__Manipulative_Therapy__Musculoskeletal_Medicine

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 Printed in China

Foreword My professional life has been enormously enhanced rather his patient is – if he treats it at the point by Karel Lewit’s teaching and I am so pleased that where pain is felt’. I can remember being so con- he has continued to enhance his book, for this lat- fused when Philip Greenman said this same thing. est edition, by adding his further distillation of how This book helps us understand more deeply about recent research should refine our management of how the motor system works and how dysfunction locomotor pain. If you liked a previous edition, you causes pain, and why that statement is true: com- will definitely want this one. pared to doctors with our ‘structural’ training, you chiropractors, osteopaths and physiotherapists are Although many would consider this a textbook, fortunate! Professor Lewit has said that it is not one; he has always wanted to make us think, and to enable us It is wonderful to see how manipulative therapy to work out our puzzles and problems with the aid and musculoskeletal medicine have developed dur- of the principles and approaches which he outlines ing Karel Lewit’s lifetime – not least through his in this book. own research and that of his younger colleague Vladimir Janda, and then Vojta and Koláˇr. I remem- I can remember, as a medical student, how my ber John Mennell in his later years insisting that teachers gave me the impression that I was learn- it is the muscles that are important’ but not quite ing, at that hospital, all that could be learnt about being able to explain why. Mitchell, Greenman humankind’s suffering, illnesses and diseases. How and others had of course shown, with the muscle- wrong they were! Karel Lewit’s teaching has cer- energy technique, that the patient’s own muscles tainly ‘shone light where there was darkness’ on my can achieve reversal of dysfunction. But one can- understanding of musculoskeletal pain. not underestimate the influence of Karel Lewit in stimulating the Czech school and many others Even after many years it remains a source of to show the underlying neuromuscular causative pleasure and even excitement that our ‘clinical mechanisms of dysfunction. And nowhere have the experience in the use of manipulation for diagno- clinical manifestations and treatment implications sis and treatment constantly reaffirms, in countless of this newer understanding been better explained patients, the principle that treatment, if technically than in this book. Karel Lewit can sift the pearls successful, brings normalization of restricted mobil- of wisdom from the side-issues, misunderstand- ity in the joint or motion segment. Normalization ings and downright wrong very effectively, as we of function also brings relief of pain.’ know (sometimes to our cost!) at meetings of the multidisciplinary International Academy of Manual But we must take it further than being proud and Musculoskeletal Medicine (formerly the FIMM of technique. ‘It is as important – and still more Academy). difficult – to adjust our thinking to the functional approach as to master the technical aspect of So, he has done all the hard work for you: read manual medicine.’ Following this statement Lewit on, and give the benefit to your patients. gives important differences between the usual, pathomorphological understanding and the func- Richard Ellis tional approach. The fourteenth of these is, ‘When treating dysfunction, the practitioner is lost – or vii

Preface The first Czech edition of this book was published necessary to revise each new edition, which was the in 1967 out of the necessity of providing instruc- main source of the truly dramatic development of tional material. There was a need to teach physicians what was originally called manual medicine – for and, later, physical therapists a new specialty – the which we are in no small degree responsible. diagnosis and treatment of dysfunction of the locomo- tor system. A way of teaching both theory and practi- The main interest at first was clearly in joints cal skills was required that did not involve spending and therefore in manipulative techniques. How- too much time in lectures. ever, the function and the physiology of the joints were unthinkable without the muscles, controlled There was no comprehensive textbook to teach by the nervous system. Since (passive) manipula- fundamental theory, functional anatomy, clinical tion appeared from the outset to be untenable with- aspects of dysfunction of the locomotor system, out (active) rehabilitation to obtain lasting results, relevant treatment indications and appropriate our interest in the musculature became obvious. preventive measures based on the findings. Nor is Through their ‘muscle energy technique,’ the there any such textbook to this day, apart from an osteopathic school of Fred Mitchell senior showed increasing number of technical manuals represent- convincingly that the patient’s own musculature ing various schools of manual medicine. This is does have an effective role to play in manipulative probably the reason that translations of this book therapy. This prompted us to develop techniques have appeared in numerous languages: German, facilitating and inhibiting muscles, which had to be Swedish, Dutch, Bulgarian, Polish, English, Italian, as simple as possible, so as to bring into play the Spanish, Russian and Japanese. The first English patient’s own muscles, since using the patient’s own edition was published by Butterworth in 1985. This muscles is a more physiological approach than that was a shortened and therefore more concise version of even the best practitioners. For this reason, self- of the original Czech and the seven German edi- treatment is of great importance. tions. The second and third English editions were published by Butterworth-Heinemann. The last Soon it became obvious that joint movement two Czech and the eighth German editions were restriction was regularly released when muscle restructured according to the English editions. This relaxation was complete. This promoted the con­ eighth (2006) German edition has been translated clusion that a tense musculature and myofas­ and updated for the present English version. cial trigger points play a predominant role in joint restriction. The starting point was initially manual therapy, but it soon became evident that the true object of This point was made in 1975 by the great ‘manual medicine’ is dysfunction of the locomotor physiologist of osteopathy, Irwin Korr. We now system; such dysfunctions account for 90% of the devote out attention as much to the diagnosis vast number of patients suffering from painful con- and treatment of trigger points as to that of joint ditions of the locomotor system. Despite this, afflic- restriction. tions of this nature are termed ‘unspecific,’ hence without diagnosis and consequently inadequately A further significant step was that it became treated. Nevertheless, these complaints are specific obvious that trigger points and joint restriction do disturbances of function: they can be precisely diag- not occur in an isolated and haphazard manner, nosed by clinical means, requiring in the first place but appear according to certain fundamental rules. specific physiological methods of treatment. The practical importance of this principle is that if the most important link of the chain is treated, Knowledge about this largely unexplored field the entire clinical picture could be normalized. This grew rapidly, and Professor Janda and I decided to does not only make treatment more economical, use the term ‘functional pathology of the motor sys- it makes it possible to plan further treatment and tem’. As our knowledge kept increasing, it became rehabilitation, and is the basis of a rational holistic approach. ix

Preface The next question to be pursued was to find the at the extremities, remain to be mobilized. This is most important causes of these chain reactions. also true of the soft tissues and the internal organs, These were closely related to the role of the mus- which have to move in harmony with the motor culature maintaining the human upright posture, system even during respiration. Manual diagnosis which is very labile. A crucial role is played by the and therapy of these tissues often play a dominant recently discovered deep stabilization system – of role, particularly with scars. the feet, the trunk, the shoulder blades, and the craniocervical junction. This is closely linked, via What then remains of manual medicine? It is the diaphragm, to respiration. Dysfunction of these clinical diagnosis with our palpating hands, with- mostly short muscles must be compensated by out which no chains of trigger points, movement movement restriction due to trigger points in the restriction or soft tissue change can be diagnosed. long muscles which, by co-contractions of flexors The object of treatment is, however, solving dys- and extensors, stabilize the upright posture with function of the motor system and all the methods the spinal column in the sagittal plane. of treatment have to serve this purpose. Analysis of the findings and problem-solving are thus our main Activation is training the deep stabilization sys- tasks. This book has therefore gradually changed into tem and diaphragmatic respiration, thus normal- a textbook not just of manipulation, but of ‘muscu- izes chains of trigger points and joint restriction, loskeletal’ or ‘neuromusculoskeletal’ medicine. without passive mobilization and even relaxation. Only well localized dysfunctions, frequently found Prof. Karel Lewit x

Acknowledgments The first English edition would have been impossi- indeed most of all, from Professor Simons. Many of ble without the devoted care and critical help of my those I named are no longer alive. English wife. To deal with such a vast, in many ways new, field made it necessary to work in a team, one I should like to express my thanks to the Cen- in which we were simultaneously both teachers tral Railway Health Institute, where I was able to and students. It was Professor Henner’s Neurologi- pursue the work in my field from 1973 to 1990, cal Clinic that made this possible. Thus it was that and to Dr Sereghy, who made it possible for me my first students were my neuroradiology teacher, to return to the neurological clinic, which I was Professor Jirout, Professor Janda, to whom I gave forced to leave in 1972. When Dr Sereghy ceased instruction in neurology and who did pioneering to head the clinic, it was thanks to Professor Kucˇera work on dysfunction of the musculature, and the and Professor Bojar that I was able to move to the anatomist Professor Cˇihák, to whom I explained rehabilitation clinic in Prague – Motol. This clinic functional radiology and who was my constant advi- offers at present the most favorable conditions sor in questions of anatomy. It is to Dr Véle that I for the further development of musculoskeletal owe what little I understand of EMG and a more medicine, under the leadership of Professor Koláˇr, sophisticated way to examine reflexes. My thanks and not only in the Czech Republic. are due to Dr Zbojan for the use of gravity for the relaxation of many muscles, to Dr Rosina for the It was a particular honor that the last Czech edi- reliable diagnosis of sacroiliac restriction, to Dr tion, which was translated for Elsevier into Ger- Kubis for the diagnosis of restriction of the upper man and now into English, was published under the ribs, and to Dr Sachse for the accurate diagnosis of name of the Czech J E Purkynje Medical Associa- hypermobility. In the scientific field, I learned in tions, for which I express my special thanks to Pro- particular from the histologist, Professor Wolf, from fessor J Blahoš. Professor Berger and Professor Ivanichev. I learned also a great deal from the physical therapists who My thanks for the quality of the illustrations are were my students: from Mrs Hermach I learned due to Mrs Istlerová and Mrs Fabianová. My thanks about exteroceptive stimulation, and got much are also due to Elsevier who pleasantly surprised me practical advice from Mrs Kafková and Klierovám in 2004 by requesting a new edition of Manuelle Verchozinová; in recent years in particular from Medizin, and in particular to the translators, Mr Professor Koláˇr about developmental kinesionology Beattie and Miss Richards, who put up with all my and stabilization. Others from whom I learned were suggestions, corrections, even criticisms, to Ms S Professor Starý, Professor Macek, Dr Stˇreda, Dr Davies, who took the responsibility for the editorial Gutmann, Dr Biedermann, Dr Wolff, Dr Gaymans, development, and to Ms S Wolfaard, who initiated Professor Greenman, Professor Ward, and finally, it all. Prof. Karel Lewit Dobˇr ichovice xi

Abbreviations ASIS Anterior superior iliac spine MRI Magnetic resonance imaging CT Computerized tomography PIR Post-isometric relaxation DC Doctor of Chiropractic PSIS Posterior superior iliac spine DO Doctor of Osteopathy RI Reciprocal inhibition EMG Electromyography TeP Tender point HAZ Hyperalgesic (skin) zone TrP Trigger point MET Muscle-energy technique xiii

Chapter One 1 History and fundamental principles Chapter contents therapy. In his treatise on joints, he speaks of para- thremata, a concept which corresponded to what 1.1 The history of manipulative therapy . . . . . 1 chiropractors would recognize as slight disloca­ tion or subluxation. Waerland expresses it in these 1.2 F undamental principles of words: ‘the vertebrae are not displaced by very reflex therapy . . . . . . . . . . . . . . . . . 4 much; only to a very small extent.’ Hippocrates goes on to say that ‘it is necessary to have a good 1.2.1 Nociceptive stimulation . . . . . . . . 4 knowledge of the spine, because many disorders 1.3 Reflex therapy . . . . . . . . . . . . . . . . 6 are associated with the spine, and a knowledge of it is therefore necessary for healing a number of dis­ 1.3.1 Indications and methods . . . . . . . 6 orders.’ He also describes how to treat the spine: 1.3.2 Choice of method . . . . . . . . . . . 6 ‘This is an ancient art. I have the greatest respect 1.3.3 Structural and functional changes . . 7 for those who first discovered it, and also for their 1.3.4 The place of reflex therapy . . . . . . 7 successors, whose discoveries will contribute to the further development of the art of healing in a natu­ 1.1 The history of ral way. Nothing should escape the eye and hands of manipulative therapy the skillful physician, so that he can reposition the displaced vertebrae on the treatment table without To begin with a chapter giving a brief outline of the harm to the patient. No damage can occur as long history of manipulative therapy is helpful for several as the treatment is undertaken in the correct way.’ reasons; not least because it is hard to appreciate its According to Hippocrates, the list of disorders unique place in medicine without such an introduc­ caused by displacement of vertebrae includes phar­ tion. It is also important for the avoidance of mistakes yngitis, laryngitis, bronchial asthma, tuberculosis of and a correct appraisal of its further development. the lungs, nephritis and cystitis, inadequate gonadal development, constipation, enuresis, etc. Manipulative therapy is probably as old as the history of humankind. Throughout that history Manipulation therapy in ancient classical times there have been healers who knew how to reposi­ can be seen on many reliefs. Patients would lie tion or ‘set’ joints, including the spine. Among some prone on a bed specially constructed for the pur­ peoples it was the custom for children to run bare­ pose, while longitudinal traction to the head and foot over the backs of their weary parents following legs was carried out. The physician performed heavy work. manipulation of a particular vertebra. This type of therapy was evidently practiced throughout Importantly in this history, in the fifth century antiquity; Galen knew that the peripheral nerves bc, Hippocrates, founder of European medicine, emerged from the spinal cord and that they were listed rachiotherapy as a further fundamental ele­ susceptible to damage at this point, as is clear from ment of medicine alongside surgery and medicinal

Manipulative Therapy his account of the treatment of the Greek Sophist in the United States endeavors to provide a com­ Pausanias. plete body of medical knowledge, whereas schools of chiropractic will not teach pharmacotherapy and sur­ Over the course of time – particularly in the last gery. Among chiropractors, there is a substantial diff­ two centuries – development took place in the primi­ erence between those of the older and the younger tive medicinal (herbal) therapy and the surgery of the generation. The older generation adheres dogmati­ Ancients, giving rise to modern pharmacotherapy and cally to the outdated theoretical and technical tradi­ surgery; however, manipulation therapy continued in tion; the younger rejects the traditional dogmas – it the same state as when the ancient classical civiliza­ strives for a rational, scientific method and strongly tions had received it from the peoples of earlier antiq­ desires to cooperate at the professional level with uity. Consequently the successes of modern medicine medical practitioners. completely eclipsed primitive manipulation therapy, causing it to slip to a great extent into oblivion. The From the technical point of view, chiropractors medical press, which enjoys generous support from confine their approach for the most part to high- the pharmaceutical industry, contributed to this pro­ velocity, low-amplitude (HVLA) treatment using cess. What we now see, therefore, is unequal develop­ short-lever techniques, taking very little interest in ment in the field of medicine, leading to a situation soft-tissue techniques. They are increasingly inter­ in which one discipline, failing to keep pace with the ested in rehabilitation and lifestyle (dietetics). progress in the other specialisms, became almost for­ gotten. All that persisted, as far as we can tell, was Osteopaths, in contrast, place emphasis on soft a group of lay persons – to some degree established mobilization and soft-tissue techniques as well – called ‘bone setters’ who practiced manipulation as HVLA treatments; however, they show a pre­ therapy. This remained the situation until into the ference for long-lever techniques, using indirect second half of the nineteenth century. (unlatching) techniques to be able to work in a targeted way. Neuromuscular techniques – muscle- It was Andrew Taylor Still (born 1828), who energy techniques (MET) – derive from the school practiced as a doctor in the American Civil War, of Fred Mitchell, sen, Greenman and Mitchell, jun. who rediscovered the importance of manipulation of the spine. In 1874 he founded a school on a pro­ Although physicians in Europe initially knew fessional basis in Kirksville, USA, with 17 students. little of manipulative therapy, even completely From the outset he also provided training to lay rejecting the concept, here too they gradually began persons. At first the courses lasted two years; later to take an interest in spinal manipulation. The dis­ they were extended to four years. At the present covery of a mechanical disorder, the herniated day, the length of training for a doctor of osteopa­ intervertebral disk, was partly responsible for this thy (DO) in the United States is the same as that interest. Attempts were made to provide relief by for medical students and permits them both to means of traction, and even to perform manipula­ exercise their profession in general practice and to tion under anesthetic. progress to specialization. While, on the one hand, osteopaths and chiro­ Around the year 1895, DD Palmer founded practors were regarded as charlatans, on the other, the chiropractic school in Davenport. Until attempts at manipulation by physicians of tradi­ then he had worked as a grocer and in magnetic tional (allopathic) medicine were rough and ready. healing. According to his own account, he wit­ Nevertheless, physicians in Europe were beginning nessed manipulation being practiced by a phy­ to concern themselves with maneuvers applied to sician by the name of Atkinson. Other sources the spinal column. As long ago as 1903, the Swiss say that he himself received treatment from physician O Naegeli published his book on neu­ Still. At first, the courses he provided lasted rological complaints, Nervenleiden und Nerven- only around two weeks, and cost 500 dollars. schmerzen. Ihre Behandlung und Heilung durch By 1911 the courses lasted a year. At present, Handgriffe. the training consists of four years of university- level study in the United States. Graduates obtain The most important proponent of manipula- the title DC (doctor of chiropractic), which enables tion therapy in Europe was the British professor them to practice as primary care physicians. of physiotherapy, JA Mennell. He made no secret of having received instruction from osteopaths. Differences between osteopathy and chiropractic His many publications (including manuals) remain persist to this day. The training given to osteopaths to this day exemplary models of their kind. How­ ever, he mainly trained physiotherapists (physical 2

History and fundamental principles Chapter 1 therapists). His successor, J Cyriax, was a passion­ courses up until the beginning of the 1960s. After ate proponent of manipulation therapy as well as 1961 this was no longer possible. Students of the an outstanding clinician and diagnostician. His FAC were therefore commissioned to organize Textbook of Orthopaedic Medicine remains to this courses in East Germany, which were to be on the day a classical textbook of the locomotor system. same lines as the FAC, and at the Charité in Berlin, However, the techniques he describes and teaches under Professor H Krauss and K Lewit from Prague. do not measure up to comparison with those of This task was more than could be done by just one Mennell. person, so it was necessary to train instructors who would later take over the leadership of the Associa­ Another individual deserving of mention is A tion. The most important of these were E Kubis, Stoddard. He was originally an osteopath, and later J Sachse, K Schildt-Rutlow, and H Tlustek. After studied medicine. His Manual of Osteopathic Tech- the reunification of Germany this group became niques can be regarded as a classical textbook of established as the Ärzteseminar Berlin (ÄMM). manipulative techniques for the spine. The London College of Osteopathic Medicine was the first Today the FAC, MWE and ÄMM together make institution to provide instruction in osteopathic up the Deutsche Gesellschaft für Manuelle Medizin techniques to physicians trained in traditional (DGMM). medicine, and these individuals played a role in the further development that took place in Europe. The development in former Czechoslovakia is The French physician, R Maigne, is one example; also of great interest, as a result of the profoundly he also studied under the neurologist and rheuma­ different political situation and especially in view of tologist, de Sèze, who was long the most influen­ the fundamental role it served as a model for other tial proponent and teacher of manual medicine in then-communist countries (including East Ger­ France. He systematically held courses for phy­ many). At the end of 1951 the Ministry of Health sicians at the medical faculty in Paris and wrote commissioned the university hospitals to undertake textbooks. Despite the leading role played by a review of the methods used by lay practitioners Maigne, there are many splinter groups in France. and practitioners of complementary medicine. To In Britain, on the other hand, the British Institute this end a chiropractor with a practice in Prague of Musculoskeletal Medicine (BIMM, and its pred­ was reviewed at the neurological clinic (under ecessor the BAMM) is organized in a unified way, Professor Henner). It was an ideal moment, when holds courses and, under Dr Richard Ellis, pub­ interest was focused on the intervertebral disk lishes probably the most important medical journal problem, and also on exploring the feasibility of in the field, International Musculoskeletal Medi- reflex therapy. An additional factor there was the cine (formerly entitled the Journal of Orthopaedic position of neurology in Czechoslovakia in Professor Medicine). Henner’s time: there was an interest in problems of pain and the locomotor system, and neuro­ The development that has occurred in the logy also had a leading role in the development of German-speaking countries is also of particular rehabilitation. interest. After the end of the war, a number of German physicians began, out of necessity, to take This made it possible for the technique of an interest in manipulation therapy. Soon they manipulation therapy to be reviewed in a clinical began to found specialist scientific associations domain. Later there came the provision of instruc­ concerned both with the critical study of the issue tion too, emanating from a prominent university and with courses of instruction. In Germany there hospital and later also provided by the Institute were two groups involved at this time, the Forsc- of Postgraduate Medical Training (under Professor hungsgemeinschaft für Arthrologie und Chirothera- Z Macek). Instruction was given in the form of a pie (FAC), initially based in Hamm but later in series of three two-week courses. Later, physi­ Boppard, whose leading figures were G Gutmann, otherapists began increasingly to be trained in neu­ F Biedermann, A Cramer, and HD Wolff, and the romuscular mobilization techniques. This is done in Gesellschaft für manuelle Wirbelsäulen-und Extrem- association with their university training. itätengelenkstherapie (MWE) under K Sell, which was based in Neutrauchburg. This model was then taken up in East Germany, Poland, the former Soviet Union, and to some Physicians from the former German Democratic extent in Hungary and Bulgaria. Republic of East Germany also took part in these Professional bodies for physicians working in manual medicine were founded in most of the 3

Manipulative Therapy countries of Europe, beginning in Switzerland, as depends on which treatment the practitioner is best well as in Australia and New Zealand; a body was able to perform, irrespective of actual suitability. also set up in cooperation with osteopaths in the United States. The International Federation for The pathomechanism underlying most of these Manual Medicine (FIMM) was founded in 1965 methods is the reflex effect; they act on sensory in London, with the Swiss physician JC Terrier as receptors to produce a reflex response in the region its first president. His son, B Terrier, has held this where the pain originates. They can therefore be post since 2004. A world congress is held every five termed methods of reflex therapy. We must next years. In this way manual therapy has become a ask which receptors are activated and which struc­ medical discipline. tures they supply. A professional body whose name refers merely to The route by which the control by the nervous a method is not entirely satisfactory to physicians, system operates is primarily that of reflex reac­ however, given that the object concerned is the tion; it would be helpful to proceed from this to an locomotor system and especially its dysfunctions. A understanding of where, how, and why we should number of bodies therefore decided to reinterpret apply one or the other method. The better we com­ the initials FIMM to represent the name Fédéra- prehend the various methods, the more effective tion Internationale de Médecine Musculosquelet- the treatment we can deliver. Since these methods tale (International Federation for Musculoskeletal are most frequently applied in painful conditions, Medicine). there follows a description of nociceptive (pain) stimulation. Despite considerable activity in scientific work, manipulation has continued to be regarded by a 1.2.1 Nociceptive stimulation great number of traditional physicians as an outsid­ er’s method; dysfunctions are little understood and, Any localized pain stimulation begins by provok­ in matters at the practical level, physicians find it ing a reflex in the segment to which the stimulated difficult to keep pace with physiotherapists, osteo­ structure belongs. In this segment we usually find paths, and chiropractors. a hyperalgesic zone (HAZ) in the skin, muscle hardening, trigger points (TrPs), painful periosteal 1.2 Fundamental principles points, movement restriction of the corresponding of reflex therapy segment of the spinal column, and (perhaps) some dysfunction of a visceral organ (see Figure 1.1). Pain – both in general and in disorders of the loco­ This enables us to diagnose the changes present motor system – is a curse that humanity has always and use whichever method is appropriate to exert suffered. The constant search for relief has led to an effect on the skin, soft tissues, muscles, peri­ a great range of treatments of all kinds. The tradi­ osteum, motion segment of the spinal column, or tional approach has regarded bed rest and – to an visceral organ involved. Working in this way and extent and with some reserve – pharmacotherapy as on a case by case basis, we can decide in each case the only reliable answer. From another standpoint which structure is the location of the most intense there are many other methods that belong mainly, changes, and which is the probable source of although not exclusively, to the realm of physical the pain. therapy, and these all have their eager proponents. These include massage, various kinds of electro­ Figure 1.1 • Reflex relations within the segment. 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

History and fundamental principles Chapter 1 Figure 1.2 • Schematic overview of afferent and efferent Once we know the source of nociceptive stimu­ connections between the periphery and central nervous lation, for example movement restriction of a spinal system. segment, and can assess its severity, then the inten­ sity of these reflex changes can provide information These reflex changes are not confined to a single about the reaction of the patient and of the particu­ motion segment. For example, visceral disturbances lar segment. We can use the subjective assessment are accompanied by viscerovisceral reflexes: pain of the pain to evaluate the nociceptive stimulus, in the region of the gall bladder produces nausea; the reflex reaction, and the central (psychological) pain in the region of the heart produces a sense of susceptibility of the patient to pain. oppression, etc. These somewhat schematic guidelines indicate This kind of effect is still more strikingly seen some possible lines of action to take in painful dis­ in the locomotor system: an acute disturbance in orders, using essentially the same approach as a one segment of the spinal column produces muscle neurologist would employ in disturbances of mobil­ spasm in substantial sections of the erector spinae; ity. This approach is essential if we are to act in a any local movement restriction produces effects targeted way, that is if we are to know why, when, in distant segments of the spinal column, after the and where we should use one or other of the meth­ manner of a chain reaction. Any serious lesion at ods of reflex therapy. First, therefore, we need to the periphery also brings about a central response: distinguish the source of pain and the reflex effects the motor pattern, or stereotype, will change in in the segment, at the suprasegmental level and at order to spare the affected structure. In this way the level of the central nervous system. altered patterns of movement are formed, and can sometimes persist after the peripheral lesion has As a rule a nociceptive stimulus produces somatic disappeared (see Figure 1.2). and autonomic changes. It is necessary to understand these changes in order to arrive at a Reflex relations between the rational, targeted course of treatment. periphery and the central nervous system The key to this difficult task lies in the functions, or the dysfunctions, of the locomotor system. Pain stimuli produce both somatic and autonomic Since this subject is the main theme of the present responses at all levels. The somatic response to the book, no more need be said at this stage than to stimulus consists mainly of muscle hardening or point out that the locomotor system is by far the the opposite response of hypotension (inhibition of most frequent source of pain in the body. This is the muscle). The expression of pain is found in the readily understandable, because not only does the form of trigger points both in hypertonic muscles locomotor system constitute about three-quarters and in (otherwise) hypotonic ones. of our body weight, but it is under the control of our will – consequently even at the mercy of our The autonomic response takes the form of reac­ whims – and has no other way of protecting itself tions in HAZs and soft tissues, and of a vasomotor against misuse than by causing pain. First and fore­ reaction (mainly vasoconstriction) within the seg­ most, then, pain warns us of harmful function or ment. At the level of the central nervous system, malfunction. Conversely dysfunction is the most these reactions may occur as stress affecting respi­ common cause of pain originating in the locomotor ration, the cardiovascular or the digestive system. system. At this level there can also be changes in motor pat­ terns, the stereotypes of muscle action. 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 significance of disturbances in muscles, joints, and shoulder blade, etc.). soft tissues can only be decided based on an analy­ sis of the pathogenesis. The particular importance Dysfunctions of the locomotor system are the most of the fasciae and active scars should be emphasized frequent cause of pain, and pain is the most in this connection. frequent symptom of dysfunction of the locomotor system. In the locomotor system and in the spinal column, there are regions of greater and of lesser importance. A sound knowledge of the dysfunctions of the loco­ There are some sections in which primary lesions motor system is therefore essential for successful occur more frequently than in others. It is vital to therapy. recognize those faulty motor patterns which are regularly found to cause relapses if left untreated. 1.3 Reflex therapy In this connection psychological factors play 1.3.1 Indications and methods a major part, because motor patterns are in part expressions of the state of mind: anxiety, depres­ Clearly the chosen therapy and method must sion, and an inability to relax exert a considerable depend on the structure upon which we wish to influence on motor function; no less important is act. In our approach to the skin, for example, a the subject’s psychological attitude to pain, since great variety of methods are available, as the recep­ pain is the most frequent symptom in our patients. tors in the skin are easy to access (e.g. by mas­ sage, electrotherapy, wheal therapy, or simple skin In addition to issues of pathogenesis, there are stretching). certain practical aspects of technique to be consid­ ered, since not all methods are equally effective or Muscle hardness (myogelosis; TrP) can be treated ‘economical.’ For example, needling or soft-tissue by massage, and more effectively by post-isometric techniques are usually more economical for the relaxation (PIR), reciprocal inhibition (RI), pressure treatment of periosteal pain points than periosteal and needling. massage, but wherever possible (i.e. if the perio­ steal point is a point of muscle insertion) we pre­ Manipulation and mobilization are mainly used fer to use PIR with RI of the muscle, because these to treat functional, reversible movement restric- techniques are painless and usually suitable for self- tions of joints or segments of the spinal column. treatment. The attractiveness of manipulation tech­ niques lies mainly in the fact that they are effective Painful periosteal points can be treated by mas­ and quick to perform. sage, soft tissue techniques, needling, or, if they are the insertion points of muscles, by PIR and RI of We can see from this that there is a wide range of the muscles concerned. possible treatments from which to select the most suitable. The decision as to which to use is reached The most appropriate treatment for disturbed by making as accurate a diagnosis as possible of motor patterns is remedial exercise. the individual changes, and from this make what is known as the ‘present relevance’ diagnosis – what 1.3.2 Choice of method Gutmann (1975) calls the pathogenetische Aktual- itätsdiagnose. This aims to identify the change that The next step is to decide which of the affected is the most important link in the chain of pathology structures is most important and which less so; at a given moment. which change is probably primary and which sec­ ondary. The severity of the disturbance is also All too frequently methods are applied which, significant. Even at the segmental level, there is a for example, stimulate the skin when no signs of a kind of hierarchy: in general, visceral disorders and HAZ have been found, or relax a muscle when no abnormal motor patterns tend to be primary. The 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 6

History and fundamental principles Chapter 1 individual links in the chain of pathology and ana­ is fundamentally important to distinguish structural lyzed their significance. We must proceed in a sys­ disturbances from functional ones. tematic fashion, starting at the peripheral level and working up to the central, applying treatment Where the disturbance is functional, it would according to our findings. be a mistake to think of the dysfunction as being exclusively a matter of reflex changes and reflex The ‘present relevance’ diagnosis according to control. What we are dealing with here is more than Gutmann enables us to identify the most significant just ‘reflexes’; these are rather ‘programs,’ having link in the chain of pathogenesis. memory and capable of being elicited. They affect the entire locomotor system and its disturbances. Nevertheless, at times the results of treatment fail to meet expectations. One of the reasons for this The most common disturbances, which are also is the presence of a lesion which causes intense the object of manipulation therapy, concern the nociceptive stimulation and dominates the clinical spinal column. The term ‘vertebrogenic’ is often picture without the patient being aware of it. This used for these, although it is not entirely applica­ may be referred to as a field of disturbance. Most ble, since vertebrogenic disorders often include commonly the source of this is an ‘active scar,’ the diseases with a pathomorphological definition, such expression of which is a HAZ, increased resistance as ankylosing spondylitis, osteoporosis, neoplasms, to shifting, and, in the abdominal cavity, a resist­ etc. Those which interest us, on the other hand, are ance that is tender on examination. If the usual mainly dysfunctions. They are not confined to the methods of therapy are unsuccessful, it is essential spinal column but also affect the limbs, soft tissues to treat the scar. Another cause of repeated failure and, most of all, the musculature, which is control­ is masked depression. This should always be consid­ led by the nervous system. In view of this it is more ered in patients presenting with chronic pain, and appropriate to speak of dysfunctions of the locomo­ needs to be treated. tor system, rather than vertebrogenic disturbances. The dysfunctions of the locomotor system that are 1.3.4 The place of reflex described here, together with the reflex changes therapy they produce, may aptly be called the ‘functional pathology of the locomotor system.’ The question as to the place of reflex therapy is as difficult to answer as that of the importance of 1.3.3 Structural and functional pharmacotherapy. Whereas pharmacotherapy has changes developed into a significant science, methods of reflex therapy for some time remained empirical, In this connection the unfortunate but frequent use and the indications for their use are ill-defined. of the term ‘functional’ as a euphemism for ‘psy­ chological’ is most regrettable – it implies a grave The indication for a given treatment is not gov­ underestimation of the importance of function erned by the particular disease (diagnosis), but and its role in pathogenesis. In rehabilitation we rather is based on the findings that are significant are primarily concerned with function, and seek in terms of the pathogenesis. If, for example, head­ at the very least to improve it when dealing with ache is due to muscular tension, then muscle relax­ conditions where there is underlying pathomor­ ation is most important. If this muscular tension is phological, structural change. This is readily under­ associated with joint restriction, then manipulation standable; dysfunction is the form in which any (mobilization) is indicated; if faulty posture is the relevant structural lesion is clinically expressed. It 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 After treatment the patient must be re-exam- tion, although it is possible to alleviate muscle ten­ ined to assess the effect, and from this we can sion, ease pain, and damp down some of the reflex make further judgments about the appropriateness effects involved, all of which can facilitate the res­ of the approach taken. If treatment has been effec­ toration of function. Additionally, they are a neces­ tive, the follow-up examination will show a change sary means of treating depression and anxiety. in the patient’s condition (short term evidence). The task then begins again to decide which distur­ To sum up, neither the diagnosis nor individual bance is now the most important. clinical findings in themselves suffice as the basis for deciding the most appropriate therapy. An Therapy is therefore never a monotonous rou­ analysis of pathogenesis is the only means of iden­ tine; at the same time the success of treatment is tifying the disturbance that is the most important always verifiable, and this aids the practitioner in at a given moment. applying a reasoned, scientific approach. 8

Chapter Two 2 Etiology and pathogenesis Chapter contents 2.9.2 S traightening up from a forward-flexed position . . . . . . . 29 2.1 T he significance of morphological changes . . . . . . . . . . . . . . . . . . . 9 2.9.3 Raising the arms . . . . . . . . . . . 30 2.9.4 Weight carrying . . . . . . . . . . . 30 2.2 T heoretical aspects of manipulation 2.9.5 T he effect of respiration on the therapy . . . . . . . . . . . . . . . . . . . 10 locomotor system . . . . . . . . . . 30 2.3 The significance of functional 2.10 T he significance of constitutional disturbances . . . . . . . . . . . . . . . . 12 hypermobility . . . . . . . . . . . . . . . 33 2.4 Motion segment and joint dysfunctions . . 13 2.11 R eflex processes in vertebrogenic 2.4.1 The barrier . . . . . . . . . . . . . . 13 dysfunctions . . . . . . . . . . . . . . . 34 2.4.2 Joint play and restriction . . . . . . 14 2.4.3 Reflex changes in joint restriction . 15 2.12 Radicular pain . . . . . . . . . . . . . . . 36 2.4.4 Is restriction an articular 2.13 The term ‘vertebrogenic’ . . . . . . . . . 37 phenomenon? . . . . . . . . . . . . 16 2.4.5 T he possible mechanism of 2.14 Conclusions . . . . . . . . . . . . . . . . 38 restriction and manipulation . . . . 16 2.1 The significance of 2.4.6 The effect of manipulation . . . . . 17 morphological changes 2.4.7 The pathogenesis of restriction . . . 17 2.5 The spinal column as a functional unit . . 19 Chapter 1 indicated the great range of applica- 2.5.1 The spinal column and balance . . 20 tion of manipulative therapy and most methods of 2.5.2 K ey regions of the spinal column reflex therapy, which can be used for many differ- ent cases of pain in the locomotor system; these in dysfunctions . . . . . . . . . . . 20 often involve pain whose cause and therefore treat- 2.5.3 The importance of nervous ment remain controversial. For a long time they were generally considered to be of inflammatory control . . . . . . . . . . . . . . . . 21 origin, for the simple reason that this provided the 2.6 D ysfunctions of the spinal column in easiest explanation for the pain. Indeed we still speak of rheumatic diseases, for example ‘soft tis- childhood . . . . . . . . . . . . . . . . . . 24 sue rheumatism,’ and many terms ending in ‘-itis’ bear witness to this attitude (spondylitis, arthritis, 2.7 Restrictions and their sequelae . . . . . . 26 radiculitis, neuritis, fibrositis, myositis, and pan- niculitis, for example). Since, however, inflamma- 2.8 T he significance of disturbed motor tion is a well-defined pathological condition which patterns (stereotypes) . . . . . . . . . . . 27 2.9 Sequelae of disturbed movement patterns . . . . . . . . . . . . . . . . . . . 29 2.9.1 Walking and standing . . . . . . . . 29

Manipulative Therapy can be demonstrated or disproved, the inflamma- discovery that disk herniation can be a cause of pain tion theory became untenable and had to be aban- was an important step historically, but the success doned for lack of evidence. of surgical treatment was often so striking that disk Pathological anatomy and the use of radiology lesions came to be held responsible for most of the to examine pathology in living patients (X-rays) many instances of pain related to the spinal column. played their part by demonstrating degenerative The principles that applied to radicular syndromes, changes. In place of terms ending in ‘-itis’ we speak mainly in the lumbosacral region, were uncritically of spondylosis, arthroses, and ‘diskopathy.’ This applied to a whole range of complaints in all parts approach offers the possibility of explaining the of the spinal column. ‘Diskopathy’ became the changes in tissues that are sometimes bradytrophic. fashionable word for what we now refer to as verte- Vascularization of the intervertebral disk becomes brogenic (or spondylogenic) disease. reduced at quite a young age and the nucleus pul- Everyday practice contradicts this view and posus dries out: the water content decreases from serves to correct it. Although disk surgery is a rou- 90% in the first decade of life to 70% in the third tine procedure for radicular syndromes of the decade. According to Schmorl, 60% of women and lower limbs, it is rarely performed for low-back pain 80% of men at age 50 show evidence of degenera- or radicular syndromes of the upper limbs, and not tive changes of the spinal column, while by the age at all for simple neck pain or vertebrogenic head- of 70 the figure is 95% for both sexes. ache. Nor is disk herniation the only possible cause The very abundance of degenerative changes of pain in radicular syndromes of the lower limbs: makes it difficult to define their pathogenetic sig- in operation statistics no disk herniation is found in nificance. Whereas the number of degenerative about 10% of the cases; many radicular syndromes changes increases with age, back pain occurs most resolve without operation, and this is true even of often between the fourth and sixth decade, to cases in which medical imaging had found a herni- become less common in old age. Subjects with con- ated disk. Disk herniation can sometimes persist siderable degenerative changes may be completely after the symptoms have disappeared, although without clinical symptoms; alternatively they may resorption is also possible. Not only that; compu- suffer an attack of acute pain which subsides after terized tomography (CT) or magnetic resonance a time (while the degenerative changes remain the imaging (MRI) examination frequently reveals a same) to leave them once more symptom free. herniated disk in healthy individuals in whom it is There can even be severe pain in young patients of little relevance. It is only significant when it cor- with no degenerative changes at all. relates with clinical findings. The main difficulty is the fact that the term To conclude, in the overwhelming majority of ‘degenerative’ is so poorly defined. It is used on cases of back pain and associated clinical symptoms the one hand for destructive lesions typically only the morphological changes discussed above do not found in the hip and knee, and on the other hand provide an explanation. For this reason this type for changes of little clinical significance, and which of pain is referred to as ‘nonspecific’ (Jayson 1970) or are better described as normal ‘wear and tear.’ Often ‘idiopathic’ (without any morphological diagnosis). 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 The vast majority of cases of pain are not changes resulting from trauma and degenerative associated with demonstrable morphological changes in the locomotor system. In effect, ones. When we find degenerative changes, we should therefore, these are patients with ‘no diagnosis.’ 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 2.2 Theoretical aspects of manipulation therapy 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 Successful manipulative treatment usually results already showing some degenerative change. The in relief of pain. We may conclude from this that an 10

Etiology and pathogenesis Chapter 2 understanding of how this therapy works will give maximum side-bending, the position of the spinous us a better insight into what causes pain in the loco- processes was generally found to be changed. motor system, especially in cases where no patho- logical changes are present. The conclusion that can be drawn from these observations is that in a structure consisting of such The explanation originally given for the effect of a number of mobile elements there can be no abso- manipulative therapy was that it involved ‘reposi- lute, fixed neutral position. The same applies to tioning’; the understanding was that what was being any changes there may be following manipulation. treated was an incomplete dislocation, for which It will be shown below that manipulation operates ‘subluxation’ became the accepted term. This was only on disturbed function, that is mobility in the what Hippocrates believed, and probably also Still affected motion segment. If, however, there is no and most practitioners providing manipulative absolute neutral position, it follows that manipula- treatment down the ages. Indeed, the sight of a tion enables the motion segments of the spinal col- patient with acute lumbago or wry neck, unable to umn to adopt the position that is most favorable in straighten up, who receives successful manipulation the particular circumstances. treatment and becomes able to stand erect, makes it little wonder that they did see this as the likely If the mobility of the motion segments of the spinal explanation. The reason that physicians have had column is normal, the spinal column itself knows far to abandon the subluxation theory lies in the radi- better than the person giving treatment which ographic findings, since X-rays show no change for position it should adopt for each particular posture the individual segments before and after manipula- or load. tion. The only change is in the abnormal posture, whose cause is muscular. According to the literature, some authors, such as Cyriax, Maigne, and Stoddard, believe that It has been shown by M Berger (personal com- manipulation exerts some kind of effect on the munication) by means of cineradiography that when disks. However, it is difficult to see how manipu- the head moves to an extreme position and back, lation could achieve repositioning of a herniated it does not return to the same neutral position as disk when its exact position can never be known. before. We were able to confirm this by means of Another point to consider is that manipulation is transoral radiography (see Figure 2.1). also effective in treating other locations, where An analogous effect was demonstrated by Jir- out (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 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 A similar principle applies not only to the pas- atlanto-occipital and atlantoaxial joints and the pel- sive mobility of joints, but also to active muscle vis. Clinical experience supports this: manipulation function. Janda in particular demonstrated the sig- is most effective in situations where there is no disk nificance of muscular stereotypes and showed that herniation, and often fails precisely in cases where faulty movement patterns (disturbances of these there is. stereotypes) produce abnormal stress on passive structures, especially joints. The precise examination techniques used by osteopaths have also provided a clearer idea of the Closely associated with movement patterns is effect of manipulation therapies; these are indi- the matter of body statics. In fact, static overload cated when we find movement restriction in a joint and its consequences have become an extremely or a vertebral motion segment, and if manipulation important issue in our modern technologically is successful, normal mobility is restored. In other developed society with its general lack of mobility. words, manipulation does not achieve a change of Here too we find that correction of faulty posture structure, as Still thought, but normalization of frequently relieves pain. The contribution made by mobility; that is of function. Brügger is particularly helpful in this connection, since he has made a special study of the hunched This is also true in cases of acute lumbago or sitting posture and its treatment. acute wry neck: the position of the neck or the back in such cases is not in fact abnormal in itself; Manual functional diagnosis thus served as a it is only the fact that the patient is unable to model for many other dysfunctions of the locomo- straighten from a position, such as flexion, or rota- tor system. The muscle trigger point (TrP) most tion plus inclination, that is pathological. Manipula- clearly demonstrates the close connection with tion (mobilization) simply frees mobility and thus pain. In saying so we should stress that morphologi- enables the patient to return to the neutral position. cal lesions are also associated with disturbances of Acute lumbago and wry neck are in fact an excep- function. This is most clearly the case for herniated tion in this regard; in the vast majority of cases the disks and may explain spontaneous recovery and position observed is normal and the finding is sim- recovery after conservative treatment (including ply one of movement restriction in the joint (or manipulation). A similar situation applies to reha- vertebral motion segment). bilitation in traumatology, where our primary aim is to improve function despite the presence of irre- Manipulative techniques are used to diagnose and versible structural changes, where the aim of reha- treat only functional movement restrictions in a joint bilitation is to achieve functional compensation. or vertebral motion segment. The purpose of manipulation techniques is simply to normalize As will be shown in more detail later, function disturbed function. and its disturbances are rarely confined to one site or structure. Diagnosis must therefore take in the 2.3 The significance of locomotor system as a whole, and consequently functional disturbances the terms ‘vertebrogenic’ or ‘spondylogenic’ will no longer suffice. Even in back pain, muscle function As the above makes clear, it is above all clinical expe- and its nervous control play an important role, as do rience in the use of manipulation for diagnosis and the functions of the pelvis and lower limbs. Since treatment that constantly reaffirms, in countless ‘vertebrogenic’ diseases or lesions include such patients, the principle that treatment, if technically well-defined pathological conditions as ankylosing successful, brings normalization of restricted mobility spondylitis and osteoporosis, the decisive criterion in the joint or motion segment. Normalization goes for the use of manipulation and other measures hand in hand with the restoration of function (bend- aimed at restoring function is whether the patient’s ing or rotation to the left or right; in the case of the complaint is due (mainly or exclusively) to dysfunc- limbs, symmetrical findings in the left and right limb). tion, or to structural (pathomorphological) changes. Normalization of function also brings relief of pain. 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 weak- ness of important methods of treatment – such as manipulative therapy, remedial exercise, and other methods concerned with improving the functioning 12

Etiology and pathogenesis Chapter 2 of the motor system – that they are often more con- Clinical criteria are the decisive factor in identifying cerned with the method than with its object or its such restriction, and are judged from the qualitative potential for diagnosis. point of view as well as quantitatively. A reduced range of motion is easy to recognize and measure in In many fields of medicine the significance of a joint, but much more difficult in motion segments findings relating primarily to function is now well of the spinal column. Qualitative changes are there- recognized. In the locomotor system, however, fore of considerable diagnostic value when dealing where function is paramount, this aspect finds with the spinal column. least acceptance. Yet the functioning of the loco- motor system is extremely complex, and diagnosis This is the case when the finding is one of of disturbed function is correspondingly difficult. increased resistance, and especially a lack of Nor is there a specific medical specialty responsi- ‘springing’ at the end of the range of motion, with ble for this area; functional disturbances seem to be abrupt resistance encountered in the end position the realm of everyone and of no one. There is an of the joint or motion segment. In a normal joint additional disadvantage in that, for the most part, the extreme position is never reached abruptly, and the only means of investigating dysfunctions of the a slight increase of pressure can always increase locomotor system is by inspection and palpation. the range of motion. In a joint with functionally Today these are often regarded as ‘subjective’ and restricted mobility, this springing or giving way has dismissed, while instrumental and laboratory meth- been lost and we abruptly encounter a hard barrier. ods are regarded as objective. This, termed joint ‘restriction’ (sometimes ‘block- ing’ or ‘blockage’), is perhaps the most significant 2.4 Motion segment and sign in diagnosis. joint dysfunctions 2.4.1 The barrier Dysfunctions of joints and vertebral motion seg- The concept of the ‘barrier’ is a familiar one in the ments (see Figure 2.2) fall into two categories: osteopathic literature. Three kinds of barrier can be hypermobility and restricted mobility; manipulative identified: therapy is concerned only with restricted mobility. 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 2.2 • The motion segment (after Junghanns). Figure 2.3 • The barrier phenomenon. A–A: the anatomical 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 only be sensed by palpation, but can be demon- with reference to joints, but is also useful in relation strated radiographically (see Figures 2.4 and 2.5). to the elasticity and mobility of soft tissues, includ- ing muscles. The barrier is therefore relevant for all Joint play is by no means only a matter of theo- mobile structures; it has a protective function. retical interest: its practical clinical importance lies in the fact that joint play reveals restriction at a stage The definition of the physiological barrier given when functional mobility is still normal, and – as above is not universally accepted. It is defined in can be seen from Figures 2.5 and 2.6 – translational 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 pas- sive 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 per- formed 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 phys- iological barrier must therefore stand. It is useful both in diagnosis and as a principle that underlies our treatment, which produces release. We recog- nize fully that this does involve subjective evalua- tion. The first, minute resistance is found by means of palpation, which of course depends on the expe- rience of the practitioner. 2.4.2 Joint play and restriction There are two types of joint movement, both of Figure 2.4 • Lateral and medial gapping of the knee joint, which are affected by restriction: visualized radiographically. 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

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, Joint play can be likened to a drawer that has stuck: visualized radiographically. 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 Restriction in a joint and particularly in a vertebral gliding motion during joint flexion. (B) Where there is a motion segment produces reflex changes, mainly dysfunction of gliding motion, passive functional movement in the segment concerned, affecting the cutaneous can injure the joint. and subcutaneous tissue and muscles. Korr (1975) movements and distraction provide a much more speaks of ‘facilitation’ in the segment. gentle method of treatment than passive functional movement. The movement restriction itself is associated with muscular tension (TrP or spasm); this can Normal joint play is necessary for normal joint similarly be said of the straight-leg raising test and movement. of the antalgic posture in lumbago or acute wry neck. Korr, a physiologist who worked on the prob- lem 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 There are some joints that are not under the same contractile forces are also used to oppose direct control of a particular muscle; obvious exam- motion’ (Korr 1975). ples are the sacroiliac, the acromioclavicular and the tibiofibular joints. Yet muscular fixation of From this we can conclude that, in their role as these joints (other than the acromioclavicular joint) a brake, muscles act as a considerable and highly is regularly found. In the case of the sacroiliac joint, variable impediment to mobility in a dysfunctional for example, this is caused by the pelvic floor, the joint. Korr continues: ‘The high-gain hypothesis is ischiocrural muscles, or the piriformis; in the tibi- consistent with, and offers an explanation for, the ofibular joint by the biceps femoris. steeply rising resistance to motion (‘bind’) in one direction and the equally precipitous collapse of In order to investigate further the role of the joint, resistance (increasing ‘ease’) in the opposite direc- we undertook the following experiments: in patients tion … They [the muscles] would also be provoked who were about to undergo operation under anes- into stronger and stronger contraction by the exag- thetic with artificial respiration, the cervical spine gerated spindle discharges as motions that tend to was examined shortly before operation. Restric- lengthen the affected muscles occur’ (Korr 1975). tions were found in ten patients, and the exact loca- tion and direction determined. The patients were This would also explain the hard ‘feel’ in the re-examined under anesthesia, which used mainly end position. All the clinical findings encountered thiopental, nitrous oxide and 100 g succinylcholine in restriction might therefore be explained as the iodide, the patients being in a state of complete result of muscle activity and not as a disturbance muscle relaxation. This involved brief interruption of of the joint itself. That is why osteopaths prefer to the intubation. In all cases the movement restriction speak of ‘somatic dysfunction’ (Greenman), a term remained unchanged during narcosis. that includes the dysfunction of the joint, the mus- cles, and the soft tissues. 2.4.5 The possible mechanism of restriction and The role of shortened muscles in movement manipulation restriction is emphasized by Janda. Muscle relaxa- tion techniques are used with much success in The importance of the experiment just referred order to mobilize joints. It is therefore appropriate to lies first in demonstrating that the joint does at this point to consider the actual role of the joint also play a part in restriction; and second in show- in restriction. ing that there is (also) a mechanical resistance. It was Emminger (1967) who first suggested that this 2.4.4 Is restriction an articular might be attributed to a trapping of the meniscoids phenomenon? as previously described by Töndury and others. Kos & Wolf (1972) showed in addition that these Clearly the view that passive movement is exclu- meniscoids do also exist in the limb joints. sively the expression of articular function is not one that can be maintained. In fact, as Korr has The physiological role of the meniscoids is to fill shown, most clinical findings in joint restriction the changing joint space as it alters during movement, can be explained by muscle activity controlled by since they are a highly mobile structure. Most joints the gamma system. If this is the case, what role is have very incongruous facets; without the menis- played by the joint itself? coids to perform this role, gapping of the joint would occur during movement. The meniscoid is intimately If we are dealing with a reflex response, what is connected with the joint capsule. Clearly such well- the origin of the stimulus that evokes it? It must nigh chaotic-seeming motion must be prone to dis- surely be more than mere coincidence that tech- turbance. However, Cihák (1981) points out that the niques which have been found in a purely empirical deep layers of the multifidus muscles are linked with manner to be effective in manipulation correspond the joint capsule and so control this mechanism. to joint anatomy. The importance of joint play is also consistent with this, as is the fact that the pop- This theory has been further elaborated by Kos ping sound, or ‘click,’ that is heard on successful & Wolf (1972). They describe the following hypo- manipulation comes from the joint. The hypotonus thetical pathogenetic mechanism: regularly observed following such manipulation is however a muscular phenomenon. 16

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, Figure 2.9 • The effect of therapy. (A) High-velocity, low- connected with the joint capsule. It has a hard amplitude thrust. (B) Repetitive mobilization. (C) Widening of free edge, which cannot easily be compressed the joint space by release technique. and projects into the joint space. the significance of the vertebral motion • Joint cartilage is hard and elastic only if the segment or the joint concerned, the effect force that acts on it does so briefly. If, however, of the manipulation also extends to distant we subject the cartilage to constant pressure, it segments; this will be discussed later. The adapts to the material exerting that pressure as effects referred to here can not only be though it were fluid. If, therefore, the meniscoid observed clinically, but can also be objectively is caught between the gliding surfaces of the demonstrated by physiological methods (see joint facets, the cartilage adapts to the hard Figures 2.10–2.13). meniscoid, embedding it (viscoelasticity) (Figure 2.8). 2.4.7 The pathogenesis of restriction This diagram clearly illustrates the mechanism of manipulative techniques. High-velocity, low-ampli- Overload and abnormal load tude (HVLA) techniques cause gapping of the joint capsule, as a result of which the meniscoid has only In the case of the most minor restrictions, we a short constricted area to overcome (Figure 2.9). know from our own experience how these come In repetitive mobilization, the meniscoid is freed about: sitting or working for a long period in an during the back-and-forth movement of the joint unfavorable position, we sense a need to stretch 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 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 Figure 2.13 • Summation electromyogram of the triceps increase in muscle activity (force) in the triceps brachii during brachii taken from three leads in a C8 root compression cervical traction. syndrome (A) before and (B) after cervical manipulation. 18

Etiology and pathogenesis Chapter 2 and move, that is to ease such minor inhibitions condition creates a stimulus in the segment, which of movement. This is the stiffness that causes us in turn produces a spasm (TrP) in the correspond- to stretch ourselves on getting up in the morning. ing region of the erector spinae muscle, in particu- Minor restrictions can therefore arise even in physi- lar in the deep layer. The effect is muscular fixation ological situations and in healthy individuals; and of the vertebral motion segment: a restriction. This these resolve spontaneously. There is a fluid tran- is the same mechanism that, according to Hansen sition between such minor restrictions following & Schliack (1962), leads to scoliosis in visceral dis- physiological stress, and persistent restrictions fol- ease. lowing pathogenic, harmful stress. Both the stress itself and the neuromuscular system of the patient Today it is possible to distinguish a number of play a role here. One pathogenic factor is overload; characteristic patterns related to visceral disease another, more frequent cause is a disturbed move- (see Chapter 7) which points to certain pathoge- ment pattern (motor stereotype) on the part of the netic rules. Another characteristic feature of this patient, consisting of an imbalance of muscle func- type of restriction is its recurrence if the internal tion which impairs the joint (Janda). disease relapses or exacerbates. Admittedly, how- ever, we know more about visceral influence upon Modern civilization brings with it very one-sided, the spinal column than about the influence of the unvaried posture and movement, causing muscu- spinal column on visceral organs. lar imbalance. Lack of movement together with static or postural overload are a characteristic fea- 2.5 The spinal column as a ture of modern life. Disturbed movement patterns functional unit and static overload are probably the most frequent causes of reversible restrictions and of their occur- The most important functions performed by the rence and recurrence. spinal column are: • giving support and protection to neural Trauma structures Trauma is a further potential cause. It is important • being the axis of motion for the body to point out that the borderline between patient • helping to maintain the balance of the body. groups suffering from overload and those suffer- ing the effects of trauma can in fact be very fluid, As we can see from the first two functions listed, because it is not always easy to say what should and these roles are contradictory; Gutmann (1965) should not be interpreted as trauma. It is usually expressed this succinctly when he said: ‘the spinal defined as a force acting on the body and capable column should be as mobile as possible and as firm of damaging structure or function. However, even as necessary.’ The implications of this become clear under normal conditions the forces acting on the when we consider the remarkable range of move- spinal column are considerable. If these forces are ment of the atlanto-occipital and atlantoaxial joints, suddenly increased because of sudden, unexpected and the fact that vital centers of the medulla oblon- movement, especially if this involves contraction gata are located at this level; these twin facts explain of the powerful muscles of the back, it becomes why disturbances of these two basic functions are extremely difficult to distinguish between overload linked. If a dysfunction produces a pain stimulus, and trauma. The somewhat vague term ‘micro- a muscular defense reaction blocks the damaging trauma’ is then used. movement. A spinal column with restricted mobility is no longer properly able to carry out its protective Reflex processes function. The effects extend to the structures of the nervous system, which in turn exerts an effect A further complex of causes involves reflex proc- on the spinal column that is causing the damage to esses within the segment. As has been stated them. Sobotka (1956) demonstrated that dam- already, the spinal column is routinely involved in age to a nerve root causes trophic changes of the disease processes in the body. Vertebral restrictions intervertebral disks. The function of the spinal col- can therefore occur following – and also as a result umn affects not only the structures inside the spinal of – disease elsewhere in the body. The primary canal, but also the entire locomotor system, includ- ing the limbs, and probably also internal organs. 19

Manipulative Therapy The existence of all these functional interconnec- and trunk. The reflexes therefore have very short tions means that the spinal column should always transmission times; changes were still being registered also be considered when the object of concern is the in the activity of the muscles investigated, even at a pelvis, limbs, or especially the muscles under central side-bending frequency of 200 side-bends per minute. nervous system control. These experiments demonstrate that the spi- 2.5.1 The spinal column and nal column is a functional unit governed by reflex balance response; if certain changes in position or func- tion occur at one end of the spinal column, these The importance of the spinal column in the main- exert an instant reflex effect along the entire spine. tenance of balance is usually underestimated. This It should be stressed that, in humans, both ends of applies in particular to the craniocervical junction. the spinal column are held relatively constant: in It is often forgotten that the labyrinth is not abso- the case of the pelvis this is achieved because of the lutely essential for the maintenance of balance and length of the legs; in the case of the head, through posture, whereas proprioception is, especially in the reflex fixation of the plane of the eyes and laby- spinal column. Clinical evidence confirms this (see rinth in space. This preservation of the head posi- Chapter 7). The experiments carried out by Norré tion is strongly maintained as a movement pattern and cow­ orkers (1976), using Greiner and coworkers’ (motor stereotype). Ushio and coworkers (1973) (1967) flexible-support chair, are particularly valu- demonstrated the deleterious effect of low-back able in this respect. The method they used involves pain on vertigo and the beneficial effect of immobi- keeping the subject’s head fixed in position while lizing the lumbar spine in lumbago. turning the trunk from side to side with a pendular motion. They were able in this way to produce nys- 2.5.2 Key regions of the spinal tagmus, purely by stimulation of the cervical prop- column in dysfunctions rioceptors (Greiner et al 1967, Hülse 1983, Moser et al 1974, Norré et al 1976, Simon & Moser 1976). So far we have considered restriction and its origins without reference to its effects on the rest of the The effects are not limited to the cervical spine. spinal column. This, however, would be to ignore Komendantov (1945, 1948) demonstrated in rab- one of the most frequent causes of restrictions: a bits that tonic reflexes can originate not only from restriction or trigger point in another section of the the neck but also from the lumbar spine. He distin- spinal column. These bring about a compensatory guishes the lumbosacral-eyes and lumbosacral-head increase in mobility in the neighboring segment, reflexes. On side-bending of the animal’s trunk in which leads to overload and ultimately a further the lumbar region around a dorsoventral axis, restriction. Chain reactions therefore come about, with the upper body and head fixed, the eyes which explains why vertebrogenic disturbances move in the opposite direction to the trunk. If tend over time to involve the entire locomotor the head is not held fixed, there is an additional system. Therefore we should always examine the slight turning of the head, also in the opposite entire spinal column, at least in terms of screen- direction. Leads from the muscles of the nictitat- ing assessment. It is important to realize, not least ing membrane and the rectus muscles (of the eye) in this respect, that not all vertebral segments have showed this to be a tonic reflex. Komendantov’s the same importance for the overall function. When experimental design enabled him to make neck performing a brief assessment we should therefore and lumbosacral reflexes compete, with the neck focus on ‘key regions.’ In most cases these are tran- reflexes usually proving stronger. However, the sition zones from one type of movement to another: effect was dependent on the extent of side-bend- ing; the greater the side-bending, the stronger the • The craniocervical junction: the delicate effect. Interestingly in the course over time, it was vertebrae of the upper cervical spine bear seen that immediately following the effect of a neck the heavy weight of the human head and also reflex, even a relatively weak lumbosacral reflex can enable extensive mobility in all directions. also assert itself. This mechanism apparently ena- Dysfunctions here affect muscle tone in the bles the animal to keep the visual field constant postural musculature and lead to disturbances during locomotion, despite the motion of the head of balance. Restrictions of the atlanto-occipital and atlantoaxial joints impair the mobility of the 20

Etiology and pathogenesis Chapter 2 rest of the cervical spine. The most important 2.5.3 The importance type of motion between the atlas and the axis of nervous control is rotation; the rest of the cervical spine is less well adapted for this, and so suffers if forced The spinal column could not act as a functional unit to compensate for a craniocervical rotation dysfunction. The vertebral artery runs through unless all its reactions were coordinated, under con- trol of the nervous system. Certain kinds of posture the atlanto-occipital and atlantoaxial joints, and can also be affected by dysfunctions in this and movement sequences play the major role in this respect; these, following the proposal of Janda, are region. • The cervicothoracic junction: this is the region termed ‘motor patterns.’ These motor stereotypes in which the most mobile section of the spinal are so characteristic of an individual that we can column meets the relatively rigid upper thoracic recognize people by their gait. There is considerable variation in the quality of these patterns, and this spine. It is also the place where the powerful goes hand in hand with the susceptibility to dis- muscles of the shoulder girdle have their attachment, providing the main connection with turbance of the locomotor system in the individual the upper limbs and explaining why this region case. Any disturbance of function in a single motion segment will have its repercussions throughout is particularly susceptible to dysfunctions. the spinal column and must be compensated. The • The middle thoracic spine is to some extent the decisive role in this is played by the nervous sys- ‘weak point’ of the muscles of the back, since tem, which is similarly important in the matter of the lumbar and cervical parts of the erector pain, for it is the nervous system that determines spinae muscles end here, and kyphosis is usually how intensely the segment will react, and where greatest at this point. the threshold of pain lies. In other words, it is the nervous system that determines whether the • One of the reasons for the considerable load dysfunction will manifest itself clinically. If the borne by the thoracolumbar junction is that reaction to the nociceptive stimulus is intense, dys- here the mechanism of motion typical of the function in one motion segment will produce an thoracic spine changes within a short distance antalgic response and alter the normal movement (at vertebra T12) to the lumbar pattern. This pattern, causing the dysfunction to become fixed, can be seen from the difference in shape of so that the condition becomes chronic. the upper and lower articular processes. If during walking the pelvis tilts from one side It is, therefore, no coincidence that dysfunctions to the other, the lumbar spine side-bends so of the motor system are more likely to be found in that the vertex of the scoliotic curve lies at subjects with labile nervous regulation, and this the level of L3, the thoracolumbar junction tends to be evidenced psychologically as well. The remaining vertically in line with the sacrum; point was emphasized by Gutzeit (1951), who saw the thoracic spine then forms a scoliotic curve the psychological factor as being characteristic for in the opposite direction. Consequently the patients presenting with vertebrogenic disturbances. thoracolumbar junction does indeed represent a Kunc and coworkers (1955) showed that the psy- junction. chological condition of patients plays a major part in recovery after disk operation. They demon- • The lumbosacroiliac joint region forms the base strated by means of experiment that these patients of the spinal column and is therefore extremely very easily formed conditioned reflexes to other important to spinal column statics. At the same pain stimuli, and that these reflexes were more dif- time the sacroiliac joints transmit movement ficult to extinguish than in healthy controls. Šrácek from the legs to the spinal column and act as & Škrabal (1975) observed two groups of psychi- shock absorbers. atric patients: 50 cases of neurosis with symptoms • In humans the feet are the body’s actual base; also the greatest density of proprioceptive, of anxiety and depression, and 25 schizophrenics exteroceptive, and nociceptive receptors with blunted affect. Restriction, most frequently is found there. Dysfunctions in this region in the cervical spine, was absent in only 5 neurotic consequently have an effect on the whole of patients and in 16 schizophrenic patients. This dif- the locomotor system; they should not be ference is statistically highly significant (p < 0.01). overlooked. Buran & Novák (1984), studying a group of 105 21

Manipulative Therapy chronic patients, distinguished constitutionally neu- The importance of developmental rotic and psychopathic patients from those who kinesiology were psychologically normal. They found a prepon- derance of the fatigue reaction in the electromyo- It is no coincidence that Janda associates distur- gram (EMG) in the neurotic patients, and more bances of motor pattern in adults with disturbances frequent occurrence of positive F-waves, indicat- of the central nervous system in infants. Devel- ing a correspondence between psychological labil- opmental kinesiology can indeed help us better ity and labile nervous regulation. Lisý (1983) found understand the pathogenesis of dysfunctions, espe- similar results in EMG studies of patients with cer- cially the effects that a structure belonging to the vical syndrome. locomotor system can exert on distant regions; in other words, on the entire system. In this context The clinical findings made by Janda (1978) are we shall attempt to present the essential thinking also worthy of note: in 100 patients with poor of Vojta & Peters (1992) and Koláˇr (1996, 1999, motor patterns, he found: 2006) on the present subject. • minor neurological signs of ‘microspasticity,’ in Neurophysiology today has no explanation for which movements were not fully coordinated, the effects exerted on each other by parts of the appearing as clumsiness locomotor system that are situated far apart, which are found as a matter of everyday experience in • slight sensory impairment, especially of manipulative therapy; nor can it explain the chains proprioception of trigger points. The principles governing these can however be explained by developmental kinesiology. • poor adaptation to stress situations and inadequate, ‘uncoordinated’ behavior. The first reflexes in the newborn (stepping reflex, crossed extension reflex) are spinal cord reflexes. All these clinical signs correspond to ‘minimal They offer no stability and do not enable posture brain damage’ (MBD). Found in 10–15% of the of any kind. The first postural reflexes arise when child population, this is quietly assumed to disap- the infant begins to observe its surroundings, raising pear without trace in adulthood. However, Janda’s and holding up its head. This is the point when the findings suggest that this brain dysfunction is in fact flexion posture of the newborn (see Figure 2.14) is manifested in adult patients in the form of verte- brought into balance with the developing extensors. brogenic disorders, poor motor patterns, and a con- This development is complete roughly at the end of siderable degree of labile nervous and emotional the third month (see Figure 2.15). regulation. The difference observed in the limbs is that the Despite the role played by muscular imbal- flexion posture gives way to a balanced, neutral ance and faulty neural control, these should posture with slight abduction, external rotation, and not be equated with joint dysfunction or extension. It should be stressed that this posture can restriction of a vertebral motion segment. be achieved shortly after birth, according to Vojta & Dysfunctions of the joints or vertebral seg- Peters (1992), who states that this can be done by ments do occasionally appear even in sub- jects 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 back- ache. In our experience, most patients with Par- kinson’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 Figure 2.14 • Posture of the newborn in the prone position. among the factors involved in the pathogenesis and clinical signs and symptoms of locomotor dysfunctions. However, they are not identical with them. 22

Etiology and pathogenesis Chapter 2 Figure 2.15 • Posture of the infant in the prone position The coactivity pattern relates to upright posture at the end of the third month of life. The infant is able to as a whole. Muscles that maintain the position of support itself on forearms, pubic symphysis, and knees. the head over the shoulders have their fixed point of attachment in the region of the shoulder girdle, stimulating points where there is an abundance of the muscles of the thorax and scapula in the pelvic proprioceptors. These points are structures on region, and the muscles of the pelvis in the region which we support ourselves; as soon as we rest on of the lower limb, down as far as the foot. As soon one of these points (forearm, elbow, or knee) for as the position of one of these superposed sections support, our posture changes automatically, remain- changes, the entire system has to react. Control of ing balanced in each case. This enables us to achieve these reflex processes in the maintenance of human the most favorable position (centering) of our joints. upright posture is located above the brainstem; it has been little researched experimentally. The extensor system is therefore younger in developmental terms than the ‘tonic’ flexor system, The long chains of antagonists which subserve and therefore more susceptible to disturbance. upright posture act on the spinal column like ropes This explains why the tonic system always predom- stabilizing a mast. However, unlike a stiff mast, inates in pathological states, pain, and even in mere the spinal column is formed by 24 vertebrae and fatigue. Both systems are involved in upright pos- the sacrum which, according to Panjabi (1992a, ture; it is therefore inappropriate to use the term 1992b), are unstable and would buckle under the ‘postural muscles’ for the tonic system alone. The strain. This is prevented by what is called the ‘deep decisive issue is which system is older or younger in stabilization system.’ developmental terms. Another system that is developed only in humans This course of development gives rise to the is that of the ‘deep stabilizers,’ which serves to coactivity of antagonists, which enables balanced, maintain the upright posture of the spinal column. upright posture and can be seen at two levels. As It consists of the deep layers of the erector spinae an example, the erector spinae is the antagonist that and transversus abdominis muscles, the diaphragm, corresponds to the pectoralis major muscle. The rela- and the pelvic floor. The last three of these support tionship is so specific that certain bundles of fibers of the abdominal wall. The abdominal cavity and its the pectoralis major correspond only to certain bun- internal pressure provide the anterior support of the dles of fibers of the erector spinae. The same kind of lumbar spine. In humans, the diaphragm plays a sig- correspondence applies to adductors and abductors nificant role as a postural muscle; only in humans is in the limbs, for instance. Clinically this is seen in the there a close link between respiration and posture, localization of trigger points. However, this antago- with the diaphragm lying horizontally. nism applies not only to individual muscles, but to the entire system. This fact is extremely important: A further function, which develops relatively late stimulation of a muscle that belongs to the extensor in infants (after the sixth month) and which is there- system inhibits the whole of the flexor system. The fore also susceptible to disturbance, is (active) rota- effect can most clearly be seen when stimulation is tion of the trunk. This plays a particularly important applied to one of the points where most receptors role in humans, since the most forceful movements, are located, such as the fingers and toes. To give an such as throwing a discus or boxing, proceed from example, stimulation of the finger extensors can pro- a rotation of the trunk. At every step the shoulder duce inhibition in the straight-leg raising test. 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), how- ever, the spinal column is less well adapted to rota- tion 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-month- old infant, the limbs are brought into the optimum 23

Manipulative Therapy Figure 2.16 • Weight-lifter’s posture. radiographically. Dysfunctions, however, appear at the same time as clinical symptoms. (centered) position and the muscles activated. This posture also corresponds to that of a weight-lifter The most typical clinical condition in children (see Figure 2.16). is cervical myalgia (acute wry neck). Although this usually remits spontaneously, traction and gentle Vojta’s developmental kinesiology offers an mobilization techniques, if well applied, should give explanation for the physiological principles immediate relief. This is particularly true for neu- governing the upright posture of humans. romuscular techniques. 2.6 Dysfunctions of the spinal In children with headache, the cervical spine column in childhood plays an important role. This is true of various types of headache, including migraine. In a group From what has been said it follows that dysfunc- of 30 children suffering from vasomotor headache, tions are regarded as primary phenomena in the manipulation produced improvement in 28 cases. pathogenesis of vertebrogenic disorders. Hence Janda (1959) reported similar success follow- studies try to investigate them in their pure form, ing traction of the cervical spine. In a group of 27 that is in the absence of degenerative changes, children suffering from migraine, only 3 failed to which can be done by studying them in children respond to manipulation treatment (Lewit 1959). and young people. Schön (1956), and later Gut- Similar results were reported by Kabátníková & mann & Wolff (1959), have shown the average age Kabátník (1966). A particularly important type of at which the first symptoms appear to be much headache in children, known as ‘school headache’ earlier than the age when they become evident 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 gynecolog- ical 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 dys- menorrhea at an early age is frequently the first sign of dysfunction of the spinal column in women. True lumbago is much less frequent in child- hood, but there are rare cases of true disk hernia- tion 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 dys- functions 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 differ- ence between the incidence in boys and girls. 24

Etiology and pathogenesis Chapter 2 Movement restriction in the cervical spine (mainly in infants was pointed out by Seifert (1975). In at the atlanto-occipital and atlantoaxial joints) was children in whom function is normal, they found found in none of the infants in crèches, in only 8 out that, on turning the head to one side, the pel- of 181 nursery school children examined, and in 73 vis turns to the opposite side. This reaction was of the 459 schoolchildren. These investigations were absent in 298 of the 1093 infants examined. Over carried out over 40 years ago, when the technique of a period of 4–9 months restriction of the atlanto- examination for the upper cervical spine was much occipital and atlantoaxial joints was found in 58% less sophisticated than it is today. It has since been of this group. Biedermann (1993) described what found that pelvic distortion in children is gener- he termed ‘KISS syndrome,’ characterized by a ally associated with craniocervical joint restriction, forced attitude of the head in the side-bending mainly in the C0/C1 segment; there is normalization position, often found in association with consider- of the pelvic findings after the C0/C1 joint has been able somatic and autonomic disturbances. These treated. In 1982 we therefore examined a group of he treated by manipulation. In a study group of 76 75 nursery school children (aged 3–6 years). We children suffering from chronic tonsillitis, Lewit & found pelvic distortion in 24, of whom 23 had move- Abrahamoviˇc(1976), found restriction of the atlan- ment restriction of C0/C1. In 12 of these children to-occipital and atlantoaxial joints in 70 (92%) of manipulation of the craniocervical joints was carried the subjects, mainly in the C0/C1 segment. out, following which there was normalization of the pelvic distortion in all cases. There is thus good rea- In evaluating these results we needed to discover son to believe that most of the children in whom we whether they were chance findings or represented found pelvic distortion in the examination we per- continuing, constant dysfunctions. In collaboration formed over 40 years ago also suffered from restric- with Janda we therefore followed up a group of 72 tion at the craniocervical junction. We also found children who started school attendance in 1960, slight scolioses in 175 of the 459 schoolchildren carrying out regular examinations over a period of examined at that time, and in 15 out of the 181 nurs- eight years. Half the number with dysfunctions of ery school children. Among the children in crèches, the spinal column were treated, and the other half this finding was made in only 1 out of 80 children. left untreated as controls. In addition to the spinal column, the rest of the locomotor system and par- The overwhelming importance of the craniocer- ticularly the musculature were tested. The results vical (atlanto-occipital and atlantoaxial) joints 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. 25

Manipulative Therapy The most important finding for our conclusions neighbor, and this is most marked in the case of was that dysfunctions in the regions of the pelvis restrictions in key regions. The most frequent con- and cervical spine remained constant and seldom sequence of chronic overload is the formation of showed spontaneous improvement. The tendency osteophytes to stabilize the motion segment. The to remain constant was greater for these than for lack of motion in the restricted segment often leads scolioses or differences in leg length. There were to disturbances of trophicity, which particularly only a few relapses after treatment. affects bradytrophic tissues such as ligaments and disks. This is confirmed by radiographic evidence, Dysfunctions of the spinal column can be found which shows osteophyte formation in temporarily even at a very young age, and even in subjects hypermobile segments (above block vertebrae). The who are clinically healthy. However, they can be usual findings in restricted segments are that two clinically manifested, usually as acute wry neck, adjacent vertebrae form a block with the narrowed headache and, in girls, as dysmenorrhea. These disk showing degenerative changes. Müller (1960) symptoms can occur in the absence of any have shown how the hypermobile segment, initially degenerative changes. created to compensate for a hypomobile one, stiff- ens in its turn as a result of osteophyte formation, 2.7 Restrictions and their so that the osteochondrosis spreads from one verte- sequelae bral segment to the next. The stabilizing role of the osteophytes, which are plate-like in shape, can best If a restriction occurs in the intact terrain of the be seen in chronic spondylolisthesis. spinal column of a child or an adolescent, for exam- ple, the consequences may seem at first sight to be Degenerative changes in themselves need not minor: there may be some transitory pain, which produce clinical symptoms. They do, however, usually disappears quickly as tends to be the case make the spinal column more susceptible to distur- with acute wry neck. The dysfunction is compen- bance, and the same applies to dysfunctions. Even sated. Of course, a restriction occurring in the rest patients with degenerative changes experience no of the locomotor system, particularly the limbs, symptoms as long as function remains compen- becomes clinically evident immediately. In the spi- sated, but there is a risk of decompensation. This nal column, consisting as it does of complex parts explains why the sequelae of trauma are usually (54 intervertebral joints, including the atlanto- more severe when degenerative changes are already occipital and atlantoaxial joints and the sacroiliac present. Frequently, what are called degenerative joints), the lack of mobility of a single joint or changes are better described as adaptive ones, or an motion segment can go unnoticed. There is, how- attempt to compensate dysfunction. ever, a price to be paid for this capacity of compen- sation: increased demands or abnormal stress on the One important sequela of degenerative changes compensating structures. This becomes especially can be a herniated disk. Here too there is a close evident when the restriction occurs in a key region relationship between structural change and dys- (see Section 2.5.2), because neighboring regions function. With modern imaging techniques we cannot easily compensate. As mentioned previ- find that disk herniation revealed by CT or MRI ously, restriction of rotation between the atlas and need not be accompanied by any symptoms; also the axis means that their role in the rotation of the that, in cases where the herniated disk does pro- head has to be taken on by the rest of the cervical duce pain, the clinical symptoms may disappear spine, which is far less suited to the task. This may despite the fact that the herniation continues to help explain why osteochondrosis of the lower cer- be evident on CT or MRI examination. The rela- vical spine is so commonly found. tionship between function and structural pathol- ogy is clearly very complicated here. Nevertheless, As a general principle, then, movement restric- in cases of disk herniation, dysfunction can be tion in one segment produces hypermobility in its 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 26

Etiology and pathogenesis Chapter 2 resistance to the translatory displacement of neigh- starting point. Even a layman will recognize awk- boring carpal bones. When mobility is restored in wardness of movement, and, more often than not, the early stages, the symptoms of paresthesia disap- such movement is uneconomical in energy expendi- pear. In other words, it is only when there is free ture; therefore the layman is also able to correct mobility between the bones forming the tunnel the most obvious aspects – just as sports trainers, that the walls can adapt themselves to the contents for instance, correct the movements of sportsmen of the tunnel in all the movements of the wrist. We and women. should remember that one wall of the carpal tunnel is formed by the flexor retinaculum. In patients with vertebrogenic pain, Janda sys- tematically applied the classic muscle test to the The dynamic role – usually also the primary role – in individual muscles involved in particular move- the interrelation between dysfunction and ments. His results revealed that the simple move- morphological change is that of function. ments used to examine muscle function in fact study a (fairly simple) movement pattern, involv- 2.8 The significance ing a number of muscles, rather than a particu- of disturbed motor lar individual muscle. Examining hip extension by patterns (stereotypes) polyelectromyography, Janda showed that it is not only the gluteus maximus muscle which contracts Disturbed motor stereotypes are perhaps the most in hip extension, as had been thought, but that the important factor in the etiology of functional, ischiocrural muscles are the first to contract, fol- reversible restrictions. This would make remedial lowed shortly afterwards by the erector spinae. The exercise the treatment of choice and especially typical disturbance of movement pattern found in the best means of prevention. It is less clear what hip extension is the belated and inadequate activ- the actual content of such therapy should be when ity of the gluteus maximus (see Figure 2.18). treating – usually painful – dysfunctions of the loco- motor system, since remedial exercise expects to Figure 2.18 • EMG study during extension of the right hip: deal with a well-defined lesion (for example pare- contraction of the right gluteus maximus is slight and occurs sis), and that is not what we are dealing with here. at a late stage. There is increased activity of the ischiocrural muscles and erector spinae bilaterally. (By kind permission It was Janda who first addressed this problem. of Janda.) The main object of remedial exercise in dysfunc- tions of the locomotor system is the correction of faulty motor patterning (disturbed movement patterns or stereotypes), that is faulty coordina- tion 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 indi- vidual moves is so characteristic that we can rec- ognize 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 27

Manipulative Therapy We learned over time to recognize in clinical exami- Table 2.1 Muscle groups exhibiting a tendency to hyperactivity nation which muscles actually take part in simple or hypoactivity test movements, by means of palpation. This ena- bles us to assess not only muscle force, but also Hyperactivity Hypoactivity quality of performance. This quality may be con- siderably altered while force remains normal. The On the dorsal aspect of the body strength of hip extension may remain normal, even if it is carried out only by contraction of the ischi- Triceps surae Gluteal muscles ocrural muscles and the erector spinae. In this case there is considerable disturbance of the movement Ischiocrural muscles Inferior part of trapezius pattern, with important consequences for locomo- tor function, as will be explained later. Lumbar section of the erector Serratus anterior spinae Regular testing of simple movements using the muscle test revealed a surprisingly constant pat- Quadratus lumborum Supraspinatus tern: certain muscle groups repeatedly showed a tendency to lesser activity (weakness) and hypo- Superior part of trapezius Infraspinatus tonia, whereas others equally regularly tended to hyperactivity and tension. This resulted in char- Cervical extensors Deltoid acteristic patterns of imbalance which are so constant and typical that we can identify them as On the ventral aspect of the body syndromes with a clinical significance. They are each characteristic of a particular clinical picture: in Thigh adductors Tibialis anterior some cases there is a preponderance of weakness, flabbiness going hand in hand with hypermobility, Rectus femoris Extensors of the toes whereas in others there is increased muscle tension and stiffness. Table 2.1 sets out those muscles with Tensor fasciae latae Peronei a tendency to hyperactivity and those that tend to hypoactivity. Iliopsoas Vasti This difference in the behavior of these two Obliquus externus Rectus abdominis muscle groups can be seen under various clinical conditions and is regularly found in painful states: Pectoralis major and minor Deep neck flexors in a painful hip it is always the flexors and adduc- tors that are tense and the glutei weak; in shoulder Subscapularis Digastric pain the pectoralis and subscapularis muscles and the superior part of the trapezius are taut whereas Scalenes the supraspinatus, infraspinatus, and deltoid mus- cles are weak; in chronic painful conditions of the Sternocleidomastoid knee the vasti are atrophic while the rectus femoris is like a tight band. Masticatory The findings are similar for fatigue: again the Upper limbs same muscles will be inhibited and their activity frequently taken over by those with a tendency to Flexors Extensors hyperactivity. This behavior continues to be found in central paresis, when again we find that muscles mental kinesiology (see Section 2.5.3), those of with a tendency to hyperactivity become spastic, the first group belong to the younger system and and those with a tendency to hypoactivity become the second group to the older one. It should be flabby. Neurologically, this kind of muscle imbal- stressed that there is no substantial difference ance can be termed ‘microspasticity.’ between the types of muscle fiber or the bio- chemistry of these two groups; the physiological Janda referred to those muscles with a ten- reason for the difference between them rests on dency to hypoactivity as predominantly ‘phasic,’ the developmental kinesiology. Both systems evi- and muscles with a tendency to hyperactivity as dently have a postural function. Examination of predominantly ‘postural.’ In terms of develop- 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. 28

Etiology and pathogenesis Chapter 2 The concept of patterning is clearly illustrated This is particularly so in the interrelationship of by looking at antagonists. For example, the ischi- antagonists, where the hyperactive muscle generally ocrural muscles and the quadriceps femoris can be has an inhibitory effect on its weak antagonist. For considered as antagonists if we are thinking of the example, hyperactive lumbar erector spinae mus- movement of knee flexion and extension. However, cles inhibit the abdominal muscles, and hyperactive during walking both these muscle groups are act- adductors the glutei. This disturbs the centering ing primarily to stabilize the leg. A similar principle of the joints involved, imposing excessive stress on applies to the abdominal and back muscles, and to them. the flexors and extensors of the cervical spine. In fact, in well-coordinated straightening up from a 2.9 Sequelae of disturbed stooping position it is mainly the deep abdominal movement patterns muscles that provide stability, a point to be remem- bered in remedial exercise. It should be stressed Having looked in detail at the nature of dis- here that when treating muscle imbalance involving turbed movement patterns, we now turn to the a predominance of the muscles that regularly tend mechanisms by which they impair the locomotor to hyperactivity, the effect of strengthening the system. weakened (hypoactive) muscle is not only experi- enced in the particular segment but also influences 2.9.1 Walking and standing the overall balance between ‘phasic’ and ‘postural’ muscles. This is particularly important where there The most frequent findings here are an imbalance is a greater density of afferent nerve receptors, so between weak gluteal muscles and hyperactive that afferent stimuli are more strongly felt; it is the hip flexors, between hyperactive lumbar erectores case at the fingers and toes, as Brügger has shown. spinae and weak abdominal muscles, and between He found that, following stimulation of the exten- hyperactive adductors and weak abductors of the sors of the fingers and toes, the patient finds it hip. In standing we see increased pelvic tilt, a pro- easier to resume upright posture; one of the other truding abdomen, and lumbar hyperlordosis. consequences is improvement in the straight-leg raising test. The actual pathogenic mechanism in standing is overload of the lumbar spine as a result of increased The training of different movement patterns tension of the erector spinae muscles; in walking, involves the interplay of a number of muscles overload results mainly from the fact that pelvic tilt reacting in sequence, whose reaction can be trig- places the hip joints in extension, and also from the gered if specific stimuli are employed. For move- weak gluteus maximus. As a result, the extension of ments of the limbs, stimulation of the periphery is the patient’s legs in walking is mainly achieved by most effective, since receptors are numerous here. extending the lumbar spine still more. This produces To facilitate walking, lifting the big toe is helpful: hypermobility of the lumbar spine in the sagittal the patient will then find it easier to dorsiflex the plane. Hyperactivity of the adductor muscles and foot; that in turn helps the flexion of the knee and above all the weak gluteus medius causes instability hip. Similarly, flexion of the fingers helps antever- in the frontal plane, especially when the patient is sion of the elbow and shoulder. What the fingers standing on one leg. The result is increased swaying and toes are for the function of the limbs, the eyes of the pelvis from side to side while walking; caus- are for the trunk: looking up facilitates straightening ing, in other words, hypermobility and overload of of the body, looking down facilitates bending for- the lumbar spine in the frontal plane. ward, while looking to the side facilitates rotation. Furthermore, as straightening of the body is con- 2.9.2 Straightening up from a nected with inhalation, and bending forward with forward-flexed position exhalation, it is enough for the patient to look up to facilitate inhalation (as when sighing). Similarly, If the trunk is imagined as a straight lever with directing the gaze downward assists exhalation. the L5–S1 disk as the fulcrum, calculation of the 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. 29

Manipulative Therapy stress involved during weight-lifting has produced The muscular imbalance involved here is a hyper- values of 1000 kg and above (Matthiasch 1956, active pectoralis major, in particular the clavicular Morris 1973). Such a force is more than the disk head of the muscle, hypoactivity of the weak rhom- could bear. Measuring intradiskal pressure, Nach- boid and serratus muscles and the inferior part of emson (1959) found that the pressure during the trapezius, and increased activity of the superior weight-lifting from a sitting position was 275% of part of the trapezius and the levator scapulae. The that when standing upright. The reason, accord- hyperactivity of the pectoralis major causes kypho- ing to Gracovetsky (1988), lies in the role of the sis in the lower part and hyperlordosis in the upper lumbodorsal fascia, into which the erector spinae, part of the cervical spine. the glutei, and the ischiocrural muscles fan out. The tension from the ischiocrural muscles enables These examples illustrate the pathogenic effects the spinal column to ‘hook in’ to this fascia, as it of faulty movement patterns on the locomotor were, so that the lever effect is eliminated. This system and spinal column. The motor stereotype mechanism is further supported by the abdomi- which leads to the most marked consequences, nal muscles, which also fan out into this fascia however, is faulty breathing. and in addition draw the thorax toward the pelvis and maintain intraabdominal pressure. The effect 2.9.5 The effect of respiration is that the correct movement pattern assists this on the locomotor system ‘unreeling’ mechanism and avoids the lever effect. When we think of respiration, we tend to focus 2.9.3 Raising the arms almost entirely on the organs of the respiratory system. In doing so, however, we forget that the Here the decisive factor is correct fixation of the thorax and diaphragm are essential to the function shoulder girdle; this is the function of the superior of the lungs. The locomotor system has to coordi- part of the trapezius and the levator scapulae from nate the specific function of respiratory movement above, and of the inferior part of the trapezius and with the function of locomotor activity. This task the serratus anterior, the first two muscles being is so complex that it would be a miracle if distur- attached to the cervical spine and the last two to bances did not occur. The most important issue the thoracic spine. here is the close link between respiration and the postural function. The faulty movement pattern typically found here is tension in the muscles providing fixation superiorly Skládal et al (1970) observed on radiographic and weakness of those providing stabilization infe- images that the diaphragm became flatter and con- riorly. The effect is to lift the shoulder blades and tracted when the patient stood on tiptoe during the place excessive load on the cervical spine. exposure. They interpreted this as being a postural reaction, and drew the further conclusion that: ‘The 2.9.4 Weight carrying diaphragm is a respiratory muscle with a postural function, and the abdominal muscles are postural The key factor here from the point of view of the muscles with a respiratory function.’ biomechanics is the position of the shoulder joint: if the shoulder of the weight-bearing arm is behind The way this is understood today is as follows: the line of gravity of the body, the shoulder girdle is the diaphragm attaches dorsally to the spinal col- fixed at the thorax by the serratus anterior, the infe- umn and laterally to the inferior costal arch, while rior part of the trapezius, the rhomboid major and ventrally the fixed point is provided by the abdomi- rhomboid minor. If the shoulder is in a raised and nal wall. Here, the co-contraction of the deep layer forward position, then the muscles providing fixa- of the abdominal muscles has a key role. Koláˇr tion are the superior part of the trapezius and the (2006) showed radiographically that the diaphragm levator scapulae, placing undue load on the cervical was angled downward in the ventral to dorsal spine and at the same time to destabilize the lum- direction if the abdominal muscles were weak. If bar spine. It is the upright positioning of the head the abdominal muscles are functioning normally, that ensures the correct position of the shoulder. contraction of the diaphragm during inhalation is accompanied by eccentric contraction of the deep abdominal muscles. This can be clearly palpated lat- erally above the iliac crest. The effect is not only to 30

Etiology and pathogenesis Chapter 2 enable the diaphragm to function in the most effi- respiratory mechanism, since the scalene muscles, cient way and, as shown by Kapandji (1974), to which normally only fix the thorax, raise the lung; expand the thorax, but also to fix the thorax to the resistance is offered by the diaphragm. This is inef- pelvis and so stabilize the lumbar spine. The acti- ficient, not only from the respiratory point of view, vation of the abdominal muscles during inhalation in that the volume of the chest increases very lit- was also described by Campbell (1978) and Bas- tle, but also for the locomotor system, because of majian (1978). the chronic overload that this causes to the cervical spine. Holding the breath (the Valsalva maneuver) reinforces this postural function. Morris et al A further effect is that fixation of the thorax to (1961) showed that the spinal column is supported the pelvis no longer occurs, causing instability of on the diaphragm when bending forward (see the lumbar spine. The pattern of lifting the thorax Figure 2.19). Experience does indeed show that during inhalation, or clavicular breathing, can be when we are about to lift a heavy weight using asymmetric, if one shoulder is raised more than the maximum force, or to perform a heavy blow or other. The stress on the cervical spine is then greater vigorous throw, we hold our breath. This is such on this side. Clavicular breathing is the disturbance an important mechanism that athletes hold their that typically occurs when sitting but not maintain- breath during demanding activity such as sprinting ing a straight posture, because this makes expansion over short distances, sacrificing the respiratory to of the thorax difficult. the postural function. An extreme form of this breathing pattern is The most important faulty respiratory stere- paradoxical breathing, in which the patient draws otype, seen from the point of view of the loco- in the abdomen during inspiration. motor system, is that in which the thorax is lifted during inhalation (Parow 1954). In this pattern ‘Passive’ exhalation is brought about mainly the thorax is lifted in the cranial direction by the through the elasticity of the lung. Active exhala- scalene and sternocleidomastoid muscles and the tion, including that against resistance, is brought superior fixator muscles of the shoulder girdle, but about mainly by the abdominal muscles as well as without expansion of the chest. Termed ‘clavicu- the erector spinae, which contract strongly when lar breathing,’ it involves a reversal of the normal 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 during exhalation. Conversely, resistance increases by attacking soldiers and weight-lifters serve a prac- in the odd segments (C1, C3, and C5 and T3, T5, tical purpose. T7, and T9) during exhalation, and disappears during inhalation. At the cervicothoracic junc- The effect of respiration is significant above all tion, and only here, in the region between C6 and for the spinal column, which means that it can be T2, resistance always increases during inhalation employed to outstanding effect in neuromuscu- and decreases during exhalation. This synkinesis lar techniques. As a general rule, muscle activ- is so effective that during side-bending all that is ity is facilitated during inhalation, and exhalation needed is to take up the slack to the point of ini- produces relaxation. The actual situation is a little tial tension, then (in the case of an even-numbered more complicated: the abdominal muscles are facil- segment) to ask the patient to inhale, and then to itated during active exhalation, especially against wait during the period of exhalation for mobiliza- resistance, and, as mentioned previously, raising the tion to take place automatically. An exception to gaze of the eyes is associated with inhalation and this rule is found in the atlanto-occipital segment; lowering the gaze with exhalation. here this synkinesis operates not only in side- bending but in all directions. The phenomenon It is appropriate at this point to explain the con- described here is so reliable that it can be used to cept of ‘respiratory synkinesis,’ in which move- correct the diagnosis as to the level of the verte- ment in one direction is linked with inhalation and bral segment. It is most marked at the cranial end in the other with exhalation. Where this is the case, of the spinal column and decreases somewhat in a it is difficult to do the reverse. Typical respiratory caudal direction; in particular, the relaxation that synkinesis can be observed during forward flexion accompanies exhalation diminishes in the lower of the trunk, and when straightening up from for- thoracic spine. The reason for this may be con- ward flexion. The fact that straightening up is usu- nected with the fact that the thorax is stabilized ally associated with looking up, and forward flexion during inhalation, and the diaphragm and quad- with looking down, makes clear why the initial act ratus lumborum as well as the deep layer of the of looking up facilitates inhalation, and looking abdominal muscles contract. We can therefore down, exhalation. Inhalation facilitates straighten- refer to inhalation–exhalation segments and exha- ing up, not only from forward flexion, but also from lation–inhalation segments. side-bending. Side-bending itself is facilitated by looking down while exhaling. Marked respiratory synkinesis can also be found in trunk rotation; in the upright position, rotation Another very important example of respiratory of the trunk (including active rotation) increases synkinesis is the opening of the mouth during inha- during inhalation, while considerable resistance lation, and the closing of the mouth during exhala- appears on exhalation. In a kyphotic sitting posi- tion. This facilitates first the masticatory muscles, tion, in contrast, resistance increases on inhalation and then in particular the digastric muscle. Inhala- and mobilization is therefore performed on exhala- tion facilitates kyphosis of the thoracic spine, and tion. active exhalation lordosis of the thoracolumbar spine, especially in lordotic posture (Lewit, Janda, Too little attention is paid to the effect of res- Veverkova 2000). Resistance to traction of the piration on the locomotor system and vice versa. cervical spine increases during inhalation; also dur- There is little awareness of the respiratory synkine- ing distraction of the hip. The resistance decreases ses, and too little use is made of them by manual during exhalation. Conversely, resistance increases therapists, despite the fact that they are physiologi- in the lumbar spine on traction in the prone posi- cal methods. Empirically, many of these effects are tion, and decreases during inhalation. Clearly, then, employed in yoga; these include not only the effects these respiratory synkineses are extremely effective on motor functions but also those on autonomic in mobilization and relaxation techniques for the ones. This is understandable when we remember spinal column. that respiration is the only ‘autonomic’ function on which we are able to exert any degree of direct One especially remarkable example of synki- influence voluntarily, that is using the voluntary nesis is that described by Gaymans (1980) in the muscles. cervical and thoracic spine. He found that, dur- ing side-bending, resistance increases in the even In this section we have attempted to show the segments (in C0, C2, C4, and C6 and in T2, T4, importance of faulty movement patterns for the T6, T8, and T10) during inhalation; it disappears 32

Etiology and pathogenesis Chapter 2 pathogenesis of dysfunctions and to explain the • Constitutional hypermobility. This type is processes involved. It seems all the more important of the greatest interest to us. In essence it to do so since modern civilization is guilty not only is a variant of the norm, but under certain of chemically polluting the environment, but also of conditions it can be significant for pathogenesis. causing extensive changes to the human locomotor As a general rule, mobility is greater in system. We move around too little, but suffer static childhood than in adulthood, is greater in overload, creating conditions that produce muscu- women than in men and, in the limbs, tends to lar imbalance, among them that of faulty breathing be greater on the non-dominant side (Sachse et while sitting in a hunched posture. al 2004). Rehabilitation focuses on faulty movement There are conditions in which hypermobility may patterns, and their diagnosis and therapy will be be an advantage, for instance in certain sports and explored in more detail in the relevant sections in employment where mobility is a requirement. of this book. As we come to understand them, it However, it involves the risk of decreased stabil- becomes clear that the methods used in manual ity, and given the predominance of static load and medicine, which are predominantly passive ones, overload in most occupations today, hypermobility are usually only lastingly effective if accompanied is inappropriate. Individuals with constitutional by the active participation of the patient. hypermobility are at a particular disadvantage when working at a computer, as a driver, or in the Faulty muscle control originating from the majority of sedentary occupations, especially if central nervous system plays a significant the hypermobility is accompanied by laxity of the part in the pathogenesis of dysfunctions of ligaments and weakness of the muscles. The situa- the locomotor system. Often, however, they tion is still more unfavorable if the hypermobility are also a consequence of disturbances is accompanied by poor coordination and quali- involving chronic pain. They, in turn, can tatively poor movement patterns (Sachse 1984). then perpetuate and intensify the basic The problem may even cross the boundary into disturbance. minimal brain damage (MBD) as described by Janda (1978). In a study of 100 cases in which 2.10 The significance rehabilitation proved difficult, he distinguishes of constitutional three types: hypermobility 1. The first is ‘microspasticity,’ showing mild Movement restrictions, dealt with in the foregoing signs of first motor neuron lesion which is sections, are the true focus of manipulation therapy; often asymmetrical. however, the experienced clinician is well aware that hypermobility is frequently an even more dif- 2. The second is characterized by ficult problem. The contributions made by Sachse hypotonicity, with asymmetrical tendon (1984, Sachse et al 2004) have been fundamental and periosteal reflexes, signs of instability in this area. The following categories can be distin- and restlessness, and – consistently with guished: the account given by Sachse – severe • Localized pathological hypermobility. This hypermobility. may be primary or secondary (it is usually 3. The third type shows disturbances compensatory, occurring in the neighboring of proprioception, which become more segment to a restricted joint). As such it is most evident with eyes closed. This is expressed frequently found in the spinal column. as a certain marked ‘clumsiness’ and • Generalized pathological hypermobility. accompanied by poor psychological This is most often found in certain congenital adaptability, which makes rehabilitation more neurological conditions. difficult. Hypermobility in itself is no more than a constitu- tional characteristic; however, there is a tendency toward instability that is pathological. The most important role here is that played by the deep sta- bilization 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 Before presenting an explanation I should stress system and dysfunctions of that system, in particu- that it is not the purpose of this book to deal with lar mechanical disturbances (Figure 2.20). the purely theoretical aspects of the pathogenesis of pain; we do however need to deal with the theo- The dynamic role – usually also the primary role – in retical inferences that can be drawn from clinical the interplay between dysfunction and diagnosis and therapy. Examination before and after morphological change is that of function. therapy enables us to arrive at certain theoretical conclusions, as we might from an experiment, and 2.11 Reflex processes the findings that are made after therapy not only in vertebrogenic show a normalization of mobility, but also a reduc- dysfunctions tion of tension in the affected muscles, and that of the soft tissues. The effect is observed after manip- Despite the importance of the mechanical factor ulation, local anesthesia, needling, relaxation of for pathogenesis, it is not identical with clinical trigger points, and massage. In each case, pain too disease. Patients do not generally tend to complain is relieved. If the pain arises as a result of having to of disturbances of mobility, but rather of pain, maintain an uncomfortable forced position, correc- whether in the back, limbs, head, or viscera. They tion of the position is often enough to bring relief. may even be suffering from considerable movement The same is true of strenuous work; when we work restrictions, yet they do not notice these. Examina- beyond our strength we hardly notice it at first, but tion may sometimes even reveal signs of nociceptive eventually pain forces it to our attention and we irritation (latent trigger points or hyperalgesic zones suspend the activity. After a short while the pain on the skin), yet the patient does not feel pain. The subsides. explanation lies in the capacity of the nervous sys- tem to react. We now need to know how it is that The common denominator in all this is the close dysfunction produces pain. connection between tension and pain in the loco- motor 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 34

Etiology and pathogenesis Chapter 2 increased tension: when there is a restriction, there general, since movement is the effect of voluntary will be increased tension when the patient tries to motion that originates in the psyche. move in the restricted direction; hypermobility will produce tension in the end position as a result Since movement is an outward effect of of excessive range of movement; static overload, psychological activity, it is also true that strenuous movements, or any faulty motor pat- psychological activity is a factor in motor function. tern must also lead eventually to increased tension. The muscular TrPs provide direct evidence of this, The nociceptive stimulus produces a reaction in the since these involve a close association between ten- segment, and the intensity of the reaction can vary sion and pain. This is in keeping with the biologi- enormously. This is clinically significant, because it cal role of pain as a warning sign: increased tension allows us to estimate the capacity for reaction in the constitutes a threat, and it is pain that delivers the individual case. This applies not only to autonomic warning. The nociceptive stimulus – in the form of reactions, but also to those of the muscles, whose overload – warns us at the stage when the distur- response may take the form of TrPs or spasm. bance is still functional and reversible. As soon as Korr’s concept of ‘segment facilitation’ is therefore we correct the posture or cease the activity causing appropriate here. There may be considerable differ- the pain, and as soon as we treat the restriction or ences between patients, and reactions may also vary muscular TrP, the tension is eased and the pain sub- considerably in the same individual under different sides. If pain made its appearance only when mor- circumstances. If, for instance, acute pain has been phological (pathological) changes had occurred, it provoked by a draught, it should not simply be would fail to fulfill its biological function. ascribed to the cold air alone, for in such patients we find restrictions in at least one segment, with Since the locomotor system is controlled by severe muscle spasm. The restrictions are clinically our will – and whim – it has no way of protecting latent, but produce a skin hyperalgesic zone (HAZ) itself other than by causing pain. In this way the in the segment. The cold draught striking this voluntary activity of the locomotor system is kept HAZ is an additional stimulus which intensifies the within due bounds by pain. The locomotor system patient’s reaction and causes muscle spasm which is therefore by far the most frequent source of pain makes the clinically latent lesions manifest. in the human body; it is more than mere coinci- dence that referred pain from other organs or sys- It is a mistake to explain the pain as due to tems is perceived in the locomotor system, and that mechanical irritation of nerve fibers, as is frequently pain receptors are located in those places where suggested. It would be a peculiar concept of the tension in the locomotor system is expressed: in nervous system (a system whose purpose is to proc- muscles, joint capsules, the attachments of tendons ess information) that would have it reacting, not to and ligaments, root sheaths, and the anulus fibrosus stimulation of its receptors, but to mechanical dam- of intervertebral disks. age to its own structures. Referred pain from the viscera is the typical model, or experimentally-in- Pain is the most common symptom of dysfunction, duced referred pain from the infiltration of hyper- and functional disturbances of the locomotor tonic saline solution into ligamentous structures of system are the most common cause of pain. the spinal column, as performed by Kellgren (1939) and later by Feinstein et al (1954) and by Hockaday The close connection between physical and psy- & Whitty (1967), and in the zygapophysial cervical chological factors in the production of pain is easy joints by Pi’tha & Drobný (1972). to understand: pain itself is both a physical and a psychological phenomenon. The same is true of Just as in these model experiments, pain arising tension and also, especially, of relaxation: it would from deep structures (joints, muscles, ligaments, be difficult to imagine psychological relaxation and internal organs) is referred, especially within the without relaxed muscles, or to imagine relaxing the affected segment, and also gives rise to correspond- muscles without being mentally relaxed. This close ing HAZs, sometimes even paresthesia, imitating interrelationship is true for the locomotor system in 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, kind of excuse for ignorance of the true causes or tendons, and insertions, are ‘myotendinosis’ (Brügger the true pathology in most cases of pain affecting 1962) or ‘myofascial pain’ (Travell & Simons 1999). the locomotor system and spinal column. Yet what other explanation is there for the fact that, follow- The soft-tissue changes, such as HAZs in the ing manipulation, not only does the pain cease, but skin and subcutaneous tissue, have mainly been mobility is restored to clinical normality and muscle described as reflex changes or as secondary phenom- TrPs and HAZs instantly disappear? These are not ena. This is usually true in acute cases where there mere coincidence; careful clinical examination can is no long history, and these changes are generally predict the rapid appearance of the effect. If these found to subside when the joints and spinal column were pathomorphological changes they would need are treated. However, in the later, chronic stage, to heal, and this requires time. these changes – especially in fasciae and muscles – can become chronic; resistance is found in the fas- The situation can best be explained by compar- ciae, muscles become shortened, and chronic TrPs ing it to the working of a car: it may break down form. Some authors call this the ‘dystrophic stage’ because of a burst cylinder or a damaged ball bear- (Popelyanski 1983, Popelyanski 1984). Pathological ing (a pathomorphological change), but another barriers are also present in such cases, however, and reason for it to fail may be that the ignition is out it is possible to achieve release. When dealing with of order, or the carburetor needs adjusting; the chronic TrPs, this can be done by means of needling. structure is intact, and the disorder is a functional, In such cases, even these changes may turn out to be reversible one. Following a simple adjustment, the functional and reversible. Nevertheless it is impor- problem is instantly resolved. tant to note that where there are ‘sticky’ fasciae (which do not shift), shortened muscles, or chronic One of the reasons for the failure to recognize TrPs, these do not subside following manipulative that dysfunction is the most frequent cause of pain treatment of joint restrictions. On the contrary, in the locomotor system is that the evidence is sim- if they do not receive specific treatment, they can ply based on clinical findings, often relying on palpa- cause chronic recurrent restrictions. tion, and this is rejected as ‘subjective.’ Connected to this we see a systematical underestimation of clin- The model described here has been that of char- ical diagnosis as a scientific discipline, and neglect acteristic painful disturbances within the segment. accorded to it in practice. Much the same applies to However, it should not be forgotten that the pain the solving of the ‘puzzle of pain’ in dysfunctions of threshold, which is under central nervous control, the locomotor system: pain is closely linked to ten- is only crossed when the nociceptive stimulus has sion and the release of tension to relief of pain, and reached a particular intensity. Only then is it actu- the key to understanding this lies in palpation. ally experienced as pain. So it is that, on care- ful examination, very frequently we find clinical In differential diagnosis of conditions affecting changes when patients have no sense of pain at all. the locomotor system, the fundamental distinction to be made is therefore between conditions due It can therefore be seen that dysfunctions of the primarily to pathomorphological changes and those locomotor system produce nociceptive stimulation caused by dysfunction. Yet even where a morpho- whose effects are felt both suprasegmentally and also logical lesion is present, dysfunctions may still play at the level of the central nervous system. The entire a significant role and should be treated accordingly; complex of function-related disturbance can be called rehabilitation is included here. the ‘functional pathology of the locomotor system.’ 2.12 Radicular pain The complex of predominantly mechanical The point having clearly been made that pain in dysfunctions and reflex changes can be termed the locomotor system is due to nociceptive stim- ‘functional pathology of the locomotor system.’ ulation of pain receptors, we must proceed to look at how and why pain arises in cases of root Unfortunately, so widespread is the lack of knowl- compression. The mechanical compression of a nerve edge, often combined with skepticism, that the does not itself cause pain but anesthesia, paresthe- concept of ‘functional pathology’ is viewed as a sia, and paresis. However, we should bear in mind that the herniated disk causing the compression 36

Etiology and pathogenesis Chapter 2 cannot impinge on the nerve fibers until after it has can conclude that radicular pain is a combination affected the dura and the dural sheaths, which are of referred pain originating from dural receptors, richly supplied with pain receptors (Wyke 1980), and signs of neurological deficit. This explains why and that with every movement of the legs and trunk autodermography, in which patients themselves the dura is being rubbed against the disk. Nor should draw their projection pain, produces the most accu- it be forgotten that Lasègue’s sign indicates menin- rate clinical localization of a herniated disk. geal involvement, even in root compression syn- dromes. This is in keeping with the clinical course: There is yet another observation that points to a first of all there is usually severe pain, and the signs functional factor in root compression: this is the fre- of neurological deficit appear later. Other clinical quent immediate improvement of muscle strength observations support this. Cerný (1948), using auto- in weak muscles and sometimes even of tendon dermography to study patients with radicular pain, reflexes, immediately after manipulation and even found that this method was more reliable in local- after traction. This has been demonstrated by elec- izing the disk herniation to the particular segment tromyography (see Figures 2.12 and 2.13), and also than the typical signs of neurological deficit. This shown by the work of Drechsler (1970) and Hanák can be understood anatomically in that spinal nerves et al (1970). They showed that, even in true radic- do not contain fibers from one segment only; they ular syndromes with muscle weakness, the speed also carry many transitory fibers from neighboring of nerve conduction may be normal. In the light of segments. As a result, the failure of a single spinal this they interpreted the weakness as reflex inhibi- nerve does not usually lead to signs of deficit. There tion. Drechsler also concluded that decreased con- is an overlap of the areas of nerve roots. duction speed indicates a poor clinical prognosis. Hanraets (1959), however, demonstrated that Radicular compression syndrome is a mixture of this is not always the case. He frequently found, root compression and reflex phenomena. The during neurological surgery, that spinal nerves vary decisive factor for localizing the cause of pain is considerably in thickness: if one is very thick, its referred pain produced by stimulation of receptors. neighbor is likely to be much thinner, because of the number of transitory fibers in individual spinal 2.13 The term ‘vertebrogenic’ nerves. If a thin spinal nerve is compressed or even severed, deficit will not be observed, because the Once the terms ‘degenerative disease’ and ‘disko- transitory fibers in the neighboring nerve roots are pathy’ had been abandoned as inappropriate, ‘ver- able to compensate sufficiently, but if a thick root is tebrogenic’ became widely adopted as a concept. It severed, the consequences are quite different. Most too is not quite appropriate: it includes pathological thin neighboring roots have very few transitory fib- conditions such as ankylosing spondylitis, and does ers that can provide compensation. When Hanraets not cover dysfunctions that lie outside the spinal (1959) stimulated such a spinal nerve during opera- column. The term is therefore acceptable only if it is tion (at that time his operations were still being used as a pars pro toto. So long as it is used for back performed under local anesthetic), his patients also pain and very closely related disorders, there can be felt paresthesia in the neighboring segments. little objection to it; the term becomes controversial if the attempt is made to apply it to pain deriving Our own findings (1958), working together with from the internal organs, as might particularly tend Starý, are also consistent with this. We examined to happen if treatment of the pain is successful. patients following intervertebral disk operations. At that time, in cases where no disk herniation was A correct understanding of referred pain, or pseu- found, the neurosurgeon cut the sensory spinal nerve. doradicular pain (to use a less accurate term), leaves Most of these patients experienced little effect, but little room for controversy. We see from the publica- some complained of permanent numbness and espe- tions of Melzack & Wall (1965), Bonica & Albefessard cially disturbances of proprioception following the (1976) and Milne et al (1981) that impulses from procedure. In these cases a thick nerve root had evi- nociceptive stimuli arriving from all structures in a dently been cut, as described by Hanraets (1959). segment converge to spinal cord cells in the lamina V The pain resulting from irritation of dural recep- tors is referred pain, which corresponds precisely to the segment affected. It is this projection pain that is shown by Cerný’s autodermography. We 37

Manipulative Therapy of the dorsal horn. This also applies to stimuli from muscle, soft tissue, body statics, or dynamics receptors in the joint capsules of zygapophysial joints, (the movement patterns or motor stereotypes). from the anulus fibrosus, or from internal organs. So it is easy to see how the locomotor system (the spi- • The most important cause of dysfunction nal column) can readily simulate visceral pain, or how is overload caused by overexertion, faulty pain from an internal organ might simulate that from movement patterns or body statics, trauma, or the locomotor system. Therefore we must constantly visceral disease. This includes joint restrictions, take this problem into account in differential diag- muscle TrPs, and soft tissue lesions, especially nosis. The therapeutic consequences are clear. We of fasciae and active scars. All these cause an should not forget, however, that many instances of increase in tension. pain described as ‘functional’ in fact have their origin in the locomotor system. • When dysfunctions in the segment persist for a long time they eventually lead to degenerative As will be seen in further chapters, vertebrovis- (adaptive) changes, and do not remain confined ceral relations are very complex; the term ‘verte- to the segment concerned but affect the entire brogenic’ should therefore be applied with caution. system. In many cases pathogenesis is due to more than one factor, and it is then better to speak of disease with • The locomotor system and the spinal column a vertebrogenic factor. Migraine is a good exam- together make up a functional unit which has ple, since the true cause is unknown, although it to compensate for any dysfunction, so that is usually accompanied by findings in the locomo- equilibrium is always maintained. In other words, tor system that do cause significant pain. We should the ‘motor program’ is reprogrammed. This gives reserve the term vertebrogenic for those conditions rise to compensatory movement patterns, often in which the spinal column (the locomotor sys- designed to reduce pain. These can persist even tem) is the decisive factor, for example when we when the primary cause is no longer present. describe a case of vertigo as vertebrogenic. • Mechanical disturbance of function alone is As Junghanns (1957) has pointed out, the role insufficient to cause pain. However, it does of the vertebrogenic factor may change over the represent a nociceptive stimulus which produces course of time. It may trigger the disease process, reflex changes, especially within the segment. but once this has started it may develop independ- If these are of sufficient intensity to pass the ently. Gutzeit (1953) very aptly characterized the pain threshold, they are experienced as pain. spinal column as being sometimes the ‘initiator,’ The specific nociceptive stimulus in the case of sometimes the ‘provoker,’ and in yet a third way as dysfunctions is understood to be increased tension. being the ‘multiplier’ of a disease state. • Pain in the locomotor system is primarily a We should speak of vertebrogenic disturbance only warning signal of harmful functioning, which when we wish to say that the spinal column is the should cause us to correct this before it causes primary and decisive factor in pathogenesis in a permanent morphological damage. It is the given case of disease. type of pain that occurs most frequently in the human body. 2.14 Conclusions • If the patient is able to describe and localize • Morphological changes cannot explain the pain, and if on clinical examination we find pathogenesis in the great majority of painful corresponding changes, above all reflex signs, conditions of the locomotor system. These then the diagnosis (once we have excluded gross changes often have the role of a locus minoris pathology) must be the relevant dysfunction. resistentiae. Undiagnosed dysfunctions are the most frequent cause of pain in the locomotor system, and • The most frequent cause of pain in the treatment which is directed only at the symptom locomotor system is dysfunction, in a joint, 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.’ 38

Chapter Three 3 Functional anatomy and radiology of the spinal column Chapter contents Manual techniques call for an accurate understand- ing of anatomy, especially when treating the spi- 3.1 General principles . . . . . . . . . . . . . 39 nal column. Textbooks of radiology are interested mainly in morphology, while our concern is mainly 3.1.1 Structural diagnosis . . . . . . . . . 39 with function, the consistent focus of the present 3.1.2 F unctional diagnosis of spinal book. The use of radiology for functional studies can greatly improve our understanding in manual column mobility (kinematics) . . . . 40 diagnosis. However, if we are to be able to interpret 3.1.3 F unctional diagnosis of radiographic images from the functional point of view, we need a good knowledge of X-ray anatomy, body statics . . . . . . . . . . . . . 40 such as we present here, as well as certain require- 3.2 Technique in functional diagnosis . . . . . 40 ments as regards technique. 3.3 The lumbar spine and pelvis . . . . . . . . 41 3.1 General principles 3.3.1 X -ray of the lumbar spine and For our purposes, X-ray diagnosis fulfills three basic the pelvis . . . . . . . . . . . . . . . 41 tasks: 3.3.2 X -ray evaluation of lumbar 1. Structural diagnosis. spinal statics . . . . . . . . . . . . . 43 2. Functional diagnosis of spinal column mobility 3.3.3 The pelvis . . . . . . . . . . . . . . 49 (kinematics). 3.3.4 The lumbar spine . . . . . . . . . . 54 3.4 The thoracic spine . . . . . . . . . . . . . 58 3. Functional diagnosis of body statics (interpretation of curvatures of the spinal 3.4.1 Functional anatomy . . . . . . . . . 58 column). 3.4.2 X -ray anatomy of the 3.1.1 Structural diagnosis thoracic spine . . . . . . . . . . . . 59 3.4.3 Evaluating functional aspects . . . 60 Structural diagnosis provides information about 3.5 The cervical spine . . . . . . . . . . . . . 62 the morphology of the bony structures. This is the essential focus of classic X-ray diagnosis, which is 3.5.1 X-ray technique . . . . . . . . . . . 62 mainly concerned with form and structure and con- 3.5.2 Assessment of X-ray films . . . . . 63 stitutes the basis of our knowledge. This type of 3.5.3 F unctional anatomy of the diagnosis is very important for manual therapy in 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

Manipulative Therapy that it alerts us to potential serious errors of diag- deviation may be observed in one particular seg- nosis, providing a warning against manual therapy ment. This may be scoliotic, increased lordosis or where inflammation, tumors, fractures, or other kyphosis, rotation, or lateral shift (‘offset’). contraindications are present. It also reveals abnor- malities and changes in structure, such as asym- The significance of these signs of irregularities in metries, which can be significant for function. the position of neighboring vertebrae (relational Diagnosis of structure can be found in the classic diagnosis) is highly controversial, and closely con- textbooks of radiology, so we shall deal here only nected with the discredited subluxation theory. It with those morphological changes that are impor- is also closely linked to the problem of asymmetry, tant for an understanding of dysfunctions. bearing in mind the fact that a degree of asymmetry is the rule rather than the exception. Jirout (1978) 3.1.2 Functional diagnosis of has shown that asymmetry of the position of the spinal column mobility atlas in relation to the axis is present in the majority (kinematics) of adults. In a study to compare children of various ages, he found that its incidence increases with age. Functional diagnosis in the narrower sense involves This can be shown particularly easily by observing movement studies of the spinal column in which the position of the spinous processes. He concluded X-rays are taken in end of range positions, in ante- that these asymmetries were the result of asym- and retroflexion (extension), side-bending and, less metrical pull of the muscles due to the dominance frequently, rotation. Examination of this kind is of one cerebral hemisphere. the only approach that can provide direct informa- tion about dysfunctions in the motion segment. It From this we can conclude that asymmetry and can also be used before and after treatment. It is of other kinds of irregularity are not in themselves value for documentation and assessment, but is too pathological, although they can be the expression time-consuming and uneconomical and the radiation of functional asymmetries. We know, for example, exposure is too great for use as a routine procedure. that if the axis is asymmetrically rotated in neutral Since manual therapy examination gives good infor- position, the entire cervical spine will rotate asym- mation on mobility and disturbances of mobility, metrically during side-bending. In general it is advis- it is generally possible to dispense with movement able to be cautious when drawing conclusions about studies. They do have an important role to play in examples of asymmetry observed on an X-ray film, research, however, and provide an understanding of and always to take the clinical findings into account the biomechanics of movement processes. when interpreting the radiographic findings. 3.1.3 Functional diagnosis of One advantage of static functional diagnosis body statics is that the examination is economical: only two X-rays are required, two projections, which must Although movement studies come first to mind correspond to each other vertically. Standard con- when we think of functional diagnosis, it is no less ditions must be observed as regards static loading. important to diagnose disturbances of body statics. As individual posture is highly characteristic, it also The images used to assess this must be taken stand- remains fairly constant. Gutmann & Véle (1978) ing (or, for the cervical spine, sitting), under static said of static function: ‘The dominating principle loading and under standard conditions. The cur- of the spinal column is body statics. All other func- vatures of the spine, as explained below, should tions are subordinate to the requirements of upright mainly be assessed from the point of view of static posture on two legs. The human body is more ready function. This applies not only to the sagittal but to accept loss of mobility or painful impingement of also the frontal plane, in which every obliquity nerve roots than to sacrifice erect posture.’ (e.g. of the pelvis during walking) produces a cor- responding scoliotic curvature and rotation. Curva- 3.2 Technique in functional ture may be regular or irregular, so that a marked diagnosis Functional diagnosis of the spinal column makes considerable demands as to technique. The follow- ing criteria must be observed: the X-rays should be 40

Functional anatomy and radiology of the spinal column Chapter 3 taken in a position that corresponds as closely as pos- This is done using a device described by Gutmann sible to the patient’s natural posture, normally either (1970), in which a plumb line indicates the verti- standing or sitting (with the exception of the antero- cal line from the head. The procedure is illustrated posterior (AP) view of the cervical spine, which is in Figure 3.1A–D and is as follows: taken with the patient supine). In general, then, any slight inclination or rotation in the patient’s posture A line which corresponds to the center of the ought not to be corrected. However, it may become cassette is drawn on the floor in front of the mid- necessary to do so in order to achieve: dle of the stand. For the AP view the patient places one foot symmetrically on each side of the line, • assessability of the X-ray films and is requested to distribute the weight of stand- ing equally between both feet, with legs straight, so • reproducibility and comparability. as to rest on a base that is in line with the center of the cassette. A plumb line extended downward Reliable criteria for comparability are therefore from the center of the cassette will therefore meet necessary. Assessability is, of course, absolutely the floor at the mid point between the patient’s essential in order to be able to evaluate the films, heels, setting the base line. A movable plumb line of so it is important to avoid distortion through errors metal wire (so as to create contrast) is attached to of projection. To achieve this, it will sometimes be the screen. The cassette is first raised to the level of necessary to correct side-bending (in the lateral pro- the patient’s occiput and this metal wire plumb line jection) or rotation (in both projections). As to the moved to a point precisely below the middle of the format, it is essential to visualize a sufficiently large occipital squama, where the external occipital pro- area to provide landmarks as means of comparison. tuberance can be palpated. This sets the plumb line In the lateral projection of the cervical spine in the that marks the head position. The cassette is then sitting position, the hard palate must be visible to adjusted (taking care not to displace it to the side) enable you to assess the posture of the head, and to the height required to take a view of the lumbar the mandible needs to be visible so as to indicate any region and the pelvis (with the central ray of the side-bending or distortion. The lumbar AP projection X-ray beam and the center of the cassette roughly at must include the coccyx and the pubic symphysis, to the height of the navel). By setting up the AP view enable you to assess correct positioning. As long as in this way, the shadow of the metal wire marks the these requirements are observed, it will be possible plumb line representing the head position, and the to evaluate and compare the films successfully, even center of the film represents that of the base line. if there are very minor errors of centering. The same procedure is used for the lateral view of Since the spinal column is a functional unit, the the lumbar spine, except that this time the patient most appropriate format for the X-ray examination stands with feet across the line on the floor that rep- is to show the entire spinal column on a single film. resents the center of the cassette, with ankles one An AP and a lateral view with the patient standing finger’s breadth behind the line. The plumb line are required, with the feet placed in a standardized for the head is positioned at a point in line with the position. If this cannot be done, the sections of the external acoustic meatus. Here – as in the procedure spinal column that have been imaged need to be described for the cervical spine – it is helpful to align assessed in the light of the clinical findings. These the central ray below rather than on the center of can then make good whatever is missing in the X-ray. the cassette, directing the beam off-center to focus approximately on the lumbosacral junction, midway 3.3 The lumbar spine and between the iliac crest and the greater trochanter. pelvis This technique has two great advantages: 3.3.1 X-ray of the lumbar spine 1. There is considerably greater absorption of and the pelvis radiation at the lumbosacral junction (on which the pelvis is superimposed) than in The imaging projections needed for routine exami- the lumbar spine. If the central ray is aligned nation of the static function and morphological as usual on the middle of the lumbar spine, changes of the spinal column are simply one AP the result is either under-exposure of the and one lateral view with the patient standing. 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