__Manipulative_Therapy__Musculoskeletal_Medicine

Therapeutic techniques Chapter 6 of the foot on the side with the clinical abnormal- ity. The technique that has proved most effective is to trace numbers and letters on the sole and to ask the patient to identify them. Not only is superficial sensitivity addressed but also proprioception, and because the patient focuses attention on decipher- ing the numbers/letters, the technique is better tol- erated in the event of ticklishness. Functional pes planus (flat foot) Rehabilitation per se is primarily directed at ‘func- Figure 6.157 • Véle’s test: when the patient’s body weight tional’ pes planus, a condition in which the arch of is shifted forward, normal reflex flexion of the toes is visible the foot collapses during the gait cycle, irrespective (left) but absent (right). of whether the foot is normal or flat in purely mor- phological terms. And here again it has proved use- the person falling forward. Véle has shown that ful to exploit afferent impulses. In the gait cycle, this reaction is absent on the lesioned side in the after heel-strike, the foot normally rolls first on to S1 radicular syndrome. However, it is very much its lateral edge, then goes into pronation on toe-off, more common for this sign to be positive in func- before completing toe-off in pronation by pushing tional faulty movement patterns of the foot stabi- off with the toes, especially the hallux. Therefore, lizers, that is when toe flexion is absent (see Figure if pronation occurs prematurely, that is if the foot 6.157). For rehabilitation, the patient learns to does not remain on its lateral edge and collapses, achieve automatic and sufficiently strong toe flexion then the patient should be instructed when walking by rocking back and forth on both feet slowly, and to perceive or sense the lateral edge of the foot. relaxing when rocking back. Recent experience has If pes planus is not extreme, then the longitudinal shown that this rocking technique is the most effec- arch will momentarily hold far better. The patient tive method of mobilization and relaxation for the then needs to be told constantly to cultivate this treatment of restrictions and TrPs in the feet and of ‘awareness’ when walking, regardless of whether chain reaction patterns related to foot dysfunction barefoot or wearing shoes. (e.g. forward-drawn posture). This is true regard- less of whether the reaction of the toes on forward Functional pes planus is also commonly char- rocking is abnormal or entirely normal. acterized by diminished tonus. As well as extero­ ceptive stimulation, gentle pressure along the This exercise, together with gait training in longitudinal axis of the toes has also proved ben- which the patient learns awareness of the lateral eficial, that is pressure that is transmitted to the edge of the foot, eliminates TrPs and movement interphalangeal and metacarpophalangeal joints and restrictions in the same way as when exercising the constitutes a proprioceptive stimulus. deep stabilizers of the trunk – further evidence that the feet are also a component part of the deep sta- Splay foot bilization system. Splay foot is primarily a weakness of the foot and Where pain due to splay foot is present, it is toe flexors in terms of their postural function. often the metatarsophalangeal joint of the fourth Patients are generally able to flex their toes strongly toe that is worst affected, with pressure from a without difficulty but are unable to utilize this in plantar direction being extremely painful. In these the toe-off phase of the gait cycle. This is indicated circumstances, counterstrain is often instantane- by the fact that the toes are unable to perform the ously effective: for this, the patient applies dorsal test devised by Véle (personal communication). pressure on to the transverse arch of the foot at For this, the barefoot patient shifts his body weight the level of the metatarsal heads, fixes the first and forward without lifting his heels from the floor. fifth metacarpal bones, and holds this pressure for Normally, this movement automatically produces 90 seconds. Padded shoe inserts are also effective, flexion of the toes, probably as they seek to prevent 295

Manipulative Therapy especially when placed under the fourth metatarso­ practitioner catches the lower angle of the scapu- phalangeal joint. lar wing between thumb and forefinger. In con- trast, the normal movement in a caudal and slightly Abductor pollicis brevis and medial direction cannot be resisted at all. hallux valgus Training the correct function of the lower fixators Weakness is often also detected in another postural of the shoulder blade is described in Section 6.7.1 muscle, the abductor pollicis brevis, especially if (see Figure 6.136). The patient learns to palpate hallux valgus is developing. The patient must then the contraction of the lower part of the trapezius, learn to abduct the big toe or perform fan-wise first in the position of facilitation and then sitting. abduction of the toes, including the little toe. This, The patient next trains the fixators of the shoul- too, is a predominantly postural function, a fact der blade (see Figure 6.137). Immediately after that explains why some time is generally needed this exercise it frequently happens that there is a before the patient masters it. However, motivation marked improvement in TrPs and restrictions in the to persist should stem from the experience that upper extremity, for example in epicondylar pain active abduction brings immediate relief from the and painful shoulder. Current experience indicates pain of hallux valgus. that, in painful conditions of the upper extremity, the stabilizing muscles of the shoulder blade play Dorsiflexion an even greater role than the cervical spine, which itself is stabilized by the shoulder blade. The form of weakness most commonly encountered is that involving dorsiflexion of the foot, with the The extremely labile craniocervical junction is big toe usually being most affected. Among a wide stabilized mainly by the short extensors and the spectrum of possible causes, the commonest is a deep flexors. In ancient times, people used to carry radicular lesion at L5. In terms of rehabilitation, it heavy loads on their heads, thus improving their is especially effective and simple to utilize the great posture. While this practice can certainly be rec- extent to which the big toe is represented in the ommended even today, it is not readily accepted. sensorimotor cerebral cortex. Rather than advising Clinical experience has shown that rapid, shak- patients to practice dorsiflexion as assiduously as ing, vertical pressure in the direction of the axis of possible, they should instead be counseled to think the cervical spine with the patient upright engages of their big toe as often as possible, especially when the deep stabilizing system of the cervical spine walking – even when wearing shoes. and has a strong mobilizing effect on restrictions and relaxes TrPs (see Sections 6.1.3 and 6.5.6 and 6.8.9 The shoulder blade and Figure 6.81C). upper cervical spine 6.8.10 The hands The muscles which stabilize the shoulder blade play a similar role for the upper extremities to that Probably the most common disorder is cramping of played by the deep stabilizing system of the trunk the hands and the hypertonus associated with it. for the lumbar spine. The most important muscles Once again, stroking along the axis of the fingers here are the lower (ascending) part of the trapezius and metacarpals is indicated here. Helpful self- and the caudal part of the serratus anterior. If these treatments include wriggling the fingers in a bowl muscles are weak, active caudal movement of the of uncooked rice or peas, or playing/exercising with shoulder (shoulder blade) with the patient prone a soft rubber ball. does not produce the normal caudal and slightly medial movement of the inferior angle of the shoul- For hypertonus of the hands, axial pressure via der blade; instead the inferior angle of the shoulder the fingertips is indicated, placing the interphalan- blade protrudes like a hook toward the spinal col- geal and metacarpophalangeal joints under pressure. umn. This movement can be easily resisted if the 6.9 Supports So far this chapter has been devoted to techniques that restore normal mobility and function; it is 296

Therapeutic techniques Chapter 6 Figure 6.158 • A simple (home-made) cervical collar. Figure 6.159 • Inflatable support cushion for lumbar kyphosis. beyond the scope of this book to deal with immo- to provide support at the point where the kypho- bilization techniques. However, it will be useful to sis peaks when the patient is sitting relaxed (see discuss some simple supports that do not necessar- Figure 6.160A). The practitioner can be satisfied as ily entail immobilization and can often be acquired to the correct placement of the cushion if he first by patients themselves. supports the patient with his fist as he sits erect and tells him to relax (see Figure 6.160B). 6.9.1 Cervical collar 6.9.3 Pelvic belt (Biedermann and Cyriax) A simple cervical collar made of latex foam can be very effective (see Figure 6.158). As soon as the Use of a pelvic belt is indicated in patients with a soft material is placed round the neck to form a ‘loosened’ pelvis, especially after childbirth. This is tube, it is sufficiently firm to support the cervical a leather belt that is 8–10 cm wide and has a pad- spine. Such collars are chiefly prescribed to pro- ded lining on its inner surface. The belt should be tect patients from jolting and jarring their neck worn below the iliac crests and above the greater during road and rail journeys. However, wearing trochanters (see Figure 6.161). To achieve suffi- a cervical collar should not become a permanent cient tension, it is recommended that the belt be habit. fastened below the pelvis at thigh level and then pulled up over the greater trochanters. It should be 6.9.2 Inflatable cushion worn for at least six weeks, particularly at night but may also be worn through the day. If they are able to lean against a chair back, hyper- mobile patients with a tendency to sag into kypho- A pelvic belt may also be prescribed for patients sis when seated should carry an inflatable cushion, with extensively weakened abdominal muscles fixed by braces or a belt, especially for use dur- in whom rehabilitation is a lost cause. This is not ing car journeys (see Figure 6.159). The cushion uncommonly the case in obese patients who have should be only slightly inflated, and should be fitted undergone multiple surgical procedures and in mul- tiparous women. A key consideration here is that 297

Manipulative Therapy Figure 6.161 • Pelvic belt (after Biedermann and Cyriax). 6.10 Local anesthesia Figure 6.160 • Locating the correct support point: Within the scope of this volume it is not possible (A) pinpointing the peak of kyphosis when the patient is to cover the innumerable treatment methods that sitting relaxed; (B) using the fist to check for optimal employ reflex mechanisms. The method that is support function. probably most popular is local anesthesia. As already emphasized in Section 5.3.3, there is no essential the belt should be worn so that it supports the difference between the effect of local anesthesia (overhanging) lower abdomen from below and does and of dry needling (Frost et al 1980). The criti- not compress the abdomen. cal factor is technique. The needle must touch the point where pain is maximal. It is not enough for the patient to feel pain; this pain must be suf- ficiently intense for the patient to react involuntar- ily, and wherever possible, the pain thus provoked should reproduce the patient’s spontaneous pain. Only when the most painful point in the pain zone is touched will needling achieve immediate allevia- tion (frequently elimination) of pain, affording relief that is just as intense as that of a local anesthetic, a fact that the patient can also corroborate instantly. The advantage of dry needling is that the posi- tion of the needle can be corrected if an analgesic effect is not obtained immediately. If the most painful point is not touched by the needle in local anesthesia, the effect is considerably diminished as soon as the local anesthetic wears off. If, however, the object is to achieve conduction anesthesia (e.g. of a painful nerve root or a peripheral nerve) or epidural anesthesia is required, then the administration of a local anesthetic is indispensable. 298

Therapeutic techniques Chapter 6 The treatment of TrPs involves the use of there are some TrPs that are not (or no longer) methods that employ reflex mechanisms: PIR, RI, entirely reversible, where needling or traumatic minimal pressure, mobilization and/or manipula- massage are necessary. In such circumstances, tion of joints and often even of chain reaction pat- however, needling is not so much a form of reflex terns arising as a result of treatment of other, often therapy but more a form of traumatization (micro- remote TrPs and other dysfunctions. However, surgery). 299

Chapter Seven 7 Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter contents 7.4.6 Shoulder pain . . . . . . . . . . . 322 7.4.7 Pain in the elbow region . . . . . . 324 7.1 P ain in the lumbar spine and 7.4.8 Pain at the wrist . . . . . . . . . . 325 pelvic region . . . . . . . . . . . . . . . 302 7.5 Entrapment syndromes . . . . . . . . . . 325 7.1.1 L ow-back pain due to muscle 7.5.1 Carpal tunnel syndrome . . . . . . 326 and ligament overload . . . . . . . 303 7.5.2 Thoracic outlet syndrome . . . . . 327 7.5.3 Ulnar nerve weakness . . . . . . . 328 7.1.2 Painful or tender coccyx . . . . . . 303 7.5.4 Nocturnal meralgia 7.1.3 Painful hip joint (coxalgia) . . . . . 305 7.1.4 Restrictions in the lumbar spine paresthetica . . . . . . . . . . . . 328 7.6 The cervicocranial syndrome . . . . . . . 329 and sacroiliac joints . . . . . . . . 306 7.1.5 L ow-back pain due to 7.6.1 Headache . . . . . . . . . . . . . . 329 7.6.2 Disturbances of equilibrium . . . . 333 disk herniation . . . . . . . . . . . 309 7.7 Active scars . . . . . . . . . . . . . . . . 338 7.1.6 Pelvic distortion . . . . . . . . . . 311 7.1.7 Forward-drawn posture . . . . . . 311 7.7.1 Diagnosis . . . . . . . . . . . . . . 338 7.1.8 Inflare and outflare 7.7.2 Therapy . . . . . . . . . . . . . . . 339 7.8 S tructural diseases associated (Greenman) . . . . . . . . . . . . . 313 with locomotor system dysfunction . . . 339 7.1.9 T he coccygeus and 7.8.1 Basilar impression and spinal pelvic floor . . . . . . . . . . . . . 314 canal narrowing . . . . . . . . . . 339 7.1.10 Low-back pain due to 7.8.2 Radicular syndromes . . . . . . . 341 restricted trunk rotation . . . . . 315 7.9 Vertebrovisceral inter-relationships . . . 348 7.1.11 Combined lesions . . . . . . . . 316 7.2 Pain in the thoracic spine and thorax . . 317 7.9.1 General principles . . . . . . . . . 348 7.9.2 Tonsillitis . . . . . . . . . . . . . . 349 7.2.1 Slipping rib . . . . . . . . . . . . . 317 7.9.3 The lungs and pleura . . . . . . . 349 7.3 Pain in the cervical spine . . . . . . . . . 318 7.9.4 The heart . . . . . . . . . . . . . . 350 7.9.5 The stomach and duodenum . . . 351 7.3.1 Muscle imbalance . . . . . . . . . 318 7.9.6 The liver and gall bladder . . . . . 352 7.3.2 Acute wry neck . . . . . . . . . . . 319 7.9.7 The kidneys . . . . . . . . . . . . . 352 7.4 Referred pain and other pain types . . . 320 7.9.8 Importance of the psoas major 7.4.1 Fibular head restriction . . . . . . 320 and rectus abdominis . . . . . . . 352 7.4.2 Painful patella . . . . . . . . . . . 321 7.4.3 Knee joint dysfunction . . . . . . . 321 7.4.4 Painful foot . . . . . . . . . . . . . 321 7.4.5 Painful heel . . . . . . . . . . . . . 321

Manipulative Therapy 7.9.9 G ynecological disorders and only be called upon and applied to best advantage if low-back pain . . . . . . . . . . . 353 the functional diagnosis is as accurate and compre­ hensive as possible. And as the number of practition­ 7.10 Post-traumatic states . . . . . . . . . . 354 ers working with these methods is increasing rapidly, the body of clinical data is also growing apace. 7.10.1 Cranial trauma . . . . . . . . . . 354 In back pain, the significant role played by the 7.10.2 Trauma to the extremities . . . . 357 spinal column is established beyond all reason­ able doubt. However, the problem is traditionally 7.11 The clinical picture of dysfunctions treated mainly or even exclusively as a morphologi­ in individual motion segments . . . . . 357 cal issue, which creates the impression that all we have to do is to find the underlying inflammatory, 7.11.1 T he temporomandibular degenerative, or metabolic disease or gross mechan­ joint (TMJ) . . . . . . . . . . . . 358 ical lesion, such as a herniated disk. We first have to satisfy ourselves that such a disease or lesion is 7.11.2 Atlanto-occipital segment . . . 358 indeed present and to what extent it is of key rel­ evance. Once patients have been ‘pigeon-holed,’ 7.11.3 Atlantoaxial segment . . . . . . 358 the largest group left over cannot be assigned to any category, that is these are patients ‘without any spe­ 7.11.4 Segment C2/C3 . . . . . . . . . 358 cific diagnosis’ whose symptoms are produced by locomotor system dysfunctions. 7.11.5 Segments C3/C4–C5/C6 . . . . 358 Because the field of pathomorphological diagno­ 7.11.6 T he cervicothoracic junction sis is amply covered in textbooks of orthopedics, (C6/C7–T2/T3) . . . . . . . . . . 359 rheumatology, and neurology, we will deal here only with issues relating to differential diagnosis. For a 7.11.7 Thoracic segments discussion of how to take the patient’s history, read­ T3/T4–T9/T10 . . . . . . . . . . 359 ers are referred back to Section 4.1. 7.11.8 Restricted trunk rotation The present chapter will consider not only the (segments T10/T11–L1/L2) . . . 359 mechanical aspects of the problem, but also the impact on the autonomic nervous system of fac­ 7.11.9 Segment L2/L3 . . . . . . . . . 359 tors such as menstruation, infection, meteorological changes, hormonal disturbances, or psychological 7.11.10 Segment L3/L4 . . . . . . . . . 359 stress. Because the term ‘back pain’ is altogether inadequate for a proper clinical understanding, it 7.11.11 Segment L4/L5 . . . . . . . . . 360 will be imperative to focus close attention on each individual section of the spinal column. 7.11.12 Segment L5/S1 . . . . . . . . 360 7.1 Pain in the lumbar spine 7.11.13 The sacroiliac joint . . . . . . . 360 and pelvic region 7.11.14 The coccyx . . . . . . . . . . . 360 The majority of lumbar and sacral dermatomes con­ verge in the lumbar region, which comprises the 7.11.15 The diaphragm and pelvic floor 360 lower lumbar spine and sacrum (see Figure 4.3). Furthermore, the most powerful muscles have their 7.11.16 The hip joint . . . . . . . . . . 360 attachments at the pelvis: this is the site of greatest mobility and is where the movements of the lower 7.11.17 The foot and fibular head . . . 361 extremities are transferred to the trunk. All of this explains the great vulnerability of this region, har­ This chapter will illustrate how the theoretical prin- boring as it does a vast number of potentially path­ ciples and the diagnostic and therapeutic methods ogenic factors that have to be assessed for relevance set out in previous chapters are applied to specific in every case. The most important dysfunctions clinical entities and symptoms involving the loco­ motor system. It should be remembered that famil­ iar clinical pictures such as back pain, shoulder pain, and headache have rarely been considered systemati­ cally from this point of view and consequently there is little on the subject to be found in the literature (Brügger, Cyriax, Gutmann, Mennell, Simons, Trav­ ell, etc.). All the more reason therefore to demon­ strate the importance of what has been discussed in earlier chapters as it ‘touches down’ in everyday clinical practice. It is of great consequence for medi­ cal theory that this new approach has yielded major and unsuspected new insights into these seemingly familiar clinical entities. This has been made poss­ible because of the efficacy and specificity of the new therapeutic measures we use. Nevertheless, they can 302

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 causing different types of low-back pain will now on the other. The individuals most commonly be reviewed, together with their respective specific affected are constitutionally hypermobile patients therapies. The term ‘low-back pain’ also includes who experience ‘ligament pain’ involving the ilio­ pain radiating laterally toward the hips or groin, and lumbar and sacroiliac ligaments (see Section 6.7.1). referred pain that is felt in the lower extremities. An extremely common finding in these patients is insufficiency of the deep stabilizer system, which is 7.1.1 Low-back pain due to linked with the compensatory development of large muscle and ligament numbers of TrPs, principally in the long muscles overload (e.g. erector spinae, quadratus lumborum, or rectus abdominis). Tender pain points are also frequently In this type of low-back pain, morphological lesions found at the inferior lumbar spinous processes and may be absent and the spinal column as such may the posterior superior iliac spines (PSISs). If there not necessarily be altered, at least at the outset. is marked postural asymmetry, pain points may be However, since this first pain category is not homo­ detected on the iliac crests and the lowest ribs on geneous, some further definition is required. the same side, especially where there are TrPs in the quadratus lumborum. Baastrup’s phenomenon The cause may be exogenous, for example heavy (osteochondrosis of the spinous processes) is com­ physical labor. More frequently, however, pain monly regarded as a cause of tenderness involving is the result of faulty posture and excessive static the spinous processes. In practice, tender spinous strain caused either by external factors or by faulty processes are encountered in hypermobile adoles­ movement patterns. Poor posture may be attribut­ cents without radiological evidence of degenerative able to adverse static development, for example changes. And in cases where Baastrup’s phenome­ leg length inequality, or to juvenile osteochondro­ non yields typical radiological signs suggestive of a sis. In most cases, however, postural abnormalities pseudarthrosis between the spinous processes, the are due to muscle imbalance arising in the context patient usually feels no pain at all. of adverse movement patterns, hypermobility, or obesity. All these sets of circumstances are char­ Therapy acterized by signs of excessive strain on locomotor system structures. Where pain is due primarily to external factors pro­ ducing excessive strain, the first-line approach is to Symptoms correct posture and dynamic overexertion patterns (see Section 8.3). However, if the underlying cause Fatigue sets in, usually in the form of trigger points is faulty statics and muscle imbalance, the guidelines (TrPs) with attachment point pain, and this increases set out in Sections 5.4 and 5.5 should be followed to become pain during postural and/or dynamic (correction of statics and use of a remedial exercise loading. Often the symptoms are more the result of program). In hypermobile patients exposed to situ­ postural strain than of movement per se. Thus, any ations of excessive static loading, attention should posture or position that the patient is required to focus on the deep stabilizer system, with recom­ hold for any length of time is registered as unpleas­ mendations for appropriate supports (see Section ant strain. Patients therefore feel the need to change 6.9) to be used especially during road or rail travel. their position, even in bed. In this context morning Acute pain should be relieved by treating TrPs (with stiffness is often reported, and while this is gradually post-isometric relaxation (PIR) and reciprocal inhi­ overcome, it can manifest itself later as pain associ­ bition (RI)) and soft tissue, especially the fascia. If ated with fatigue and excessive strain. necessary, needling or local anesthesia can be used. Clinical signs 7.1.2 Painful or tender coccyx The typical imbalance in the lumbosacral region A painful or tender coccyx is the result of muscle is characterized by weakness of the abdominal dysfunction involving the gluteus maximus and and gluteal musculature on the one hand, and by levator ani and their points of attachment to the hyperactivity of the hip flexors and erector spinae coccyx. 303

Manipulative Therapy Symptoms instead hypotonus with the patient, so to speak, sit­ ting on the coccyx without the ‘cushioning’ of the In the majority of cases where the coccyx is tender buttocks. The patient can practice PIR of the glu­ to palpation, patients report pain not in the coccyx teus maximus regularly at home, several times daily itself but in the lower back. In low-back pain, on the (see Figure 6.124). other hand, about one-fifth of patients experience coccygeal tenderness on palpation. The opposite is Based on clinical experience and on therapeutic also true: reports of coccygeal pain may in fact be results it can be assumed that tension in the gluteus attributable to painful lower sacroiliac joint dysfunc­ maximus and the levator ani is the main cause of a tion, a painful ischial tuberosity, a TrP in the coccy­ tender coccyx, that is it represents a tendomyop­ ­ geus muscle (pelvic floor), or exceptionally even pain athy of these muscles. Contraction and relaxation of referred from the hip. In such cases, however, ten­ the gluteus maximus (PIR) are coupled with PIR of derness does not involve the tip of the coccyx itself the levator ani. Increased tension in these muscles but rather one side of the coccyx only. Falls on to is associated with psychological tension, and relaxa­ the coccyx play a negligible role in chronic coccygeal tion of these muscles leads not only to a reduction pain. History taking in our patients revealed that only in coccygeal pain but also to psychological relaxa­ about one-fifth had experienced any previous falls on tion. Finally, in the patient with low-back pain, it is to their coccyx. In particular, patients complain of important never to miss a tender coccyx, otherwise low-back pain when seated. There may sometimes any treatment given may be doomed to failure. be constipation and patients may report dyspareunia. Case study Clinical signs R J; male; born 1922; civil servant. In obese patients, in particular, examination dis­ closes a hyperalgesic zone (HAZ) in the form of M edical history a small fat pad on the sacrum. Another important sign is hypertonus of the gluteal muscles, and some­ Pain in lower back and buttocks since 1977, perma- times a TrP in the iliacus or piriformis. Most char­ nently troublesome since Spring 1982. Pain worst on acteristically, however, there are TrPs in the levator getting up in the morning or after sitting for lengthy ani but these can only be detected on examination periods. Coughing sometimes provoked stabbing per rectum. Patrick’s sign and the straight-leg rais­ discomfort. The patient’s medical record showed ing test may also be mildly positive. However, the that he often suffered from tonsillitis in boyhood (ton- pathognomonic sign is an exquisitely tender (pain­ sillectomy performed at age 10 years). He had also ful) tip of the coccyx, in response to even the had typhoid fever and pneumonia. Sports activities: slightest touch. Palpation must include the ventrally skiing, ice-skating, tennis, horse-riding. No record of curved end of the sacrum. The true pain point will accidents. never be located if palpation covers only the dor­ sal surface of the coccyx. Sacral palpation may be Clinical findings difficult not only due to hypertonus of the gluteus maximus but also because the patient resists by Examination on 11 June 1983 revealed some limi- clenching the buttocks. A painful coccyx is always tation of retroflexion, atlanto-occipital movement curved ventrally; a coccyx that is straight and points restriction on both sides, and a painful coccyx. caudally is never painful. T herapy Therapy Mobilization of C0/C1 into anteflexion, and trac- The treatment of choice is PIR of the gluteus max- tion manipulation. PIR of gluteus maximus muscles. imus, during which the levator ani also contracts Home exercise for self-treatment: gluteus maximus and relaxes at the same time. The conventional relaxation. approach per rectum is used only exceptionally if there is no hypertonus of the gluteal muscles but At the follow-up examination on 4 July 1983 the patient’s low-back pain had improved, occurring now with reduced frequency and intensity. If he stood for longer periods, he noticed pain in the region of his sacrum. On examination his coccyx was no longer painful; the key finding now was extreme weakness of the abdominal muscles, with separation of the rec- tus abdominis. He was advised to wear a lumbar belt. 304

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 7.1.3 Painful hip joint and hip in osteoarthritis of the hip. This results (coxalgia) in the characteristic posture typified by exces­ sive lumbar lordosis. The PSIS is also frequently In a series of 59 patients with a painful hip joint painful. with no or very slight osteoarthritis of the hip, low- back pain was the most frequent complaint (Lewit Therapy 1977). Conversely, signs of a painful hip are com­ mon in patients with low-back pain. It is therefore The choice of treatment depends largely on the justifiable to discuss the painful hip in this section stage of osteoarthritis of the hip and to what because the hip also needs to be considered in the extent any anatomical changes permit functional setting of low-back pain. improvement. It is beyond the remit of this vol­ ume to discuss the full range of therapeutic Symptoms options available in the fields of physical medicine and surgery. The most important form of con­ Patients complain of pain on prolonged walking, servative therapy is traction. Where anatomical especially when climbing hills and stairs or on hard changes are not (yet) detectable, traction with a paved surfaces, when standing for long periods, and high-velocity, low-amplitude (HVLA) thrust can when lying on the painful hip. However, pain is be instantly effective. Otherwise, traction with relieved by lying down for extended periods. The PIR constitutes the treatment of choice in this set­ pain is usually felt in the low back, hip, and groin ting (see Section 6.1.2). The effect can be further and it may radiate in segment L4 toward the knee, enhanced by shaking. The efficacy of this tech­ causing patients often to complain of knee pain. nique is probably attributable to the relaxation Sometimes pain localized at the knee is the first of all the muscles that place the hip joint under and only sign of (incipient) osteoarthritis of the hip: pressure. It is evidently the most effective form of the pain is experienced on climbing stairs but not conservative treatment and it should be performed when descending. daily, as far as possible. Clinical signs Because self-treatment is not really practicable, the following procedure can be adopted: once the On examination, Patrick’s sign is strongly positive, patient has learned how to relax during therapy, and when passive mobility is tested, the extreme then anyone in regular contact with the patient limits of movement, especially internal rotation, (family member, friend, colleague) can perform are painful, particularly if a light springing force is resistance by placing their hands in the patient’s applied in the extreme position. In osteoarthritis groin. The patient then does the rest. of the hip there is movement restriction consist­ ent with the capsular pattern described by Cyriax If there is a muscle imbalance, it is usually (1977, 1978) (internal rotation is most severely the abductors that are weak and the hip flexors limited, see Section 4.10.5). Active abduction and adductors that are hyperactive. This is often is also painful. The characteristic pain points are apparent in the Trendelenburg test (the hip drops found at the femoral head palpated in the groin, at during standing on one leg); more usually, how­ the insertion points of the adductors at the pubic ever, it is lifted, causing the center of gravity to symphysis, and at the pes anserinus of the tibia shift over the standing leg, thus relieving the (which is also interpreted as knee pain). Further weakened abductors. In this case the hyperactive, pain points include the greater trochanter (which shortened muscles should be relaxed and also pos­ provides attachment for the abductors) and the sibly stretched, and the weakened muscles should iliac crest. Increased tension of the hip flexors is be strengthened. responsible not only for pain at their attachment point, the lesser trochanter, and for TrPs in the Lifestyle advice is particularly important. tensed muscles, but also for flexion at the knee Patients should avoid prolonged periods of walk­ ing (especially on hard pavements or asphalt) and standing. Soft heels and soles should be encour­ aged, and in severe cases the use of a walking stick (on the healthy side) is recommended. Weight loss is imperative in patients who are obese. 305

Manipulative Therapy Case study treated that the first signs of osteoarthritis of the hip were diagnosed; these typically responded to trac- S Z; male; born 1922; university professor. tion. This case also illustrates the close connection between the L3/L4 segment and the hip. M edical history 7.1.4 Restrictions in the lumbar At the initial examination on 7 May 2002 the patient spine and sacroiliac complained of pain in his right thigh that woke him at joints night; he had no pain on walking, and no back pain, only slight stiffness in the neck. These conditions share common ground in terms of their etiology, clinical features, and therapy. Mobi­ Clinical findings and therapy lizing therapy constitutes the first-line approach for movement restrictions in the lumbar motion seg­ On examination the patient was found to have ments. reduced fascial mobility in the cervical region, restricted movement of the fibular head, and Symptoms restricted movement in Lisfranc’s joint on the right side. He received treatment for these. In the acute stage mobility is severely restricted, and straightening up (extension) usually presents At the follow-up examination on 22 May 2002 the more difficulty than flexion. Often there is pain patient reported that he was free from pain at night, on coughing and sneezing. In more chronic cases his neck was not as stiff, and he had only minimal there is usually stiffness after longer periods of sit­ pain intermittently in his thigh. ting and/or bed rest, and this improves on move­ ment. Retroflexion is generally more restricted than The patient was seen again on 27 April 2004. anteflexion, and the most characteristic complaint While he had no recurrence of his original discom- is pain on straightening up after anteflexion. Side- fort, he now had pain at the back of his thigh and bending is also often painful and as an early sign sometimes a stabbing pain on walking. there is no rotational synkinesis during this move­ ment (normally, the upright pelvis rotates in the He was now found to have reduced spinal direction opposite to side-bending). Pain is usually anteflexion, retroflexion, and side-bending without asymmetrical and may radiate to the hips, buttocks, pain, increased tonus in the thoracolumbar erector lower abdomen, groin, and lower extremities, and spinae, and a positive femoral nerve stretch test on cranially toward the thoracic spine (referred pain). the right side, consistent with a movement restric- tion between L3/L4. L3/L4 were mobilized, after Clinical signs and therapy which the femoral nerve stretch test was nega- tive, and the patient practiced the McKenzie tech- Typical signs of movement restriction are found. nique in the prone position for self-mobilization into One early sign is the absence of rotational synkine­ extension. sis of the pelvis during side-bending. The specific symptoms in the individual motion segments are At a follow-up examination on 18 May 2004 the listed in Table 7.1. What used to be designated as patient reported considerable improvement, but ‘movement restriction of the thoracolumbar junc­ climbing stairs was still painful. Patrick’s sign was tion’ is now termed ‘movement restriction on trunk now positive on the right side, internal hip rotation rotation’ (see Section 3.4.1). Movement restriction was largely restricted on the right side and was of L2/L3 is a rarity. possible only up to 20° on the left side. Dorsiflexion at the hips was also limited. Internal rotation of the It should be noted that a positive straight-leg right hip improved to 20° following isometric trac- raising test is caused by spasm (TrP) of the ischio­ tion with shaking. X-rays revealed narrowing of the crural muscles while a positive femoral nerve joint space in the right hip and a translucent area at stretch test is caused by spasm of the rectus the right acetabulum. The patient and his wife were trained so that they could perform self-treatment regularly. C ase summary This patient presented initially with quite unchar- acteristic symptoms. Then in 2004 important find- ings were made in the lumbar spine at L3/L4 for the first time; when these were treated, improve- ment ensued. It was not until after this disorder was 306

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 Table 7.1 Clinical signs in movement restriction of the lumbar spine and sacroiliac joints Clinical sign Trunk rotation L3/L4 L4/L5 L5/S1 Sacroiliac joints Absence of rotational synkinesis − + + + ++ Straight-leg raising test: ischiocrural − − + + + muscle spasm (TrPs) Femoral nerve stretch test: rectus − + − − − femoris spasm (TrPs) Patrick’s sign: adductor spasm (TrPs) − + + + + Spasm (TrPs) of thoracolumbar erector ++ − − − − spinae Spasm (TrPs) of lumbar erector spinae − + + + − Spasm (TrPs) of quadratus lumborum ++ − − − − Spasm (TrPs) of psoas major ++ − − − − Spasm (TrPs) of piriformis − − + − − Spasm (TrPs) of iliacus − − − + − Painful iliac crest + + − − − Painful greater trochanter + + + − − Pain at PSIS − + + + + Referred pain in L4 segment − + − − − Referred pain in L5 segment − − + − − Referred pain in S1 segment − − − + + Pain at pubic symphysis + − − − + Pain in upper part of sacroiliac joint − − − + ++ Pain in lower part of sacroiliac joint − − − − ++ femoris. Patrick’s sign is positive when there are painful and causing patients to report hip pain. A TrPs in the adductors. The characteristic TrPs for TrP in the iliacus muscle is experienced as pain in the individual motion segments are very important the lower abdomen, or sometimes in the groin, pos­ for the clinical diagnosis: TrPs of the psoas major, sibly simulating some gynecological complaints and, quadratus lumborum, and erector spinae for rota­ when it occurs on the right-hand side, appendicitis. tional restriction, and TrPs of the rectus femoris for The typical pain emanating from the lumbosacral segment L4, of the piriformis for L5, and of the ili­ and sacroiliac joints cannot be differentiated. TrPs acus for S1. The TrPs in the psoas major are respon­ in the iliacus muscle are more likely to indicate a sible for pseudovisceral pain on restricted trunk dysfunction at L5/S1. rotation, and TrPs in the rectus femoris for thigh and knee pain that mimics a painful hip (‘pseudo- Sacroiliac joint restriction occurs far more often hip’). In the case of TrPs in the piriformis, pain as a secondary phenomenon than was previously occurs laterally in the buttocks, making side-lying assumed. It commonly reflects muscle fixation due to movement restriction of the fibular head with 307

Manipulative Therapy TrPs in the biceps femoris, or due to restrictions of At the follow-up examination on 24 August 2004 L4/L5 as a result of TrPs in the piriformis and in the ranges of movement on standing were com- the pelvic floor. When these disorders are treated, pletely normal, just slightly uncomfortable, and the normal function of the sacroiliac joints is restored. restriction at L4/L5 was mobilized without difficulty However, since none of these muscles directly con­ and with an HVLA thrust into flexion, after which the nects the ilium with the sacrum, this restriction is patient was pain-free and required no further treat- not strong; consequently, minimal force is always ment. sufficient when mobilizing the sacroiliac joints, and HVLA thrust techniques are superfluous. There is C ase summary one condition, however, in which sacroiliac joint restriction plays a major role: namely osteoarthritis Jones’ counterstrain technique in the pain-free of the hip, and even as a sequel to hip replacement direction was helpful as an initial step, and then surgery. In such cases sacroiliac joint mobiliza­ careful mobilization into flexion was possible. The tion can greatly relieve the patient’s pain. Indeed, deep stabilizers were also exercised as breathing sacroiliac joint restriction after hip replacement was corrected. About 14 days later a minor residual surgery may be the frequently unrecognized cause of restriction was released easily. The possible role of persistent symptoms. an intervertebral disk lesion was considered. Case study Case study V M; male; born 1979; professional dancer. M J; male; born 1967. M edical history M edical history The patient sustained a lifting injury while dancing The patient had been experiencing low-back pain in March 2004, producing ‘a cracking sound’ in his and subscapular pain since 2002. The pain was lower back. The intense pain subsided after a few worse at night. A general medical assessment was hours but returned in June 2004. By then the pain inconclusive. was very severe and could only be relieved if the patient was supine with knees flexed; in the mornings C linical findings he had difficulty getting up and dressing, and he also experienced considerable pain when seated. How- At examination on 2 August 2005 there were TrPs on ever, he had no pain when he coughed or sneezed. the right side in the thoracolumbar erector spinae, psoas major, and quadratus lumborum. Trunk rota- Clinical findings and therapy tion to the left was restricted. Retroflexion was also painfully restricted. When he was examined standing on 11 August 2004, anteflexion, retroflexion, and side-bend- Therapy ing were possible to only a minimal extent, and even seated anteflexion was restricted. When he PIR of the quadratus lumborum on the right side was prone, however, retroflexion in a straight-arm while side-bending to the left with the patient stand- press-up position was possible. Therefore counter- ing: the patient performed side-bending to the left strain was applied in the press-up position in lordosis to take up the slack, then looked up and breathed for 90 seconds. Afterward, seated anteflexion was in deeply, straightening up a little in the process. He possible to some extent. Next, a flexion restriction at then looked down, breathed out, and relaxed into L4/L5 was diagnosed and carefully mobilized. Fur- side-bending. He repeated this three times and then thermore, there were still active TrPs in the erector actively and energetically performed side-bending to spinae and these were found alongside TrPs in the the left side. Afterward, not only were the TrPs in the coccygeus (pelvic floor). The deep stabilizers were quadratus lumborum released, but also those in the activated to encourage diaphragm breathing instead psoas major and erector spinae in the chain reaction of clavicular breathing. Self-mobilization of the lum- pattern on the right side. Trunk rotation was sym- bar spine (McKenzie method) and correction of the metrical on both sides. The patient’s home exercise faulty breathing pattern were assigned as home was therefore to perform PIR-RI of the quadratus exercises. lumborum on the right side on a daily basis. At the follow-up examination on 16 August 2005 the patient stressed that he was pain-free for the first time since 2002, but on closer questioning he 308

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 admitted that slight pain was still present at the level to manage is bending forward (even slightly), as of the lumbosacral junction. The extent of trunk rota- over a wash basin, because in this position contrac­ tion and retroflexion were normal, but retroflexion tion of the erector spinae is maximal and therefore was still rather painful. TrPs were detected in the the pressure on the disk is at its greatest. The ‘pain­ rectus abdominis on the left side and its attachment ful arc’ described by Cyriax (1977, 1978) also gen­ at the pubic symphysis was slightly tender; the left erally manifests itself in this position. Pain when fibular head was restricted with a TrP in the biceps turning over in bed and when getting up is also femoris; there was also a TrP deep in the left sole highly characteristic. with movement restriction of the second tarsometa- tarsal joint. After shaking mobilization of the foot, Clinical signs all TrPs disappeared, including the TrP in the rectus abdominis. Retroflexion was now also completely In acute cases there is a characteristic antalgic (or pain-free and we recommended the patient to use a relieving) posture that is also adopted in response foot roller for his left foot. to radicular pain. The most typical antalgic pat­ tern is lumbar kyphosis with the pelvis displaced C ase summary toward the side of the lesion (and deviation of the trunk to the opposite side; see Figure 7.1). Typical low-back pain due to restricted trunk rotation with TrPs in the psoas major, quadratus lumborum, and erector spinae muscles. As a secondary finding, there was a TrP in the rectus abdominis on the left side with a tender attachment at the pubic symphy- sis, rendering retroflexion painful (due to stretching of the rectus abdominis), and this is always interpreted as low-back pain (!). This TrP forms a chain reaction pattern with TrPs in the biceps femoris and sole of the foot, with the foot being the dominant point. 7.1.5 Low-back pain due to disk herniation The subject of this section is disk herniation with­ out radicular compression. It is essential to know when disk herniation should be suspected in sim­ ple low-back pain. The conditions described thus far have been functional disorders. Here, however, we are faced with a defined pathological lesion with a correspondingly serious prognosis. It must be remembered that many instances of disk herniation are completely devoid of clinical relevance, and for this reason the prognosis is favorable even with con­ servative therapy. At the same time, dysfunctions play an important role here. Symptoms If we discount acute attacks, the clinical course as Figure 7.1 • Typical antalgic posture in acute intervertebral a rule is more severe than in straightforward func­ disk herniation. tional disorders, that is to say attacks last longer and the condition has a greater tendency to relapse. Coughing and sneezing are generally very painful. The posture that is particularly difficult for patients 309

Manipulative Therapy Anteflexion while standing is generally severely commonest causes are to be found in the deep sta­ limited and the straight-leg raising test is posi­ bilizer system (in conjunction with faulty breath­ tive (except in lesions at L3/L4 where the femoral ing), the feet, faulty movement patterns, active nerve stretch test is positive). All movement that is scars, movement restrictions, and TrPs in the key at odds with the antalgic posture is painful. There region as well as the fascia. need not be any movement restriction in the seg­ ment affected by disk herniation. When movement No less important are general measures: these restriction is present simultaneously, springing of include avoiding situations that routinely trig­ the lumbar spine continues to elicit pain even after ger recurrences, and protecting the lumbar region the restriction has been released. Conversely, an against chill after perspiring. (experimental) traction test may bring marked pain relief. Case study In the more chronic stage, anteflexion is lim­ B J; male; born 1930; professor of clinical medicine. ited while standing, but normal when the patient is seated (with knees flexed). Another very typical Medical history sign is the painful arc described by Cyriax (1977, 1978) (see Section 4.6.1). Here, too, the straight- The patient was seen on 11 March 2004 complain- leg raising test and the femoral nerve stretch test ing of low-back pain radiating primarily to his left in segment L3/L4 are positive, much more so than thigh. The pain was worse at night and the patient when there is only joint restriction. A most valu­ had difficulty getting up in the mornings. He also able diagnostic sign is pain on springing the lumbar reported pain on coughing and sneezing. His low- spine, irrespective of whether restriction is present back pain had started after a hiking tour in the or not. mountains. For two years he had also had pain in his right arm, the mobility of which was limited. When he Therapy was younger he had no history of pain whatsoever. In February 2004 he sustained a fall on to his coc- Manual traction taking account of antalgic pos­ cyx. A tonsillectomy had been performed when he ture may be attempted in the acute stage. In other was 11 years old. words, if the antalgic posture is in kyphosis, then traction is performed with the patient supine over C linical findings the practitioner’s knee, but if the antalgic posture is in lordosis, then traction is performed with the Examination revealed pes planus on both sides, but patient lying prone. If traction is well tolerated it more pronounced on the right. When standing, the may procure immediate relief. Counterstrain to patient’s right knee was slightly flexed. He had a exaggerate the antalgic posture is also highly effec­ kyphotic posture and retroflexion was extremely lim- tive. This might be termed ‘manipulative first aid.’ ited. In relative terms, extension in his right knee was more limited than flexion. Joint play in the knee was If these techniques fail to bring immediate relief, restricted. A TrP was present in the iliacus muscle epidural anesthesia and bed rest in the antalgic on the left side. There was also a hard restriction in posture should be considered, as should analge- segment L5/S1 and the springing test was extremely sic medication. However, bed rest should be kept painful. There was limited mobility of the deep lum- as brief as possible because energetic (‘aggressive’) bar fascia. therapy in the acute stage is the most important step in preventing chronicity. Therapy Traction may also be helpful in the chronic We first performed mobilization for the fascia, fol- stage, provided that the patient finds it agreeable lowed by rhythmic traction, and then mobilization of and improvement is detected afterward. In every L5/S1 into rotation to the right, followed by mobiliza- instance it is important to proceed in a manner tion into flexion to the left. After this the TrP in the that is consistent with the clinical findings, and this iliacus could no longer be palpated and the patient approach presupposes a fresh examination at every was assigned a home exercise to practice extension follow-up visit. In this process, chain reaction pat­ (McKenzie technique) while supine. A lumbar belt terns should be sought in order to shed light on the was prescribed for rectus abdominis diastasis. pathogenesis. Current knowledge indicates that the At the follow-up examination on 20 April 2004 the patient felt that his condition had improved. He sometimes had pain radiating to his legs but this 310

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 improved on walking (despite osteoarthritis of the Clinical findings knee). Even then the springing test was painful. On this occasion the patient was trained how to practice In this dysfunction an (apparent) asymmetry is retroflexion while standing. palpated at the pubic symphysis and at the ischial tuberosities. Inspection from the side reveals a for­ On 28 June 2006 the patient was symptom-free. ward shift of the pelvis relative to the patient’s feet, of the shoulder girdle relative to the pelvis, and of C ase summary the head relative to the shoulders (see Figure 7.2). TrPs in the rectus abdominis are a typical finding, The repeatedly painful springing test, the relief of with the abdomen often drawn in and not participat­ pain after traction, the pain on coughing and sneez- ing in respiration. The attachments of this muscle at ing, the only moderate improvement, and the diffi- the pubic symphysis and at the inferior costal arch culty experienced with the McKenzie exercise in the with the xiphoid process are tender. Hypertonus supine position are suggestive of disk herniation in of the gluteal region is also found, with increased the setting of simple low-back pain with referred pain resistance of its soft tissue against shifting in a cra­ – but without neurological abnormalities. nial direction. Further TrPs are located in the biceps femoris with restricted mobility of the fibular head 7.1.6 Pelvic distortion and, when the chain reaction pattern is complete, there are TrPs and restrictions at the feet, often Pelvic distortion is always a secondary symptom with asymmetric tactile perception on the soles of (see Section 4.5.3). The clinical picture is there­ the feet. A forward-drawn posture is also always fore dependent entirely on the condition in which associated with increased tension (hypertonus) of pelvic distortion is (also) detected and which is also the erector spinae throughout the back and neck. the object of therapy. If treatment is correct, pel­ vic distortion also disappears. It is encountered far The most important clinical test is to sit the more frequently in children and adolescents than in patient down. If hypertonus disappears, especially adults, and it is generally a consequence of a restric­ in the neck, then we know that the disorder origi­ tion at the craniocervical junction. Adolescent girls nates not from above but from the feet (in cases with pelvic distortion also frequently present with where the chain reaction pattern is complete). The dysmenorrhea. Here, too, the true cause is prob­ underlying pathological mechanism is as follows: ably a dysfunction at the lumbosacral junction with where TrPs are present in the biceps femoris, the a TrP in the iliacus. In the final analysis the Rosina postural fixation of the pelvis via the ischial tuber­ test (see Section 4.5.5) also indicates that pelvic osity and the sacrotuberal ligament is impaired, and distortion in patients with normal sacroiliac joints it is held in place by compensatory tension of the can be provoked by head rotation and that this is a abdominal and gluteal muscles. palpatory illusion, as has been confirmed radiologi­ cally. On the side where the rectus abdominis has its insertion and hypertonus exists, palpation reveals 7.1.7 Forward-drawn posture that the symphysis is higher, and on the side of the tensed biceps femoris it is found that the ischial Symptoms tuberosity is lower. Interestingly, these differences are only ever detected with the patient in the prone Because this disorder affects posture as a whole, position, and never standing. There are numerous symptoms may occur at every level of the locomo­ osteopathic techniques by which this asymmetry tor system, although they are strikingly common in can be corrected, but nothing in the radiological the cervical region. appearance is altered. What does change is the posi­ tion of the palpating fingers (‘palpatory illusion’; The following pathological mechanism in par­ see Figure 4.11). In our experience this finding has ticular is responsible for low-back pain: TrPs in the nothing to do with the sacroiliac joints. rectus abdominis produce attachment point pain at the pubic symphysis and prevent retroflexion of the Therapy trunk. This is perceived as low-back pain and can be eliminated directly by relaxing the abdominal mus­ If increased tension in the dorsal muscles disap­ cles or by local anesthesia of the pubic symphysis. pears on sitting down, treatment of the most caudal 311

Manipulative Therapy Figure 7.2 • Forward-drawn posture (A) before and (B) after treatment. lesion is indicated, where possible at the feet (key Case study region), or in the event of negative findings there, at the fibular head. Forward rocking (see Section 6.8.8 B K; female; born 1985. and Figure 6.157) causing reflex toe flexion is cur­ rently the most effective and indeed the simplest Medical history form of (self-)treatment. Findings at the buttocks and abdomen are almost always secondary, and they The patient was seen on 22 February 2005 complain- may have their origin in the deep stabilization sys­ ing of headache. In December 2004 she had been tem, especially in the pelvic floor. struck by an automobile and knocked to the ground. She had landed on her back and occiput, was briefly It must be stressed that forward-drawn posture unconscious, and was admitted to hospital. Her is a very common disorder: we saw 90 cases over headaches did not start until a few days later and a two-year period. Treatment in patients with for­ were now constant. The patient also reported flicker- ward-drawn posture is so effective that restricted ing in front of her eyes and dizziness when perform- mobility at the craniocervical junction, for example, ing certain movements; when this occurred she had is also released. a tendency to stagger to the right. Since 2003 she had also experienced low-back pain occasionally in If a patient with headache and restricted mobility in the mornings and during her menstrual periods. She the cervical region is found to have a forward- underwent surgery for an umbilical hernia at the age drawn posture, and if the neck muscles are tensed of 11 years and she suffers from bronchial asthma. on standing but become relaxed on sitting, then any treatment that is limited to the cervical region C linical findings alone is bound to be unsuccessful. Examination disclosed hypermobility; the patient had a typical movement restriction at C0/C1 with TrPs in the sternocleidomastoid muscle and the short extensors of the upper cervical spine, a restriction at 312

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 T1/T2 on the left side with a restriction of the first rib the history is a factor here. Our experience indicates on the left side, TrPs in the diaphragm and the pec- that this disorder is highly relevant although the true toralis major (right side), quadratus lumborum (right pathological mechanism is far less clear. Nevertheless side), erector spinae, gluteus medius, and in the we know today that movement restriction of the hip pelvic floor (right side), in the thigh adductors (right is a routine finding on the side of inflare and that this side), at the right fibula with TrPs in the biceps femo- disappears immediately after therapy. ris, TrPs in the soleus, and restricted movement in Lisfranc’s joint with TrPs in the sole and on the dor- Clinical findings sum of the right foot. Inflare and outflare are in fact characterized by pelvic T herapy asymmetry (as described by Greenman & Tait 1988): on one side (usually the right) the anterior superior Activation of the deep stabilizers, first in the supine iliac spine (ASIS) appears to be more lateral and flat­ position, then by lifting the knees while seated; the tened, while on the other side (usually the left) the patient palpated contraction of the lateral abdominal ASIS appears to be more medial and ventral. As a wall with her own hands. Then clavicular breathing result the triangle formed by the right and left ASIS was corrected in front of a mirror: during inhalation and the umbilicus is pulled out of shape (see Figure she palpated for contraction of the lateral abdominal 7.3). These findings create the impression that one wall and the lower abdomen while simultaneously half of the pelvis is tilted outward and the other half checking in the mirror to see whether her thorax was inward. Hypotonus (reduced muscle tone) is pal­ lifting. After repeated exercise, all TrPs and restric- pated on the side of the flattened ASIS, while relative tions were eliminated. Her home exercise was to hypertonus is palpated in the lower abdomen on the practice breathing correctly in front of the mirror. opposite side. It appears to be important that internal rotation at the hip on the side of the prominent ASIS At the follow-up examination on 15 March 2005 is routinely found to be clearly restricted compared the patient was virtually pain-free. Correct fixation of with the other side (Lewit & Olšanská 2005). This the thorax during breathing was verified and she was asymmetry is readily visible in slim patients; in obese recommended to continue with regular exercises to patients, however, this possibility must be remem­ activate the deep fixators. bered and palpated for. Unlike Greenman, we are of the opinion that there is generally no sacroiliac joint C ase summary dysfunction. The case of this patient illustrates how dysfunc- tions of the deep stabilizers provoke chain reaction patterns in all sections of the locomotor system and how all TrPs and restrictions can be eliminated by activating (exercising) this system. The umbilical hernia, for which the patient underwent surgery at the age of 11 years, is a further indicator of a major weakness in this system. 7.1.8 Inflare and outflare (Greenman) Symptoms In our experience these conditions frequently take Figure 7.3 • Outflare (patient’s right side) and inflare the form of low-back pain and radicular pain with (patient’s left side). a severe clinical course, and they are also encoun­ tered in patients with residual discomfort follow­ ing intervertebral disk surgery. In the vast majority of cases the patient’s history contains evidence of a fall on to the buttocks and/or coccyx. This fact, coupled with the often very favorable effect of ‘repositioning,’ awakens the suspicion that trauma in 313

Manipulative Therapy Therapy and inflare on the left, and the femoral nerve stretch test was positive on the left side. Internal rotation at For specific therapy, on the side where the ASIS the hip joint was 25° on the left and 45° on the right. appears flattened (outflare) and with the patient’s Dorsiflexion in the right talocrural joint was restricted knee and hip flexed at right angles, the practitioner (80° compared with 100° on the left side). adducts the patient’s thigh (as when testing the ilio­ lumbar ligament, see Figure 4.13) until the slack is Therapy taken up. He then tells the patient to resist adduc­ tion for 5–10 seconds and breathe in, then to relax Treatment involved ‘repositioning’ the pelvis. After and breathe out. PIR is repeated two or three times, this treatment all findings became normal, apart from and then the patient adducts the thigh flexed at the the right talocrural joint, which was also mobilized. knee and hip against repetitive resistance (RI). At follow-up examination on 12 July 2005 the On the other side (inflare), the practitioner patient was able to walk normally, but he felt slight takes up the slack on the thigh abducted at the pain in his left lower leg on running. Over the inter- knee and hip (as when testing for Patrick’s sign, vening four-week period the patient had had only two see Figure 4.43). The patient resists abduction headaches. The findings now comprised a move- for about 5–10 seconds and breathes in, and then ment restriction at C1/C2. The fascia on his left lower relaxes into abduction while breathing out. PIR is leg showed poor mobility relative to the underlying repeated two or three times, and then the patient bone, a sign of an active scar following the accident, performs abduction against repetitive resistance or and there was a TrP in the adductors on the left side. else abducts the thigh maximally (RI). Afterward, After treating the fascia of the left lower leg, there was the practitioner checks whether the ASISs are sym­ no longer a TrP in the adductors, and the movement metrical, whether muscle tone in the lower abdo­ restriction at C1/C2 was also released. The findings men is now balanced, and whether internal rotation at the pelvis and hips were symmetrical. at both hip joints is now identical. C ase summary Case study The principal symptoms associated with claudica- R D; male; born 1946. tion were abolished following treatment of outflare and inflare, and the findings in the cervical region Medical history were also improved immediately after treatment, as reflected in the reduced frequency of headaches. The patient was first seen on 14 June 2005. He had The pain in the patient’s left lower leg was a residue been involved in a road traffic accident in August from a comminuted fracture with an active scar; after 2004, following which he had been unconscious for these were treated there was normalization of the almost a week. On his left side he sustained several TrPs in the adductors and of the movement restric- fractured ribs and a fractured lower leg. He was a tion in the upper cervical spine. The movement professional downhill skier and recalled having fallen restriction in the right talocrural joint was not linked on to his coccyx on numerous occasions. He had with the other dysfunctions; it may have been the experienced back pain for the past 18 years related result of excessive strain caused by an antalgic pos- to his sporting activity, and had suffered one or two ture adopted by the left lower leg after fracture. headaches every week since adolescence. The symptom that actually prompted him to consult us 7.1.9 The coccygeus and was pain in the left groin that radiated into his thigh pelvic floor and on account of which he had to remain standing in order to get moving again. The coccygeus forms part of the deep stabilization system and can be understood only in the context C linical findings of the locomotor system as a whole. We should fur­ ther recall the role of the levator ani in conjunction On examination, lumbar spinal mobility with the with the sphincters and the gluteus maximus. Here patient standing was normal, head rotation was lim- we are dealing with an entirely different func­ ited in both directions, there was restricted mobility tion of the pelvic floor, which contributes to erect of C1/C2, restricted mobility of the fibular head with a posture and respiration; disturbances of this func­ TrP in the left biceps femoris, outflare on the right side tion are announced by a TrP in the coccygeus. The 314

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 palpatory technique for this TrP is described in visceral pain. TrPs in the erector spinae may also Section 4.5.8 (see Figure 4.12). be responsible for pain felt underneath the shoul­ der blades. The pain here may have an acute onset, Clinical findings particularly on picking up an object placed to one side of the patient, causing lifting to occur with a The numerous chain reaction patterns originating in rotating movement. This mechanism is also impor­ the deep stabilizers, and in the pelvic floor in partic­ tant in evolutionary terms: only humans generate ular, are described in Section 4.20. One especially maximum forces by trunk rotation, for example as characteristic finding is a usually very clear TrP in when throwing the discus. Farfan et al (1996) have the thoracic erector spinae; mechanical stimulation emphasized that the intervertebral disks in par­ of this TrP produces not only an observable, local ticular are not well adapted to powerful rotational twitch response but also contraction of the lumbar movements. erector spinae with brusque dorsiflexion of the pel­ vis. This phenomenon was described by Silverstolpe Clinical findings (1989) and Skoglund (1989) who termed it the ‘S reflex.’ Trunk rotation is widely regarded as a function of the thoracolumbar junction because, on anatomi­ Therapy cal grounds, it has been claimed that the joints of the lumbar spine do not permit rotation and that Relaxation of this TrP can be obtained by release the ribs pose an obstacle to rotation, at least of the achieved using simple sustained pressure (as for upper and middle thoracic spine. It has already diagnosis). However, this is felt to be painful by the been shown in Section 3.4.1 (see Figure 3.19) that patient and, what is worse, relapses usually develop this is an erroneous view and that coupled move­ quickly. We have therefore elaborated a relaxation ment associated with scoliosis and rotation can be technique that the patient can practice on a daily regularly observed in the lumbar and thoracic spine: basis (see Figure 6.143). side-bending (scoliosis) produces rotation, and rota­ tion produces side-bending. On clinical examina­ However, the process begins with activation of tion, patients with restricted trunk rotation are the entire deep stabilizer system and involves exer­ found to have TrPs in the thoracolumbar erector cising the concerted action of the diaphragm, the spinae, the psoas major, and the quadratus lumbo­ deep abdominal muscles, and the pelvic floor. This rum on the side opposite to the lesion. In this con­ has been described for the rehabilitation of breath­ text it is sufficient to treat one of the three muscles ing in Section 6.7.7 (see Figures 6.155 and 6.156). in this chain to restore trunk rotation. Compared Interestingly, this activation relaxes not only the with these three powerful muscles, the joints do TrPs in the pelvic floor and diaphragm, but also gen­ not appear to play a major role here. erally all other TrPs linked with them. The patient is then instructed to exercise actively with the aim It should also be recalled that vertebral frac­ of normalizing respiratory movement patterns and tures are most commonly encountered at T12 and the deep stabilizer functions of the trunk. However, L1, especially in osteoporosis. In such patients if the TrP in the coccygeus persists, the patient trunk rotation is indeed considerably restricted, at needs to practice its relaxation. least on one side. Careful neuromuscular mobiliza­ tion (using only visual and respiratory synkinesis) 7.1.10 Low-back pain due to achieves instantaneous pain relief here in a very restricted trunk rotation gentle way. Symptoms Therapy Patients complain of low-back pain, apparently due Treatment takes the form of PIR and RI of one of to painful attachment points of the erector spinae the three muscles in the chain, namely, the erector and quadratus lumborum dorsally on the iliac spinae (see Figure 6.115), the quadratus lumbo- crest. TrPs in the psoas major may cause pseudo­ rum (see Figure 6.120), or the iliopsoas (see Figure 6.122). 315

Manipulative Therapy As a relatively recent phylogenetic function, following treatment of trunk rotation. The focus there- trunk rotation is very commonly restricted and fore simply needs to be on correcting trunk rotation. often occurs in a chain along with many other dys­ This was reflected in the exercise prescribed for the functions. The link with restricted rotation of the patient at home. The subscapularis muscle is a com- cervical spine appears particularly important. In mon source of shoulder/arm pain, especially after such cases, restricted trunk rotation should be exertion. treated first. Usually it is then no longer necessary to treat the cervical spine. 7.1.11 Combined lesions Case study Needless to say, the individual forms of back pain described above rarely occur in isolation. Usually H K; female; born 1919; professional translator. they present as mixed or combined lesions, with the clinical picture being dominated by a different M edical history factor in each case. And this does not happen by chance. All the structures involved in the etiology The patient came to us on 1 July 2003 complain- of low-back pain are somehow interconnected, and ing of pain in her cervical and lumbosacral regions. many are closely linked in a chain reaction pattern. Cervical pain had been present since 1998, and low- Movement restriction at L4/L5 often fixes the sacro- back pain since the onset of puberty at the age of 13 iliac joint via the piriformis, the sacroiliac joint itself years. She had experienced low-back pain both dur- is closely connected to the hip, and this in turn to ing menstruation and during three pregnancies. Her segment L3/L4, while the pelvic floor has a special most recent episode of low-back pain had occurred relationship with the adductors, and also with the in May 2003, but by early July it was cervical pain biceps femoris and fibular head. that was dominant. Her occupation as a translator involves keyboard work at a computer. She reported Case study having undergone a hysterectomy and ovarectomy in 2000. J F; female; born 1906. Clinical findings and therapy M edical history Examination revealed a slight movement restriction Our patient since 1962, she was obese with a to the left at C4/C5, TrPs in the diaphragm on the slouched posture consistent with lumbar hyperlor- right, and in the psoas major, quadratus lumborum, dosis and weak abdominal muscles. Low-back pain and erector spinae on the left. Trunk rotation was 30° started in 1957, often occurring when the patient to the right and 45° to the left. Therefore the quad- bent forward. ratus lumborum was treated using gravity-induced PIR coupled with visual and respiratory synkinesis. C linical findings and therapy After this, not only trunk rotation but also head rota- tion was completely normal; moreover, the TrP in the Initial examination revealed movement restriction diaphragm on the right side was no longer palpable. in segment L5/S1 and pelvic distortion, and sub- The patient’s home exercise consisted of PIR and RI sequent examination showed a painful coccyx (this for the quadratus lumborum. relapsed twice). Later the clinical picture came to be dominated by hip pain (without osteoarthritis), then At the follow-up examination on 30 July 2003 the again by lumbosacral movement restriction and a patient made a point of saying how much the exer- painful coccyx, followed by pain at the L5 spinous cise program was helping, but she still had low-back process, and (since 1968) sacroiliac restriction. The pain and right shoulder pain as a legacy from tidy- patient’s condition improved slowly in response to ing up on the previous day. The principal finding on remedial exercise and weight reduction, but she examination was a painful subscapularis on the right continued to require treatment periodically. side, which was treated using PIR and RI; otherwise the examination yielded no abnormalities. C ase summary Case summary It is certainly uncommon to encounter such a wide range of pelvic lesions in an individual, not concur- In elderly patients, in particular, low-back pain is rently but occurring in alternating sequence over a frequently associated with restricted trunk rota- tion and is also typically coupled with slight restric- tion of head rotation. The latter resolves immediately 316

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 number of years. Despite the often close anatomical TrPs in the diaphragm and pelvic floor also plays an relationships, it is important to differentiate the individ- important role here. Patients with restricted trunk ual dysfunctions precisely so that they can be treated rotation suffer not only from low-back pain but also in a targeted manner and so that remedial exercises from pain between or beneath the shoulder blades can be prescribed as specifically as possible. (attachment points of the iliocostal muscle). 7.2 Pain in the thoracic Therapy and self-mobilization (see Figure 6.74) spine and thorax simultaneously serve to strengthen the interscapular component of the erector spinae. Where painful ten­ The thoracic spine is the least mobile section of the der points are present at the sternocostal joints, spe­ spinal column. Because of this stability it is only rel­ cific relaxation of the bundles of the pectoralis major atively rarely the site of the primary lesion in dys­ with insertion there has proved effective (see Fig­ functions. On the other hand, pain in the thoracic ure 6.109). While highly effective, self-mobilization region is often referred pain from the viscera, and (see Figure 6.38) is indicated only if lordosis in the it is here that vertebrovisceral inter-relationships thoraco­lumbar region does not occur in the process. are most clearly apparent. A special warning against diagnostic error is particularly apposite in this region. Less frequently than in the lumbar and cervi­ One important condition that manifests itself prima­ cal spine (where acute low-back pain and acute wry rily in the thoracic spine is juvenile osteoc­ hondrosis, neck are common conditions), acute episodes of pain the commonest cause of kyphosis in adolescents. may occur in the thoracic spine, due especially to rib Stiffness of the kyphosed thoracic spine has to be dysfunction. Such episodes can be even more dra­ compensated for by lumbar hyperlordosis, and it is matic than acute low-back pain or neck pain, because there that pain is most commonly felt. patients are unable not only to move but also even to breathe without pain. Manipulation and mobiliza­ Patients complain mostly of pain between or tion are complicated by the fact that mere contact at below the shoulder blades. Here, again, pain in the the rib is excessively painful; on the other hand, local dorsal region may be the result of excessive strain anesthesia at the transversocostal joint is easy to per­ due to external factors or to muscle imbalance and form because the structure is superficial. However, excessive static loading. One particularly common a similar acute pain on respiration may also be pro­ culprit is a kyphotic sitting position associated with duced in the very early stage of pneumonia (before working at the computer. The typical muscle imbal­ the typical rise in temperature). ance is shortening of the pectoralis major and weak­ ness of the interscapular muscles and of the lower 7.2.1 Slipping rib fixators of the shoulder blade. Major stiffness is detected especially at the point where the kyphosis Symptoms peaks. On the other hand, hypermobility can also be linked with pain, generally in a flat back in the Here attention will be drawn to a clinical condition upper thoracic region. that is by no means rare but is only seldom recog­ nized. Slipping rib presents as intense pain localized Movement restrictions may be present not only in the lower thorax and upper abdomen, sometimes in the apophyseal joints between the individual associated with pain on respiration and coughing (or vertebrae but also at the joints between vertebrae sneezing). Large, forceful movements of the upper and ribs, and they produce very similar symptoms. extremity on the side of the lesion may also be pain­ Deep breathing can be painful in both scenarios. Of ful. Generally, suspicion falls on a wide variety of course, this is particularly the case with rib lesions, diseases of the thoracic and upper abdominal organs, where it is useful to distinguish between pain on and these patients usually undergo a great many vis­ inhalation and pain on exhalation. It is essential for ceral examinations (which all prove negative). the differential diagnosis to exclude pleural disease. Clinical findings The techniques for diagnosis and therapy have been discussed in the appropriate sections in Chap­ A simple maneuver can be valuable in confirming ters 4 and 6, with regard to both movement restric­ the diagnosis. With the patient seated or supine, tions and TrPs. The deep stabilization system with 317

Manipulative Therapy the practitioner hooks her fingers under the last treated. Following further examination on 4 July 2002 ribs at the upper end of the patient’s abdominal the patient’s condition was considerably improved, cavity (similar to the situation shown in Figure and she reported feeling only slight tension in the 6.112) and exerts pressure on the ribs with her fin­ axilla. The serratus anterior was found to be short- gers underneath against her thenar eminence above. ened; this was relaxed and stretched. Relaxation of At that moment the patient experiences sharp pain. the serratus anterior was then assigned as her home This response clinches the diagnosis of slipping exercise. rib (Heinz & Zavala 1977). Interestingly, we have encountered slipping ribs relatively frequently in C ase summary women with pain following breast cancer surgery. The slipping rib was found to be crucially important Therapy for the symptoms experienced by this patient. The far more typical findings made at the initial examina- tion proved to have little relevance. Therapy consists of mobilization using the fingers 7.3 Pain in the cervical spine hooked beneath the inferior costal arch to exert repetitive springing pressure ventrally and later­ The clinical features of neck pain per se are rela­ ally. This mobilization is always painful but gener­ tively straightforward by comparison with low-back ally brings instantaneous relief. Only in exceptional pain. By contrast, the clinical features of vertebro­ cases is local anesthesia necessary at the inner mar­ genic disorders in the cervical region, the so-called gin of the tenth rib, while surgical removal of the ‘cervical syndrome,’ are far more complex than painful rib may be considered as a last resort. Treat­ those of lesions of the lumbar spine and pelvis. ment of the spinal column or of the costovertebral joints is ineffective in this condition and the true 7.3.1 Muscle imbalance pathogenesis is unknown. Pain may result from excessive strain due to exter­ Case study nal factors or from muscle imbalance. Most com­ monly, static overload due to long periods of C M; female; born 1929. working with the head bent forward plays a promi­ nent role. A similar effect is produced by a for­ Medical history ward-drawn posture as a result of faulty statics (see Figure 3.39). The typical signs of muscle imbalance First seen by us on 4 June 2002 complaining of have been described in Section 4.20.3. burning pains in the thorax, usually occurring at rest and apparently without any provoking factors. Onset Symptoms of pain just one month previously. The patient had undergone surgery in 1992 to remove her left breast, Initially, signs of fatigue occur, followed by pain, after which she experienced transient swelling of the most frequently after working at the computer with feet; no symptoms at all prior to surgery. head bent forward or in a fixed position. Jolting in automobiles and other types of vehicle may elicit Clinical findings and therapy similar pain. Restricted movement at C3/C4 to the left side, TrPs Therapy in the diaphragm on the left side, the thoracic fas- cia on the left side showed reduced mobility relative Wherever possible, long periods spent with the to the underlying structures, and the fifth sternocos- head bent forward should be avoided and fixed tal joint was painfully tender. The fascia was treated positions should be corrected. Remedial exercises and the attachment point of the pectoralis at the fifth should be employed to correct any muscle imbal­ costotransversal joint was released. The restriction ance. Clavicular breathing, a faulty respiratory at C3/C4 was also treated, after which the TrP in the diaphragm could no longer be palpated. At follow-up examination on 25 June 2002 the patient reported no major improvement. She also still complained of ‘spasm-like back pain.’ On this occasion a slipping rib (left side) was diagnosed and 318

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 pattern characterized by thoracic lifting (without Therapy widening) during inhalation, is a particularly com­ mon expression of a disorder of the deep stabiliza­ The first step is post-isometric traction (see Figure tion system, and this requires treatment. 6.52): this must be performed in the direction that is most agreeable to the patient and in which the Any TrPs and movement restrictions found patient also finds it easiest to relax. One alternative should be treated. Later, during the rehabilitation is a simplified version of Jirout’s maneuver (2000): phase, muscle imbalance is corrected, paying par­ for this, the patient is supine with the cervical spine ticular attention to clavicular breathing as the most precisely in a neutral position. If rotation to the common manifestation of this. right is restricted (as is usually the case), the prac­ titioner’s thumb takes up contact with the patient’s In terms of lifestyle advice, correct positioning left acromion, which must not be elevated, stimu­ in bed at night is especially important (see Section lates this a little with the thumb and instructs the 8.3.1). patient to offer (isometric) resistance against this pressure and then to let go again. This procedure is 7.3.2 Acute wry neck repeated two or three times. In those exceptional cases where head rotation to the left is restricted, Symptoms resistance is offered on the right-hand side. This technique has the advantage that no contact at all is The pain often has its onset after rest in bed (in made with the painful neck region. The acute mus­ an unsuitable position), after a sudden jerk of the cle spasm is usually corrected after this maneuver, head, or after an automobile journey with the win­ as after post-isometric traction. dow open. The patient complains of neck pain, frequently on the right side and radiating toward Only after this step is complete can the remain­ the shoulder and/or occiput, and of stiffness. Auto­ ing restrictions or TrPs then be treated specifically; nomic symptoms such as nausea or drowsiness may possible chain reaction patterns from other areas also be present. of the locomotor system can also be diagnosed and treatment can be continued as appropriate. Clinical signs Differential diagnosis The patient’s head is rotated to one side, more usu­ ally to the left. Rotation to the right and inclination It is important not to confuse the common form of to the left are restricted, but anteflexion and retro­ wry neck with spasmodic torticollis, a mistake that flexion also suffer. Segment C2/C3 is most com- can be easily made because in the initial attack pain monly involved, and in exceptional cases C1/C2 or is the dominant clinical feature of both. However, C3/C4. However, in the acute stage it can be dif­ although pain diminishes with each relapse, the ficult to localize the dysfunction precisely. Further, fixed position in spasmodic torticollis continues to it is important to realize that another segment is deteriorate. The powerful spasm of the sternocleido- usually restricted, for example C5/C6, as well as a mastoid on one side and of the splenius capitis on segment at the cervicothoracic junction. Simulta­ the other will then be noted, but without the typi­ neously, numerous TrPs are present in the area of cal signs of true movement restriction. the short extensors at the craniocervical junction, and in the sternocleidomastoid, levator scapulae, Meningeal bleeding must also be considered in and trapezius. A very characteristic finding is a pain the differential diagnosis. This may also begin with point on the lateral aspect of the spinous process of acute neck pain radiating to the head, and here too the axis (during the examination the practitioner the patient will avoid movement and jolting. How­ should not forget to bend the patient’s head to one ever, the movement that is primarily restricted is side!). A pain point in the horizontal part of the tra­ anteflexion, although here it is a meningeal sign. pezius close to the shoulder blade is an important Side-bending and rotation are not affected. prognostic indicator: finding this TrP suggests that a cervicobrachial syndrome or even a radicular syn­ If the pain is not acute, then neck pain is just one drome may be imminent. of many signs of what is termed the ‘cervical syn- drome.’ It is unusual for neck pain not to be com­ bined with either headache or shoulder pain, that is 319

Manipulative Therapy pain in dermatome C4. Among other sources, pain In the L5 pseudoradicular (reflex) syndrome, is also referred to this segment from the diaphragm. a TrP in the piriformis plays a major role and this There is often also a HAZ posterior to and below may even persist after the movement restriction at the mastoid process, which is suggestive of restric­ L4/L5 has been released. The piriformis may also tion at the craniocervical junction. cause fixation of the sacroiliac joint, and for this reason restrictions at the sacroiliac joint are quite 7.4 Referred pain and other often found concurrently with restrictions at L4/ pain types L5. Where a TrP is simultaneously present in the biceps femoris, a restricted and sometimes painful The lower extremities fibular head may also be encountered. (see 7.4.1–7.4.5) The S1 pseudoradicular (reflex) syndrome is It will be useful at this point to review the material caused not only by lesions of the L5/S1 motion seg­ on the subject of referred pain presented in Sec­ ment but also by lesions of the sacroiliac joint. The tion 2.11. Table 7.1 lists those spinal segments sacroiliac ligaments and the ischial tuberosity may where individual movement restrictions produce also give rise to pain in this segment. The TrP in the referred pain. As in true radicular syndromes, in iliacus is generally consistent with the movement the pseudor­adicular (or reflex) syndromes provoked restriction at L5/S1. Further findings in this seg­ by movement restrictions we encounter referred ment may include TrPs in the ischiocrural muscles (or radiating) pain exclusively in segments L4, L5, and movement restriction at the fibular head. and S1. The structure that may complicate all three In the L4 pseudoradicular (reflex) syndrome, pseudoradicular (reflex) syndromes is the coccyx. pain radiates down the ventral aspect of the thigh A painful coccyx may be associated with a positive toward and even below the knee; in the L5 syn­ Patrick’s sign, a mildly positive straight-leg raising drome, pain radiates down the lateral aspect of the test, and TrPs in the iliacus and even in the piri­ thigh and lower leg to the lateral malleolus; and in formis and gluteus maximus. In exceptional cases a the S1 syndrome, pain radiates down the dorso­ painful coccyx may even simulate hip pain. lateral aspect of the lower extremity toward the heel. In the L4 syndrome, the femoral nerve stretch The upper extremities test is positive (TrP in the rectus femoris), while in (see 7.4.6–7.4.8) the L5 and S1 syndromes, the straight-leg raising test is positive (TrPs in the ischiocrural muscles). Besides Referred pain is not the exclusive preserve of the the referred pain, there may also be paresthesia. The lower extremities. Dysfunctions are often found TrPs in the key muscles were listed in Table 7.1. that have their origin in the upper extremities; they may be complications of vertebrogenic and even of It may also be helpful to consider which other radicular syndromes. structures are also capable of triggering the same patterns of referred pain. The referred pain in L4 In the upper extremities, too, it is common to may stem not only from a lesion in the motion seg­ find pain that is referred from lesioned structures in ment L3/L4 but also from the hip joint, and for the cervical spine. Here, however, unlike the lower this reason it may be difficult to distinguish a pain­ extremities, referred pain does not exactly follow ful hip with (minimal or) no osteoarthritis from an the individual segments/dermatomes. Instead, the L3/L4 lesion. Pain at the knee may even be caused pattern is consistent with that produced by TrPs in by both these lesions, especially where TrPs in the the individual muscles close to the cervical spine adductors produce pain at the pes anserinus on and cervicothoracic junction, with pain characteris­ the tibia. tically referred to the shoulders, elbows, and hands. A mildly positive Patrick’s sign may also be elic­ 7.4.1 Fibular head restriction ited in the L4 pseudoradicular syndrome if there are TrPs in the adductors. The femoral nerve stretch Movement restriction involving the fibular head is test is probably the most useful tool for differenti­ closely linked with faulty statics (see Figure 6.25). ating between the two lesions. Locally, it may give rise to lateral pain at the knee 320

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 and cramping in the calf. Often it is a secondary The commonest complaint is foot pain that is finding in dysfunctions involving the foot. Fibular often associated with cramps in the foot and calf head restriction is regularly associated with TrPs and with paresthesia, although tunnel syndromes in the biceps femoris, a muscle that plays a criti­ may be present in exceptional cases. What is far cal role in the anatomical fixation of the pelvis. more important is that the feet constitute a key Where pelvic fixation by the biceps femoris is inad­ region in the locomotor system. The foot and its equate, there is a compensatory response by the muscles are required to stabilize the almost spheri­ rectus abdominis together with the gluteal muscles, cal talocrural joint. Futhermore, the sole of the and then TrPs are found principally in the rectus foot and the toes possess the highest density of abdominis, causing a forward-drawn posture. proprioceptors and exteroceptors. The soles of the feet may be hypersensitive as well as relatively 7.4.2 Painful patella hyposensitive, and not infrequently the soles of the feet also react asymmetrically to exteroceptive In true knee pain (not pain that is referred to the stimulation (see Section 6.3). The consequence of knee) it is most important not to overlook a painful all this is that the feet, like the deep stabilization patella. A healthy patella should move freely on the system, are a source of very common chain reaction articular surfaces of the femur and tibia. It should patterns involving the entire locomotor system; therefore be checked whether the patella is freely the most characteristic finding is a forward-drawn mobile in all directions and whether gentle pres­ posture. sure on the patella during mobility testing produces grinding resistance and pain. The technique for this 7.4.5 Painful heel is described on page 198 and can often bring instan­ taneous relief. Attachment point pain at the upper When walking and standing, patients not infre­ margin of the patella may be caused by TrPs in the quently complain of a painful calcaneal spur. This rectus femoris, but also by increased tension in the is quite simply pain at the attachment of the plantar tensor fasciae latae. aponeurosis, a structure that becomes painful when there is increased tension in the aponeurosis itself. 7.4.3 Knee joint dysfunction This is chiefly the result of TrPs in the deep flex­ ors of the sole of the foot. At the same time there Dysfunctions of the knee (tibiofemoral) joint are are generally also movement restrictions in the foot characterized by a capsular pattern in which flexion as well as dysfunctions in the lower extremities, is gradually more restricted than extension. Lateral including the fibular head. Dysfunctions are some­ springing (gapping) and joint play on one or other times also found in the pad of soft tissue at the side are also often restricted. Unlike the hip joint, heel. the knee is most painful when the patient walks downstairs or downhill. In this case mobilization by Treatment takes the form of PIR of the foot flex­ rapid shaking is most effective, and this is also true ors (see Figure 6.132). Activation of the toe flex­ in particular for osteoarthritis of the knee. ors by rocking forward is even more effective (see Section 6.8.8 and Figure 6.157). Needling of TrPs 7.4.4 Painful foot has also proved most beneficial, yielding far better results than a series of local anesthetic infiltrations The clinically important articulations in the foot around the calcaneal spur. are the ankle joint, the tarsal joints, and particularly the tarsometatarsal joints. Restrictions primarily Another commonly encountered complaint is involve Lisfranc’s joint, the second and third meta­ not only Achilles tendon pain itself, but pain where tarsophalangeal joints, the talocrural joint and, to a the Achilles tendon attaches at the heel. Here, too, lesser extent, the talocalcaneonavicular and subtalar treatment primarily takes the form of PIR-RI of joints. The main TrPs are found in the deep flexors the TrP in the soleus muscle; this is usually highly of the sole of the foot and dorsally between the effective, with the result that needling is gener­ metatarsal bones. ally superfluous. Achilles tendon pain should be differentiated from pain in the underlying soft tis­ sue between the Achilles tendon and the tibia (see Figure 6.65). 321

Manipulative Therapy 7.4.6 Shoulder pain rib provoke only shoulder pain. At examination, with the patient’s shoulder blade abducted, a typi­ This is the commonest form of referred pain radiat­ cal pain point is found at the costal angle. This pain ing into the upper extremity and constitutes a clini­ point on the first rib is the articulated junction with cal problem as complex as that of low-back pain. the manubrium sterni. In the other ribs, too, there This is probably due to the fact that the shoulder is often a pain point that can be palpated at the region corresponds to segment C4 and that numer­ sternocostal joint – the attachment point for the ous structures refer pain to this segment, in partic­ pectoralis minor. Rib movement here is commonly ular the diaphragm with the phrenic nerve. Clinical restricted, and manipulation is indicated to cor­ experience suggests that any type of pain originating rect this. However, where movement is restricted in the cervical spine, the cervicothoracic junction, in several ribs, this is usually attributable to TrPs in or the upper ribs – and even in the visceral organs the subscapularis and to impaired mobility of the of the thorax and upper abdomen – is felt in the thoracic fascia. shoulder region. Frozen shoulder A diagnosis of ‘humeroscapular periarthropathy’ The clinical picture of frozen shoulder is in fact a merely betrays the incompetence of the person pathological condition involving the scapulohumeral making it because this somewhat vague label in joint. It has been described in classic terms by Cyr­ fact covers a number of quite specific dysfunctions. iax, and is a phenomenon that is unique in arthro­ logy because it is caused by contracture of the joint capsule (Cyriax, de Sèze). Shoulder pain due to disturbed Symptoms muscle function The patients, more usually women and predomi­ In the shoulder region pain can be caused by nantly between 45 and 65 years of age, develop increased muscle tension with TrPs, especially intense shoulder pain that radiates down past the where the patient is under excessive strain. The elbow as far as the wrist. The pain is often at its muscles most susceptible to painful increases in most intense at night, preventing patients from tension are the upper part of the trapezius, the sleeping, and tends to worsen when the arm hangs levator scapulae, the sternocleidomastoid, the sub­ down, carrying a weight, or on moving the shoulder. scapularis, the infraspinatus, the pectoralis major At first there is only slight restriction of movement, and minor, the diaphragm, and sometimes the but this rapidly increases. According to Cyriax deltoid. (1977, 1978), three stages can be distinguished: Symptomatic therapy here consists primarily 1. The first stage is characterized by extreme of PIR and RI, and sometimes needling; over and pain and rapid deterioration of the range of above this, it is important to understand and treat movement. the cause of excessive strain. 2. In the second stage the pain subsides Pain referred from the but there is hardly any improvement in spinal column movement restriction. This pain is most commonly evoked by a certain 3. In the third stage the movement restriction movement – or position – of the head. TrPs are then melts away (hence the name ‘frozen detected in the corresponding muscles, and move­ shoulder’). ment restrictions are diagnosed in the correspond­ ing spinal segments; these are then treated. Each stage lasts for about three or four months, with the result that when the disorder follows its Pain originating in the upper ribs radiates to the natural course the patient becomes symptom-free shoulder blade and shoulder. Lesions of the first after about a year. However, this is not the case in secondary forms, for example following stroke or trauma. 322

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 Clinical signs that allows the head of the humerus to slip through under the acromioclavicular ligament during abduc­ Examination of range of movement reveals the typi­ tion. The subdeltoid bursa together with the rotator cal capsular pattern as defined by Cyriax (1977) and cuff is the key player in this mechanism, and calci­ corrected by Sachse (1995): with the shoulder blade fications are detected around the bursa where this fixed, abduction is most restricted, followed by mechanism is disturbed. Degenerative changes are external rotation, with internal rotation being least seen in the rotator cuff with tears, especially in the affected. Joint play may be normal provided that supraspinatus tendon, and alleged impingement. arm abduction is not already considerably restricted. This is further proof that we are not dealing here Pathophysiology with movement restriction such as is familiar from other joints. Pain points are found at the attachment During abduction, the head of the humerus is of the deltoid, and in the subscapularis and infrasp­ required to glide caudally in the glenoid cavity. This inatus. In severe cases there is muscle atrophy in the movement is also reflected in the play of the joint. deltoid, supraspinatus, and infraspinatus. The pain Any disturbance of this gliding motion is an obsta­ may also be associated with autonomic symptoms, cle to abduction. Consequently, restoration of this such as cyanosis and edema, especially involving the gliding function is the therapy of choice. hands and fingers, and with algodystrophy. Symptoms Therapy Pain may appear only on abduction or even spon­ In the acute stage the most important step is to taneously when the patient is at rest. Two types of alleviate pain using analgesics (by the intrav­ enous impaired abduction are distinguished: either there route, where necessary). It is also important to is simple restriction of abduction by degrees or treat all concomitant painful dysfunctions, for there is a painful arc, as described by Cyriax (1977, example in the cervical spine, cervicothoracic junc­ 1978). Where a painful arc is present, abduction tion, and ribs. In particular, treatment of the T1/T2 initially proceeds normally up to the point where segment often yields good results. It is important to the head of the humerus engages the coraco-acro­ relax tensed muscles with TrPs. Isometric traction mial ligament. The patient feels a sharp pain, but is used for this (see Figure 6.12). Relaxation of TrPs as soon as this obstacle is overcome, abduction may in the subscapularis by means of PIR-RI, needling, continue through to its full extent without pain. or local anesthesia appears to be most important. It is worthwhile trying intra-articular injections of Clinical findings cortisone preparations. If this brings improvement, then administration may be repeated no more than There is restricted abduction, or a painful arc only on once. It is advisable for the patient to wear the arm abduction but which the patient can move through. in a sling during the acute stage so that it does not Joint play is regularly absent (see Figure 4.42). hang down. Active exercises are not feasible until the second, less painful stage and should never Therapy be such as to provoke pain. Excessively energetic, painful exercise will merely delay improvement. First and foremost there is mobilization to restore Warnings should be issued against heat applications, joint play (see Figure 6.12). This has an instanta­ especially in the acute stage. neous effect in the vast majority of cases but may need to be repeated a few times. Surgery is super­ Pain provoked by arm abduction fluous. Rotator cuff tears have also been detected (impingement syndrome) on ultrasound in clinically healthy individuals. Patients who experience pain principally or exclu­ Painful long head of triceps brachii sively during abduction of the arm (but with nor­ mal external and internal rotation) are encountered In 1994, Krobot described a pain that occurred on more commonly than those with a capsular pattern. exercising the triceps brachii and that is felt in the This fact may be attributable to the mechanism shoulder, axilla, and shoulder blade. On examina­ tion, the patient is unable to raise the lesioned arm 323

Manipulative Therapy in front to ear level and experiences pain when Therapy doing press-ups. An extremely painful TrP is found in the long head of the triceps brachii just under the Osteoarthritis and simple movement restriction axilla. Therapy consists of PIR and RI of the triceps should be treated with mobilization; in patients with brachii (see Figure 6.101) or needling. osteoarthritis, mobilization needs to be performed repeatedly over an extended period (see Figure 6.16). The acromioclavicular joint 7.4.7 Pain in the elbow region Dysfunction of the acromioclavicular joint is one of Epicondylar pain is a very frequent complication the commonest (and yet rarely diagnosed) causes of the cervicobrachial syndrome. It is encountered of shoulder pain. A traumatic origin is especially far more often at the lateral than at the medial epi­ common: any force acting on the shoulder from the condyle of the humerus. side, for example following a fall, is first absorbed by the acromioclavicular joint. Lateral epicondylar pain Clinical signs The epicondylar region provides the attachment points for those muscles involved in the prehen­ Painfully restricted adduction of the arm across the sile function of the hands. Excessive strain and chest toward the opposite shoulder is suggestive of increased muscle tension (TrPs) play an important the diagnosis. The joint space is tender to palpation. role here. Although the lateral epicondyle is pal­ pated through the brachioradialis muscle, the latter Therapy is a bystander here. The muscles producing attach­ ment point pain at the lateral epicondyle are the Therapy consists pre-eminently of mobilization supinator, the extensors of the fingers and wrist, the (see Figures 6.14 and 6.15). However, this must be biceps brachii, and the triceps brachii. It is no coin­ performed using a minimum of force and it is help­ cidence that tennis elbow and writers’ cramp share ful to supplement mobilization by shaking in the a common pathogenesis. In the first case the tennis direction in which distraction is intended. player is unable to relax the grip between strokes, and compounds this error by not holding the racket The clinical course is more severe if there is sufficiently in radial abduction and extension at the radiol­ogical evidence of osteoarthritic changes or, wrist. In the second case the writer is tense and more rarely, of joint space widening. In such cases holds the writing implement in a cramped fashion. the pain can be relieved using local anesthesia (not into the joint space!) and cortisone preparations. Symptoms The sternoclavicular joint Pain at the lateral aspect of the elbow, radiating up and down the arm, and more intense when the Simple movement restriction here without osteo­ hand grips something firmly. The pain may sud­ arthritis is rare. A painful sternoclavicular joint is a denly intensify to the point where patients often common finding in rheumatoid arthritis. drop objects: breaking crockery is a common early sign of epicondylopathy. Symptoms Clinical signs The patient feels pain locally beneath the medial end of the clavicle, radiating into the shoulder, Typically, there is a deep pain point where the supi­ neck, and thorax; the pain is provoked by move­ nator is located and where the biceps tendon has ments involving the shoulder blade (e.g. lifting the its insertion. See Figures 6.97–6.100 for details arms). It is important to point out that pain origi­ concerning diagnosis of the individual muscles nating at the medial end of the clavicle is not neces­ here. Joint play radially is also impaired. Because sarily a sign of a sternoclavicular joint lesion. The the normal movement between radius and ulna is sternocleidomastoid muscle also has attachment at restricted, there is also impairment of the lateral the clavicle, and close by is the articulation between the first rib and the manubrium sterni. True osteo­ arthritis of this joint is relatively rare. 324

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 abduction of the hand (this depends largely on the 7.4.8 Pain at the wrist joint play between radius and ulna). Consequently, there is often concurrent pain at the wrist with In wrist dysfunction, the structure most frequently restricted radial abduction, a painful styloid proc­ found to be painful is the styloid process of the ess of the radius, and/or painful tendovaginitis, radius. As already mentioned in Section 7.4.7, this especially on the radial aspect. This is particularly process is closely related to joint play at the elbow also the case after Colles’ fractures because follow­ and between the radius and ulna. Radial abduction ing a fall on to the hand – irrespective of whether of the hand is regularly found to be restricted. fracture ensues or not – the force of the impact is always transmitted via the radius to the elbow. In Another structure that is frequently painful chronic cases the periosteum at the epicondyle is is the carpometacarpal joint of the thumb where hyperalgesic and the patient reacts painfully even osteoa­ rthritic changes are found particularly fre­ to the very lightest percussion. quently. There may also be TrPs in the thenar emi­ nence. Here therapy is mainly directed at (self-) Therapy mobilization through shaking (see Figure 6.4). This consists of relaxation of tensed muscles with In patients with rheumatoid arthritis it is par­ TrPs using PIR and RI, mobilization, shaking free ticularly common to find painful changes involving any restrictions at the elbow, and self-treatment. the wrist. Soft-tissue techniques may be attempted where there is a pain point at the periosteum of the epi­ In all the painful conditions of the upper extremity condyle (see Figure 6.66). If these measures are dealt with in Section 7.4, insufficient stabilization of ineffective, needling, local anesthesia, or cortisone the shoulder blade by the lower part of the trapezius preparations may be tried. Repeated stroking has and by the serratus anterior can play such a decisive proved effective in chronic cases. Rehabilitation is role that, after scapular instability has been treated, essential in the long term, the goal being to over­ the local symptoms may clear up without any local come the patient’s cramped tension. It is always treatment. Patients should therefore be routinely vital to screen for dysfunctions in the cervical spine examined for scapular instability (see Section 6.8.9). and insufficient fixation of the shoulder blade, where these are found, to identify their chain reac­ A painful styloid process of the radius is generally tion patterns and treat them accordingly. associated with impaired radial abduction and movement restriction at the elbow. Medial epicondylar pain Symptoms 7.5 Entrapment syndromes This condition is characterized by pain at the Entrapment syndromes have become fashionable medial epicondyle. especially in circumstances where the intention is to ignore the potential role of dysfunctions. It is then Clinical signs possible to explain pain in terms of trapped nerve structures. This view fails to recognize that pain is The principal findings on examination are tension registered not in the nerve itself but in its receptors. (with TrPs) in the flexors of the forearm and impaired In principle, neurology teaches us that peripheral springing of the elbow in a medial direction. nerves process not only pain but also other modali­ ties. Therefore if nerve compression causes pain at Therapy all, then alongside pain other modalities (includ­ ing motor activity) must also be impaired. Conse­ Therapy consists primarily of PIR and RI of the quently, if only pain is present without hypesthesia flexors (see Figure 6.101) and mobilization (shaking) or weakness, we should never simply assume nerve in a medial direction; self-treatment is performed compression or an entrapment syndrome. along similar lines. Here, too, severe cases may be characterized by hyperalgesia of the periosteum at The entrapment syndromes of the upper extrem­ the medial epicondyle; treatment for this is identi­ ity not infrequently occur in combination. cal to that advocated for the lateral epicondyle. 325

Manipulative Therapy 7.5.1 Carpal tunnel syndrome cise (see Figure 6.82). It has been found to be par­ ticularly helpful for patients to wear an orthosis or This condition is attributed to compression of the elasticated support at night to fix the wrist in mild median nerve in the narrow tunnel formed by the dorsiflexion, the position in which intra-articular carpal bones and crossed by the transverse car­ pressure in the carpal tunnel is least pronounced. pal ligament. Compression first affects the blood vessels supplying the nerve, and this explains the If increased resistance is not detected when joint important role of ischemia. play is tested, local anesthesia or cortisone prepara­ tions may also be tried. In the stage characterized Symptoms by incipient weakness and atrophy and by typical electromyography changes, surgery to release the transverse carpal ligament is usually indicated. The patient complains chiefly of numbness and tin­ Pathogenesis gling in the hand and fingers, and later also of pain. In the initial stages, these symptoms are felt only The carpal tunnel is a channel that is formed by on waking up in the morning but later they are suf­ a large number of small bones that move in rela­ ficiently severe to waken the patient at night. In the tion to one another. This channel must be able to more advanced stage, pins and needles and pain are accommodate its contents comfortably in response felt even during the day, particularly on raising the to every type of hand movement. It is easy to arms. Pain may then also radiate up the arm as far understand, therefore, that a disturbance of joint as the shoulder. Relief is obtained when the arms play will result in conflict between the walls of hang down loose, while shaking the hands improves the channel and its contents, and that restoration the blood supply. Heavy physical work exacerbates of joint play constitutes a form of treatment that the symptoms. reflects the pathogenesis. Clinical signs Case study In the initial stages, we have to provoke the symp­ K O; female; born 1936. toms for the purpose of examination; the simplest method is to instruct the supine patient to raise the Medical history arms vertically and then wait to establish whether paresthesia occurs. In the more advanced stages, The patient first came to us on 24 June 2003 com- pressure or percussion on the median nerve above plaining of tingling in her right hand that kept her the wrist may elicit a sharp tingling pain (Tinel’s awake at night. To get rid of it she had to get up and sign). There is also constant hypesthesia in the ter­ shake her arm. The symptoms started on or about ritory of the hand supplied by the median nerve 10 June 2003 after she had been painting a fence. and weakness with atrophy of the abductor pollicis brevis; this muscle must always be tested. Charac­ C linical findings teristic thenar wasting is encountered only in the advanced stages of the disease. On the basis of our Examination disclosed increased resistance on test- own experience we would stress that even in the ing for joint play of the carpal bones and tingling was early stages of carpal tunnel syndrome increased promptly elicited in the arm elevation test with the resistance is found when testing joint play between patient supine. the carpal bones. T herapy Therapy The individual carpal bones were mobilized and dis- In the early stages, mobilization, carpal bone dis- traction manipulation was performed at the wrist. traction and stretching of the transverse carpal lig- The patient was prescribed an orthosis to wear at ament are indicated (see Figures 6.98–6.101) and night. self-applied traction is prescribed as a home exer­ The patient notified us by telephone on 7 July 2003 that she was symptom-free. She reappeared on 14 October 2003 with acute low-back pain and a lumbosacral mobility restriction. There had been no recurrence of tingling in her fingers, and she 326

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 complained merely of numbness in her fingertips. becoming worse when carrying heavy loads. Because Her skin there had a typical glossy appearance of the plethora of individual dysfunctions, the clini­ (slight reddening, erasure of skin creases) and this cal picture (especially the pattern of pain) is any­ responded excellently to skin stretching. thing but uniform; for example, headache may also be present due to movement restriction at the C ase summary cranioc­ ervical junction. It is worth emphasizing that, by contrast with the carpal tunnel syndrome, severe Typical carpal tunnel syndrome in the functionally weakness or atrophy rarely occur. reversible stage. This was diagnosed most elegantly using the arm elevation test with the patient supine; Clinical signs tingling was elicited after a brief latency period. The following tests are useful for provoking the 7.5.2 Thoracic outlet syndrome symptoms: • Adson’s maneuver: the pulse at the radial This syndrome is attributed to compression of the brachial plexus mainly in the gap between the artery is weakened (or disappears) on bending anterior and middle scalenes and the muscle attach­ the patient’s head back and turning it to the ments at the first rib, and in the region of the supe­ same side. rior thoracic outlet. Principally, it causes paresthesia • Hyperabduction test: the patient’s arm, bent (numbness, pins and needles, pain) in the upper at the elbow, is taken into maximal abduction extremities, this being most intense on the ulnar and the radial artery pulse is palpated. aspect of the fingers. • Pulling the arm downward, as when carrying a load, and feeling for the radial artery pulse. This syndrome is predominantly the result of More important, however, is diagnosis of the indi­ dysfunctions involving the highly complex struc­ vidual dysfunctions in the region of the superior tures that constitute the superior thoracic outlet. thoracic outlet. Only in exceptional cases are there The prerequisite for effective therapy is to identify signs of neurological deficit. Cervical myelopathy any disturbances in these individual structures and is generally present where there is major weakness their relevance in each case. In detail, these com­ with atrophy and, of course, paresthesia. prise increased tension (TrPs) of the scalenes, TrPs in the pectoralis minor (Hong & Simons 1993), Therapy increased tension of the upper fixators of the shoul­ der girdle, and TrPs in the diaphragm. Closely Therapy depends on the analysis of the individual related to these muscle disorders, there may be clinical findings forming the links in the chain. movement restriction at the craniocervical junc­ Given the unmistakable role of the scalenes, it is tion, the cervicothoracic junction, and the upper evident that clavicular breathing is the crucial fac­ ribs, in particular the first rib. The true cause of tor in the pathogenesis, coupled with involvement this increased tension (TrPs) is clavicular breathing of the deep stabilizer system. (i.e. lifting the thorax during inhalation), which is associated with insufficiency of the deep stabilizer Case study system. B I; female; born 1960. It is no wonder, in view of this complexity and the lack of understanding concerning dysfunctions, Medical history that surgical decompression procedures are per­ formed on the scalenes, the first rib, or a cervical First seen on 18 October 2000 complaining of pain rib, instead of pursuing the true cause, the treat­ in the cervical region with stiffness, headache, shoul- ment of which is highly rewarding. der pain, and tingling in the fingers. Her symptoms started in the cervical region, and she had experi- Symptoms enced tingling in her hands for the past two or three years, especially when working at the computer for The symptoms consist principally of paresthesia long periods. Apart from an operation to correct hal- involving the upper extremity (including the hands), lux valgus, her other details were unexceptional. more apparent on the ulnar aspect, and typically 327

Manipulative Therapy C linical findings and therapy tingling had reappeared in her upper extremities and fingertips and she was experiencing knee pain. Examination disclosed thoracic dextroscoliosis, Examination now revealed only skin changes at the increased tension in the scalenes on both sides, and fingertips and tingling on the soles of her feet; these movement restriction of the first rib on both sides were treated by exteroceptive stimulation. The tho- and of the cervicothoracic junction. The patient’s racic outlet syndrome itself was no longer present. breathing was normal. Her first rib and cervicotho- racic junction were treated and her scalenes were C ase summary relaxed; self-mobilization of the first rib was assigned for home exercise. Typical thoracic outlet syndrome with increased ten- sion in the scalenes (although without characteristic At the follow-up examination on 1 November clavicular breathing), and with the repeated finding of 2000 the patient felt better, less stiff, and reported TrPs in the diaphragm and pelvic floor (coccygeus). only occasional tingling in her hands. TrPs were now The ‘glossy skin’ changes at the fingertips (erasure detected in the subscapularis and pectoralis major of skin creases and slight reddening) are not unusual on the left side, and her thoracic fascia showed poor in this context. Skin stretchability at the fingertips is mobility relative to underlying structures. When the invariably limited, and skin stretching eliminates tin- fascia were treated the TrPs disappeared; self-treat- gling. The combination of increased tension in the ment of the thoracic fascia was recommended as a scalenes and TrPs in the diaphragm often produces home exercise (see Figure 6.62b). feelings of tightness, interpreted by this patient as shortness of breath. The patient was seen again on 16 May 2001. She had been symptom-free up to the start of that 7.5.3 Ulnar nerve weakness month, but now her neck was painful again and she was experiencing tingling in her hands. She also Ulnar nerve weakness will be mentioned here only complained of shortness of breath. TrPs were found in passing. The cause is generally to be found in the in the diaphragm and again there was increased ulnar nerve canal and only very rarely in Guyon’s tension in the scalenes with restricted movement of canal in the wrist region. This condition is not an the first rib on both sides. Her left fibular head was object for manipulative therapy, but it does need also restricted. Her diaphragm and scalenes were to be distinguished from the two entrapment syn­ relaxed, the first ribs and cervicothoracic junction dromes described above. In terms of carpal tunnel were treated, and her fibula was mobilized. As a syndrome it is necessary to differentiate between home exercise we prescribed relaxation of the dia- median nerve and ulnar nerve involvement. In phragm and self-treatment for the first rib. terms of differentiation from the thoracic out­ let syndrome, it is important to identify patterns On 5 June 2001 she had only transient tingling of weakness and atrophy that are characteristic of in her fingertips. Her pelvic floor was painful on the the ulnar nerve, as well as a true hypesthesia, since right side. Her pelvic floor was relaxed and her fin- these hardly ever occur in thoracic outlet syn­ gertips were treated using skin stretching. drome. The patient was again symptom-free and 7.5.4 Nocturnal meralgia appeared for a further examination on 9 May 2002. paresthetica Since April 2002 she had been complaining of short- ness of breath, with feelings of tightness in the left This condition is the commonest entrapment syn­ half of her thorax. Since the beginning of May she drome affecting the lower extremity. had also been experiencing pain in her neck and upper extremities. Once again there were TrPs in the Symptoms diaphragm and TrPs on the left side in the pectora- lis major, psoas major, quadratus lumborum, pelvic Patients complain of excruciating tingling and hypes­ floor, hip adductors, and biceps femoris, and move- thesia in the territory innervated by the lateral cuta- ment restriction at the fibular head. After PIR of the neous femoral nerve along the lateral surface of the diaphragm, all TrPs were eliminated, including the restriction at the fibula; only the first ribs with the cer- vicothoracic junction were treated. On 11 June 2002 the patient had only tingling in her fingertips, and this was treated with skin stretching; her scalenes were also relaxed. The patient was once more symptom free until 4 August 2004 when she was seen again because 328

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 thigh, involving an area about the size of the palm of that in the cervicocranial syndrome the cause is the hand. This nerve traverses the lateral end of the more frequently a lesion at the craniocervical junc­ inguinal ligament. Due to increased tension in the tion, just as the lower cervical spine is more likely iliopsoas and tensor fasciae latae, the inguinal liga­ to produce pain in the upper extremity, there are ment itself becomes tense, producing compression frequent exceptions. This is understandable if we of the nerve. consider the musculature: long muscles such as the sternocleidomastoid, scalenes, trapezius, and Therapy levator scapulae react to all dysfunctions in the cervical region by developing TrPs and referring Therapy consists of relaxation of the iliopsoas and pain to the head and arms. The intensity of the tensor fasciae latae muscles. nociceptive stimulus and the individual’s response are crucial in determining whether pain is felt only Case study locally in the neck or whether pain will be referred elsewhere. V V; male; born 1950. Headache is yet another example illustrating that Medical history the locomotor system is involved in the pain process. The patient had complained of numbness and pain on the lateral surface of the left thigh since February 7.6.1 Headache 1988. Otherwise he had never been ill. Headache with a cervical component C linical findings This is an extremely frequent type of headache. In Examination on 13 April 1988 revealed TrPs in the our view it also includes ‘tension headache’ which is psoas major and iliacus on the left side. Trunk rota- sometimes thought to be mainly psychological. tion was restricted to the right (40° to the right and 60° to the left) and extension was restricted at L5/ Increased muscle tension is due to many fac­ S1. Hypesthesia in the territory characteristic for the tors, and in the classic description by Wolff (1948) lateral cutaneous femoral nerve was detected on the increased tension of the neck muscles is part of lateral aspect of his left thigh. the clinical picture of tension headache. Increased muscle tension is the consequence of practically all T herapy disturbances of the locomotor system, regardless of whether it emanates from excessive strain due to Treatment consisted of mobilization of trunk rotation external factors, faulty head posture, muscle imbal­ to the left and mobilization of L5/S1. For exercising ance, or psychogenic tension or whether it stems at home the patient was recommended to self-treat from TrPs due to movement restrictions. There can using gravity-induced PIR of the iliopsoas and tensor be no doubt that psychological problems have a role fasciae latae. to play in headache (see Section 4.1), but this does not alter the fact that increased muscle tension is a When seen again on 5 December 1988 the muscular phenomenon that can be treated appropri­ patient complained of pain between the shoul- ately and effectively using physiological methods. der blades. Asked about the pain in his thigh, he reported that this had cleared up within a few days. Neither is ‘vasomotor’ headache incompatible with headache of cervical origin: the mere fact that 7.6 The cervicocranial the cervical spine plays a role militates in favor of syndrome its reflex origin. If we assume that disturbed func­ tion plays the role of a nociceptive stimulus, then This syndrome covers headache of cervical origin a vasomotor reaction to that stimulus is bound to as well as other clinical symptoms, such as dis­ occur. turbances of equilibrium, and even neurological symptoms, such as nystagmus. The underlying dysfunction of the cervical spine here can be the same as in simple neck pain. While it may be true 329

Manipulative Therapy As this type of headache is very frequent, it complain only of pain in the forehead or the tempo­ should not be diagnosed simply on the basis of ral region. Even pain radiating into the face can be exclusion, that is after every other possible ori­ referred pain of cervical origin, as has been shown gin has been ruled out, as the neurology textbooks by Travell (1981). Very often, however, facial pain often teach. Admittedly, serious pathology must be is also the result of TrPs in the masticatory muscles excluded; but it should be remembered that head­ (orofacial origin). ache due to locomotor system dysfunction has its own characteristic features (see also Section 4.1). Clinical signs Examination will usually reveal chain reaction pat­ terns that involve the entire locomotor system. The clinical picture is dominated by dysfunctions For example, in a series of 38 patients with non- in the cervical region, which form chain reactions migraine-type headache, we detected an average of with dysfunctions in other parts of the locomotor 6.3 TrPs, of which 34 were in the sternocleidomas­ system. However, these are no different from dys­ toid, 31 in the short extensors of the craniocervi­ functions encountered in pain states that are lim­ cal junction, 23 in the diaphragm, 17 in the erector ited only to the cervical region. Common findings spinae, 13 in the quadratus lumborum, 11 in the include muscle imbalance, TrPs with movement masticatory muscles, 11 in the biceps femoris, and restrictions (especially affecting the craniocervical 6 in the soles of the feet. TrPs in the biceps femoris junction), faulty posture, and clavicular breathing. and the soles of the feet are linked to a forward- The most important pain points are on the lateral drawn posture, which is associated with tension in surface of the spinous process of C2 (more fre­ the neck muscles on standing (see Section 4.20). quently on the right), at the posterior arch of the atlas (in the short extensors), at the posterior mar­ Symptoms gin of the occipital foramen magnum, at the trans­ verse processes of the atlas, in the upper part of the Everything that is characteristic for vertebrogenic trapezius, and in the sternocleidomastoid. pain is also true for cervicocranial headache (see Section 4.1). In particular, this applies to the posi­ The frequent pain points on the occiput in the tion of the head, for example working for long peri­ region of the nuchal line are usually secondary; ods with the head bent forward (seamstresses), further pain points are found on the scalp (the sitting at the computer, headache on waking due restricted mobility of which is an important soft- to an adverse position of the head during sleep, and tissue finding, as is that of the fascia in the cervical a forward-drawn posture on standing due to inad­ region). Although the exit points of the trigeminal equate fixation of the pelvis. nerve may suggest trigeminal neuralgia, isolated tenderness at the exit point of the first branch is The pain is generally asymmetrical, often uni­ more suggestive of headache of cervical origin. Typ­ lateral, and usually paroxysmal, that is the patient ical HAZs are found behind the mastoid processes, enjoys pain-free intervals or days with only mini­ in the vicinity of the eyebrows (Maigne 1996), and mal pain interspersed with hours or days of intense at the temples. The common TrPs in the diaphragm pain. Summing up all of this, together with the point to involvement of the deep stabilizer system, material presented in Section 4.1 concerning the and a forward-drawn posture to involvement of the role of autonomic, endocrine, and psychological feet, in particular if increased tension in the dorsal factors, we come to the surprising conclusion that neck muscles (typical in forward-drawn posture) the more features a headache has in common with ceases when the patient is seated. migraine, the more likely it is that a vertebrogenic factor is implicated in its causation. Therapy The localization of the pain is also important. The This follows the same rules as for any other cer­ diagnosis of cervicocranial syndrome is rendered vical dysfunction. It may be worth stressing that likely if the patient complains of pain radiating from special attention should be devoted to the crani­ the neck into the temples and eyes. However, this ocervical junction, the mobility of which should in itself is insufficient for a diagnosis. In adoles­ be tested in all directions. The pain points should cents and in children particularly, headache is fre­ also not be overlooked. All chain reaction patterns quently the first sign of disturbed cervical function should always be identified. If pain regularly begins long before neck pain has been felt. Children often on waking, we must enquire about the sleeping 330

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 position of the patient and correct this where nec­ muscles. Interestingly, patients are usually aware essary. Muscle TrPs are best treated by PIR and RI. of pain in the temples but not of pain in the other TrPs that remain unresponsive are treated with need­ masticatory muscles, which may be far more pain­ ling; and pain points on the scalp are treated prima­ ful on palpation. rily using the specific soft-tissue technique. The same also applies for HAZs at the forehead, temples, and Palpation of TrPs in the digastricus (behind nose. Stroking should also be considered. the angle of the mandible and at the floor of the mouth) is not straightforward. The simplest way to The mandibulocranial syndrome diagnose increased tension is to move the thyroid cartilage and/or the hyoid bone from side to side. Headaches due to a painful temporomandibular Where the increase in tension is considerable, there joint (TMJ) and to TrPs in the orofacial system also may even be visible deviation of the thyroid carti­ have their origin in the locomotor system but not in lage, in which case the contours of the floor of the the cervical spine. They are far more common than mouth are also distorted. was previously thought, and if correctly diagnosed, they can be treated effectively. Two causes should Therapy be distinguished: PIR of the relevant muscles is the treatment of 1. Poor occlusion in which there is choice, followed by self-treatment (see Section malpositioning of the teeth on biting together 6.6.2). If the joint is involved, isometric traction is a because teeth are missing or dentures do not useful addition. However, where there is malocclu­ fit properly. sion, prosthetics and/or orthodontics are essential. In most cases, disturbance of function in the oro­ 2. TrPs in the masticatory muscles due to facial system is bound up with changes elsewhere faulty muscle control (as in bruxism), faulty in the locomotor system, particularly in the cervical movement patterns on chewing, or increased spine, and the primary task is to discover in a judi­ psychological tension. Where TrPs are present cious manner the most relevant link in the chain. in the masticatory muscles, the TMJ is also generally painful. Case study Symptoms T L; male; born 1947. There is great similarity with pain emanating from Medical history the transverse process of the atlas or from the attachment point of the sternocleidomastoid; how­ First seen on 26 November 1987, the patient com- ever, the pain may also mimic neuralgic pain in the plained of dizziness on waking on the morning of 17 vicinity of the trigeminal nerve. Where there is August 1987, with a sensation of pulling to the right; increased tension in the digastricus, there is often he experienced vomiting for two days. Subsequently, dysphagia with the sensation of a lump in the brief attacks of dizziness occurred when bending the throat. Patients commonly complain of dizziness head forward and to the side; this lasted for about (Costen’s syndrome). a month. Later there was headache and pain in the neck, mainly on head rotation. From 1985 there was Clinical signs a history of headache at the occiput, radiating to the eyes and associated with nausea. No other history Mouth opening may be restricted (it is normally of illness. possible to insert three knuckles between the upper and the lower incisors). During opening and clos­ C linical findings and therapy ing of the mouth there may be deviation of the chin to one side, or the chin may retract prematurely At examination, readings on two scales showed a while the TMJ moves forward, causing a popping weight difference of 5 kg (30 kg on the right, 35 kg on sound at the joint. There may be tenderness at the the left); deviation in Hautant’s test was to the left, TMJ and TrPs should be looked for at the tempo­ disappearing on head anteflexion and rotation to ralis, masseter, and internal and external pterygoid the left. Examination showed TrPs in the masseter on both sides and in the digastricus. The digastri- cus was therefore treated on both sides. Immedi- ately after treatment, Hautant’s test was negative. 331

Manipulative Therapy Self-treatment of the digastricus was prescribed as a (see Figures 3.51 and 3.52). Restricted mobility at home exercise. the craniocervical junction is a common additional At the follow-up examination on 10 December 1988 finding. there were no symptoms at all. However, there was still a difference in the two-scale test. The clini- Therapy cal course confirmed that the symptoms were due merely to dysfunction. If there is movement restriction – especially involv­ ing the craniocervical junction – this should be Anteflexion headache treated, as it aggravates the symptoms. The main therapeutic measure is to advise the patient to In the modern-day workplace the commonest avoid head anteflexion – for instance, by using a working position is sitting, with the head bent sloping desk especially when reading and writing. forward. The resultant excessive strain produces In fact, the incidence of these headaches increased anteflexion headache. Hypermobile subjects are with the introduction of horizontal classroom tables particularly prone to this type of headache. Other to replace the old-fashioned sloping desks. These groups of common sufferers include accident vic­ children should also avoid forceful anteflexion of tims and school children. We therefore share Gut­ the head, as when turning somersaults. However, mann’s (1968) opinion that headaches in children carrying loads on the head is beneficial. are far less often due to psychogenic factors than to an adverse head posture. Migraine Symptoms I have already pointed out that many of the charac­ teristic symptoms of headache of cervical origin fit The children are pain free on waking. Not long the clinical picture of migraine, and also that vaso­ after the start of the school day, especially after motor disturbance is compatible with headache of long periods of reading or writing, they start to cervical origin. Nevertheless it would be wrong to fidget because they find it hard to keep still. The suggest that migraine as such is just another verte­ headaches as such start only later. During weekends brogenic disease, simply because involvement of and holidays the children are usually pain-free. As the spinal column or of the locomotor system var­ the condition worsens, the headaches start ever ies very widely from case to case. In practice, earlier in the day and the children find it increas­ however, in the large majority of migraine patients ingly difficult to concentrate, with the result that (including children) we find numerous dysfunc- performance at school deteriorates, and they are tions in the locomotor system, including clavicular repeatedly reprimanded or even punished. Small breathing where the thorax is lifted during inha­ wonder then that they are not keen on school; and lation. For example, Sachse et al (1982) found this is why their condition is often explained away restricted mobility of the cervical spine in 19 out as ‘school headache’ of psychogenic origin. These of 22 patients with classic migraine, and normal same patients also experience pain on jolting, espe­ respiration patterns in only three patients. Bakke cially when travelling by road or rail and when turn­ et al (1982) and Clifford et al (1982) have reported ing somersaults. greatly increased electromyographic activity of head and neck muscles during provoked attacks Clinical signs of migraine. In our own case series of 40 migraine patients studied between 1998 and 2003, we dis­ The anteflexion test is positive, that is if the covered an average of 7.7 TrPs, in 32 cases in the patient’s head is held for a short time without force diaphragm, in 31 cases in the sternocleidomas­ in maximum anteflexion, merely by taking up the toid, in 26 cases in the erector spinae, in 24 cases slack, pain sets in after 10–15 seconds. Immediate in the pelvic floor (coccygeus), in 23 cases in the pain may be indicative of a movement restriction at short extensors of the craniocervical junction, the craniocervical junction or, in exceptional cases, and in 18 cases on the soles of the feet. In a ran­ of meningism. Pain points are found particularly domized controlled study, Tuchin et al (2000) have around the posterior arch of the atlas, and signs demonstrated the beneficial effect of manipulative of hypermobility are often visualized on X-ray therapy. 332

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 It therefore appears that, as with many internal load the standing leg more. The direction of the diseases, the pain of migraine is associated with dys­ movement restriction in the cervical spine, in con­ functions and especially with TrPs in the locomotor trast, plays only a subordinate role for the very rea­ system, and that these changes are contributory son that more than one restriction is often present causal factors and potentiators of the pain. Inter­ and these are not always in the same direction. estingly, the deep stabilizers, that is the diaphragm, pelvic floor, and feet, play a major role here. In a consecutive series of 106 patients without dizziness (Lewit 1986) we detected a disturbance Differential diagnosis pattern in 55 cases. A locomotor system dysfunc- tion was consistently present, but not always I must again stress the importance of differential involving the cervical spine; sometimes the mastica­ diagnosis. Understandably, patients in the early tory muscles and even the feet were involved. After stages of serious pathomorphological disease will be treatment of the relevant dysfunction, the distur­ treated with analgesics for their pain and it is gen­ bance pattern also reverted to normal in every case. erally the failure of symptomatic treatment that These were the same type of patients in whom prompts further investigation. The same also applies Norré et al (1976) reported nystagmus and move­ to manual therapy. With the gentle manipulation ment restrictions at the craniocervical junction but techniques currently at our disposal, however, the without dizziness. risk of unwanted side effects is less than with phar­ macotherapy. The surest way to avoid diagnostic Finally, it should be noted that the maintenance error (or to correct it) is for patient follow-up to be of equilibrium (and of disturbances to equilibrium) as long as possible: headache patients do not usually depends on proprioception with sensory input from lose their headaches within a short period, and as the locomotor system, labyrinth, and eyes, all of soon as something out of the ordinary occurs in the which is integrated in the brainstem. Dizziness or clinical course, fresh diagnosis and examination are vertigo are experienced if there is a disturbance to necessary. A short and progressive clinical course is any one of these systems. always a warning sign. The maintenance of equilibrium is a function of the 7.6.2 Disturbances of locomotor system that permits upright body posture. equilibrium Forms of dizziness/vertigo The importance of the craniocervical junction for maintaining equilibrium was explained in Section Ménière’s disease 2.5.1. The most significant symptom of disturbed equilibrium is dizziness or vertigo. If patients are Ménière’s disease is characterized by attacks of routinely examined using the two-scales test and rotational vertigo, lasting for hours or even days, in Hautant’s test (see Figure 4.45), it will be found which the patient is able to indicate the direction that many patients without dizziness at all show a of rotation (clockwise or anticlockwise) and there is weight difference of 5 kg or more when standing usually nystagmus toward the affected ear. Vertigo with each foot on separate scales. Hautant’s test in is accompanied by nausea and vomiting, typically these patients is then generally positive, at least in coupled with tinnitus and disturbance of hearing. one head position – usually retroflexion and rotation Attacks need not always be that severe, in which of the head in the direction opposite to the devia­ case they are shorter, without tinnitus and audi­ tion. In contrast, anteflexion and rotation of the tory disturbance, and instead of the characteristic head in the direction of deviation cancels out any rotational vertigo the patient experiences a swaying deviation that is already present in a neutral posi­ sensation (rather like sea-sickness). tion. It is therefore legitimate to speak of a ‘cervi­ cal pattern.’ In the two-scale test the patient must Positional vertigo be instructed to place weight on both legs equally otherw­ ise there will be an automatic tendency to These patients suffer short attacks (lasting just a few seconds) of true rotational vertigo on changing 333

Manipulative Therapy the position of the head in space, that is together his head to the left. He repeated this ‘experiment’ with the rest of the trunk, and not necessarily on until he provoked a genuine Ménière’s attack. From changing the position of the head relative to the that time onward he had constantly suffered from trunk. Patients close their eyes tightly while the dizziness and a feeling of unsteadiness. He therefore attacks are in progress. If it proves possible to open came to see us on 15 January 1960. the patient’s eyes, then nystagmus will be observed. Clinical findings Cervical dizziness In Hautant’s test with his head rotated to the left This polymorphous group consists of short attacks there was deviation to the right. On turning from the of dizziness provoked by certain head positions supine to the side-lying position, dizziness with sec- and/or movements of the head in relation to the ond-degree rotational nystagmus counterclockwise trunk: the patient has the sensation of being pushed was provoked. or pulled to one side, forward or backward, and is apprehensive of falling. Nausea or vomiting and tin­ Case summary nitus are absent, but headache is usually present concurrently. Over the course of his illness this patient exhibited a wide variety of forms of dizziness, ranging from sim- Cervical syncope attacks ple feelings of unsteadiness and positional vertigo through to classic Ménière’s attacks with tinnitus and These are extremely violent attacks that are pro­ cervical syncope, which caused him to fall down. He voked by a pathogenic head position, most typically was further able to provoke a true Ménière’s attack retroflexion and rotation to one side. The patient by head rotation against the trunk, as in ‘cervical’ is briefly aware of intense dizziness, falls to the dizziness. ground and loses consciousness for a short time. These attacks are described as ‘cervical syncope’ or This abundantly illustrates the importance of ’drop attacks’ and loss of consciousness need not obtaining from the patient the most precise details necessarily occur. possible regarding the nature of the dizziness experi- enced. The first step therefore is to establish exactly Mixed and transitional forms what the patient means by the words ‘I felt dizzy’. In very general terms, patients use the word ‘dizzy’ to Not infrequently, we are called upon to treat describe their fear of falling, for example when look- patients who experience different types of dizziness ing over the edge of a precipice. Sometimes these at once or in whom the type of attack changes dur­ are circulation-related attacks of weakness, a feeling ing the course of their illness. of ‘drunkenness’ that is of cerebellar origin, or even ataxia and other situations in which the patient’s Case study legs give way. It is therefore our professional duty to closely question patients who use the word dizzy. K I; male; born 1908; surgeon. And as soon as we hear the phrase ‘My head was spinning’, the (obligatory) question then is whether M edical history spinning was clockwise or counterclockwise. Patients may also feel that they are being pulled or The patient suffered from concussion after an auto- pushed to one side, forward or backward, or expe- mobile accident in 1948. Two days later, there was rience a swaying sensation. Findings may also be slight dizziness when he bent his head to the right. negative in the interval between attacks. Three years later, he developed tinnitus and acute paroxysms of Ménière’s disease, usually lasting for Clinical signs two to three days. Three years later these attacks ceased but the patient had a feeling of instability and Only if it is possible to examine the patient dur- a fear of falling. He actually fell three times, with the ing a classic Ménière’s attack can we observe the feeling that the ground had ‘come up and hit him in typical signs of labyrinthine disorder, character­ the face’. In 1959, lying under an automobile with his ized by nystagmus to one side with deviation (of head turned to the right, he felt sharp pain and diz- the arms or trunk) to the opposite side, that is ziness which disappeared instantly when he turned toward the side of the labyrinthine lesion; this is best detected using Romberg’s test. For this, the patient stands with heels close together and eyes 334

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 closed, with the head at first in a neutral position; following ‘spray and stretch’ and anesthesia of the the trunk will deviate to the side of the labyrin­ sternocleidomastoid, and have also been reported thine lesion. When the head is rotated to the side following PIR of the masticatory muscles. of the labyrinthine lesion the trunk then deviates (sways) backward; when the head is rotated to Importance of the vertebral artery the opposite side, the trunk deviates forward. In the interval between attacks these findings may The cervical spine acts to maintain equilibrium by be negative; however, Hautant’s test (as outlined means of receptors in muscles, tendons, and joint below) may nevertheless be positive in different capsules, but also indirectly through the supply of head positions in cases where there are lesions in blood to the labyrinth and brainstem via the verte­ the locomotor system. bral artery. The role of the brainstem is to inte­ grate proprioceptive, labyrinthine, and visual input. Routine examination using Hautant’s test in Hence the tendency to explain most equilibrium patients with locomotor system dysfunction gen­ disturbances, not as the consequence of faulty affer­ erally reveals a characteristic pattern, regardless of ent stimuli due to dysfunction, but rather as the the type of disturbance of equilibrium, and indeed consequence of a mechanical circulatory disorder often even in patients not experiencing any dizzi­ of cervicogenic origin in the territory of the verte­ ness. In 72 examinations in 69 patients the position bral artery. It is therefore vitally important to know that provoked deviation of the forward-stretched when a vertebral artery lesion should be suspected arms was head retroflexion and rotation of the head as a potential cause of a disturbance of equilibrium: in the opposite direction to that of deviation. In contrast, deviation of the forward-stretched arms • In patients of advanced age, particularly if there disappeared on head anteflexion and rotation in the are other signs of arteriosclerosis. direction of deviation. Commonly there is no devia­ tion in a neutral position, this phenomenon only • If there are drop attacks (cervical syncope). occurring on head retroflexion. It then becomes more pronounced when the head is additionally • If retroflexion of the head coupled with rotation rotated in the opposite direction to that of devia­ produces dizziness, particularly in the absence tion. (In purely labyrinthine disorders, deviation of movement restriction, or if retroflexion of with the patient seated leaning against the back of the head coupled with rotation continues to a chair is not dependent on head position.) In what produce dizziness after movement restriction might be called ‘typical’ cases, deviation was also has been released. A positive de Kleyn test dependent on the direction of movement restric­ is further confirmation. This test should be tion, but only in 70% of cases. However, movement performed gently. It may also trigger positional restrictions were often present toward both sides vertigo, and this needs to be distinguished and in more than one segment. After treatment on clinical grounds: positional vertigo is for movement restriction, deviation is generally no characterized by a sudden onset with a short longer seen. latency period and also ceases abruptly. It is even more important that when provocation It is important to stress here that a cervical fac­ is repeated, positional vertigo can no longer be tor may be present in all forms of vertigo and diz­ triggered. Vertebral artery insufficiency increases ziness; this is apparent from testing (as described when the test is repeated. Due to rotation of above) and from the results of treatment. the head, arterial blood flow is suppressed on the side from which the head is turned away. Comparable treatment results were obtained In a positive de Kleyn test, the insufficient predominantly with manipulative therapy in 70 artery is the one on the side to which the head patients with cervical dizziness and in 33 patients is turned. with mixed forms (Lewit 1963). Positional ver­ tigo responds least well to manual therapy. Where • Certain X-ray findings: retrolisthesis, in auditory impairment is also present, this may also particular if oblique pictures of the cervical be improved, although far less often than diz­ spine in head retroflexion show a narrowed ziness itself. The vast majority of our cases had intervertebral foramen (see Figure 3.26). dysfunctions in the vicinity of the craniocervical A difference in the obliquity of the joint junction and masticatory muscles (TMJ). Similar space in the same segment is also particularly results were obtained by Travell & Simons (1999) important (see Figure 3.58), because it enforces rotation on retroflexion. Marked uncovertebral 335

Manipulative Therapy neoarthrosis may also have an adverse effect on Therapy the vertebral artery. Therapy essentially follows the same principles as All of these clinical criteria are merely suggestive of already outlined for other locomotor system dys­ possible vertebral artery insufficiency, the only defi­ functions, provided that the practitioner is satis­ nite proof being provided by Doppler sonography fied that these play an important role in the case in and arteriography. question. Once examination of the locomotor sys­ tem has been completed, the practitioner should The more recent literature has in many cases analyze the findings, identify any chain reaction pat­ called into question the results of the de Kleyn test terns, and then look for the key link in the chain. in light of ultrasound findings; however, Nefye­ dov & Sitel (2005) have also provided ultrasound Positional vertigo confirmation of the usefulness of this test. Clini­ cal experience speaks clearly in favor of the de It is assumed that the free mobility of otoliths plays Kleyn test; many patients become dizzy and many a role in positional vertigo and that these can there­ fall down when they retroflex the head and rotate fore be ‘mobilized’ by changing position rapidly. For in the standing position, as when hanging out the example, the patient might sit up and lie down in washing, cleaning windows, or painting a ceiling. quick succession, rotate head and trunk from one These patients should therefore be warned against side to the other while lying down, or sit up and such activities. lie down again with head rotated. The maneuver that produces vertigo will cease to do so after a few Differential diagnosis repeats. Therapy then also follows the same lines: ideally in the early morning while still in bed, the In the large majority of cases with involvement of patient practices the maneuver that provokes posi­ the vertebral artery there is also involvement of the tional vertigo until this ceases to happen. This can cervical spine. This is no mere coincidence if we also be repeated several times; the patient is then consider the close anatomical inter-relationships and less likely to suffer an attack while out and about. the fact that elderly patients often have simultane­ The results are incomparably superior to those ous degenerative changes affecting both the blood of pharmacotherapy, which produces undesirable vessels and spinal column. Compared with a normal side effects in these cases, such as drowsiness and vessel, a sclerotic artery reacts much more sensitively stupor. to mechanical irritation from the cervical spine. Vertebral artery insufficiency A high proportion of patients with disturbances of equilibrium also suffer from disturbances of The intimate pathogenetic inter-relationships the cervical spine, as is borne out by the litera­ between the cervical spine and the vertebral artery ture, which refers to the ‘posterior cervical sym­ are of major consequence for therapy. We know pathetic syndrome’ (Barré 1926) and ‘cervical from experience with angiography that a sclerotic migraine’ (Bärtschi-Rochaix 1949). Both authors artery when punctured reacts in a far more spas­ describe a combination of cervicogenic headache modic way than a normal healthy artery. The same with disturbances of equilibrium and involvement is true following mechanical irritation produced by of the vertebral artery and nerve, sometimes even the cervical spine. Hence the need for appropriate with symptoms of mild neurological deficit. Vítek therapy. This also forms the background to the con­ (1970) makes the point that headache in patients troversy as to whether manual therapy should be with arteriosclerosis is generally caused by distur­ considered in this setting or whether it might dam­ bances of the cervical spine. age the vertebral artery. If there is vertebral artery involvement, then From what has already been stated in Section mild focal neurological symptoms must be expected 5.1.2, it is clear that serious complications arise and other pathological processes must also be principally as a result of major technical errors in excluded. From our own experience, we would the application of manual therapy. On the other stress here that an improvement in the patient’s hand there can be no justification for leaving a dys­ condition following manual therapy by no means function untreated if it is known to be a source excludes the presence of an intracranial space-occu­ of mechanical irritation to the vertebral artery. pying lesion. 336

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 Most severe dysfunctions occur in the vicinity of patients with dizziness or vertigo: provided that the the craniocervical junction, and it is there that the indication and technique are correct, there are very most favorable effects of manual therapy in the few conditions for which there is a more effective vertebral artery syndrome are seen. This is because conservative therapy. in normal functioning of the craniocervical junc­ tion the loops of the vertebral artery in this region Case study allow for head rotation without increasing tension in the artery. If head rotation is impaired at the P E; female; born 1934. craniocervical junction, head rotation has to take place below C2, which means that it occurs at the Medical history level of the vertebral artery canal, that is between the transverse processes of the cervical vertebrae, The patient was first seen 21 August 1986, com- thus exposing the artery to shearing forces if rota­ plaining of vertigo which was worse when she lay tion takes place. down, giving a sensation of pull to the left and for- ward rotation. During an attack in June she had This is further borne out by our own clinical actually fallen. Such attacks had occurred repeat- experience. In a group of 70 patients with dizzi­ edly over the past 11 years; on one occasion while ness, vertigo, or both, 21 showed signs indicative exercising, for example, she had fallen on to her right of vertebral artery involvement. Whereas in those side, after head retroflexion. Since then her condition patients without vertebral artery involvement man­ had deteriorated, with nausea and buzzing in her ual therapy failed in only 10%, in the group with ears. She had suffered with headaches since 1973, vertebral artery involvement manual therapy was and low-back pain since 1984. The patient had suf- unsuccessful in 28.5% of cases, but yielded excel­ fered from tonsillitis repeatedly, and from low-back lent results in 38% and positive results in a further pain during menstruation and in the course of two 33.5%. In most instances, therapy took the form of pregnancies. mobilization at the craniocervical junction, exclu­ sively using gentle neuromuscular techniques that Clinical findings and therapy do not produce any more strain than the spontane­ ous head movements performed by the patient on a On examination there was deviation to the right in daily basis. Hautant’s test, which disappeared on head ante- flexion and rotation to the right. The readings in the These results are also significant for diagnosis. two-scales tests were 30 kg on the right and 37 kg If no improvement of the patient’s condition fol­ on the left. There was a movement restriction at C0/ lows on from treatment of the cervical spine, the C1, and a painful coccyx. After mobilization and a inescapable conclusion is that the symptoms are traction thrust, Hautant’s test was negative, while attributable exclusively to an arterial disturbance. the scales showed 33 kg and 34 kg with both legs Adequate manipulative treatment thus not only fully load-bearing. gives satisfactory results in cases where other con­ servative modalities have failed, but also permits At follow-up examination on 11 September 1986 identification of those patients in whom arterio­ vertigo was less frequent, but there was no change graphy is indicated with a view to possible surgical in its intensity. This had given her particular problems treatment. on one occasion while watching storks flying over- head. Hautant’s test showed deviation to the left, It should be remembered that skillful mobilization is but only on retroflexion of the head and rotation to the most effective form of conservative therapy for the right. Anteflexion and retroflexion of the head vertebral artery insufficiency where there is a provoked dizziness, which soon ceased in a neutral simultaneous dysfunction in the (upper) cervical position. There was again restriction at C0/C1 and at spine. C7/T1. The de Kleyn test was strongly positive. At a further follow-up examination on 29 September 1986 Finally, we would emphasize that the above con­ the vertigo remained unchanged; the de Kleyn test siderations should not deter anyone from treating was positive on mere retroflexion of the head and became worse on left rotation. We recommended angiography, which was performed on 6 January 1987 and revealed wear and tear of the left vertebral artery. The patient underwent surgery on her left ver- tebral artery at the end of January 1987. 337

Manipulative Therapy The patient was seen again on 6 April 1988, when we may also diagnose increased skin drag, which she complained of pain in her left arm, stating that enables us to recognize active scars very quickly. it had started after femoral artery catheterization for angiography. She was found to have a movement The importance of active scars in pathogenic terms restriction of the first rib and increased tension in her is also easy to understand: when our body moves, scalenes. She was no longer suffering from dizziness. this movement is not limited to our muscles, joints, and bones, that is the locomotor system proper, but C ase summary all other tissues have to contribute harmoniously to this movement, that is they have to stretch and shift This case study illustrates in particularly impressive relative to each other. If this associated movement fashion the diagnostic value of manual techniques. is disturbed (and this is a largely neglected field of research), then the function of the locomotor system To reiterate: the differential diagnosis of dizziness will also be impaired by reflex mechanisms. And this and vertigo touches on many clinical specialties, also applies to the visceral organs. and in many cases interdisciplinary diagnostic clari­ fication is needed. 7.7.1 Diagnosis 7.7 Active scars At first sight the diagnosis of an active scar appears to be extremely straightforward: in each layer we In a publication dating from 1947, Huneke look for a pathological barrier, that is we test for described how symptoms of pain in the locomotor skin stretch, subcutaneous folding and stretching of system, often at remote locations, subsided imme­ the fold, the typical resistance pattern of TrPs, the diately following local anesthesia of scars, a finding degree to which fascia and areas of resistance can be that he termed the ‘instant relief phenomenon’. He shifted, and pathological barriers in the abdominal attributed this effect to the use of novocaine. While cavity. However, the following difficulties should be at the time his observations attracted widespread highlighted, on the basis of extensive clinical experi­ attention and ushered in the era of neural ther­ ence: in the case of surgical scars, the skin incision is apy, that is administration of local anesthetics into often selected so as not to produce a cosmetic blem­ pathogenic foci (Dosch 1964, Gross 1979), general ish. However, the actual surgical procedure involving interest in its use for the treatment of scars slipped the deeper-lying structures may take place some dis­ back into oblivion. tance away from the incision, and this fact needs to be realized if pathological barriers are to be detected Despite this, the efficacy of treating scars con­ there. The diagnosis of resistance in the abdominal tinued to be investigated and over the years it was cavity demands special skill. Surgery today makes found that it was not the local anesthetic but rather widespread use of laparoscopic procedures, and for the act of needling that was responsible for the this reason nothing will be palpated in the superficial effect (Lewit 1979). However, the crucial devel­ layers. We therefore have to rely on our palpatory opment here was that the clinical characteristics, skill if we are to identify the location and direction diagnosis, and therapy of soft tissue came to be rec­ of resistance in the abdominal cavity. And it is no less ognized. Today, scars have become a model for the important to be able to recognize the release phe­ study of soft-tissue pathology. This is because a scar nomenon reliably; for if there is no release phenom­ may involve all layers, from the epidermis, subcuta­ enon, then we are dealing not with a scar but with neous tissue, muscles, and fascia, right through to a pathological process in the abdominal cavity. The the abdominal cavity, for example, and each layer requisite diagnostic steps then have to be initiated. has to be diagnosed and treated separately. Clinically, it is important that palpation for resist­ ance should not be limited to areas above the pubic All these layers share a common feature: if they symphysis. Resistance is commonly found below the do not behave normally, then their ability to stretch symphysis in toward the pelvis, especially after gyne­ and move relative to each other is impaired. As with cological operations, and complicated deliveries are a all other mobile structures, it is also necessary here frequent cause. As abdominal scars are stretched by to differentiate between a normal (physiological) backward bending they restrict extension of the lum­ barrier and a pathological one. Where a pathological bar spine, and the patient interprets this as low-back barrier is diagnosed, we speak of ‘active scars’. And it is only when the surface of the skin is stroked that 338

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 pain. In the absence of segmental restriction in the C linical findings and therapy lumbar spine, backward bending is then restored by treatment of scars in the abdominal region. Examination of the patient revealed a chain of TrPs extending down to her left foot. The patient’s history However, diagnosis alone is not enough; it is evoked a suspicion of an active scar in her lower also important to determine relevance. An active abdomen, and in fact resistance was palpated in her scar need not necessarily be a factor in the symp­ left hypogastric region. Once the release phenome- toms for which the patient is being treated. In non was obtained, the patient’s symptoms (including order to determine relevance, a complete exami­ TrPs) cleared up. nation should be followed initially by treatment of the scar so that we can determine whether or not At follow-up examination one month later the the dysfunctions and their chain reaction pattern patient’s condition had largely improved, treatment can be influenced by our intervention there. This in the lower abdomen was repeated and at the is important because if the effect is positive, then same time her cervicothoracic junction was treated we continue to target the scar with our treatment. by traction manipulation. After this the patient was Conversely, if a relevant active scar is not treated, symptom-free. then all other therapy will remain unsuccessful. Case summary 7.7.2 Therapy This case is instructive for the following reasons: the In every case therapy consists of taking release patient’s symptoms started shortly after she had through to the very end. In the case of areas of given birth; palpation of her hypogastric region con- resistance in the abdominal cavity it is often neces­ firmed painful resistance; and a release phenomenon sary to change direction, depending on where fur­ was obtained, simultaneously with the ‘instant relief ther resistances can be palpated. The patient will phenomenon’ described by Huneke (1947). often indicate where the referred pain is felt in the locomotor system (usually in the back). It is impor­ 7.8 Structural diseases tant to understand that a single treatment will associated with not usually suffice and that it is generally helpful locomotor system also to stroke the skin surface and to prepare the dysfunction deeper layers for treatment by using hot packs. The number and frequency of treatments will be deter­ 7.8.1 Basilar impression and mined by the clinical course. spinal canal narrowing The pathogenic effect of resistance in the These two anomalies have in common the ability abdominal cavity depends not on the organ or even to cause compression syndromes, the former of the on its position, or whether this or that structure in medulla oblongata, the latter of the cervical part of the abdominal cavity is palpated, as practitioners of the spinal cord. They are both congenital conditions visceral osteopathy insist. It is determined solely that also share a tendency for symptoms to become by the pathological barriers in the abdominal cavity apparent only in (very) advanced old age. From this that interfere with the harmonious cooperation of it follows that we are dealing here with decompen­ the viscera as the body moves. sation due to degenerative and functional change. Provided that surgical intervention is not indicated Case study immediately, it is therefore possible to embark on treatment aimed at the restoration of function. B W; female; born 1967. In basilar impression there are frequently no signs Medical history of neurological compression, and patients complain only of symptoms similar to those reported in the First seen on 3 October 2000 complaining of pain in cervicocranial syndrome. In such cases the treat­ her arms and shoulders. She had given birth three ment procedure is the same as for patients who do years previously; the baby weighed 4 kg and the not present the anomaly. However, even patients patient lost a great deal of blood, had a high fever, and received antibiotics. Her shoulder pain started soon after the baby was born. 339

Manipulative Therapy with some signs of compression in the posterior cra­ After conclusion of treatment the patient’s con- nial fossa may improve after manipulation. The same dition worsened in March 1958, prompting her is true for cervical myelopathy and for narrowing of renewed admission in April 1958. At a subsequent the cervical spinal canal, not only with regard to pain follow-up examination in March 1959 the patient symptoms but also for milder forms of weakness. complained of vertigo attacks. Her bilateral sway on standing was immediately improved following The case studies below illustrate the importance traction combined with head rotation. At her last of treating dysfunctions of the locomotor system follow-up visit on 13 May 1961 the patient had no caused by neurological diseases of organic origin. further gait disturbance and had only occasional attacks of dizziness. She had first-degree nystag- Case study mus, and her neck was freely mobile. Gait spastic- ity was minimal. Hautant’s test indicated slight lateral K M; female; born 1895. deviation to the right side, which was abolished immediately after traction. Medical history Case study First seen on 27 January 1957. The patient and her family had a history of pulmonary tuberculosis. Since H A; male; born 1893. 1948 she had suffered from headache, and from cervical and low-back pain. Her hearing and sight M edical history had been deteriorating since 1954. She complained of a feeling of vertigo (being pulled backward and The patient felt pins and needles in the first, third, sometimes to both sides). She also had pain radiat- and little finger of his right hand in February 1950. ing down her arms and numbness in her fingers. His hand gradually became weaker and so clumsy that he could no longer shave. C linical findings C linical findings Examination revealed second-degree vertical nys- tagmus downward and when looking to the side, Findings included atrophy of the interossei and diagonally. The corneal reflex was weak on the left, adductor pollicis muscles on the right, restricted there was slight paresis of the VIIth cranial nerve extension of the fingers, and exaggerated reflexes at on the left; when her tongue was extruded it devi- C5–C7. The palmomental reflex was positive. There ated to the left. The patient had a very short neck was no disturbance of tactile perception. X-ray of the with limited inclination and rotation to either side. In cervical spine showed only minor signs of cervical the upper extremities, the deep tendon reflexes were spondylosis. Initially, the putative diagnosis was pro- increased and more marked on the left; Hoffmann’s gressive spinal muscular atrophy (Aran-Duchenne). sign was positive on both sides. There were exag- gerated tendon reflexes in the legs and pyramidal The patient was examined again between 1951 tract signs were present. The patient lacked stability and 1954. Minor symptoms involving the left hand when standing and had a spastic gait. were also detected. There was little change in neuro­ logical findings. Myelography with air insufflation X-rays of her skull and cervical spine showed showed disk protrusion at C3/C4 and C5/C6. There marked basilar impression. C6 was shifted forward rel- was slight hyperalbuminosis. ative to C7, and there were spondylotic osteophytes at C6. Myelography with air insufflation revealed a protru- Because of the myelography findings the patient sion dorsally below the foramen magnum extending as was invited for further follow-up in October 1955. far as the level of the arch of the axis, while the anterior On closer examination, the areas of muscle atrophy subarachnoid space was of normal width. The cere- were found to correspond to segment C8 where brospinal fluid was normal. This was a case of basilar there was also discrete hypesthesia. impression with the Chiari-Arnold malformation. Therapy Therapy A simple traction test improved sensation in the Manual traction of the cervical spine was started patient’s right hand and he was able to oppose experimentally at the beginning of March 1957. his fingertips again. Manual therapy was therefore By the end of March the patient was able to walk started, and this was followed by significant improve- without difficulty and nystagmus was noticeably ment to the extent that the patient was able to shave improved. The patient was treated by manual trac- himself again after years of being unable to do so. tion on an outpatient basis until the summer of 1957. 340

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 These case studies show that both in basilar impres­ 7.8.2 Radicular syndromes sion as well as in cervical myelopathy it is possible to achieve clinical improvement by using therapy The radicular syndromes are also generally caused that is targeted at function. Similar findings have by a pathomorphological lesion (most commonly also been made in syringomyelia. a herniated disk), primarily affecting the lower extremities where dysfunctions play a major role. Case study In the upper extremities the process is more complex, leading to narrowing or compression S M; female; born 1905. of the intervertebral canal, with disk herniation being a rather rarer cause. Other morphological M edical history changes include narrowing of the spinal canal in both the cervical and lumbar regions. Although The patient had complained of pains in the neck, less common, space-occupying lesions should shoulders, and arms since 1949, and later of a also be considered as possible causes of radicular burning sensation in her left cheek and watering of compression. her left eye. Gradually her left hand also became weaker and clumsy; by 1953 her right hand was also With the exception of space-occupying lesions, affected, and her gait had been deteriorating since the pathomorphological changes listed here do not 1952. constitute absolute indications for surgery. Even without surgery the great majority of radicular syn­ C linical findings dromes heal as a result of functional compensation and resorption of the intervertebral disk. This is At the initial examination in early 1953 the patient also why conservative treatment is so often success­ had Horner’s syndrome on the left and first-degree ful, that is traction, manipulation, various types of nystagmus; the left corneal reflex was weak; mus- reflex therapy, remedial exercise, and stabilization cular atrophy (in both arms) was worse on the left methods. Indeed, surgery in isolation fails more and there were trophic changes in the skin. The C5 often than not if it is not followed by appropriate reflexes were abolished on both sides, the C6 and rehabilitation, that is if we do not help to restore C7 reflexes were weak, while the C8 reflex was nor- normal function. This is why the problem of disk mal on the left and exaggerated on the right. There herniation is dealt with in this book. The interplay were also pyramidal tract signs on the right. The of changes in structure and function constitutes a abdominal reflexes were abolished, while the deep complex problem in terms of diagnosis and patho­ tendon reflexes in both legs were exaggerated. genesis. Therapy The clinical differences between radicular syndromes in the upper and lower extremities are The patient was X-rayed in October 1953 during her considerable and so the two will be dealt with sepa­ first stay in hospital. At that time traction of the cer- rately. The reader is also referred back to Section vical spine was tried experimentally. Prior to traction 2.12. the patient was able to abduct her shoulders only to 150° on both sides; after traction this increased to Radicular syndromes in the 170° on the left and 160° on the right. Traction ther- lower extremities apy was therefore prescribed and shoulder mobility was restored to normal within three weeks. History taking During a further hospital stay in 1954 the patient Although radicular syndromes share many com­ complained once more of shoulder pain that again mon features with other vertebrogenic disorders, cleared up after traction. Nevertheless, the neuro- they possess certain special characteristics. The logical examination showed progressive deteriora- first is that, in most cases, pain radiating into the tion of her underlying condition. By this time there lower extremity is preceded by low-back pain. This was a complete absence of reflexes in her left arm, is why disk herniation is thought to be the main while on the right side only the C8 reflex was pre- cause not only of radicular pain, but also of low- served. Despite this deterioration in objective find- back pain. However, because low-back pain occurs ings, the patient felt better and more able to move her arms at the shoulders. This was attributable to pain relief following the improvement in vertebrogenic dysfunction. 341

Manipulative Therapy much more frequently than radicular syndromes, legs will also be restricted. In patients with an exag­ this merely indicates that only low-back pain that geratedly erect posture, trunk anteflexion will often is caused by disk herniation is likely to be a precur­ be impaired, even when the patient is seated with sor of radicular syndromes. This is why the char­ knees bent. In less acute cases, posture when stand­ acteristic symptoms of discogenic low-back pain ing at ease may be more or less normal but ante­ were described in Section 7.1.5. There are, how­ flexion with straight legs will be reduced as long ever, radicular syndromes in which the pain starts as straight-leg raising is impaired. Anteflexion in in the legs and is never preceded by low-back pain. the seated position should then also be tested. Not In such cases, low-back pain usually appears only infrequently, shortly after anteflexion has started, later, if at all. Pain felt in the buttocks occurs com­ a painful barrier is encountered (the ‘painful arc’ monly, hence the old term ‘sciatica.’ Radicular pain described by Cyriax (1977, 1978)); once this has may have a sudden onset after a lifting injury or been overcome, anteflexion then proceeds normally. when getting out of bed in the morning. It may also This pattern suggests a herniated disk. begin so insidiously that the patient cannot remem­ ber precisely when it started. For best advice to be It is important to point out that antalgic posture given in individual cases, it is important to elicit and movement limitation in radicular syndromes from the patient details of those circumstances that are not due to motion segment restriction, and that aggravate symptoms and that bring relief. indeed such restriction may be absent. In the L5 and S1 radicular syndromes, the straight-leg raising Radicular pain differs from simple referred pain test is generally clearly positive. However, when the in that pain and numbness radiate down as far as pain occurs, it should also be established whether or the toes; the pain is accompanied by paresthesia not it is possible to flex the straight leg still further with pins and needles or numbness; and patients at the hip. More rarely there may be a ‘painful arc,’ have the feeling that they cannot reliably con­ as described by Cyriax, in which the patient experi­ trol the affected leg. Sometimes patients are also ences pain when the leg is raised a little, followed aware of weakness. Pain is typically felt on cough­ by no pain when the straight leg is flexed further ing, sneezing, defecation, and, sometimes, laughing. at the hip. The femoral nerve stretch test is a reli­ Except in acute cases, walking tends to alleviate the able indicator of a lesion in segment L4. When the pain. However, if patients complain of pain when straight non-lesioned leg is raised and the patient walking, it is essential to ask whether they have to experiences pain on the lesioned side, this is indica­ stop after a certain distance and what position they tive of disk herniation. The femoral nerve stretch then adopt. This is the only way to identify inter­ test should never be omitted, thus ensuring that we mittent claudication. do not overlook the L4 radicular syndrome in which the straight-leg raising test can be negative. Clinical signs Of major significance are the neurological signs The patient is often able to describe the pattern of root involvement, such as motor weakness and of pain and paresthesia on the affected extremity. hypesthesia, without which the diagnosis of true The typical antalgic posture is frequently encoun­ radicular syndrome is inconclusive because of the tered when the patient is examined in the standing often highly deceptive nature of referred pain. position (see Figure 7.1). Here, too, however, there For this reason, even minimal weakness of a mus­ are exceptions: for example, patients who adopt an cle, hypotonus, or hypesthesia consistent with the extremely erect posture and are entirely unable to segment in question may be highly significant and bend forward. The more common antalgic posture, should be carefully looked for. that of anteflexion with the pelvis deviating toward the painful side, is easily explained because it is The following sections will now discuss the the position that keeps the intervertebral foramen symptoms of the individual radicular syndromes of as wide as possible. The lordotic posture has been the lower extremities. Radicular syndromes L4, L5, explained in terms of the position of the herniated and S1 are the only conditions here of any clinical disk relative to the dural sac and the nerve root relevance. (de Sèze & Welfling 1957). L4 radicular syndrome If the straight-leg raising test is positive, then Pain radiates over the ventral aspect of the thigh to anteflexion in the standing position with straight the knee and can radiate further on the anteromedial aspect of the leg down to the medial malleolus. In 342

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 this syndrome, the straight-leg raising test is often ing of the gluteal fold in the standing position (hypo­ only mildly positive, whereas the femoral nerve tonus). According to Véle (personal communication), stretch test is always strongly positive. There is an early sign is the weakened reaction of the toe weakness of the quadriceps femoris and of the hip flexors when the patient leans forward (but without flexors (rectus femoris) when the patient is seated standing on tiptoe). Characteristically there is no toe and the patellar reflex is weakened or absent. Where flexion on the side of the radicular syndrome. The major weakness is present, walking down stairs is weakness is also clearly evident when the patient troublesome, as is straightening up from the knees- tries to walk on tiptoe. The Achilles tendon reflex is bent position while loading the lesioned leg. The weakened or abolished. This syndrome is also often patient’s gait may be unsteady. Hypesthesia may be characterized by a definite disturbance of proprio­ present on the anterior aspect of the thigh. ception. A comparison of both sides reveals that the patient notices passive movement of the lateral toes L5 radicular syndrome later on the lesioned side than on the healthy side. Pain and paresthesia radiate laterally over the but­ In this syndrome, too, we find increased resistance tocks and down the thigh and lower leg as far as to stretching of the interdigital fold of skin between the lateral malleolus and then over the instep to the third and fourth, and fourth and fifth toes, and the big toe where hypesthesia is also found. None increased resistance on dorsoplantar movement of of the routinely tested tendon reflexes is altered. the third metatarsal bone against the fourth, and the The muscles most commonly affected by weak­ fourth against the fifth. ness are the extensor hallucis longus and the exten­ sor digitorum brevis. Aside from weakness of these Problems of diagnosis muscles, their reduced tonus can be very easily pal­ pated close to the tibial margin and above the lat­ In clinical terms, a radicular syndrome can be reli­ eral malleolus. In severe cases the tibialis anterior ably distinguished from referred pain; however, is also weakened and hence also dorsiflexion at the establishing when a radicular syndrome is caused talocrural joint and dorsiflexion of the toes. This is by disk herniation is far more difficult. A herniated clearly apparent during heel-walking owing to the disk may be clinically ‘silent’ and radicular com­ dorsiflexion weakness of the foot (‘signe du talon’). pression may be caused by a narrow spinal canal, a Severe weakness may be seen in the very acute narrow lateral recess, or a space-occupying lesion. stage, so that the patient’s foot hangs flaccidly, pro­ Localization can also be more problematic than ducing a steppage gait. This should not be confused would appear at first sight. Anomalies are encoun­ with the far rarer condition of peroneal nerve weak­ tered along the course of nerve roots, and computed ness. Internal rotation of the hip is also weakened tomography (or magnetic resonance imaging) often (Horácek 2000). discloses more than one herniated disk. Only one of these will probably be relevant clinically. Patients A valuable neurological sign is increased resist­ who have been immobilized for long periods often ance when stretching the skin of the interdig­ develop thrombophlebitis, the pain of which must ital fold between the first (big) and second toes, not be confused with radicular pain and must be and between the second and third toes, as well as treated specifically. increased resistance on dorsoplantar movement of the first metatarsal bone against the second, and If surgery is indicated, the diagnosis must first the second against the third, especially in patients be confirmed by imaging techniques. However, in whom pain radiates as far as the toes. The pain­ even these are not infallible. Although imaging may ful key muscle (TrP) is the piriformis, and hence reveal more than one herniated disk, it can provide the patient will report pain in the hip. little information regarding their clinical relevance. S1 radicular syndrome Neurogenic intermittent claudication Pain and paresthesia radiate dorsally over the but­ (radicular claudication) tock and thigh as far as the lateral malleolus and then laterally along the foot to the little toe. Hypesthesia Some remarks on the problem of neurogenic inter­ is consistent with this pattern. The weakened mus­ mittent claudication (radicular claudication) will cles are the fibularis, the triceps surae (especially the be apposite at this point. In this syndrome, which lateral part), and the gluteal muscles, causing lower­ is intimately linked with a narrow spinal canal, the patient at rest often has no clinical signs. The 343

Manipulative Therapy symptoms, usually pain shooting down into the leg, C4/C5, which was also treated. Afterward there was only become apparent when the patient starts to no deviation in Hautant’s test. X-ray of the lumbar walk; after a certain distance, the pain is sufficient spine showed typical signs of a narrow spinal canal to compel the patient to stop walking, crouch, and and a pseudospondylolisthesis of L4 relative to L5. – if possible – sit down. After a few moments the patient is able to walk on, but after about the same At follow-up examination on 18 October 1989 the distance has been covered the episode is repeated. patient’s condition had improved, but she had expe- As a rule, very little is found at examination. The rienced a severe attack of pain during September patient usually also experiences pain after long peri­ and still needed to rest after walking 200 meters. ods of standing. On examination there was restricted anteflexion in the L5/S1 segment with lumbosacral hyperlordosis Neurogenic intermittent claudication always has and shortening of the lumbar erector spinae. On this a serious prognosis and therapy is difficult. Often occasion, L3–S1 was stretched into flexion and the the diagnosis is not even made at all because findings patient was told to use the ‘cradle’ exercise at home at examination are minimal. A detailed case history (see Figure 6.144) and to practice self-mobilization is therefore crucial. If these patients are asked when into retroflexion while standing. In November and they feel pain, the response is invariably ‘On walk­ December the patient was much improved; there had ing’. Except in the acute stage, however, that is nor­ been just one painful attack, and pain during walking mally not the case. Therefore, as soon as a patient was clearly less intense, enabling her to engage in who is symptom-free at rest reports pain on walk­ systematic walking training. ing, we must ask whether this makes the patient stop and adopt a particular position. Many patients At a further follow-up visit on 24 January 1990, suffering from neurogenic intermittent claudica­ the patient volunteered that she no longer had to tion escape diagnosis and this creates the mistaken interrupt her walks and sit down; it was enough if impression that it is a rare condition. Some patients she bent forward slightly. Examination again revealed also present only with low-back pain. a forward-drawn posture, with increased tension in the straight abdominal muscles, tenderness on both Case study sides at the pubic symphysis, and hypertonus in the gluteals. After sustained pressure in the vicinity of the H M; female; born 1926. ischial tuberosity, tonus in the gluteal and abdominal muscles was normalized and the forward-drawn Medical history posture was corrected. The patient’s further home exercise was then to strengthen her abdominal The patient complained of low-back pain and pain muscles. in her left leg. Pain did not increase on coughing or sneezing. Low-back pain began in 1965, mainly Case summary when walking; since 1986 the patient has needed to sit down after walking about 200 meters; after two This case illustrates that compensation for radicular minutes’ rest she can continue walking. Since March intermittent claudication due to a narrow spinal canal 1989 she has had severe pain in her left leg, espe- can be achieved by treating dysfunctions, namely cially when standing. by utilizing exercises that train flexion of the lumbar spine, such as the ‘cradle’ or the McKenzie tech- Clinical findings and therapy nique of flexion self-mobilization (Haig AJ, et al 2006, Witmann JM 2006). It also demonstrates the chain At examination on 28 August 1989 she had a reaction pattern linking the gluteal muscles with the marked forward-drawn posture, and retroflexion was abdominal muscles and the craniocervical junction. restricted. There was deviation to the left in Hau- (If this case had been seen today, the feet would also tant’s test, cervical spine examination showed move- be included in that chain.) ment restriction of C0/C1 in all directions, and there was marked hypertonus of the abdominal and glu- General therapy teal muscles. After sustained pressure was applied to the gluteals, tension was normalized, not only in Acute stage the gluteals but also in the rectus abdominis, and the Radicular syndromes also pose major problems patient’s forward-drawn posture disappeared. Also in terms of therapy. In the acute stage, rest in the the movement restriction at C0/C1 was now hardly antalgic position is indicated. The increased muscle noticeable. Slight movement restriction remained at tension in the antalgic position encourages rest, and pillows can be improvised to support this position. 344

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 Analgesics, administered intravenously if need be, (see Figure 6.73). Where there is insufficiency of are also indicated. If traction in the antalgic posi­ the deep stabilization system in the lumbar spine tion brings relief, then traction (see Section 6.1.3) and feet, priority should be given to activating this and counterstrain (see Section 6.2.2) may be tried system. Active scars must also not be overlooked, as first aid if there is a direction of ease. If some and their treatment should even be undertaken so improvement sets in after these measures, then the that we can satisfy ourselves as to their relevance. attempt can be made to mobilize into flexion, and even to deliver an HVLA thrust. Resistant TrPs should be needled if they are not abolished when chain reaction patterns are For further therapy, emphasis nowadays is placed treated or following PIR and RI. Faulty movement on the detailed analysis of findings and on tailoring patterns should be treated by remedial exercise the therapeutic approach to the chain reaction pat­ incorporating sensorimotor training. Quite specifi­ terns of dysfunctions found. Often there are uni­ cally, patients who report pain on anteflexion and lateral chain reaction patterns extending from the lifting should be instructed how to lift correctly cervical region down to the feet: these are char­ (see Section 6.8.6) and how to stabilize their stance acterized by ‘fascial binding’ and by insufficiency at the wash basin. of the deep stabilizer system in the lumbar spine and feet. It is important to remember that during the chronic stage other lesions in the lower extrem­ If relief cannot be obtained by traction, coun­ ity may complicate recovery: these may be due terstrain, or mobilization, then root infiltration or to cramp or to movement restrictions particularly epidural anesthesia is the most effective method. involving the fibula and the feet. Important findings Another option is needling of the most painful such as outflare and inflare must not be overlooked. TrPs or of an extremely hyperalgesic interdigital Complications arising from the hips, whether in fold (the insertion point for the needle should then the form of coxalgia or incipient osteoarthritis of be between the metatarsal bones). Active scars, the hip, are also by no means rare. The same is true where present, must be addressed wherever possi­ with regard to a painful coccyx. Possible complica­ ble at the start of therapy. When needling or local tions arising from thrombophlebitis must not be anesthesia are performed, needle insertion must forgotten in patients who have been immobilized always reproduce intensive pain. However, where for long periods. manual soft-tissue techniques or PIR and RI are effective, preference should be given to these non- The indications for surgery invasive methods. Although the conservative therapy described here Where necessary, the above measures can be is generally effective, there remain cases of radicu­ supported with analgesics. Rest in the antalgic posi­ lar syndrome in which all efforts fail and surgery is tion should be permitted only for as short a time indicated. Indeed, it is no exaggeration to claim that as is necessary. In cases of acute pain where even it is the very effectiveness of our conservative ther­ standing upright is distressingly uncomfortable, it is apy that enables cases requiring surgery to be identi­ a mistake to refer patients to a practice some dis­ fied earlier. The problem is to decide at what point tance away for an injection or physical therapy. we consider our conservative therapy to have failed. Naturally, opinions on this vary, partly because the Chronic stage course of the disease varies greatly from one case During the subchronic and chronic stage, the chief to the next. For example, if there is absolutely no objective of treatment is to restore normal func­ improvement in intense pain in an acute disease tion. In this endeavor, treatment should be guided course, surgery should not be deferred for long so by familiar principles governing the restoration of as to spare the patient unnecessary suffering. How­ joint function using manipulative techniques. Treat­ ever, in most cases some improvement is achieved, ment on the painful side is always given into flexion although this may turn out to be merely temporary. so as to ease the strain on the nerve root. And even Where the disease course fluctuates, our decision is before starting to mobilize the joints, we should much more difficult. It is necessary also to decide also always treat the fascia if these are not freely whether we are dealing ‘merely’ with a herniated mobile against the underlying structures. disk or with a narrow spinal canal, since the latter is always associated with a worse prognosis. The exercises advocated by McKenzie are help­ ful in the long term for intervertebral disk lesions 345