Manipulative Therapy: Musculoskeletal Medicine

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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