesion is a pathomorphological one or a dysfunction, or a combination of both. In that case there is the further decision as to which disturbance is currently the more relevant. Errors in diagnosis may arise; in such cases inflammatory, metabolic, or neoplastic diseases may be involved. For this reason laboratory tests should always be carried out (including blood count and erythrocyte sedimentation rate), and X-rays requested if there is the least suspicion. Pathological processes can often be difficult to diagnose clinically in the early stages, so that the practitioner can only prescribe pain relief. In cases such as these where it is not yet possible to arrive at a diagnosis, treatment of dysfunctions using today’s techniques involves no more risk than analgesics, which are indeed more likely to produce undesired side effects. The regular follow-up examinations given to patients during therapy mean that the warning comes from the course of the disease; the practitioner should be alert to warning signs such as repeated relapses, persistent failure of therapeutic measures to achieve much effect, and deterioration in the patient’s condition. However, it would be a mistake to overestimate the capacity of the test procedures used for these examinations. The practitioner should carry out testing directly after treatment to check the immediate effect; but it is wrong to suppose that a favorable finding, indicating success at this immediate stage, can be any proof that pathomorphological processes are not present. Even where there is pathomorphological disease, dysfunctions can develop and feed the symptoms at the moment when we are administering therapy. These may include restrictions and TrPs which it is quite legitimate to treat. This is an appropriate point to describe typical sources of error and how they can be avoided. If, despite repeated treatment and self-treatment, restrictions and identical TrPs repeatedly occur in the same segment, the cause is either internal disease in a location corresponding to that segment, or a correspondingly located tumor or other pathological
Diagnosis of dysfunctions of the locomotor system
process in the region of the spinal column. For example, in a young patient, recurrence of a sacroiliac restriction, if bilateral, suggests sacroiliitis. Recurrent back pain in postmenopausal women, especially if it occurs following physical stress, suggests osteoporosis.
4.21.2 Case studies Case study 1 A. F., carpenter, born 1915. This patient underwent surgery in 1959 for a painful tumor on the left thenar eminence, and for a Dupuytren’s contracture of the fourth finger on the left hand. In 1959, he began to experience pain in the back of the neck, with stiffness. The pain became increasingly severe and the patient was admitted to a neurological hospital at the beginning of 1961. A contrast study of the spinal column (myelography) yielded no particular findings, and the patient was therefore referred to us for manual therapy in May 1961. By the autumn of that year he had received treatment four times, and each time the success was only temporary. Despite the absence of neurological symptoms, and simply on the basis of the course of the illness, we recommended that the contrast investigation be repeated. On readmission to the neurological hospital in October 1961, the patient was found to have stiffness of the neck and he was holding his head in a fixed position slightly bent forward and permanently rotated to the right. Erb’s point on the right was tender to pressure, as were the spinous processes of C2–C4. Mobility of the head was restricted in all directions, but especially left rotation. The one other finding was a static, evidently functional, tremor of the right hand. Pneumomyelography after injection of 30 ml of air by the lumbar route, with the patient sitting and the head in maximum anteflexion, showed a well-defined tumor at C2. Cerebrospinal fluid albuminocytological dissociation was found. Symptoms of a radicular lesion at C8 appeared for the first time following the pneumomyelography. This striking finding led us to a diagnosis of neurinoma at C2, partially intradural and located on the ventral aspect of the cord. The patient underwent operation and a neurinoma of the spinal root of C2 was removed. The unbearable pain subsided immediately following the operation. The conclusions to be drawn apply not only to other sections of the spinal column but also to restrictions in the craniocervical region with forced attitude of the head in the case of brain tumors with an occipital pressure cone; this behaves like an extramedullary tumor.
Chapter 4
Case study 2 F. M., born 1914. This female patient was an unskilled worker. From September 1961 she complained of occipital headaches, repeatedly accompanied by vomiting. She was examined as an outpatient at the neurological hospital in November 1961, when cervicocranial headache was diagnosed. Manipulation was performed and brought instant relief from the pain, lasting about a month. At the follow-up examination at the end of December 1961 there was intense pain at the nape of the neck and the spinous process of C2 was tender to pressure. This time, manipulation brought no relief; injection of procaine at the pain point was then tried, also without success. At the next follow-up examination in mid February 1962 the patient was holding her head in a forced attitude in anteflexion and inclined to the left. Passive mobility testing of the head did not find any typical restriction, but merely found resistance; overcoming this produced a reaction of nausea. This suggested forced attitude of the head as a result of increased intracranial pressure. Plain film X-ray of the head showed signs of increased intracranial pressure at the sella turcica. On hospital admission on 21st February 1961, the patient was entirely symptom free and the neurological findings and electroencephalogram (EEG) were normal. However, pneumoencephalography showed an occipital pressure cone. Only a very small amount of the air entered the third ventricle, and showed it to be displaced to the left. This finding led the hospital to perform angiography of the right internal carotid, which revealed a vascularized tumor in the right parietal region, located parasagittally and suspected to be a meningioma. Only after the pneumoencephalography did the beginnings of papilledema and slight disturbance in the EEG become evident. The patient underwent surgery in mid May 1962, and a falx meningioma of the right parietal region was removed. In this case an occipital pressure cone initially caused a very ordinary cervicocranial syndrome that responded well to manipulation. Later came the development of the forced attitude, and it was important for the manual practitioner to distinguish this from restriction (the typical hard end-feel is absent).
A restriction that is not resolved either spontaneously or in response to treatment, and/or relapses within a short time, suggests visceral disease in the corresponding segment, or a tumor.
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4.21.3 Common differential diagnoses Acute pain Chronic, relapsing symptoms are not the only type to give rise to differential diagnostic decisions; acute pain is another. This is especially so if the pain appears following accidents, and manual techniques can also be used to deliver first aid. The practitioner not only needs to be able to exclude fractures and dislocations, but also torn ligaments and joint capsules, hematomas, etc. Acute pain at the back of the neck, occurring together with severe headache, can be the result of subarachnoid hemorrhage. Since this is not a joint disturbance but an acute meningeal syndrome, the movement direction that is restricted is not rotation or side-bending but anteflexion of the head.
Herniated disk In the case of pain in the lumbar region, perhaps the most frequent question that needs to be asked is whether there is disk herniation. This problem is dealt with in more detail in Sections 7.1.5 and 7.8.2.
Psychosomatic disorders In patients whose main concern is pain, the practitioner very frequently has to decide to what extent psychological factors play a role; every instance of pain is also a psychological experience. Understandably, medical practitioners base their approach on the presence or absence of clinical signs in a condition that the patient describes as painful. Unfortunately, few doctors have the relevant specialist knowledge to diagnose and understand dysfunctions, which are the most frequent cause of pain. The key is this: if the patient is able to give a precise description and localization of the pain, and this information remains consistent on repeated questioning, it is unwise to dismiss it as merely psychological. In doubtful cases our guide is the course of the illness, based on observation over time and knowledge gained of the patient. These enable us to compare the clinical findings, and the changes that take place in them, with the patient’s own statements. In contrast, if the patient finds it difficult 164
to describe or localize the pain at all precisely, and there are frequent changes in the patient’s statements, it is likely that the pain is (mainly) of psychological origin.
Masked depression The problem posed by masked depression is an important one because it can indeed take the outward form of back pain and headache. This is because psychologically caused tension and tense posture do actually bring about painful dysfunctions, especially in the orofacial system and cervical region, and at the coccyx as a result of tension of the gluteal muscles and pelvic floor (levator ani). The diagnosis is hard to establish at the first examination; during the course of treatment it is found that after a short while the patient complains of fresh pain, and tension is found at the locations described. This should be a cue to ask targeted questions about whether the patient feels depressed or has experienced sorrow in the past. The most important question to ask is whether the patient suffers from disturbed sleep; the typical pattern of sleep disturbance is for the patient to fall asleep normally, but to wake in the (very) early hours of the morning and be unable to go back to sleep. A conclusive diagnosis is obtained by test prescription of mild antidepressive drugs.
Fibromyalgia syndrome There is an essential distinction to be made between muscle pain that occurs in most cases of back pain in the form of TrPs on the one hand, and fibromyalgia syndrome, which has been much explored in the literature. This is a chronic systemic disease affecting mainly women. The painful muscles are found bilaterally; they are numerous, and not confined to the trunk, but also found on the limbs. The pain is accompanied by fatigue, and there is morning stiffness similar to that in rheumatoid arthritis. Patients suffer from sleep disturbance, especially of non-REM sleep. The combination of chronic pain, fatigue, and sleep disturbance is associated with a mood of depression. On palpation, the muscles that are painful either behave like TrPs or feel hypotonic and doughlike. Tenderness in hypotonic muscles is a particularly characteristic finding in this disorder. The laboratory findings are not characteristic and the pathogenesis unknown. The cause is thought to
Diagnosis of dysfunctions of the locomotor system
lie in a lowering of the pain threshold in the central nervous system. Mild antidepressants and carefully judged physical exercise are recommended as treatment. In our experience, there is some benefit in light massage that the patient experiences as pleasant, administered over fairly long periods of time. The usual analgesics are not very effective.
Inflammatory conditions Inflammatory conditions also play a role. Rheumatoid arthritis is usually not difficult to recognize. This does not generally tend to affect the spinal column as often as it does the limbs, but this very fact makes it important to be aware of inflammatory, destructive lesions in the region of the atlas and axis. For this reason, where vertebrogenic symptoms appear in patients with existing rheumatoid arthritis, an X-ray should be performed. Another condition that should particularly be borne in mind is ankylosing spondylitis. This should be considered in cases where the patient’s symptoms first occurred around the age of 20, from then on taking a progressive course without lasting periods of remission. Characteristically patients report pain at night, which regularly wakes them at the same time in the very early hours of the morning and forces them to get up and move about. The first clinical sign is generally recurrent sacroiliac restriction, often bilateral. The restriction soon extends to the entire lumbosacral segment, then to rotation of the trunk, and especially stiffening of the thoracic cage, where springing pressure elicits no springing. Consequently there is clavicular breathing and exaggerated abdominal breathing. Laboratory findings are also important in the diagnosis of this condition. One such finding is the HLA-B27 antigen, which suggests a hereditary cause. The radiological findings are also significant; a positive finding in the X-ray of the sacroiliac joints
Chapter 4
shows the contours of the joints as ill-defined. In the early stages the joint space is widened, but later it may be ossified. On the spinal column, syndesmophytes develop and bridge the intervertebral disks, so that in the fully developed stage the anteroposterior film shows the spinal column as looking rather like a stick of bamboo. Typical as these radiological changes are, they may be absent. Diagnosis is especially difficult in female patients, because the disease often follows a milder course which does not then lead to stiffness. In males, progressive stiffness, gradually extending in the cranial direction, is the rule. This development can occur largely painlessly, in which case the impression is given that the disease did not begin until around age 40 or even later. The consequences are particularly severe for patients in whom the disease develops in the hip joints. In the early stage it is mainly the palpation findings that are characteristic. This fact makes it difficult to achieve early diagnosis, and calls for practice.
4.21.4 Conclusions Perhaps the main point to be made in conclusion is that diagnosis of dysfunctions of the locomotor system is a new field of clinical medicine, and a difficult one. In differential diagnosis we need to be aware that in most cases, including structural changes, the earliest clinical manifestation takes the form of disturbed function. Moreover, patients referred for pain due to ‘mere’ disturbed function are usually dealt with as outpatients, who cannot be examined as thoroughly as those in a hospital ward, where the technical facilities available are also greater. The practitioner in charge of such cases must remain constantly aware of the innumerable pitfalls; nothing is more dangerous than a sense of infallibility. This section on differential diagnosis should also serve as a warning.
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Chapter Five
Indications for and principles underlying individual treatment methods
Chapter contents 5.1 Manipulation . . . . . . . . . . . . . . . 168
5.1.1 Indications . . . . . . . . . . . . . 168 5.1.2 Contraindications . . . . . . . . . 169 5.1.3 Traction . . . . . . . . . . . . . . . 170 5.2 Soft-tissue manipulation . . . . . . . . . 171
5.2.1 Skin stretching . . . . . . . . . . . 171 5.2.2 Stretching a soft-tissue fold (connective tissue) . . . . . . . . . 171 5.2.3 Application of pressure . . . . . . 171 5.2.4 Restoration of deep tissue mobility 171 5.2.5 Treatment of (active) scars . . . . . 172 5.2.6 Relaxation of muscles . . . . . . . 172 5.3 Reflex therapy . . . . . . . . . . . . . . 172
5.3.1 Massage . . . . . . . . . . . . . . 5.3.2 Exteroceptive stimulation . . . . . 5.3.3 Local anesthesia – needling . . . . 5.3.4 Electrical stimulation . . . . . . . . 5.3.5 Acupuncture . . . . . . . . . . . . 5.3.6 Soft-tissue manipulation versus reflex therapy . . . . . . . .
172 173 173 174 174 174
5.4 Remedial exercise . . . . . . . . . . . . 175 5.5 Treatment of faulty statics . . . . . . . . 176 5.6 Immobilization and supports . . . . . . . 177 5.7 Pharmacotherapy . . . . . . . . . . . . . 178 5.8 Surgery . . . . . . . . . . . . . . . . . . 178 5.9 Lifestyle . . . . . . . . . . . . . . . . . . 178 5.10 The course of manipulative treatment . 179 5.11 Conclusions . . . . . . . . . . . . . . . 180
5
The indications for a particular treatment method should be established not only on the basis of the clinical diagnosis but also following an analysis of the pathogenesis so as to identify which lesion is most important at a given moment and is therefore likely to be the most effective object of therapy. Every therapeutic action should therefore result from a fresh examination, to keep up to date with the ongoing development of the patient’s condition. In this setting it is of the utmost importance to identify chain reaction patterns of dysfunctions and to pinpoint the most relevant link in the chain. In establishing the indications for a particular treatment, it follows that no therapeutic intervention should be applied before examination of the patient has been completed and the findings have been meticulously analyzed. If therapy is determined according to the principles set out here, it is likely to be effective and the condition of the patient should be found to have changed at follow-up examination. If the patient’s condition is unchanged, treatment was not adequate and should (generally) not be repeated. Critical assessment of the preceding treatment and ongoing audit and review are essential here. To reiterate: this is primarily a question of analyzing the factors contributing to the pathogenesis and not simply of conventional clinical diagnosis. This attitude rules out an indiscriminate routine approach (e.g. ‘a series of intradermal injections’ or ‘a series of infiltrations’), presupposes critical assessment of any preceding treatment, and thus also enables the treatment program to be corrected in light of the results obtained with preceding treatments (evidence-based strategy).
Manipulative Therapy
5.1 Manipulation 5.1.1 Indications Manipulative treatment is indicated if there is functional movement restriction (a pathological barrier) of a joint or spinal motion segment, and if this is considered relevant to the patient’s symptoms. In this setting, too, it should be emphasized that the decisive factor is not the clinical condition as such or even the clinical diagnosis (headache, dizziness, low-back pain), but rather the importance of the movement restriction for the pathogenesis. Once this concept has been fully grasped, definition of the action required in spondylosis, disk herniation, osteoporosis, or ankylosing spondylitis is a straightforward matter: these conditions in themselves do not form the object of manipulative treatment. Nevertheless, if it is felt that movement restriction is a factor in patients with these diagnoses, then the restriction should be treated with a manipulative technique that is appropriate in the given circumstances. Given the questionable importance of spondy losis for the pathogenesis, it is highly probable that diagnosis of a movement restriction will be the key finding. In disk herniation, concomitant movement restri ction may often cause the patient’s condition to deteriorate considerably and in such cases manipulation can be very successful. While it is far from easy to predict a successful outcome, it is always worth making an attempt with an appropriate technique. Scoliosis is certainly not an object for manipulation, as in itself the condition does not usually cause pain. If a patient with scoliosis feels pain, and movement restrictions are diagnosed, these are far more likely to be the cause of that pain and should be treated. Manipulation is indicated if movement restrictions interfere with remedial exercise. In both osteoporosis and juvenile osteochon drosis, stiffness (leading to immobility) will cause the patient’s condition to deteriorate. Adequate gentle mobilization techniques are therefore indicated to restore mobility. Spondylolisthesis and basilar impression cannot be influenced by manipulation, but in clinical terms they are more often than not symptom-free. Here, too, dysfunctions associated with movement 168
restrictions can be, and frequently are, the true cause of discomfort. In ankylosing spondylitis, movement therapy is indicated, and therefore (self-)mobilization tech niques are also appropriate; these have to be applied, however, to those segments that still show some degree of mobility. The reason why manipulation may be regarded as safely indicated in all these patient groups is that the methods advocated in this book are extremely gentle and very effective neuromuscular mobilization techniques. They utilize the inherent muscle forces of the patient rather than those of the practitioner; indeed the practitioner tends to function more in a ‘directorial’ capacity, instructing the patient what to do and frequently allowing the patient to perform self-treatment.
High-velocity, low-amplitude thrust techniques After gentle mobilization has been performed, the experienced practitioner will sometimes sense that the effect is still not entirely satisfactory; for example, a segment may still not be completely freed from several neighboring segments or, despite a measure of improvement, an area remains that still requires treatment. Preceding mobilization ensures that such a segment is well-prepared for a high-velocity, low-amplitude (HVLA) thrust. Following the work of Mierau et al (1988) we know that use of HVLA thrust techniques is followed by temporary hypermobility, and that a very intensive reflex response characterized by hypotonus or reduced muscle tone is achieved, which can be beneficial in radicular compression or entrapment syndromes (e.g. carpal tunnel syndrome). HVLA thrust techniques should be delivered with a minimum of force, and the cracking or popping sound within the joints should never be ‘enforced’ by the practitioner. If the segment has been well prepared for a thrusting maneuver, then the technique should succeed with consummate ease. This also applies to the situation in children who are too young to cooperate; here it is important to exploit the precise moment when they are relaxed. However, this presupposes excellent technical skill. In this connection it is worth quoting Stoddard’s (1961) system of recording degrees of joint mobility (Figure 5.1, Table 5.1).
Indications for and principles underlying individual treatment methods
Figure 5.1 • Schematic diagram for recording the
degree of movement restriction (Stoddard’s system). The degree of restriction is indicated in the various directions: 1 for side-bending and rotation to the right; 2 for retroflexion and rotation to the left. Hypermobility is indicated by the use of an arrow labeled with the number 3 and extending beyond the perimeter of the circle.
5.1.2 Contraindications The major technical advances achieved in the field of manual medicine in recent years have brought about a sea change specifically in the area of indica-
Table 5.1 Stoddard’s classification of joint mobility
Classification
Description
0
No mobility, ankylosis, not suitable for manipulative treatment
1
Severe movement restriction, only mobilization techniques to be applied
2
Slight movement restriction, both mobilization and thrust techniques can be used
3
Normal mobility, best left alone; however, if there is movement restriction in one direction, a thrust technique in the free direction can be useful (Maigne)
4
Hypermobility, all types of manipulative treatment should be avoided
Chapter 5
tions and contraindications. The situation can now be summarized concisely as follows: there is no real contraindication to manipulation and no possibility that patients will be harmed by it. What is contraindicated, however, is poor technique. Nowadays the basic approach comprises mobilization with neuromuscular techniques that primarily make use of the patient’s inherent muscle forces. This would be like forbidding the patient any spontaneous movements. HVLA thrust manipulation is employed to a very limited extent only and the ground is generally thoroughly prepared beforehand using mobilization techniques. The following cardinal errors must be avoided: • Over-frequent use of HVLA thrust techniques. • Delivering an HVLA thrust before the patient is properly relaxed and before the slack has been taken up. • Trying to enforce manipulation of any type against protective muscle spasm or in a direction that causes pain. • Performing cervical manipulation in retroflexion, side-bending, and rotation with traction, especially in cases where the patient does not tolerate this position. • Repeating HVLA thrusts at short intervals (i.e. of less than two weeks); in this context, even over-zealous examination of mobility in a painful direction may be contraindicated. In the debate surrounding contraindications, repeated reference is made to serious incidents and even fatalities, such as those reported by Dvorák & Orelli (1985), Grossiord (1966), Krueger & Okazaki (1980), Lorenz & Vogelsang (1972), and cited in the memorandum issued by the German Association of Manual Medicine (1979). Basing their calculations on the results of a questionnaire sent to members of the Swiss Association of Manual Medicine, Dvorák & Orelli (1985) computed the number of serious complications after manipulation (thrust techniques) to be 1:400 000. By far the most important cause of serious complications is undoubtedly injury to the vertebral artery, the wall of which may split longitudinally. Given the low incidence of vertebral artery damage and the rarity of such incidents, more recent publications (up to 2004) have suggested that these findings may be coincidental. Unfortunately, an almost constant feature of the literature cited is a failure to specify the particular technique that was held responsible for the complications in question: this is rather like discussing 169
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postoperative complications without giving details of the surgical technique used. One exception, however, is the publication by Dvorák & Orelli (1985), which includes the following highly characteristic account:
Case study A 35-year-old woman collapsed while attending a funeral and suffered from wry neck for three weeks afterward. Within the space of a few days she underwent HVLA thrust manipulation three times, administered by a qualified, experienced chiropractor. The patient was supine and manipulation consisted of passive rotation, reclination, and sidebending of the head. This was followed immediately by a short period of unconsciousness and later by tetraplegia. The patient was extubated after mechanical ventilation for 36 hours and administration of dexamethasone. After four months the patient was symptom-free apart from slight unsteadiness of gait. HVLA thrust techniques in acute wry neck are questionable in themselves, but to use the dangerous combination of ‘rotation, reclination, and sidebending’ is to court disaster. Another grave error was to repeat the thrusts in quick succession within the space of a few days because the patient’s condition did not show any improvement. In the few instances where detailed case reports are available, serious complications have indeed occurred most frequently when HVLA thrust techniques are repeated within a short space of time.
It should be emphasized here that HVLA thrust techniques are inappropriate for painful and severe movement restrictions, even if several adjacent segments are involved simultaneously. In such cases, HVLA thrusts are not only traumatizing but also ineffective, whereas neuromuscular techniques have proved outstandingly beneficial. For this reason, HVLA thrust techniques hardly ever form the initial component of therapy. The following contraindication may be inferred: if it is a mistake to perform thrust manipulation in the painful direction where there is major movement restriction, then use of this technique is also contraindicated where pain and gross movement restriction are present in all directions. In reversible functional movement restrictions, a distinction is made in any case between the direction of restriction and the direction of ease; movement restriction in all directions does not suggest dysfunction and therefore does not constitute an indication for manipulation. 170
For obvious reasons, manipulation of any kind is out of place in hypermobility. While this does not mean that no movement restriction should be treated in a hypermobile patient, it would be better to avoid thrust techniques because temporary hypermobility always follows any thrust maneuver. Other contraindications include destructive condi tions of an inflammatory or neoplastic nature. It is clear that no one would try to treat this type of pathology by manipulation; unfortunately, particularly in the initial stages of such conditions, diagnostic error is often unavoidable. The specialist usually sees such patients in hospital, at a later stage, when the putative diagnosis has already become clearer. Nevertheless, with modern-day techniques, these patients should come to no more harm than from the administration of analgesics. If, in a case of diagnosed tumor pathology, coexisting movement restriction is considered harmful to the patient’s condition, there is no reason why such a restriction should not be treated with an appropriate technique (see Case study 2 in Section 4.21.2). While working at the neurology clinic in PragueVinohrady, I deliberately gave manipulation at the craniocervical junction to a patient with a decompensating acoustic neuroma; he was then able to be referred to the neurosurgery clinic in a wellcompensated state. It is regrettable that a vertebral artery syndrome is considered to be a contraindication in this setting. Admittedly, treatment must only ever be given in a direction that is well tolerated, but there are few disorders where restrictions involving the craniocervical junction are more disastrous.
5.1.3 Traction Traction is essentially a form of mechanotherapy or manipulation, but unlike other methods of manipulation it is generally accepted in traditional medicine. Within the framework of manipulative techniques, traction of the cervical and lumbar spinal column has a specific role in radicular compression syndromes in those spinal regions and in disk herniation. In fact, traction can also be useful for diagnosis: if it relieves discomfort in the lumbar region, then the diagnosis of a herniated disk is corroborated. Traction is also indicated in acute wry neck and low-back pain. One important point must be emphasized, however: it is essential first to establish in each case
Indications for and principles underlying individual treatment methods
whether experimental traction brings the patient any relief. If no relief ensues, we must first seek to modify the technique so that discomfort is alleviated, and then desist if traction still fails. One reason for the failure of traction is restriction of movement, either at the craniocervical junction or in the lumbar spine. Once this restriction has been released, traction is often well tolerated, provided that it is implemented gently and with technical skill, preferably by hand.
5.2 Soft-tissue manipulation Soft tissue, in particular the deeper layers including the fascia and connective tissue, is intimately connected with the locomotor system, muscles, and joints. It is the function of soft tissue to be stretchable while yet able to resist stretch, and to be capable of being shifted while yet able to resist shifting. All this should take place in harmony with the locomotor system and may involve considerable ranges of movement. The same also applies for the viscera: there are no standard measures whatsoever for the degree to which the internal organs may also move. Changes in soft tissue have usually been considered to be reflex changes, that is secondary changes. This is not always the case, however, particularly in the chronic stage of painful conditions, and in endocrine and metabolic disorders. The tissue changes then form what is termed a ‘terrain’ (or constitutional factor). Clinically, a physiological and a pathological barrier can be detected in all soft tissue: both types of barrier constitute a possible indication for therapy, enabling disordered function to be corrected in precisely the same way as in restricted joints. If the soft-tissue changes are significant, they produce reflex inhibition of the locomotor system; it is then advisable to treat such softtissue lesions before performing joint mobilization, as the treatment itself may have a considerable mobilizing effect.
5.2.1 Skin stretching This technique is specific for hyperalgesic zones (HAZs). It has an effect similar to that of Kibler’s skin-fold rolling test (1958) and of connective tissue massage as advocated by Leube & Dicke
Chapter 5
(1951). However, it is absolutely painless and may also be used by the patient for self-treatment. The technique can also be applied to very small skin areas, such as the skin fold between fingers or toes, where HAZs may develop, especially in radicular syndromes radiating to the fingers or toes. HAZs are a useful sign of a radicular lesion and their treatment can be highly effective. Examination usually starts with a test for skin drag by gently stroking the skin surface with a fingertip. Skin drag in a HAZ is heightened due to increased moisture (sweating) and so permits rapid identification of the area where skin stretching should be performed.
5.2.2 Stretching a soft-tissue fold (connective tissue) The deeper layers of connective tissue can be folded and, after the barrier has been engaged, stretched. This technique is particularly effective for treating short or taut muscles and scars. The fold can be formed between the fingers or sometimes between the full length of the lateral edges of both hands. Stretching should never involve compression. Once the barrier is engaged, release is obtained spontaneously.
5.2.3 Application of pressure In cases where a tissue fold cannot be formed, the application of very light pressure can obtain tissue release. The pressure applied is just sufficient to sense the moment of increased resistance when the barrier is engaged. After a brief latency period, the resistance disappears and the practitioner’s finger spontaneously sinks more deeply into the tissue. This method is especially effective for deep-lying trigger points (TrPs) and scars, particularly in cases of painful resistance in the abdominal cavity.
5.2.4 Restoration of deep tissue mobility Where there is a pathological barrier, restriction of fascial mobility against bone is a characteristic finding, and restoration of normal mobility is indicated. As with fascia, this also applies to the scalp and its mobility against the underlying bone, to 171
Manipulative Therapy
the soft-tissue pad at the heel, and to the mobility of adjacent bones connected mainly by soft tissue, such as the metacarpal and metatarsal bones and the fibular head with the tibia. The situation is similar with regard to the mobility of subperiosteal tissue in painful periosteal points found especially at the attachments of tendons and ligaments. In most instances these are chronic changes to which the term ‘dystrophic’ may be applied, even though they may be reversible in functional terms.
5.2.5 Treatment of (active) scars Scars are located chiefly in the soft tissue, involving all its layers. Where healing is uncomplicated, a scar will be asymptomatic and all the layers involved will stretch and shift like those in the surrounding tissue. However, if healing is not straight forward, but more frequently for no apparent reason, many years later, a scar may become active in stressful situations and may even recurr after successful treatment. Examination will disclose resistance in some or all of the tissue layers penetrated by the scar. Such a scar is termed ‘active.’ Pathological barriers will then be found in all soft-tissue layers, and the patient will report pain when these are examined. Because a scar generally passes through several soft-tissue layers, it can be a particularly rich source of pathology, causing dysfunctions of muscles and joints. The process of scar examination begins with a test for skin drag, often the most rapid guide as to what is happening. However, the diagnosis can also be difficult. Following surgery the operative field may (for esthetic reasons) be at some distance from the surface wound. Because surgery is often performed only by laparoscopy or with a laser, it is frequently necessary to rely on findings elicited by deep palpation. The same is true for internal injuries without surface scarring, for example following a difficult childbirth. In this setting (compared with the situation in organic disease), palpation of the release phenomenon is of major diagnostic significance. Typically, the diagnosis here can be helped by the finding that locomotor symptoms had their onset shortly after surgery or trauma. Undiagnosed active scars cause problems that keep recurring until they have been treated; however, their treatment can bring surprising successes, described by their discoverer Huneke (1947) as the ‘instant relief phenomenon.’ Huneke himself 172
injected novocaine into scar tissue and attributed the resultant effect to this intervention. However, simple needling yields the same result. Nevertheless, therapy using soft-tissue techniques is far more precise because it is based on the diagnosis of all scar layers. The term ‘instant relief phenomenon’ emphasizes not only the immediate effect but also the fact that all symptoms disappear with a single intervention. This is generally over-optimistic; the soft tissue in the vicinity of a scar often requires repeated treatment, and not infrequently the scar is just one of a larger number of factors in the pathogenesis. It may itself also be prone to recur.
5.2.6 Relaxation of muscles Post-isometric relaxation (PIR) is the specific therapy for muscle tension with or without TrPs. Here, too, the first step is to take up the slack by lengthening the muscle so as to engage the barrier. This method, which will be described in detail in Section 6.6, has a similar effect to the spray and stretch method of Travell & Simons (1999) and is effective not only on TrPs in muscle, but also on the points where tensed muscles attach to the periosteum, and on referred pain in particular. PIR is painless and is suitable for use in a self-treatment setting. We routinely combine it with reciprocal inhibition (RI) achieved by antagonist stimulation. It should be emphasized here that the vast majority of TrPs can be treated via reflex mechanisms merely using minimal pressure and generally in the context of chain reaction patterns. However, chronic TrPs do exist; these need to be diagnosed and then treated with painful needling or with hard ‘traumatizing’ massage.
5.3 Reflex therapy This acts on the same structures as soft-tissue manipulative therapy, but is generally less specific and is consistent with the traditional methods employed by physical therapists.
5.3.1 Massage This term covers a broad spectrum of techniques that have developed from time immemorial; massage can be used to treat soft tissue and even periosteum. From the clinical standpoint, it should be used when
Indications for and principles underlying individual treatment methods
and where changes are found in the tissue, changes that manifest themselves primarily as altered tension. The experienced massage therapist will adapt the technique to these changes so as to release tension in the tissues where it is detected, and to bring relief. Deep massage may be applied to the periosteum, but this is painful. There are also some TrPs that do not respond to reflex methods and that require deep friction, a certain degree of traumatization. Bearing this in mind, it would seem that massage is a universal method that is potentially applicable in all reflex changes produced by pain (or nociceptive stimuli); and indeed that is the case. Massage is pleasurable, routinely brings relief and is therefore also very popular with patients. Unfortunately, the effect is usually only short-lived, whereas the procedure is very time-consuming. At the same time, some massage techniques can be quite painful. Massage is invariably a purely passive form of treatment, demanding no active involvement whatsoever from the patient. For this reason massage is indicated only as a preparation for other, more specific and hence more effective treatment modalities, and is not the therapy of choice for locomotor system dysfunction. The term ‘reflex massage’ is also used occasionally. It is sufficient to point out that any massage, any palpatory activity, triggers a reflex, depending on the tissue that is being massaged.
5.3.2 Exteroceptive stimulation Although this method does not exploit the barrier phenomenon, it is nevertheless appropriate for inclusion here because it is a manual method that is used in a targeted manner in response to specific findings. It is based primarily on stroking, which is indicated in circumstances characterized by minor changes in tactile perception. From a purely theoretical standpoint, afferent conduction is the prerequisite for control by the nervous system. Exteroceptive stimulation is one of the few methods to take account of this. It is used not for gross neurological disorders, but merely for dysfunctions that are comparable to a HAZ. These dysfunctions are most clearly evident on the soles of the feet where an asymmetrical response to stroking or brushing is often observed and patients also confirm that they are aware of the difference. With greater experience it is possible to discern that changes in muscle tone are also
Chapter 5
consistent with minor asymmetries in tactile perception. These asymmetries can be corrected by stroking. However, the practitioner must be able to sense the reaction during stroking. Stroking (our preference is to trace numbers and letters – proprioception) in asymmetric tactile perception on the soles of the feet is so effective that it is invariably indicated, and is performed on the side that is considered abnormal.
5.3.3 Local anesthesia – needling Local anesthesia and needling are among the most widely used methods of treating painful lesions. It may appear unorthodox to deal with these two methods together, and yet it should be recalled that one does not simply use local anesthetics to relieve pain for the short period during which the anesthetic has effect. The popularity of local anesthesia is due to the fact that its effect far outlasts the direct (pharmacological) action of the anesthetic. It has further been shown that the effect appears not to be dependent on the local anesthetic injected. In fact, Kibler (1958) used sodium bicarbonate, and Frost et al (1980), in a double-blind study, compared the effect of mepivacaine injections with that of physiological saline injections in the management of myofascial pain. It was shown that, if anything, physiological saline solution was more effective than the local anesthetic. The common denominator in all these methods is, of course, the use of the needle. The effect, however, does appear to depend very much on how precisely the needle touches the pain point. Needling is most effective when the needle is able to reproduce the patient’s spontaneously reported pain and its radiation pattern. In the case of TrPs, a twitch response should be provoked wherever possible, whether a local anesthetic is used or not. If the exact spot is successfully located, then analgesia can be produced immediately simply with a dry needle (Lewit 1979), both at TrPs and at other pain points. Injection of local anesthetics is, of course, necessary if the intention is to interrupt conduction in nerve structures, for example in nerve-root infiltration or epidural anesthesia. One special method of using local anesthetics is to raise intradermal blebs, although this technique is advisable only where administration is within a HAZ. Here, too, it is immaterial whether the bleb is produced using a 173
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local anesthetic, physiological saline, or distilled water (although the latter is more painful). It is interesting that, just as after manipulation (so, too, after successful needling or local anesthesia), the immediate relief obtained is often succeeded by a painful reaction lasting for a period of hours, or one or sometimes two days. It is only after this reaction has subsided that the therapeutic effect proper becomes established. For this reason such treatment should not be repeated before seven days have elapsed. Repetition is indicated if improvement has been achieved but there is still some residual pain.
5.3.4 Electrical stimulation This category includes a variety of methods that ultimately act on the same receptors and therefore produce comparable effects. Pain can be alleviated by reflex mechanisms in response to electrical impulses, diadynamic current or transcutaneous stimulation and many other similar modalities. They compete successfully with more traditional methods such as poultices, cupping, leeches, etc. All these methods, especially if they are used relatively gently, can help to alleviate pain.
5.3.5 Acupuncture This discussion of reflex therapies must touch briefly on acupuncture, one of the most venerable modalities in this category. Considerable difficulties arise the moment we attempt closer analysis of its mode of action. According to the orthodox view, acupuncture treatment is based on organ diagnoses and less on principles of pathogenesis, although some modern authors (Bischko (1984), for example) concede that acupuncture works primarily in cases of disturbed function rather than in structural pathology. The choice of acupuncture points is based on ‘meridians’ and is entirely empirical. From a theoretical standpoint, the most questionable issue surrounds the concept of ‘energies’ that are not at all susceptible to measurement. For scientific analysis, therefore, it will be necessary to examine the individual constituent elements that go to make up the system of acupuncture. One such element is the effect of needling: this was confirmed as medically effective in an older publication by Travell & Rinzler (1952), and I 174
myself (Lewit 1979) described the ‘needling effect’ in 312 pain points in 241 patients. There would seem to be sufficient clinical evidence to support the efficacy of this treatment. There appears to be a growing tendency among modern Chinese doctors to select their needle insertion points not only according to the traditional ‘meridians,’ but also on the basis of the segmental anatomy of innervation. Instead of needling, electrical stimulation has also been introduced (Chang 1979). Melzack et al (1977) have pointed out important analogies between the TrPs of Travell & Rinzler (1952) and traditional acupuncture points. Gunn et al (1976) found that of 100 acupuncture loci chosen at random, 70 were motor points in muscles. Other acupuncture loci are attachment points of tendons and ligaments; if these are tender, they can be treated by performing PIR on the muscles for which they serve as attachment points – for example the fibular head (TrP of biceps femoris or by mobilizing the fibular head), or the che-gu (4 equ L14) acupuncture point by PIR of the adductor pollicis brevis. Patterns of chain reactions (see Section 4.20) help us to understand functional relationships based on physiological principles and thus might provide a rational explanation for the phenomenon of ‘meridians.’ Careful examination often reveals that many acupuncture points can be tender at palpation and that increased tension can be felt at these sites. This is borne out, too, by the measurement of reduced electrical skin resistance in the vicinity of acupuncture points. A rational, scientific attitude to acupuncture is important because it might enable us to establish the indication more precisely in the context of dysfunctions; it would then be possible to identify those circumstances where acupuncture might be the treatment of choice.
5.3.6 Soft-tissue manipulation versus reflex therapy Soft-tissue manipulation techniques act on the same structures that are the targets for most other methods employed in physical (reflex) medicine. Technically, they are based on the diagnosis and correction (release) of a pathological barrier and thus form part of the canon of manual therapy. There is one fundamental difference between the human hand and all the other instruments at
Indications for and principles underlying individual treatment methods
our disposal: it provides us with information about the processes unfolding at every stage of therapy and offers feedback so that we can continually correct or modify our approach. Once the barrier has been engaged and release has been pursued to the very end, we can sense how the tension dissipates, and we then know that the patient’s pain has subsided – at least at the site in question. The difference between massage and soft-tissue manipulation is primarily that massage, with its relatively rapid rhythmic movements, does not take precise account of the barrier and release phenomenon. Despite the rapid movements involved, massage is far more time-consuming, diagnostic criteria are often lacking, and self-treatment is not really possible.
5.4 Remedial exercise Having discussed the indications for methods that are intended to act directly on painful dysfunctions, we will now turn our attention to methods targeted at the more complex functions. In this setting, remedial exercise has a prominent role to play. Two essentially different types of remedial exercise should be distinguished. In the first type, patients learn to use their own muscles to restore joint mobility, to relax their own TrPs and also to treat soft-tissue parts that they can reach themselves. These techniques will be described systematically in conjunction with the corresponding manual therapy techniques. The second type of remedial exercise is intended to correct faulty movement patterns (or stereotypes), which are associated with muscle imbalance and are frequently the true cause of painful dysfunction. The object of remedial exercise in such cases is to correct a faulty movement pattern that has been diagnosed and is considered relevant to the patient’s problem. Without this diagnosis of a faulty movement pattern and subsequent assessment of its relevance in terms of the pathogenesis, remedial exercise is simply a frustrating waste of time. It should be the role of the physician to make this diagnosis and assessment. The technical aspects are then the domain of the physiotherapist. A physician who is able to establish the correct indication for remedial exercise should also be able to assess the effect that the physiotherapist has achieved.
Chapter 5
The first criterion for establishing the indication, namely the diagnosis of faulty movement patterns and muscle imbalance, often presents an insuperable problem in the acute stage when pain distorts all movements and it is impossible to differentiate between a pain reaction and a faulty movement pattern. Moreover, the patient is also still unable to execute any normal movement patterns. The second criterion in determining whether remedial exercise is indicated is the relevance of the faulty movement pattern to the patient’s problem. Here the decision can be more difficult, for example, than in the case of a movement restriction or a TrP, because remedial exercise is far more time-consuming and laborious. Muscle imbalances are also common in asymptomatic patients and to embark on a course of remedial exercise in every case would be most unrealistic. Remedial exercise is therefore indicated where we are satisfied that the faulty movement pattern we have diagnosed is so important that, if left uncorrected, the patient’s condition is bound to recur. Indeed, specific remedial exercise is indicated precisely to prevent these frequent recurrences. Nevertheless, there are cases where the findings are so serious that there is no need to wait for recurrences. One criterion is the degree of muscle imbalance. In other cases we must consider the circumstances that trigger recurrences: for example if they routinely occur when a patient lifts a heavy object or bends forward. In such cases we study the patient’s forward-bending movement pattern and then demonstrate the correct way to bend forward and straighten up again, also while lifting. The same is true for carrying loads, sitting at the computer, etc. However, faulty breathing patterns are the most disastrous of all because they are intimately linked with the stability of the spinal column. To make remedial exercise as effective as possible, and to make it a routine procedure, it is essential to set clear and attainable goals. This means that we should not set out to achieve ‘ideal movement patterns,’ but instead we should concentrate on the fault that is the chief cause of the recurrent problem. When we do this, it is often possible to obtain results within a short period, after a few clear instructions have been given. However, if we try to achieve more than this, then remedial exercise therapy may take months. It is also essential to recognize the limits of what is possible. Unlike manipulation or needling, remedial exercise demands the active cooperation of the 175
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patient. Some movement patterns can be so deeply ingrained that it is difficult to modify them, especially if the patient is no longer young. And the problem of motivation is a hugely important issue. If patients are not really interested in improving their condition, then any attempt at rehabilitation is a waste of time. It cannot be sufficiently emphasized, however, that the art of the good physiotherapist consists not only in technical competence but also in an ability to motivate patients. The intelligence of the patient also plays a role. Here we would do well to recall the remarks made in Section 2.6 concerning patients who, from childhood, are incapable of forming optimal movement patterns and therefore find it difficult to implement corrections. This group also includes individuals gifted with high intelligence who are virtually ‘handicapped’ the moment motor skills are called for. The patient’s general physical condition must also be taken into account: cardiac function, circulation, obesity, generally weakened abdominal musculature after repeated surgery and/or childbirth, recurrent hernias or decompensating scoliosis in old age – any of these may present insurmountable obstacles from the outset. Despite these limitations, remedial exercise should constitute the most important modality implemented by the physiotherapist for dysfunctions involving the locomotor system. The importance and effectiveness of remedial exercise have increased considerably now that we have a better understanding of how specifically to treat the deep stabilization system of the trunk and feet. This is why it is so crucial to devote time primarily to these active methods of rehabilitation and to a lesser extent to passive procedures such as massage, and the many different forms of electrotherapy. Finally, there is the question of whether and under what circumstances these remedial exercise methods can be prescribed for preven tive purposes. This is a perfectly reasonable consideration given that, in our modern technically advanced world, patterns of harm are continuously inflicted on the locomotor system from childhood. Regrettably, a solution to this problem is difficult to find, mainly because group therapy is not easy to arrange. One possible solution might be to recommend yoga techniques (e.g. breathing exercises, ‘spinal’ techniques, etc.) or methods utilized in Chinese exercise systems (e.g. Tai Chi) and certain strategies advocated in back schools. 176
5.5 Treatment of faulty statics The diagnosis of faulty statics has been described in Section 3.1 and Section 4.2. Contributing causes often include muscle imbalance and external influences (e.g. ergonomic factors), and faulty statics need to be treated accordingly. We will take the opportunity here to deal with the correction of obliquity. Obliquity in the pelvic region and in the lower part of the lumbar spine can be compensated for with corrective footwear. Because such footwear is beneficial only if it is worn permanently, prescription of this interventional measure must be approached in a purposeful and responsible manner if it is to be effective. Considerable thought must be given to ensure that such an intervention is properly indicated. The decision is relatively straightforward if obliquity is due to fairly recent trauma, for example a leg-shortening injury or unilateral compression of the lumbar spine. Unilateral (asymmetric) flat foot as a further possible indication can be best identified on examination if the patient stands on the lateral margins of both feet, causing the pelvis to become horizontal while at the same time the pelvis which deviated to the higher side returns to the mid position. However, because pelvic obliquity in most cases gives rise to secondary compensa tion during growth, the decision then becomes far more complex. In such circumstances assessment is impossible without X-ray analysis, as described in Section 3.1. Ultimately, however, the decision must also be taken on clinical grounds. Clinically, static pain is a chronic, recurring phenomenon associated with excessive static loading, primarily on standing. Examination reveals pelvic deviation toward the higher side. When a board of suitable thickness is placed under the foot of the ‘shorter’ leg, the patient’s pelvis should become horizontal and lateral deviation should also be reduced. Since X-ray images demonstrate this result much more precisely, the indication for such correction should be established on the basis of the clinical and X-ray findings before and after placing the board under the patient’s foot. It is also important to be guided by the patient’s reaction. If a thin insert about 1 cm thick is placed under the foot of a normal subject with the instruction to distribute weight equally on both legs
Indications for and principles underlying individual treatment methods
without bending the knees, the insert will cause considerable discomfort. Where pelvic obliquity is present, one of three different responses may be expected: 1. The patient may find the insert positively comfortable. 2. The patient may feel that the insert makes no difference. 3. The patient may find the insert uncomfortable. In the first case we can expect the patient to tolerate the correction well and instructions should be given to wear the insert at all times, even in indoor slippers wherever possible. In the second case a degree of adaptation may be necessary and the patient should be allowed to become accustomed to the insert gradually. In the third scenario the patient should be advised to try wearing the insert for brief periods; however, if the patient fails to adapt, wearing the insert should not be rigorously enforced. The type of shoe correction implemented is important in itself. A heel insert fitted inside the shoe is practical, but has the disadvantage that the shoe fits less well. For this reason, it is better to lower (shorten) the heel on the shoe of the longer leg. However, this is practicable only where leg length difference is minimal. Where leg length difference is greater than 2 cm, the sole must be thicker on the shoe of the shorter leg, otherwise the foot would be uncomfortable. It is not necessary though to compensate fully for leg-length inequality. If there is no difference in leg length and the pelvis is level, but obliquity is detected in the lower lumbar spine, this will have implications during both standing and sitting. In this instance corrective compensation must also be provided when the patient is seated by placing a thin board under one ischial tuberosity. X-rays will be required to demonstrate the need for such measures. The most frequent and most serious fault in sitting is kyphosis due to hypermobility of the lum bar spine. In such cases a back support should be prescribed where the kyphosis peaks. If that is not possible, then it is recommended that the sitting surface should be tilted forward or that the patient should sit in the oriental manner with legs crossed, or on the heels (Japanese fashion), which causes the pelvis to tilt forward. A forward-drawn posture (see Section 4.20.3 and Section 7.1.7) is also very important in this context.
Chapter 5
5.6 Immobilization and supports In the acute stage of lesions involving the locomotor system, muscle spasm ensures immobilization. The same also applies after trauma, when healing makes immobilization imperative. However, immobiliza tion becomes highly problematic once a condition threatens to become chronic, and if the objective is full recovery, that is restoration of normal function, then immobilization presents an outright obstacle. For this reason immobilization should only ever be a temporary measure in circumstances where the aim is to restore normal function. Permanent immobilization signifies simply that there is no hope of functional recovery. Unlike immobilization, however, supports need not greatly interfere with mobility while protecting the patient against excessive static loading, an important consideration in sedentary occupations. And it is primarily hypermobile subjects with lax muscles and ligaments who find it difficult to adapt to excessive static loading, particularly when, as in most modern means of transport, jolting is a compounding factor. Automobile drivers and passengers should be recommended to use an inflatable cushion to support themselves at the point where their kyphosis peaks when they are sitting in a relaxed position. Many hypermobile subjects suffering from headache should wear a soft supporting collar when riding in automobiles or using other means of transport. Elderly, obese patients with weak abdominal musculature, or with scarring and hernias, need a firm lumbar belt. Patients with ligament pain in the pelvic region require a firm pelvic belt, as proposed by Biedermann (1993) and Cyriax (1978) (see Section 6.9). Most of these supports should be worn primarily under conditions of excessive static loading, and the pelvic belt should be worn at night.
Immobilization should be only as minimal and as brief as necessary. However, in light of the increasing incidence of excessive static loading, thoughtfully selected supports can often be recommended.
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5.7 Pharmacotherapy Since the main focus of this book is on dysfunctions of the locomotor system, it will be understood that pharmacotherapy can be effective only within certain limits. It is hardly likely that a restricted joint, an immobile fascia, or faulty motor patterns related to breathing or to carrying loads will respond to pharmacological correction. On the other hand, it is clear that disturbed function in itself is not synonymous with disease and pain. It is only with the onset of reflex changes, which are felt to be painful, that the patient will report symptoms. Then it is possible to employ pharmacological means to reduce the intensity of the reaction to nociceptive stimulation. Moreover, the pain threshold is a major factor and this can be influenced by pharmacotherapy. It is therefore sometimes useful to prescribe medicines that lower the response of the autonomic nervous system; in particular, non-steroidal anti-inflammatory drugs (NSAIDs) are suitable for this purpose. It is important to issue warnings concerning the misuse/abuse of all types of analgesics in the setting of chronic pain. Dependence may develop and it is no coincidence that reduction of the analgesic dose is often the first step taken when patients are admitted to pain clinics. Analgesics are frequently combined with muscle relaxants, and a great many combination products are available. Prescription of these products can be beneficial only in cases where general muscle tension has been demonstrated. However, the most commonly encountered patient category comprises constitutionally hypermobile individuals suffering from localized painful muscle tension. In such patients the combination of analgesics and muscle relaxants can serve not only to increase hypermobility and poor coordination, but also to complicate specific rehabilitation because fine muscle control tends to deteriorate. The most rewarding effects of pharmacotherapy are achieved where patients with locomotor pain and suffering from masked depression are treated with mild antidepressants – a scenario that is not at all uncommon. As a rule, treatment with corticosteroids is not indicated in locomotor system dysfunctions. Local application of corticosteroids should also only ever be implemented in exceptional circumstances. Pain points on the periosteum and
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at tendon and ligament attachments, as well as muscle TrPs, can generally be treated successfully using relaxation and soft tissue techniques, and by needling and local anesthesia. Corticosteroids should be prescribed only if these physiological methods have failed. Their administration should be repeated only if they elicit some improvement at the first attempt. However, corticosteroids are suitable for use where inflammatory changes are present.
5.8 Surgery If the patient’s clinical condition is due to disturbance of function alone, there should be no question of surgical intervention. However, disturbed function may be the consequence of structural changes that necessitate surgery. This scenario is encountered most commonly in radicular syndromes and other disorders associated with intervertebral disk lesions. Conservative measures primarily aimed at restoring function are frequently successful here. It is therefore not always straightforward to decide when still to adopt a conservative approach or when to intervene surgically (see Section 7.8.2). Spinal canal stenosis may also be a (contributing) cause of radicular compression or even of spinal cord compression. Cauda equina syndrome, a condition characterized by acute bladder and bowel paralysis and rapidly progressive muscle weakness, constitutes an indication for emergency surgery. Instability, for example in progressive spondylolisthesis or following trauma, may also provide an indication for surgery. Instability due to odontoid abnormality may also be dangerous. It should be noted here that the conservative management of instability has become far more effective in recent years.
5.9 Lifestyle Lifestyle questions probably play the most impor tant role of all in the context of treating and preventing dysfunctions in the locomotor system. Lifestyle issues have been left almost until last because they do not constitute a therapeutic method in the true sense of the word, and a separate chapter has been devoted to this subject (see Chapter 8).
Indications for and principles underlying individual treatment methods
One of the most important tasks facing the practitioner during history taking is therefore to discover the potential sources of trouble in the patient’s daily routine so that warnings can be given to steer clear of harmful lifestyle habits. Indeed, if we succeed in detecting these important clues, we should already be able to give very useful advice after the first examination. However, if patients refuse to desist from a clearly harmful lifestyle, then any therapy offered is destined to fail.
5.10 The course of manipulative treatment The clinical examination provides information about the entire locomotor system or, at least, all key regions. Only once the examination stage is complete is it possible to consider whether we are faced with a typical chain reaction pattern or with a set of individual disorders of dubious connection. In the former, more typical scenario, treatment should be given to the link in the chain that appears to be most relevant. Then all findings must be checked again. Ideally, the chain reaction will no longer be present and it is then clear what home exercise needs to be assigned to the patient: for example, if the key link was in the foot, rehabilitation will focus on the foot dysfunction. If a secondary finding is diagnosed, for example a painfully restricted acromioclavicular joint, then this can also be treated. However, if the chosen link turns out to be wide of the mark, then an attempt should be made using another link in the chain. And this is by no means uncommon because the first attempt at treatment is frequently used for diagnostic purposes; the diagnostic process proper ends with the first intervention. It is not unusual for this intervention also to be selected on diagnostic grounds so as to confirm the importance of a particular finding – something that applies especially with active scars. However, if no chain reaction pattern at all is detected, then the findings made should be treated, and if there is an effective form of self-treatment, then the patient’s home exercise can be assigned. The first follow-up examination about two weeks later then assumes special importance. On that occasion the working hypothesis from the first examination will be either verified or found to require revision. Depending on the outcome of the follow-up examination, the subsequent
Chapter 5
rehabilitation plan will be continued or reviewed and modified. If the findings have definitely improved and the patient’s home exercise is clear, then the interval between further follow-up examinations can be increased. Even if the initial results are favorable, patients with a longer history of such problems should be followed up for longer – ideally for several months – because the natural course of dysfunctions tends to be chronic and relapsing. If no improvement is reported at the first follow-up examination, the first question to ask the patient must be: Did your condition improve briefly or not at all? The first intervention sometimes produces a very marked but short-lived effect. The follow-up examination may reveal one of two fundamentally different situations: 1. The findings are unchanged. This means that treatment has produced no results or that there has been a rapid recurrence of the patient’s condition (which is not much better). 2. The original findings have been corrected but new factors are now producing similar symptoms. In the latter case the condition may actually be regarded as having improved even if the patient does not feel any better. In the cervical region in particular, a highly characteristic pattern may develop in which lesions tend to migrate in a caudal direction until they disappear. In the former case, however, we must ask ourselves whether the initial analysis was correct and whether we failed to identify the true cause. Alternatively, the underlying condition may be more serious than appeared at first sight and may in fact be caused by pathomorphological changes. A further reason may be that patients often perform their home exercise wrongly or skip it altogether, for example, a simple self-mobilization technique or relaxation of TrPs. If, despite the failure of treatment, there is a continuing conviction that the original diagnosis was correct, then the treatment may be repeated once more. If initial improvement is again promptly followed by recurrence, then the underlying cause of this must be sought. A clinical finding will often be made in the corresponding segment; in the thoracic outlet syndrome this is almost always reflected in clavicular breathing (i.e. lifting of the thorax during inhalation), with poor stabilization of the trunk, which then needs to be corrected.
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However, the dysfunctions themselves can also be extremely complicated and multiple chain reaction patterns may be present, each one competing with the others. In such cases rapid results are unlikely and the patient will need to be monitored for a prolonged period. Chronic recurrent conditions such as migraine are routinely associated with dysfunctions of the locomotor system and tend to improve once these dysfunctions are treated. However, they may recur after a relatively long interval, and then the patient will need to be treated again. Where manipulation was discussed in a preventive context (see Section 5.4), this should also be understood to include the prevention of recurrence: rehabilitation, which regularly follows on from our treatment, with patients themselves playing an ever-increasing role, is truly synonymous with the prevention of recurrence.
5.11 Conclusions The ability correctly to establish whether or not a particular therapeutic intervention is indicated is the practical result of the pathophysiological thinking outlined in the theoretical sections of this book. Because the patient’s symptoms are usually the result of many individual factors, the chief task of the practitioner is to single out on each occasion the factor that currently appears to be the most important and also the most accessible to treatment. In this regard the recognition of characteristic chains of dysfunctions has done much to define this process more precisely. If we are successful at the patient’s initial visit, then a different therapeutic approach will quite
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likely be required when we next see the patient. Our aim is not constantly to promote one particular type of therapy but to normalize function and hence to relieve the patient’s symptoms. To do this we select the method that appears to be most advantageous. Such a strategy makes it difficult to determine which method has been most effective: manipulation, remedial exercise, or needling of a pain point. It would not be easy to justify the indication for further manipulation if movement restriction is no longer present, or for continuing to needle a pain point if this can no longer be detected. It therefore becomes difficult to determine statistically which method was most successful. If a patient with acute appendicitis is cured and remains symptom-free after removal of the inflamed organ, the surgeon does not have to provide statistical proof that surgery was indicated. If a pain point or TrPs disappear after PIR, RI or needling in a patient with locomotor system dysfunction, or if a patient has learned how to normalize respiration and does not slip back into clavicular breathing (lifting the thorax during inhalation), then something has been achieved even if other lesions which still cause symptoms have yet to be treated. This approach may seem rather unusual and complex, but it is consistent with the multifactorial nature of locomotor system dysfunction. It also precludes a monotonous, routine modus operandi characterized by a propensity for series of injections, repeated manipulation of a spinal segment, or the courses of electrotherapy so beloved of physiotherapists. The journey is a demanding one, but the effort involved is worthwhile both for the patient’s well-being and for refining the practitioner’s skills.
Chapter Six
6
Therapeutic techniques
Chapter contents
6.5 Self-mobilization . . . . . . . . . . . . . 236
6.1 Manipulation . . . . . . . . . . . . . . . 182
6.1.1 General principles governing technical aspects . . . . . . . . . 182 6.1.2 Extremity joints . . . . . . . . . . . 187 6.1.3 The spinal column . . . . . . . . . 201 6.2 Indirect techniques . . . . . . . . . . . . 223
6.2.1 Johnston’s functional techniques 223 6.2.2 Strain and counterstrain . . . . . . 225 6.3 Exteroceptive stimulation . . . . . . . . 225
6.3.1 Tactile perception and muscle tone . . . . . . . . . . . . 6.3.2 Assessing altered tactile perception . . . . . . . . . . . . . 6.3.3 Normalizing tactile perception . . 6.3.4 Altered superficial tactile perception following surgery (due to scarring) . . . . . . . . . . 6.3.5 Individual characteristics of perception . . . . . . . . . . . . 6.3.6 Self-treatment . . . . . . . . . . .
225 226 227 227 229 229
6.4 Soft-tissue manipulation . . . . . . . . . 230
6.4.1 Skin stretching . . . . . . . . . . . 6.4.2 Stretching a connective tissue fold . . . . . . . . . . . . . . 6.4.3 Sustained application of pressure . . . . . . . . . . . . . 6.4.4 Shifting (stretching) the deep fascia . . . . . . . . . . . . . 6.4.5 Mutual shifting of metacarpal and metatarsal bones . . . . . . . 6.4.6 Painful periosteal points . . . . . .
6.5.1 Self-mobilization by stretching . . 6.5.2 Self-mobilization of the sacroiliac joints . . . . . . . . . . . 6.5.3 Self-mobilization of the lumbar spine . . . . . . . . . . . . 6.5.4 Self-mobilization of the thoracic spine and ribs . . . . . . . . . . . 6.5.5 Self-mobilization of the cervicothoracic junction and first rib . . . . . . . . . . . . . . . 6.5.6 Self-mobilization of the cervical spine . . . . . . . . . . . . 6.5.7 Self-mobilization of the extremity joints . . . . . . . . . . .
237 238 238 240 242 243 245
6.6 Post-isometric relaxation and reciprocal inhibition . . . . . . . . . . . . 246
6.6.1 Basic principles . . . . . . . . . . 6.6.2 Muscles of the head and neck . . 6.6.3 Muscles of the upper extremity . . 6.6.4 Muscles of the trunk . . . . . . . . 6.6.5 Muscles of the hip region . . . . . 6.6.6 Muscles of the lower extremity . .
246 248 255 261 270 272
230
6.7 Training weak muscles (facilitation) . . . 279
230
6.7.1 Muscles of the trunk . . . . . . . . 279 6.7.2 Muscles of the hip . . . . . . . . . 285
231
6.8 Re-training to correct faulty movement patterns . . . . . . . . . . . . 285
231 235 236
6.8.1 Standing on both feet . . . . . . . 6.8.2 Standing on one leg and walking . 6.8.3 Sitting . . . . . . . . . . . . . . . . 6.8.4 Anteflexion . . . . . . . . . . . . .
285 286 287 289
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6.8.5 Lifting the arms . . . . . . . . . . . 6.8.6 Carrying loads correctly . . . . . . 6.8.7 Breathing . . . . . . . . . . . . . . 6.8.8 The feet . . . . . . . . . . . . . . . 6.8.9 The shoulder blade and upper cervical spine . . . . . . . . . . . . 6.8.10 The hands . . . . . . . . . . . . .
290 292 293 294 296 296
6.9 Supports . . . . . . . . . . . . . . . . . 296
6.9.1 Cervical collar . . . . . . . . . . . 297 6.9.2 Inflatable cushion . . . . . . . . . 297 6.9.3 Pelvic belt (Biedermann and Cyriax) . . . . . . . . . . . . . 297 6.10 Local anesthesia . . . . . . . . . . . . . 298
In the preceding chapters we have outlined the diagnosis of locomotor system dysfunctions, their pathogenesis, and the reflex changes they produce. Building on that foundation, we then considered the indications for specific therapeutic methods. However, to describe them all would go beyond the scope of this book. This chapter will confine itself principally to manipulative techniques, including those for soft tissue and especially for muscles, and to rehabilitation in the setting of locomotor system dysfunctions.
6.1 Manipulation 6.1.1 General principles governing technical aspects The objective of manipulation is to restore normal mobility to joints, including joint play. In this context we distinguish between two types of manipulation: mobilization and high-velocity, low-amplitude (HVLA) thrust techniques.
The positioning of the patient The patient should lie or sit in such a way as to be relaxed. The patient’s lying or sitting position should be selected so that the joint to be treated is ideally centered, allowing maximal muscle facilitation and relaxation. The joint that is the object of treatment must be accessible, and one of the articulating 182
bones should be fixed either by the patient’s own position or by the practitioner. The height of the manipulation table must be adjustable; this is absolutely essential given the large number of techniques in which the patient is seated and the major height variations in patients and practitioners.
The position of the practitioner The position adopted by the practitioner relative to the patient is in many ways decisive for the technique that is to be used. The practitioner must be in a comfortable and stable position in order to be relaxed at all times. If the practitioner is not relaxed, the patient too will be unable to relax. When treatment movements are performed correctly, the practitioner’s hand and forearm always form an extension of the direction of motion. However, this in itself is not sufficient to ensure optimally gentle yet effective movement. Movement impulses should emanate from the practitioner’s whole body, with forces usually generated by the feet and legs, as when throwing the discus or putting the shot. Any practitioner who becomes breathless or perspires during manual therapy is doing it wrongly. It may reasonably be said that during manipulation, especially of the spinal column but also during diagnostic examination, the practitioner’s body forms a harmonious moving unit with the patient’s body, rather like a dancing couple. This harmony between the mover and the moved is the secret of a flowing, gentle and hence elegant technique.
Fixation When techniques are performed correctly, one of the bones articulating in the joint being manipulated is fixed while the other is mobilized. In extremity joints it is usually the proximal bone that is fixed, that is supported by the body of the practitioner or by the treatment table. For effective fixation the mobilizing force should not act across two joints. In this process the practitioner’s hands are close (but not too close) to the joint so as to avoid any lever action. In the spinal column, fixation is achieved by correct positioning where possible. In the seated position, good fixation of the caudal spinal segment via the pelvis can be obtained if the patient sits astride the treatment table.
Therapeutic techniques
The starting position of the joint and the direction of treatment Treatment of the joint is performed once the slack has been taken up but not in a position in which the joint itself is not overstretched. If it is in an extreme position, the joint will be locked and cannot be treated. This principle must also be adhered to when treating the spinal column. According to Kaltenborn (1989), the direction of movement during gliding mobilization depends on whether the concave joint surface is located on the proximal (fixed) articulating bone or conversely whether the convex joint surface is located proximally and the concave joint surface distally (see Figures 2.7 and 6.1). In the first instance, gliding of the distal partner occurs in the opposite direction to functional bone movement, whereas in the second case, gliding of the distal partner occurs in the same direction as functional bone movement. Accordingly, in the first case, the convex distal partner is mobilized primarily in the opposite direction to functional bone movement, whereas in the second case, mobilization occurs in the same direction as functional bone movement (see Figure 2.7). For this reason mobilization of the first phalanx relative to the metacarpal head, for example, should be mainly in a palmar direction.
Taking up the slack (engaging the barrier) Taking up the slack (engaging the barrier) represents the first and crucial phase of manipulation: it is the prelude to release in the context of mobilization and to an HVLA thrust when a thrusting technique is being used. In peripheral joints we attempt to take up the slack by approaching the limit of joint play, where possible with simultaneous distraction of the joint. In a normal joint this is never a hard or sudden action. A hard end-feel when the limit of joint play
Figure 6.1 • Schematic illustration of directions of joint play.
Chapter 6
is reached is characteristic of a movement restriction. Functional movement in the spinal column cannot always be distinguished from joint play because movements in an individual motion segment cannot be performed actively and therefore resemble joint play to a certain extent. We know that we have taken up the slack (engaged the barrier) the moment we sense the first slight resistance (indicative of the physiological barrier). This must be performed gently and cautiously, and once the barrier has been engaged we should wait. The commonest reason for error and failure is to misinterpret active resistance by the patient as a sign that we have taken up the slack. This invariably happens if the patient senses pain or feels threatened by a rapid, harsh examination technique. ‘Locking’ is an additional factor in the spinal column, especially when long levers are used (see Section 6.1.3). This term refers to techniques in which all spinal segments are ‘locked’ except the one that is being manipulated.
Manipulation After the slack has been taken up (the barrier has been engaged), there are two ways to restore normal mobility: 1. Either by a gentle springing movement, but more often simply by waiting, in order to obtain release and thus normalize the barrier. 2. Or, by delivering an HVLA thrust, once the barrier has been engaged and the patient is relaxed.
Simple mobilization Mobilization can be achieved by gentle rhythmic repetitive springing, or usually just by waiting at the barrier with minimal pressure in the direction of functional movement or joint play. When simply waiting for the release phenomenon to occur, the practitioner must be able to sense precisely when release has fully run its course, otherwise both practitioner and patient will be ‘robbed’ of success. If the practitioner opts for rhythmic springing at the barrier, care must be taken not to lose the end position, otherwise the springing action can become too coarse and painful. And pressure must never be increased during springing simply because the effect obtained is insufficient. On the contrary, springing will be 183
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suppressed if springing back is prevented by increasing the pressure exerted. It appears that the therapeutic effect depends on (spontaneous) springing back to the barrier at the initial end position. Rhythmic repetitive springing is especially effective in joints that, when restricted, are not directly fixed or moved by muscles. In particular these include the sacroiliac, acromioclavicular, and sternoclavicular joints. To some extent the same also applies in extremity joints where shaking mobilization has proved especially useful. In the spinal column, preference is usually given to the release phenomenon option, although in combination with techniques involving muscular facilitation and inhibition (neuromuscular techniques).
Neuromuscular mobilization techniques Here we may differentiate between techniques that act on specific individual muscles and others that have an effect on the locomotor system as a whole. A feature common to all of them is that they facilitate, potentiate, and automate the release phenomenon.
Post-isometric relaxation
Wherever possible, post-isometric relaxation (PIR) is supplemented by reciprocal inhibition (RI). According to Mitchell et al (1979), only a minimum of resistance is used here. After taking up the slack, the practitioner offers resistance for 5–10 seconds as the patient exerts minimal pressure in the direction opposite to mobilization, and then the patient is instructed to ‘let go’. After a short latency period, release (i.e. mobilization) occurs and the practitioner then waits for the patient to relax. Starting from the newly gained position, the process is repeated once or twice. It is important not to interrupt the patient’s relaxation prematurely. The longer relaxation lasts, the better the effect and the fewer repetitions needed. If the patient fails to relax during PIR, the simplest solution is to extend the isometric phase, even for up to 20 seconds. An important improvement was achieved by Zbojan (1984) with his introduction of gravity-induced relaxation: in this technique, where possible, the weight of the head or (part of) an extremity is isometrically raised a little against gravity and then relaxed as gravity takes over. This can be repeated three times. Zbojan recommends holding both the isometric phase and the relaxation phase for 20 seconds each. This exercise can be done at home by 184
the patient as a self-treatment method on a daily basis.
Reciprocal inhibition
Wherever possible, PIR may be supplemented with RI: here the patient exerts light pressure in the direction of mobilization while the practitioner applies rhythmic repetitive counterpressure using minimal force. Active rhythmic repetitive movement in the restricted direction against resistance from the practitioner or (following gravity-induced relaxation) as a single powerful movement, also in the restricted direction, achieves RI of the muscles that are restricting movement.
Rhythmic repetitive muscle contraction
In isolated situations, rhythmic repetitive muscle contraction can act to produce mobilization directly, for example rhythmic contraction of the scalenes with their attachment points at the first and second ribs, or of the psoas major at the thoracolumbar junction.
Respiration
(See also Section 4.15.3.) As a rule, inhalation has a facilitating effect and exhalation an inhibitory effect, especially on the muscles of the trunk. Therefore, it is usually appropriate to combine inhalation with isometric resistance and exhalation with relaxation. However, there are important exceptions to this rule: forced exhalation facilitates the abdominal muscles, and maximal exhalation in lordosis facilitates the erector spinae muscles and thus mobilizes the thoracic spine into extension. In kyphosis, in contrast, the thoracic spine is mobilized by inhalation. From gymnastics we are accustomed to associating inhalation with straightening up and exhalation with anteflexion (and with side-bending). Mouth opening is associated with inhalation and mouth closure with exhalation. Where movement in one direction is associated with inhalation, and in the opposite direction with exhalation, this phenomenon is known as respiratory synkinesis. One characteristic of respiratory synkinesis is that it is difficult to perform a particular movement during the respiratory phase that is not associated with it, for example to bend forward while inhaling. Of particular interest is the mobilizing effect of respiration during side-bending, as noted by Gaymans (1980). During inhalation or exhalation, different spinal segments are facilitated or relaxed in an alternating pattern. Broadly speaking, with the exception of the cervicothoracic junction, the even-numbered
Therapeutic techniques
segments are inhibited (fixed) during inhalation and relaxed during exhalation, while conversely the oddnumbered segments are inhibited (fixed) during exhalation and relaxed during inhalation. Other forms of respiratory synkinesis also serve to promote mobilization. During isometric traction, for example, we exploit the fact that neck muscles become tense during inhalation and relax during exhalation, resulting in stretching. During isometric traction of the lumbar spine in lordosis when the patient is prone, tension is increased during exhalation whereas relaxation occurs during inhalation. This happens because the lumbar erector spinae in lordosis contracts during exhalation.
Eye movement (visual synkinesis)
Eye movement facilitates movements of the head and trunk in the direction of gaze and inhibits movements in the opposite direction. While this does not hold for side-bending, looking up facilitates straightening into a neutral position and out of side-bending. Looking up facilitates inhalation and looking down facilitates exhalation – a respiratory synkinesis that should be taken into account for combination with respiratory techniques. However, according to Gaymans (1980), maximal excursion of the eyes has an inhibitory effect.
Zbojan’s use of gravity
Where possible, use can be made of Zbojan’s (1984) gravity-induced technique (see above): during the isometric phase it is sufficient to raise the head or leg a little, hold for 20 seconds and then relax for 20 seconds.
Combining techniques
It will be self-evident that these methods can be combined to excellent effect. This applies in particular to the combination of PIR, respiratory synkinesis, visual synkinesis, and gravity-induced techniques. As a result the isometric phase (resistance exerted by the patient) and the relaxation phase can be largely automated, thus enabling the practitioner to dispense with repeated instructions to the patient of the type: ‘When you press, use only minimal force’ and ‘Relax completely’. If rotation to the right is restricted, for example, the practitioner can instruct the patient to look left during the isometric phase and breathe in, and then to look right during the relaxation phase and breathe out. This is especially appropriate when we are dealing with patterns of respiratory synkinesis.
Chapter 6
For mobilization into side-bending, the practitioner tells the patient to look up during the isometric phase and to look down during the relaxation phase if it is the even-numbered segments (C0, C2, C4) that are involved. The use of gravity-induced techniques is particularly suitable for combination and for achieving automation. For this, the levers should be arranged so that the force involved is neither too great nor too small. The greater the number of elements, the greater the potential for optimal combinations and for self-treatment, for example self-mobilization of the atlas against the occiput (at the same time also relaxation of the SCM muscle) while supine with the head rotated (see Figure 6.96). In view of the wide-ranging possibilities, a warning is also appropriate concerning incorrect combinations. Looking up does not work in combination with exhalation and neither does looking down in combination with inhalation. We must also bear in mind that looking up facilitates straightening up (retroflexion) and looking down facilitates forward-bending (anteflexion). For mobilization into side-bending, for the even-numbered segments, it will be useful to proceed in the manner described in the preceding paragraph. For the odd-numbered segments (C1, C3, etc.), exhalation during the isometric phase should not be combined with looking up and inhalation during the relaxation phase should not be combined with looking down. Therefore the combination of respiration with eye movements should be avoided in this case. If visual synkinesis is to be combined with respiratory synkinesis, then the instruction to look in a particular direction must precede the instruction to inhale or exhale. At the cervicothoracic junction and also in the thoracic spine it is essential for the neck to be held in extension during mobilization into sidebending. It is therefore correct during the isometric phase to give the instruction ‘Look up and breathe in’ but not to say ‘Look down’ during the relaxation phase because the patient would then bend forward. Consequently, the instruction in the relaxation phase is ‘Let go and breathe out’. It is very important for the patient always to breathe in and out as slowly as possible so that both the isometric phase and the relaxation phase are sufficiently long. It is therefore useful, for example, first to say to the patient ‘Look to the right’ and then after a short latency period to add ‘And breathe in slowly’; and also to say ‘Look down’ and after a certain latency period to add ‘Breathe out’. If the patient finds it difficult to breathe in and out slowly, then it is very useful for the patient to breath-hold at 185
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the end of inhalation before the instruction is given to breathe out. However, if this also fails to solve the problem, then the patient has a significant faulty breathing pattern (assuming that an organic respiratory disorder is not to blame). Remedial exercises to correct this seriously disordered breathing pattern are then indicated. As a technical note, release may take considerably longer than the process of exhaling slowly. Therefore the best solution is simply to instruct the patient to carry on inhaling and exhaling until release is complete. Once release has started, it will automatically follow its course to the end no matter how the patient continues breathing. If our combinations are well thought out, the sum total of physiological stimuli involved will considerably enhance the effectiveness of our mobilization techniques, make them less time-consuming and render them largely suitable for self-treatment, which also considerably strengthens the treatment program. PIR can be routinely supplemented with RI, thus allowing a further goal to be realized: taken collectively, all these neuromuscular techniques mean that it is the patient’s own muscles that are increasingly used to achieve mobilization. It will come as no surprise that maximal use of the patient’s own muscles is more ‘physiological’ than the best manipulation techniques delivered by the practitioner.
(i.e. by releasing the slack that has been taken up), we give the patient time to tense up as a reflex anticipatory reaction. When that happens, manipulation fails or becomes unduly forceful. If the above conditions are met, HVLA thrust techniques are never forceful because the thrust corresponds to a weight of not more than 1000 g. However, there are also situations where highvelocity maneuvers are not even necessary, thus allowing an even gentler approach, as in distraction manipulation in the cervical and cervicothoracic region with the patient seated. Mierau et al (1988) have shown that HVLA thrust techniques are followed immediately by a state of hypermobility in which the barrier is temporarily overcome. This also explains both the very intensive reflex effect and the presence of a certain degree of risk because the barrier fulfils a protective function. Leaving to one side a small number of incidents that have been widely discussed, it is generally true to say that forceful and frequently repeated HVLA thrusts carry a risk of permanent hypermobility. Figures 6.2 and 6.3 illustrate the different effects achieved with mobilization and HVLA thrust techniques.
HVLA thrust techniques
Immediately after treatment, whether this consists of mobilization or manipulation, its effect must be checked by testing (see Section 4.17).
These techniques consist of a high-velocity but non-forceful movement of small amplitude, starting from the end position gained (i.e. after taking up the slack) and going in the direction in which the slack was taken up or mobilization was performed. In the process, a barrier seems to give way, and as a rule we hear the joint ‘pop.’ Immediately afterward we sense a considerable reduction in muscle tone and increased mobility. The following technical conditions must be observed: • While taking up the slack the practitioner must be able to sense the moment when the patient is completely relaxed. • The end position is reached (or the barrier is engaged) using a minimum of force. • The HVLA thrust must start from the end position already gained, that is we must never back off before delivering the thrust. And this is the typical error made by almost every novice because we are used to drawing back our arm before delivering a blow. Here, however, it is a crucial mistake because as we back off 186
Testing to check the effect
Record keeping The purpose of keeping records is to ensure detailed documentation of the examination and in particular of any therapeutic interventions so that data are available in case the material later needs to be written up for publication or for an expert legal report. This aspect should not currently pose any difficulties given the general use of computers for data storage.
Follow-up treatment and aftercare If we discount acute cases where we are in fact administering first aid and where patients should be invited to attend for follow-up within a week, it is generally possible from the case history to offer advice concerning any lifestyle aspects that may require correction. The patient is then given home exercises that can be used either as part of a selftreatment plan or as a basis for a clearly specified
Therapeutic techniques
Chapter 6
Figure 6.3 • Tension curve during joint distraction and the effect of ‘joint cracking’ (adapted from Roston & Wheeler Haines 1947). (A) Tension increase without joint cracking. (B) Sudden ‘give’ at the moment of cracking.
6.1.2 Extremity joints
Figure 6.2 • Distraction of the metacarpophalangeal joint using a force of 8 kg after mobilization (A, B) and after an HVLA thrust (C, D).
course of physiotherapy. The patient should be invited to attend a follow-up appointment within two to three weeks. Failure to issue such instructions and to set goals is professionally irresponsible and betrays a lack of understanding of rehabilitation. It is always advisable to inform the patient that treatment of any kind may often be followed by a painful reaction lasting for anything from one to three days, after which improvement sets in. If patients are not given such a warning, the inevitable result is that practitioners will be bombarded with telephone calls during the first 24 hours about conditions that are ‘worse now than they were before!’
The techniques used in the manipulation of extremity joints are aimed almost exclusively at restoring joint play. Because examination of joint play is technically identical with the mobilization of these joints, both will be described here simultaneously.
Joints of the upper extremities Interphalangeal joints Dorsopalmar shift, distraction, and laterolateral shift are used for mobilization (and examination). The practitioner fixes the patient’s proximal phalanx between the thumb and forefinger of one hand, supported either against his own body or the treatment table. Taking the patient’s distal phalanx between the thumb and second finger of the other hand, the practitioner mobilizes the distal phalanx in one of the above directions, always applying distraction at the same time. It is advisable to keep thumb 187
Manipulative Therapy
and forefinger at right angles to the direction of movement.
Metacarpophalangeal joints Because these joints are almost spherical (ellipsoid), joint play is tested in all directions, including rotation and distraction, using a technique similar to that described for the interphalangeal joints. The practitioner fixes the patient’s metacarpal head between the thumb and forefinger of one hand, supported against his own body or the treatment table, and takes hold of the first phalanx between the thumb and forefinger of the other hand. Here too mobilization is always performed while applying distraction. Only the thumb and forefinger holding the phalanx can be at right angles to the movement only in the dorso-palmar direction. In this case, distraction in a palmar direction is effective; this can be performed as an HVLA thrust using the first phalanx of the forefinger as a fulcrum – and is often administered as first aid following sprains. The practitioner can also take hold of the first phalanx from above so that the hand and forearm hang down, and then perform distraction by shaking. These last two techniques can also be used in a self-treatment setting (see Figure 6.4).
The carpometacarpal joint of the thumb The trapezium is first located by palpating the styloid process of the radius. Distal to this there is a groove which corresponds to the scaphoid, which then articulates with the trapezium as the wrist broadens again. Fixing the trapezium between the thumb and forefinger of one hand, the practitioner
uses the thumb and forefinger of the other hand to take hold of the first metacarpal bone as close to the carpometacarpal joint as possible. Here too mobilization can be performed in a dorsopalmar and laterolateral direction, with the practitioner’s thumbs and forefingers positioned at right angles to the direction of movement. For distraction, the terminal phalanx of the patient’s thumb is grasped using the little finger of the practitioner’s mobilizing hand and a pull is exerted via the terminal phalanx. The following technique is suitable for postisometric traction and HVLA thrust manipulation: placing his right hand round the ulnar aspect of the wrist of the patient’s supinated right hand, the practitioner takes hold of the metacarpal between the thumb and forefinger of his other hand, so that the proximal phalanx of the forefinger forms a fulcrum close to the carpometacarpal joint dorsally (below), and the thumb, located a little more distally, performs gentle dorsal compression to achieve distraction. The practitioner can amplify this effect further by hooking his little finger round the distal phalanx of the patient’s thumb (see Figure 6.4A). Once the barrier is engaged, an HVLA thrust is now delivered. The patient can also be instructed to offer slight resistance to distraction, to relax after 5–10 seconds and then to repeat this. Afterward the practitioner takes hold of the patient’s pronated hand from the ulnar aspect using the opposite hand. Using the other hand he then grasps the patient’s first metacarpal so that the radial edge of the proximal phalanx of his forefinger forms a fulcrum close to the carpometacarpal joint on the palmar side (below) and the thumb
Figure 6.4 • Treatment of the carpometacarpal joint of the thumb (A) into supination with distraction and gentle dorsal compression and (B) into pronation with distraction and gentle palmar compression.
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performs gentle palmar compression
