__Manipulative_Therapy__Musculoskeletal_Medicine

Manipulative Therapy Another conundrum is whether muscle weakness Radicular syndromes in the is a factor in determining the indication for surgery. upper extremities The answer to this common question is as follows: evidence of a peripheral nerve lesion is one of the Radicular syndromes C6, C7, and C8 are the main characteristic signs of a radicular syndrome. Expe­ conditions here of any clinical relevance. rience has shown that even patients with marked radicular weakness usually recover well after pain Symptoms has improved. However, there is one exception, namely where there is sudden onset of weakness. In Patients complain of pain radiating down the arm to typical cases the patient describes excruciating pain the fingers, coming either from the neck, or usually that disappears suddenly (overnight) so that sleep from the shoulder blade. Pain is frequently worst is possible. On waking the patient can no longer when the patient is in bed, and is exacerbated on lift the foot or toes. Examination confirms exten­ head retroflexion, and less often on head anteflex­ sor paralysis. If in such cases no improvement takes ion. A high pillow is therefore helpful in most cases place within 24 hours, emergency surgery is indi­ and many patients sleep sitting up. Pain is typi­ cated to avoid permanent nerve root paralysis. cally accompanied by paresthesia and a feeling of weakness. Another indication for emergency surgery is the cauda equina syndrome, a disturbance of sphincter Clinical signs function leading to bladder and bowel disorders. There is a danger that the manual therapy practi­ The characteristic pain points are at Erb’s point tioner may not recognize this condition. This is (located above the clavicle, at the side of the neck either because patients are unwilling to mention it in the mass of the scalenes) and a point medial to (especially if the sphincter lesion is incomplete); or the superior medial angle of the shoulder blade. because they may not be aware of its importance The latter is a TrP in the interscapular part of the and may even be over-preoccupied with the pain. It trapezius which tenses like a cord on maximal hori­ is therefore essential to know when to ask patients zontal adduction of the arm. Pain is usually trig­ about their control of micturition and bowel action. gered by head retroflexion and rotation to the side This question is particularly relevant if the Achilles of the lesion, that is by a movement that causes nar­ tendon reflex is absent on both sides in a patient rowing of the intervertebral foramina, even if there with acute bilateral radicular pain, or more rarely is no movement restriction at all. There are also with simple low-back pain. patients in whom pain is aggravated on anteflexion (Frykholm 1969). The nerve root stretches tight Surgery is indicated far more rarely for patho­ (and causes pain) if it follows a descending course logical hypermobility or instability. It is indicated in from the cervical cord (Adams & Logue 1971a,b,c). spondylolisthesis that is not (yet) fixed, particularly Otherwise anteflexion tends rather to afford relief, in adolescents. Radiological imaging has a key role as it widens the intervertebral foramina. to play here. It is worth emphasizing that nowa­ days, by activating the deep stabilization system, we C5 radicular syndrome are in a far better position to restore stability using This is a rare condition that is characterized merely conservative methods. by shoulder pain. The biceps tendon reflex is weak and there is weakness of the deltoid and possibly of Finally, surgery cannot ever do more than remove the biceps brachii. a local mechanical lesion that constitutes an obsta­ cle to therapy and rehabilitation. It does not and C6 radicular syndrome cannot eliminate the locomotor system dysfunc­ Pain radiates over the radial (lateral) aspect of the tion or restore normal function. Surgery should be upper arm and forearm to the thumb and forefin­ viewed as just one element in the treatment of a ger, and here hypesthesia may be found. There is disturbance that affects the whole locomotor sys­ weakness of pronation and of the radial prona­ tem but requires a complex approach that is deter­ tion reflex. This can be elicited with the patient’s mined by the needs of the individual case. Gentle arm flexed so that the forearm is supported, for mobilization can be started a few weeks after sur­ gery (at sites further away from the operated seg­ ment it can be applied even earlier) before moving on to active rehabilitation. 346

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 example, on the patient’s knees; the practitioner C8 radicular syndrome then taps on the styloid process from the palmar Pain radiates over the ulnar (medial) aspect of the aspect to obtain a pronatory jerk. (This is in con­ upper arm and forearm to the fourth and fifth fin­ trast to the styloradial reflex which produces flex­ gers. Hypesthesia may be found in this area. There ion at the elbow, corresponding more to segment is weakness of the long digital flexors and grip C5.) Some patients with this syndrome also have strength is reduced. This is consistent with a weak­ winging of the scapula. This is best tested by the ened digital flexor reflex. Typically, there is weak­ patient stretching both arms forward and maintain­ ness of the abductor muscle of the little finger. ing this position for a while. Sometimes there is also atrophy of the small mus­ cles of the hand, including the adductor pollicis. Case study The C8 radicular syndrome is rare and needs to be differentiated from the thoracic outlet syndrome, T L; male; born 1941; professional wrestler. ulnar nerve weakness, and cervical myelopathy. Medical history General therapy Treated by us since 1971 for recurrent neck pain By contrast with radicular syndromes of the (connected to his sporting activity) that responded lower extremities, their counterparts in the upper well to manual therapy. The patient had a recurrence extremities pose a less difficult problem because of neck pain in the spring of 1973, but he did not disk herniation is a less prominent feature here. As attend for treatment and the pain persisted. Toward a result, conventional conservative therapy is gener­ the end of 1973 surgery was considered. After a ally effective and failures are less common. Never­ temporary improvement, the patient’s condition theless, a radicular syndrome should be classified again deteriorated. It was not until 5 February 1974 as a more serious condition than a cervicobrachial that he was referred to us again for treatment with reflex syndrome because it involves not merely dys­ the diagnosis ‘cervicobrachial syndrome.’ function but radicular compression in the interver­ tebral canal, although dysfunctions may also play C linical findings and therapy some role in the pathogenesis. Examination revealed pronounced winging of the In the acute stage, treatment begins with admin­ shoulder blade, and the pronation reflex on the left istration of analgesics and post-isometric traction side was abolished. There was movement restriction in the antalgic position, and with soft-tissue tech­ at C2/C3 to the left and at C5/C6 to the right; these niques for the neck and extremities, especially if were released without difficulty. An intensive program a painful interdigital fold is present and there is of remedial exercise was prescribed because of the increased resistance on dorsopalmar movement of muscle findings. Marked improvement, including the the metacarpals against each other. Mobilization winged shoulder blade, was obtained over a four- is then performed, depending on the existing chain month period. reaction pattern, often starting at the craniocervical junction and the cervical spine provided that there Case summary are no major dysfunctions in the deep stabilization system, including faulty respiration. If increased A serious C6 radicular syndrome was misdiagnosed tension disappears after these measures, then they because the patient’s winged scapula was over- may be followed by extremely gentle traction looked (probably because the patient was not exam- manipulation of the lower cervical spine with the ined from behind). patient seated (see Figure 6.52b). If typical TrPs then still persist, for example in the scalenes (Erb’s C7 radicular syndrome point), the upper and lower parts of the trapezius, In this by far the most common of the radicular or the diaphragm, then PIR and RI are brought into syndromes involving the upper extremities, pain play. Needling in particular is indicated for TrPs that radiates over the middle of the dorsal aspect of do not respond to those treatments. the arm toward the second to fourth fingers, being maximally pronounced in the middle finger; hypes­ Surgery is indicated in those relatively rare cases thesia may also be found in this area. There is typi­ where conservative therapy fails. Preoperative diag­ cal weakness of the triceps brachii, and the triceps nosis is performed using medical imaging techniques. tendon reflex is weak. 347

Manipulative Therapy 7.9 Vertebrovisceral As already stated in Section 1.1, any practitioner inter-relationships who finds no pathological changes to corroborate a diagnosis should first look for a disturbance in the 7.9.1 General principles corresponding segment of the locomotor system before labeling a disorder as psychogenic. The pejo­ The possibility that reflex inter-relationships rative use of the word ‘functional’ in general and between different structures may exist side by side especially in connection with the locomotor system with referred pain in the same body segment has reflects a lack of awareness that tends to underesti­ already been discussed in Section 2.11. The practi­ mate the significance of locomotor system dysfunc­ cal clinical aspects of this phenomenon will now be tions. It is this underestimation, combined with considered. ignorance, that gives unqualified lay manipulators the opportunity to claim ‘miracle’ cures. In very broad terms, the following five possibili- ties should be envisaged: The other side of the coin (point 2) is the warn­ ing that pain perceived in the locomotor system 1. The spinal column (motion segment) is may be a deceptive sign masking serious underlying causing symptoms that are mistaken for visceral disease. This suspicion is strengthened if visceral disease. the symptoms of spinal segmental disturbance tend to relapse repeatedly without obvious cause. While 2. Visceral disease is causing symptoms that are the error in point 1 is more common, that in point interpreted as a lesion in some part of the 2 is all the more fraught with danger. locomotor system. Point 3 is of major theoretical significance and 3. Visceral disease is producing changes in the demonstrates that visceral disease is actually one locomotor system, such as TrPs, movement of the possible causes of dysfunction in the motion restrictions, etc. segment (see Section 1.1). Clinical experience teaches that certain visceral diseases are associated 4. Visceral disease that has caused changes in with characteristic patterns in the locomotor sys­ the locomotor system has subsided; however, tem. These patterns are of considerable diagnostic the resultant dysfunctions have persisted and importance and are described below. They are so are simulating visceral symptoms. specific that their recurrence is in all probability predictive of a recurrence of the visceral disease. 5. A disturbance in the motion segment is It is therefore literally ‘in our hands’ to make the triggering visceral disease or (more likely) is diagnosis and influence the prognosis. activating already latent visceral symptoms (hypothetical). Point 4 follows on from point 3. If the visceral disease has been cured and we manage to treat the The first two points highlight the necessity for pre­ reflex dysfunctions caused by it, we obtain most cise differential diagnosis and the problems associ­ satisfactory results and can thus confirm the suc­ ated with this. The spinal column with its motion cess of visceral treatment. Here patients and prac­ segments can in fact produce symptoms that may titioners alike tend to draw the following incorrect mimic symptoms arising in the viscera and that are conclusion: because of persistent symptoms due to frequently interpreted as such by both patients and secondary dysfunctions in the motion segment, the practitioners. This explains why patients who have patient still feels affected by the visceral disease. been successfully treated by lay manipulators believe If after treatment of the dysfunction the patient is they have been ‘cured’ of their visceral disease. symptom-free, all the credit for the success of ther­ apy is then given to the practitioner who treated No less important is the fact that these differen­ the dysfunction, even though the underlying vis­ tial diagnoses are not always sufficiently recognized’. ceral condition had already been cured. However, if consequently, when no pathological changes are the dysfunction recurs in the same motion segment, found in the visceral organs, the term ‘functional’ is this is generally an early sign of a recurrence of the used to describe these disturbances. And given the visceral disease. prevailing ignorance concerning dysfunctions, the word ‘functional’ tends to be used as a euphemism Point 5 is the pipe-dream cherished by many for ‘of psychogenic origin’ or even for ‘malingering’. (lay) practitioners in the past; even today, however, it remains conjectural. Nevertheless, it would seem 348

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 justifiable to assume that lesions in a motion seg­ (Lewit & Abrahamovicˇ 1976). Thirty-seven of these ment of the spinal column may impair function in patients were followed up again three years later. the corresponding internal organs. This is borne out Eighteen patients remained without tonsillitis recur­ by the vasomotor response in the whole segment to rence, but in 7 cases movement restriction did recur which pain is referred. In such cases we can see the and had to be treated. Two patients had a few recur­ disorder clearing up as soon as we treat the motion rences of tonsillitis without movement restriction, segment. Reactions of this kind have been noted 3 suffered repeatedly from tonsillitis, and 9 under­ particularly in connection with the cervicocranial went tonsillectomy. In total, 13 patients remained syndrome, especially at the craniocervical junc­ without any recurrence of movement restriction. tion, including disturbances of equilibrium. Similar Interestingly, the tonsillitis patients had hardly any phenomena have been observed in connection with HAZs in the cervical region, but there was increased certain cardiac arrhythmias. According to Schwarz muscle tension (défense musculaire) laterally at the (1996), a motion segment dysfunction may activate floor of the mouth below the tonsillar bed. latent disease in an internal organ. Multiple patho­ genic factors may also need to be considered in It can be concluded from this study that chronic terms of their cumulative impact. As well as those tonsillitis goes hand in hand with movement restric­ that affect the locomotor system, other factors may tions at the craniocervical junction, mainly in seg­ be important in terms of their influence on the ment C0/C1, and that these have a tendency to organism as a whole, for example infections, meta­ become chronic. This means that there is a danger bolic disturbances, menstruation, diet, etc. None of of permanently disturbed function in one of the these individual factors on its own would be suffi­ key regions of the locomotor system. In addition, cient to provoke disease, but it is legitimate to refer our experience suggests that movement restriction to them as risk factors. in this region is associated with an increased suscep­ tibility to recurrent tonsillitis. 7.9.2 Tonsillitis 7.9.3 The lungs and pleura Systematic questioning when taking the case his­ Recognition of the close interplay between respira- tory in patients with vertebrogenic disturbances tion and the locomotor system has also improved reveals a strikingly high incidence of tonsillitis. In our understanding of the relationship between the a randomly selected sample of 100 cases from our lungs and the function of the thorax. Pronounced files, 56 patients had a history of chronic relapsing clavicular breathing or paradoxical breathing may tonsillitis and/or tonsillectomy. This finding was be the underlying cause of dyspnea in the absence made particularly often in patients with movement of any disturbance of the organs of respiration. Of restriction of the occiput against the atlas. It there­ course, pain experienced in the context of pleurisy fore seemed justifiable to investigate this problem or pneumonia needs to be differentiated from pain further. due to rib movement restriction or a slipping rib. In a study sample of 76 predominantly ado­ Palpation of rib mobility is useful here. In pleu­ lescent patients with chronic tonsillitis, move­ ral disease the impairment of mobility involves ment restriction at the craniocervical junction was the greater part of one side of the thorax whereas detected in 70 cases, in the great majority of them movement restrictions affect one or just a few between the occiput and atlas. Following tonsillec­ motion segments. tomy, movement restrictions were still present in the vast majority of these cases. However, where The respiratory disease in which involvement of movement restrictions were previously not present the thorax has been studied most is obstructive res- or had been treated, they developed only in excep­ piratory disease (Bergsmann 1974, Köberle 1975, tional cases after tonsillectomy. They could there­ Sachse & Sacshe 1975, Steglich 1971). The follow­ fore not be interpreted as a consequence of surgery. ing factors play a key role here: rigidity of the chest wall further increases resistance during respiration, In 40 non-operated patients in long-term fol­ and the inspiratory position of the thorax in asthma low-up who underwent just one manipulative pro­ patients is worsened by clavicular breathing, which cedure, 26 remained without tonsillitis recurrence is typical for that disease. Movement restrictions of and 15 without movement restriction recurrence the ribs are also associated with pulmonary rigidity, 349

Manipulative Therapy as detected by Köberle (1975) principally in seg­ pattern of disturbances and the pseudocardiac ments T7–T10. In a group of 23 patients, Sachse & syndrome emanating primarily from the loco­motor Sachse (1975) found a taut pectoralis major in 15 system. Rychlíková (1975) has shown that the cases and a weakened lower trapezius in 15 cases. more complete the described pattern of (reflex) Increased tension in the scalenes is the most fre­ changes in the locomotor system, the more likely quent change associated with clavicular breathing. it is to be secondary to primary heart disease. A TrPs in the diaphragm are also common. number of important clinical criteria can aid the distinction between true angina and pseudo­angina. Therapy comprises mobilization of movement Pain in true angina is dependent on physical effort, restrictions in the thoracic spine and ribs, and such as climbing stairs, and responds within sec­ remedial exercise for asthma patients who adopt onds to administration of nitroglycerine. Retros­ a clavicular breathing pattern, so that respiratory ternal pain also tends to be indicative of a cardiac resistance (which is increased in this disease) can origin. On the other hand, pain provoked by certain be kept as low as possible. positions of the body or by specific movement(s) is more characteristic of pseudo­angina. Attacks As a result of thoracic rigidity, extremely pro­ are shorter in true angina than in the pseudoangina nounced clavicular breathing in combination with syndrome. The course of the disease is also differ­ abdominal breathing, both with and without short­ ent: if locomotor system dysfunctions recur or are ness of breath, is often encountered in ankylosing aggravated despite specific treatment, this should spondylitis. This is important because despite the be taken to indicate that the true cause is primary presence of ankylosis, specific remedial exercises heart disease. The role of the locomotor system in can achieve a correct thoracic breathing pattern pain of cardiac origin is borne out by the fact that thanks to the elasticity of the ribs. Rychlíková (1975) did not find any signs of loco­ motor system dysfunction in a group of patients 7.9.4 The heart who suffered a myocardial infarction without pain. Of all the vertebrovisceral inter-relationships, that between the heart and the spinal column has Regardless of whether the locomotor system received most attention. This is due not only to the dysfunction pattern is primary or secondary, its importance of the problem, but also to the fact that treatment is always justified, as is rehabilitation for in the largest group of patients, that is in those with locomotor system dysfunction. If increased resist­ angina, the role of pain is comparable to that in tho­ ance is detected when shifting fascia around the racic dysfunctions. Pain of cardiac origin is also felt thorax, the gentlest approach is to begin by releas­ in the thorax, while pain referred from the heart is ing the fascia before using neuromuscular treatment localized mainly to the shoulder and left arm. techniques that address movement restrictions and TrPs simultaneously. This is followed by rehabilita­ Patients with angina show a characteristic pattern tion with training to correct breathing and posture. of disturbance that includes movement restrictions In view of the difficulties of diagnosis, cardiological involving the thoracic spine, especially segments monitoring is always indispensable. In cases where T3–T5 and most commonly T4/T5, the third to cardiological treatment is successful and loco­motor fifth ribs on the left side, the cervicothoracic junc­ system dysfunctions recur during the course of tion, and often the craniocervical junction. Most rehabilitation, it should be emphasized that these commonly, TrPs are located paravertebrally at the are often the first sign of a recurrence of heart dis­ level of T4, in the pectoralis major, subscapularis, ease, even before any evidence appears on the elec­ serratus anterior, and upper part of the trapezius on trocardiograph (ECG). the left side. TrPs in the scalenes go hand in hand with painful sternocostal joints in the vicinity of While the role of angina in the development of T3–T5 on the left side where the attachment points locomotor system dysfunctions appears to be estab­ of the pectoralis minor are also located. Clavic­ ular lished, the same cannot be claimed for the role of breathing is also often encountered in this setting, the locomotor system in the pathogenesis of heart with the patient experiencing sensations of tightness disease. There is one cardiological condition, how­ not dissimilar to those felt in angina. ever, where reflex locomotor system involvement seems well founded: paroxysmal tachycardia with It is obviously imperative to distinguish as clearly no organic heart lesion. There are some cases where as possible between angina with its characteristic 350

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 tachycardia occurs regularly if a certain movement 7.9.5 The stomach and restriction is present but where cardiac rhythm duodenum reverts to normal when the restriction is released (Vecan & Lewit 1980). Although hard evidence for As in heart disease, painful conditions in these a role of the locomotor system in the causation of organs may well produce reflex changes in the loco­ organic heart disease is lacking, it would seem rea­ motor system. We had the opportunity to study sonable to concede that it could be a possible risk the characteristic pattern in a group of young ulcer factor. patients aged between 15 and 22 years (Rychlíková & Lewit 1976). The characteristic pattern of dis­ The prime significance of the treatment of loco­ turbance was noted primarily in segment T5/T6. motor system dysfunction in heart disease lies in Compared with a control group of similar age, there the relief of pain, which greatly enhances the reha­ was an increased incidence of movement restric­ bilitation of these patients, as illustrated by the fol­ tions at the craniocervical junction. However, the lowing case study. most striking finding was pelvic distortion (87% as compared with 44.4% in the controls). There was Case study also increased muscle tension in the thoracic erec­ tor spinae in segments T5–T9 on both sides, with a K H; female; born 1937. maximum at T6, and a HAZ in the same region on both sides – also significantly more common than Medical history in the control group. It is interesting that these changes were almost symmetrical, with a very slight The patient reported pain between the shoulder preponderance on the right side. However, there blades and radiating into her neck and thorax, mainly was no difference between the cases of gastric and on the left side. The pain had an acute onset on the of duodenal ulcer. morning of 5 February 1980. The patient reported retrosternal ‘burning,’ and an ECG was taken, reveal- In this group, the intensity of reflex changes ing normal findings. The patient first became aware correlated with the intensity of pain; where there of pain in her neck and thorax in 1976. In her youth was no pain, as in some cases after surgery, there she had repeatedly suffered from angina. She had were also no locomotor system dysfunctions. It also received psychiatric treatment for depression. must be added that this was the pattern found in The patient played basketball as an adolescent. young patients; in older patients suffering from ulcers the incidence of pelvic distortion is very C linical findings and therapy much lower. Examination on 9 December 1980 revealed a bilat- Case study eral movement restriction at C0/C1, and limited retroflexion at T4/T5 and T6/T7. TrPs were present V S; male; born 1922; X-ray technician. in the pectoralis major and there was a pain point at the sternocostal joint at T4 on the left side. The Medical history patient also presented with pronounced clavicular breathing but without any increase in scalene mus- Since 1960 the patient had suffered from low-back cle tension. The movement restrictions at C0/C1, pain that radiated into his thighs. He had been T4/T5, and T4/T7 were treated, as well as the painful treated for a gastric ulcer since 1948. attachment point of the pectoralis major at the fourth sternocostal joint. The patient experienced relief C linical findings and disease course immediately after treatment and a start was made on correcting her faulty breathing pattern. At examination on 28 February 1969 the patient was found to have movement restrictions at C1/ On 6 January 1981 the patient developed acute C2 on both sides, and of T5/T6 and L5/S1 into cervical myalgia with a typical movement restriction extension. One year later, on 27 February 1970, he to the right at C2/C3 and C5/C6. Isometric traction reported pain in his thorax and right hypogastric and mobilization of C5/C6 was followed by trac- region. Examination again revealed a slight move- tion manipulation of C5/C6 with the patient seated, ment restriction at C1/C2, and palpation elicited and a residual TrP in the upper part of the trapezius pain in the right upper abdomen and at the psoas was treated by PIR. On 13 January 1981 the patient major, but nothing conclusive was discovered in the was symptom-free. This was evidently a case of a vertebroc­ ardiac syndrome. 351

Manipulative Therapy thoracic spine. This set of findings was insufficient to pain radiates into the groin. A thorough analysis explain the patient’s symptoms and prompted a full of reflex changes in the locomotor system in kid­ clinical examination, with ulcer pathology being con- ney disease has been made by Metz (1986). In 208 firmed on X-ray. cases of chronic kidney disease (glomerulonephri- tis, pyelonephritis) he found the following pattern: 7.9.6 The liver and gall bladder movement restriction at the thoracolumbar junction (T11–L1), and increased tension at the lowest ribs Because pain is a prominent feature in disorders and in the psoas major, quadratus lumborum, and of the liver and gall bladder, reflex changes must the thoracolumbar erector spinae. Metz emphasized be anticipated here too. According to Rychlíková that pain only became manifest in these patients (1974), the motion segments most frequently with ‘genuine’ renal disease when the above loco­ affected by dysfunction are T6–T8. There is also fre­ motor system findings were apparent. quently pain that is referred to the right shoulder, as borne out by a HAZ in the C4 dermatome and TrPs Pelvic distortion and a markedly increased inci­ in the upper part of the trapezius on the right. Non- dence of faulty statics in the lumbar spine and pel­ inflammatory gall bladder dysfunction can sometimes vis were present (according to Metz) especially in be halted successfully using reflex techniques. nephroptosis (downward displacement of the kid­ ney), where the symptoms were also determined Case study decisively by locomotor system dysfunctions. Symp­ toms and locomotor system disturbance patterns Professor L O; male; born 1906; theater manager. were identical in a group of 40 patients with neph­ roptosis and another 40 patients after nephropexy: M edical history they primarily involved the thoracolumbar junction with unilateral hardening of the psoas major. The The patient was referred to us for treatment because patients were mainly asthenic, hypermobile women of chronic low-back pain radiating into both legs. with faulty statics, recurrent movement restrictions Despite many treatments, his symptoms had been at L5/S1, and ligament pain. (Nowadays we would constant since 1956. He also complained of pain seek to identify insufficiency of the deep stabiliza­ between the shoulder blades that troubled him par- tion system.) In these cases, however, locomotor ticularly when he moved his head. system dysfunction proved to be the decisive cause of the renal symptoms. Clinical findings and therapy 7.9.8 Importance of the When he was examined on 18 January 1961 the psoas major and rectus patient omitted to mention his gall bladder condi- abdominis tion. Pelvic distortion was detected, together with faulty movement patterns that necessitated reme- Because the psoas major is located deep in the dial exercise therapy. On 11 July 1961 the patient abdominal cavity, it may provoke symptoms similar complained of gall bladder pain. His low-back pain to those associated with other internal abdominal worsened. On 26 October 1961 he suffered an epi- structures. This is extremely important for differ­ sode of biliary colic that made remedial exercise ential diagnosis. As we have noted, there is a reflex impossible. Extensive HAZs were found in the tho- increase in tension in the psoas major secondary to racic region and there was a painful spinous process kidney disease. Most frequently this is associated at T9, which was treated by rotation manipulation. with TrPs in the psoas major and limitation of trunk The pain disappeared almost at once. The patient rotation. Where there are faulty movement pat­ returned regularly for follow-up until 1965 and there terns, this muscle has a tendency to shorten (due to were no further recurrences of biliary colic. increased tension) and can cause flexion at the hip simultaneously with (paradoxical) lumbar lordosis. 7.9.7 The kidneys The psoas major should be examined for shorten­ ing (see Figure 4.55). Palpation of the typical TrPs Reflex changes are most clearly apparent in patients is performed from the side with the patient supine with renal colic. They always occur on the painful side in segments T10–T12 in the lower back and 352

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 and legs extended: the practitioner presses and women with dysmenorrhea and normal gyneco­ snaps the muscle against the patient’s spine, which logical findings who had low-back pain with typical is in lordosis because the legs are extended. TrPs in onset at the menarche. This condition rarely dete­ the psoas major are linked in a chain with those in riorates and very often improves after childbirth. the quadratus lumborum and the thoracolumbar A second large group developed symptoms during erector spinae, and are responsible for the functional pregnancy and after delivery, that is dysfunctions limitation of trunk rotation to the opposite side. occurred at a period when there is increased strain on and vulnerability of the spine and pelvis. A third TrPs in the psoas major may also be the cause of group consisted of 59 patients with gynecologi­ pain in the ‘post-cholecystectomy syndrome.’ Like cal conditions giving rise to low-back pain. These other painful structures in the abdominal cavity, were apparently viscerogenic disorders. The fourth TrPs in the psoas major may also give rise to ten­ and largest group of patients were women suffering sion and rigidity (défense musculaire) in the rectus from minor dysfunctions of the spine and pelvis, in abdominis. Because of the location and size of the whom gynecological examination was carried out as psoas major, TrPs in this muscle can simulate symp­ a routine diagnostic procedure, but with negative toms associated with most of the abdominal viscera: findings. duodenum, gall bladder, kidneys, pancreas, and ver­ miform appendix. Not only is the pain intense, but In a group of 150 pregnant women, 48 had a his­ there may also be autonomic reactions such as loss tory of dysmenorrhea (Lewit et al 1970). Of these of appetite and a feeling of indigestion, etc. Ther­ 48 patients, 38 had lumbosacral movement restric­ apy involving PIR and RI is simple and effective. tion or pelvic distortion. Findings in the lumbosacral spine and pelvis were ‘normal’ in only 10 women. Increased tension in the abdominal muscles, ‘Normal findings’ meant that pain was generally felt especially the rectus abdominis, is often a sign of only in the hypogastric region but not in the lumbar painful visceral disease. However, it is also encoun­ region. Moreover, low-back labor pains during an tered in locomotor system dysfunction, particularly otherwise normal delivery were closely correlated in patients with a forward-drawn posture on stand­ with dysfunctions of the spinal column and pelvis. ing, where it is caused by a chain reaction pattern extending from the feet via the fibula and associ­ In another group of 70 women with menstrual ated with TrPs in the biceps femoris. As a result the pain and normal gynecological findings, treatment anatomical fixation of the pelvis is disturbed from of the spine, mainly by manipulation, brought con­ below, leading to TrPs in the rectus abdominis with siderable improvement in 43 cases, improvement in painful attachment points at the pubic symphysis, 13 cases, and no improvement in 14 cases. xiphoid process, and neighboring ribs, with for­ ward-drawn posture, restricted retroflexion while In summary, it appears that low-back pain may standing, and (referred) low-back pain (see Figure have its origin in the female pelvic organs and may 6.121). Needless to say, TrPs in the abdominal mus­ become manifest during childbirth and menstrua­ cles are also capable of simulating visceral pain. tion as well as following gynecological disease or surgery. In a very large number of patients, low- 7.9.9 Gynecological disorders back pain is of locomotor system origin and is and low-back pain mistakenly attributed to primary gynecological dis­ turbances. One reason for this may be a TrP in the Gynecological disorders have always been tradi­ iliacus which is palpated as a site of tender resist­ tionally associated with low-back pain. From our ance in the hypogastric region. Menstrual pain with modern-day perspective the role of gynecologi­ otherwise normal gynecological findings, especially cal disorders as a leading cause of low-back pain in when localized in the low back, is usually of verte­ women has been overestimated. It was the gynecol­ brogenic origin and is often the first clinical mani­ ogist Martius (1953) who placed critical emphasis festation of locomotor system dysfunction on the importance of the locomotor system. Labor pains felt in the low back in an otherwise Novotný & Dvorák (1984) conducted a study normal delivery should also be interpreted as being in 600 women attending a gynecology clinic at of vertebrogenic origin. Current knowledge also the University of Prague. They subdivided these points to the importance of the pelvic floor. Screen­ patients as follows: the first group comprised 113 ing for a TrP there should also be conducted as rou­ tine (see Figure 4.12) and, if found, its treatment is a major preventive factor. 353

Manipulative Therapy Research conducted by Mojžísová (1988) and 7.10 Post-traumatic states Volejníková (1992) suggests that manual therapy may offer some prospect of success in women with The important role of trauma in the causation of sterility of cryptogenic origin (i.e. with negative vertebrogenic disorders was pointed out in Sec­ organic findings). tion 2.4.7, and it was emphasized in Section 4.1 that a record of trauma in the patient’s history is In women with locomotor system dysfunction, a characteristic feature of vertebrogenic disor- history taking should include questions to elicit ders. Right from childhood people are exposed to information about dysmenorrhea, especially in the risk of injury, and when spinal dysfunction is adolescence, and low-back labor pains during detected in children, trauma is often one of the key childbirth. causes. These dysfunctions may remain latent and un­noticed due to compensatory adjustments (by Case study other motion segments, for example), and these in turn may lead on to secondary changes. B B; female; born 1933. In this way, the ground is prepared that allows Medical history the effects of subsequent trauma to be even more devastating. Trauma impacting an already com­ The patient had suffered from headaches since the promised spinal column readily produces further age of 12, and subsequently from metrorrhagia and decompensation, and even apparently trivial trauma pain on menstruation. She was first referred to us by may set this in motion. The words ‘apparently her gynecologist on 16 October 1958. trivial trauma’ deserve emphasis here because the forces acting on the spinal column are so great that Clinical findings and therapy even an uncoordinated movement may expose it to a sudden load amounting to several hundred kilo­ Examination revealed pelvic distortion with devia- grams. tion to the left, and her left PSIS was painful as was retrof­lexion in the lumbosacral region. Segments C1/ Once the acute consequences of trauma have C2 and L5/S1 were treated. subsided, it is often noted that there is a latency period after which the post-traumatic syndrome On 15 January 1959 the patient reported that develops gradually – a pattern that is typical in menstruation was much improved but her head- cranial trauma, for example. It is often forgotten aches were unchanged. Manipulation of L5/S1 and that the spinal column also suffers following most of the cervicothoracic junction was repeated. injuries to the extremities, the trunk and, in par­ ticular, the head. In the initial phase, however, the The patient subsequently reported that menstrua- local injury takes center stage, and because the spi­ tion now lasted for one week instead of two weeks nal effects are still in the latency period referred to as in the past, and her headaches were more bear- above, they are commonly neglected. able. She remained under our treatment but her headaches never disappeared completely. Low-back 7.10.1 Cranial trauma pain was now present only from time to time. To illustrate this point, let us take concussion as On 20 February 1962 menstruation had again an example. It stands to reason that any force act­ increased to eight or nine days. Pelvic distortion to ing on the head must also affect the cervical spine. the left had returned and temperature measurement Similarly, from the size and weight of the human revealed a difference of 0.5° at the PSIS. Treatment skull compared with the cervical spine, it will be of the lumbosacral junction was repeated. obvious which of these two structures represents the site of lessened resistance, in relative terms. It The patient was last seen by us on 9 July 1967 is also therefore no coincidence that the majority because her menstrual pain had worsened. On this of injuries to the cervical spine, including vertebral occasion we detected pelvic distortion to the right. fractures, are concomitant effects of craniocere­ bral trauma. This fact is also borne out by autopsy Case summary The case of this patient repeatedly illustrates the dependence of menstrual symptoms on lumbosacral segment dysfunction. 354

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 findings: without exception, in all 20 cases of death Case study after head injury, Leichsenring (1964) also found serious damage to the cervical spine. T M; female; born 1949. We can only concur with Junghanns (1952) Medical history who wrote that symptoms usually attributed to concussion were in reality caused by trauma to The patient was first seen by us on 25 May 1959 the cervical spine. And this opinion is also shared complaining of headache. In November 1958 she by Gutmann and others. In fact, a striking simi­ had received a blow in the neck from a school bag larity exists between the post-concussion syn­ and had experienced intense local pain to begin drome and the cervicocranial syndrome. In both with. She then vomited before lunchtime. Ever since conditions, patients experience headache that is that first day she had had headaches every day and frequently paroxysmal and is associated with diz­ had to stay at home for three weeks. At the time of ziness or vertigo. This was first described by Barré her initial presentation she was suffering from head- & Liéou (1926) as ‘posterior cervical sympathetic aches several times a week, localized to her occiput, syndrome’ and later by Bärtschi-Rochaix (1949) as frontal region, and sometimes involving her entire ‘cervical migraine’ occurring in the wake of cranial head. trauma. C linical findings and therapy The close relationship between concussion (closed head injury) and whiplash injury is also The clinical findings were unexceptional, although evident from a study conducted by Torres & Sha­ X-rays revealed dextrorotation of the axis. A piro (1961) in which they compared the clinical re­positioning effect was achieved by manipulation and electroencephalogram (EEG) findings after and at the follow-up examination on 22 October concussion or whiplash injury. The neurologi­ 1959 the patient stated that she had been symptom- cal findings were virtually identical, with the dif­ free up until the middle of October when the pain ference that pain was more common in the neck had returned, prompting the repeat of manipulation and arms after whiplash injury. EEG abnormali­ (after five months). ties were present in 44% of patients after con­ cussion and in 46% of patients after whiplash C ase summary injury. In both cases temporal lobe foci were seen predominantly. In this young girl’s case the blow to her cervical spine simulated a post-concussion syndrome with head- With ever-increasing numbers of vehicles on the ache and vomiting. roads, the incidence of whiplash injury is rising all the time. Whiplash injury often causes dispropor­ As this case illustrates, forceful rear-end impact is tionately severe symptoms and poses a problem in not the only mechanism capable of causing whip­ terms of therapy. Such incidents usually involve an lash injury. For example, it may also be produced by unexpected rear-end impact that causes the trunk a fall on to the shoulder and we even know of one of the individual(s) leaning back against the auto­ case where the condition was brought about by the mobile seat to suddenly jerk forward at high speed; impact of a wave against the head while the patient in this process the head and neck engage in a whip­ was in the sea. Although the underlying mecha­ lash movement relative to the trunk. This can be nism bears some similarity to distortion, the clinical particularly harmful if the head is also rotated rela­ course is far more severe. In computed tomogra­ tive to the trunk. Immediately after the accident phy scans obtained in such patients, Dvorák (1989) it is common for the whiplash injury victim to feel detected tears in the alar ligament with hypermo­ that little of note has occurred, with any symp­ bility of the craniocervical junction, a finding that toms being minimal. It is not until hours or a few explains the often unfavorable response to HVLA days later that the often considerable symptoms thrust techniques. of a severe post-traumatic cervicocranial syndrome develop, and these commonly take a chronic One complication of whiplash trauma has course. In very recent whiplash injury, gentle been described by Berger (personal communi­ examination often reveals hypermobility, whereas cation) under the designation ‘stiff or frozen movement restrictions develop later due to muscle neck syndrome’. He has reported the following TrPs. characteristic pattern based on an analysis of 20 cases: movement is restricted, slow and jerky on 355

Manipulative Therapy cervicomotography (which involves registration of Case study head movements in three planes simultaneously: fast movement; slow movement, eyes and head K E; female; born 1941. following a pendulum; passive movement). Passive movement is less restricted than active, and slow Medical history movement has a greater range than fast movement. Rotation with the patient supine (fixation at T1) The patient had slipped and fallen over on 5 April is less restricted than rotation in the sitting posi­ 1958. Although she did not lose consciousness after tion. There is marked hypertonus in muscles and the fall, she vomited and complained of headache. soft tissues and there are extensive HAZs. Patients report intense pain radiating into the head and C linical findings and therapy arms, often accompanied by dizziness and blurred vision. In this stage, patients cannot tolerate any Neurological findings were normal. The transverse type of physical therapy, whether mobilization, process of the atlas was tender to the touch and its manipulation, or massage. They require immobili­ movement was slightly restricted. The pain ceased zation, a supportive cervical collar, and sometimes instantaneously following manipulation on the left side. cryotherapy. At follow-up examination on 12 August 1958 the By 1965 we had followed up more than 65 post- patient reported that she had experienced no further concussion patients who had lost consciousness symptoms at all since manipulation. after an accident. Abnormal neurological findings (signs of disturbed equilibrium) were present in Case study one case. By contrast, clinical findings in the cervi­ cal spine were normal in only six cases. The results K J; male; born 1910; bricklayer. of manipulation and reflex therapy were excellent in 37 cases, good in 8 cases, and unsatisfactory in M edical history 10 cases. The patient fell from a height of 2 meters on 6 August In a further group of 95 cranial trauma patients 1958 and was unconscious for a short time. When without concussion, seen during the period from first seen by us on 7 August 1958 he complained of 1964 to 1970, movement restrictions involv­ pain in the temples. ing the cervical spine were absent in only 4 cases. Interestingly, the predominant finding was move­ Clinical findings and therapy ment restriction at C1/C2. A painful anteflexion test, indicative of ligament pain, was present in 10 His nasopalpebral and labial reflexes were exagger- patients who were treated without success. ated, and head rotation to the right was restricted. After treatment of C1/C2, head rotation was normal. From the perspective of prevention, the acute stage following trauma is most important of all. At follow-up examination on 23 April 1959 the In this respect, post-concussion patients offer patient notified us that he had been entirely symptom- a model for acute spinal trauma because they free since manipulation. are routinely admitted to hospital and there­ fore are not lost to medical examination. With a Case study view to preventing later complications, a series of 32 patients in the acute post-trauma stage was V B; male; born 1910. referred to us for examination and treatment. All the patients were fully conscious, with no suspi­ Medical history cion of intracranial hemorrhage, and with negative X-ray findings in the skull and cervical spine. A While riding his motorbike, the patient collided with chronic disease course evolved in only one patient, an automobile and was unconscious briefly, later who also developed arterial hypertension. Treat­ complaining of headache with dizziness. ment was further unsuccessful in one patient with dizziness and a calcaneal fracture. Twenty-four Clinical findings and therapy patients (75%) became symptom-free immediately after treatment. At examination, Hautant’s test showed deviation to the right with first-degree nystagmus to the left. However, manipulation was not successful. On the next day, the patient was hospitalized for vertigo. As on the previous day, the findings were 356

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 unchanged, with marked limitation of cervical spine styloid process; and this may not start until after rotation to the left. The attempt to treat this with the plaster cast has been removed following a manipulation again proved unsuccessful. On 9 June Colles’ fracture. Examination then regularly reveals 1958 the patient returned, with a diminished corneal impaired radial abduction at the wrist with move­ reflex on the left, first-degree nystagmus to the right, ment restriction between the radius and ulna; how­ and mild hypermetria of the left arm. X-ray showed ever, the cause is located at the elbow where there asymmetry at C3. Manipulation of the C2/C3 seg- are signs of a lateral epicondylopathy. Any treat­ ment abolished the nystagmus and hypermetria, and ment administered at the site of the pain is futile, the patient reported immediate relief. The patient but pain is immediately relieved by treatment for was symptom-free at follow-up examinations on 18 movement restriction at the elbow. June 1958 and 12 July 1958, and all findings were normal. A fall on to the shoulder is likely to affect not only the cervical spine but also the structure that Bartel (1980a, b) has published almost identical bore the direct brunt of the impact, namely the results: in 50 cases examined immediately after acromioclavicular joint and/or a first rib. head injury he detected movement restriction in all patients but 2, the lesion being most frequently After foot injury, with or without fracture, we located at C1/C2. In 40 cases, a single treatment usually find movement restrictions in the tarsometa­ was sufficient, usually involving neuromuscu­ tarsal and intertarsal joints, as well as in the ankle lar techniques. Treatment had to be repeated in 6 joint. After knee injury there is often movement cases, in 2 of these without success. (As a historical restriction at the fibular head. footnote to the three case studies presented above, it should be pointed out that neuromuscular tech­ Functional coxalgia is not uncommonly the niques were still unknown in 1958.) sequel to a sprain of or fall on to the hip. Appro­ priate mobilization or manipulation is the proper These experiences suggest a preventive role for procedure immediately after injury, and the effect manipulative therapy in acute head injury while is often seen promptly. However, this depends movement restrictions are still in the early stage. on diagnostic precision in excluding fracture and Lack of awareness and understanding concerning hematoma. Early treatment will avoid later compli­ manual diagnosis and therapy means not only that cations and prevent the condition from becoming this opportunity is frequently missed but also that chronic. the patient complaining of pain quite literally has insult added to injury, being told that there are no As described in Section 7.1.8, major lesions such organic findings and hence the pain must be ‘all in as outflare and inflare dysfunction result mainly the mind.’ from trauma following a fall on to the buttocks (coccyx). 7.10.2 Trauma to the extremities 7.11 The clinical picture of dysfunctions in What is true for head injury is equally valid for individual motion other parts of the locomotor system: a patient who segments falls on a hand may also suffer from indirect injury to the cervical spine, while one who falls on a foot The most frequent symptom of locomotor system may also sustain injury to the pelvis and lumbar dysfunction (especially involving the spinal column) spine. A fall on to the shoulder may have the same is pain and the structure which most frequently effect as whiplash injury. expresses pain is the muscle with its TrPs and painful attachments. It is the great achievement A number of typical lesions are encountered in of Travell & Simons (1999) to have systematically the extremities after injury. A fall on to the hand, described the muscles that harbor TrPs. Closely whether the radius is fractured or not, gener­ related to muscle TrPs are the articulations of the ates a force on the radius that pushes it upward at spinal column and their dysfunctions – movement the elbow, causing dysfunction at the elbow joint. restrictions in particular – and it seems most impor­ Clinically, this is often manifest as pain at the tant now to give a concise overview of the clinical symptoms of dysfunctions in the individual motion 357

Manipulative Therapy segments. However, it should be emphasized that 7.11.3 Atlantoaxial segment muscle TrPs also determine the clinical picture as soon as dysfunctions occur in the spinal articula­ Dysfunction in this segment is most commonly the tion (motion segment). Examination techniques result of trauma, but otherwise it is encountered for these dysfunctions are described in detail in less frequently. Although headache predominates, Chapter 4. neck pain is usually also present. 7.11.1 The temporomandibular There is a typical pain point at the lateral surface joint (TMJ) of the spinous process of the axis, more commonly on the right side. There are characteristic TrPs in the The main symptom is headache on the side of the sternocleidomastoid and levator scapulae. Head rota­ affected joint, with pain radiating strongly into the tion is restricted, usually to the right, whereas side- ear and face. When taking the patient’s history, bending (‘nodding’) is more often restricted to the questions should always be asked about missing left. This is the only cervical segment in which rota­ teeth, badly fitting false teeth, or trauma. However, tion restriction is not necessarily in the same direc­ pain may also be caused by increased tension in tion as restriction of side-bending. In this segment, the masticatory muscles, and psychological tension rotation takes place precisely around a vertical axis. (teeth grinding, bruxism) may also be a factor. The masticatory muscles are in a chain with the muscles 7.11.4 Segment C2/C3 at the craniocervical junction and consequently the clinical picture may be difficult to distinguish from This is the segment where acute wry neck occurs. dysfunction at the craniocervical junction. Dizziness However, this does not mean that it is the only or vertigo or possibly tinnitus may also be present. segment in acute wry neck where movement is Dysphagia and dysphonia may be noted where restricted. there is increased tension at the floor of the mouth, also involving the digastricus. The most prominent TrPs are found in the sterno­ cleidomastoid, levator scapulae, and the upper part 7.11.2 Atlanto-occipital of the trapezius. Pain may therefore be felt not only segment in the head but also in the shoulder. A pain point is routinely found at the lateral edge of the spinous Patients commonly complain of headache felt at process of the axis (usually on the right side), and the occiput, mainly on one side. History taking rotation and side-bending are usually restricted to often reveals evidence of recurrent tonsillitis or oti­ the right. tis media. Pain typically occurs in the morning and may waken the patient during the night. 7.11.5 Segments C3/C4–C5/C6 TrPs are located primarily in the short exten­ sors of the craniocervical junction and in the upper Although headache may be present, pain referred to part of the sternocleidomastoid. Other pain points the arms is the characteristic finding here, in partic­ are found at the posterior arch of the atlas, at the ular epicondylar pain at the elbow, more frequently transverse processes of the atlas, at the nuchal line, on the lateral aspect. This may occur in combina­ and at the posterior margin of the foramen mag­ tion with pain at the styloid process and with teno­ num. Mobility testing reveals restriction of ante­ vaginitis that is common on the forearm. flexion and retroflexion most commonly, followed by restriction of side-bending to the left, and then Most TrPs are found in the deep layers of the of side-bending to the right. Joint play is reflected paravertebral muscles, in the upper part of the tra­ in dorsal shifting of the occipital condyles relative pezius, in the middle part of the sternocleidomas­ to the atlas. As with all motion segments in the toid, and in the muscles with increased tension in cervical spine, there is frequently an important epicondylar pain – the supinator, the finger and TrP in the diaphragm. The mobility of the scalp is hand extensors, and the biceps and triceps brachii. restricted relative to the underlying tissues. Movement restriction at C3/C4 is sometimes also accompanied by symptoms of restriction at the 358

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 craniocervical junction. There may be ‘binding’ of 7.11.8 Restricted trunk the cervical fascia. rotation (segments T10/T11–L1/L2) 7.11.6 The cervicothoracic junction (C6/C7–T2/T3) Pain is characteristically felt in the low back or between the shoulder blades. If the condition is Even here headache is no exception, but cervico­ acute, the patient will often volunteer the informa­ brachial and shoulder pain in particular is typical, tion that it has been provoked by straightening up in association with paresthesia. All the joints of suddenly from anteflexion with rotation. Because the shoulder may thus be involved, as well as the limited trunk rotation is not due to restricted first ribs. joint movement but to TrPs in the thoracolumbar erector spinae, psoas major, and quadratus lum­ Muscle tension is increased (with TrPs) primarily borum, the pain is felt principally at the attach­ in the upper and middle parts of the trapezius, and ment points for these muscles – at the iliac crest in the sternocleidomastoid, scalenes, diaphragm, (low back) and at the lower ribs (below the shoul­ subscapularis, and infraspinatus as well as in the der blades), but hardly ever at the thoracolumbar corresponding fascia. Together with the movement junction. Kyphotic posture is the consequence of restrictions at the cervicothoracic junction, the sca­ psoas spasm, which may also provoke pseudovis­ lenes and the pectoralis minor are responsible for ceral symptoms. If TrPs are simultaneously present the thoracic outlet syndrome, which is frequently in the abdominal muscles, then the pubic symphy­ in a chain with the carpal tunnel syndrome. sis and xiphoid process may be tender. There is a viscerovertebral inter-relationship between these 7.11.7 Thoracic segments motion segments and the kidneys. Trunk rota­ T3/T4–T9/T10 tion here is generally restricted in the direction opposite to the side where the muscle TrPs are Because pseudovisceral pain is particularly com­ located. mon in these segments, differential diagnosis is of prime importance. Symptoms on the left side may 7.11.9 Segment L2/L3 simulate pain from the heart, lung, stomach, and pancreas; on the right side they may simulate pain It is rare for this segment to suffer from dysfunc­ from the gall bladder, liver, duodenum, and lung. If tion; when it does, it causes low-back pain. TrPs thoracic pain is not of visceral origin, it is usually are found in the gluteus medius, below the iliac secondary to dysfunction either of the cervical or of crest. the lumbar spine (assuming that the patient is not suffering from a severe form of juvenile osteochon­ 7.11.10 Segment L3/L4 drosis). The exception to this rule is pain in the region where thoracic kyphosis peaks and the erec­ Like the other more caudal lumbar segments, tor spinae is weakest, approximately at the level dysfunction here is characterized by pain that is of T5. In rib dysfunctions there may also be pain referred to the lower extremities. It is largely iden­ at the sternocostal joints, which provide the main tical to pain originating in the hip joint, and is felt attachment points for the pectoralis major and in the hip and the groin, radiating ventrally down minor. If the rib lesion is acute, breathing in and out the thigh to the knee and sometimes beyond as far is painful. Painfulness in the vicinity of the inferior as the tibia. costal arches is a characteristic sign of a slipping rib. Muscle spasm with TrPs in the rectus femoris The most important TrPs are in the pectoralis is characteristic, and therefore the femoral nerve major and minor subscapularis, serratus anterior, stretch test is positive; the straight-leg raising test erector spinae, the diaphragm and pelvic floor, and is usually negative. Further TrPs are found in the only rarely in the latissimus dorsi. The mobility of hip adductors, and for this reason Patrick’s sign is the deep fascia is disturbed on the back (in a cranial mildly positive. direction) and especially around the thorax. 359

Manipulative Therapy 7.11.11 Segment L4/L5 7.11.14 The coccyx Pain in this segment is felt in dermatome L5 that Only about one-fifth of patients in whom the coc­ travels down the lateral aspect of the leg, from the cyx is tender at palpation feel their pain as coccygo­ thigh to the lateral malleolus. dynia. Instead they tend to complain of low-back pain. Conversely, if patients report pain arising from The characteristic TrP is in the piriformis, and the coccyx, it may in fact originate from the lower therefore pain is felt mainly in the hip. There is part of the sacroiliac joint, the pelvic floor, or even usually also increased tension in the hamstring mus­ from a painful ischial tuberosity. This is especially cle group, especially the biceps femoris, and the the case when the coccyx is tender not in the mid­ straight-leg raising test is therefore positive. There line but to one side. Pain is felt mostly when the may be pain and movement restriction at the fibu­ patient is seated. The part played by trauma tends lar head. Increased tension in the rectus femoris to be overestimated: psychological tension is a key and hence also in the ischiocrural ligament and piri­ factor. formis muscle often results in secondary movement restriction at the sacroiliac joint. TrPs are present in the levator ani, gluteus max­ imus, hip adductors, ischiocrural muscle group, and 7.11.12 Segment L5/S1 sometimes also in the piriformis and iliacus, which explains why Patrick’s sign and the straight-leg rais­ The pattern of pain here is consistent with derma­ ing test may be positive. tome S1, and radiates down the back of the leg as far as the heel and lateral malleolus. 7.11.15 The diaphragm and pelvic floor There is increased tension in the hamstring mus­ cle group and the straight-leg raising test is posi­ The most easily palpated TrPs of the deep stabiliza­ tive. As in dermatome L5, there is therefore often tion system are found in the diaphragm and pelvic movement restriction of the fibula, with second­ floor. From these starting points, innumerable chain ary sacroiliac restriction. A TrP in the iliacus is very reaction patterns extend upward to the craniocer­ characteristic, with pseudovisceral symptoms in the vical junction and masticatory muscles, and down­ lower abdomen. In hypermobile patients there is ward to the pelvis and lower extremities. Screening often a pain point at the spinous process of L5. for these TrPs should therefore be performed as routine in all patients. TrP relaxation is exception­ 7.11.13 The sacroiliac joint ally straightforward and effective, particularly in the diaphragm, but activation is generally the pre­ Because the pattern of pain distribution here too is ferred option in stabilization system dysfunction. consistent with dermatome S1, it is virtually indis­ tinguishable from that experienced in lumbosacral 7.11.16 The hip joint movement restriction. Owing to the wide variations in anatomical topography in this region, the pain When merely dysfunctional or in the early stages point (indicated by many patients as lying above of osteoarthritis of the hip, the hip joint most fre­ and medial to the PSIS) cannot be differentiated quently causes (asymmetrical) low-back pain radiat­ from the neighboring lumbosacral joint. ing into segment L4. Knee pain is therefore often an early indicator of osteoarthritis of the hip. By con­ The TrP in the iliacus muscle is characteristic trast with the situation in vertebrogenic low-back of the lumbosacral joint and differential diagnosis pain, it is walking for longer periods that is painful, is possible only on the basis of mobility testing. In especially over a hard terrain; and by contrast with cases where the lower part of the sacroiliac joint knee dysfunction, stair climbing is also painful. is painful, the pain may be felt to one side in the sacro­coccygeal region. Current knowledge with The key TrPs are located in the hip adductors, regard to chain reaction patterns of dysfunctions flexors, and abductors. A positive Patrick’s sign and indicates that most sacroiliac restrictions are second­ the characteristic capsular pattern are typical. ary in nature, apart from those in osteoarthritis of the hip. 360

Clinical aspects of locomotor system dysfunction (vertebrogenic disorders) Chapter 7 7.11.17 The foot and point. The most important faulty movement pat­ fibular head terns relate to functional flat foot and automatic flexion of the toes during the toe-off phase of the The foot is a key region of fundamental importance. gait cycle and when the body’s center of gravity However, the main chain reaction patterns extend is shifted forward. Afferent pathway disorders via the fibular head and may even start from there are especially important here, characterized by if findings at the feet are negative. increased or diminished tactile perception, along with simultaneous alterations in muscle tonus that In the foot itself there are often movement are often asymmetrical. The typical chain reaction restrictions between the individual bones, as well pattern is a forward-drawn posture that extends as TrPs in the deep plantar muscles with attach­ from the fibular head to the biceps femoris and ment point pain at a calcaneal spur. TrPs are also onward via the abdominal, gluteal, and back mus­ located dorsally between the metatarsal bones. cles to the craniocervical junction. The foot pos­ TrPs in the soleus muscle are associated with sesses all the key characteristics of the deep pain in the Achilles tendon and its attachment stabilization system. 361

Chapter Eight 8 Prevention of locomotor system Chapte dysfunctions 8.1 Importance and incidence of locomotor rheumatism, etc. Many patients who suffer con- system dysfunctions . . . . . . . . . . . 363 stantly from these painful conditions do not even seek medical help, having learned from experience 8.2 Principles and goals of prevention . . . . 364 that conventional treatment is ineffective: and so they escape the record. Even so, the statistics are 8.3 Lifestyle factors . . . . . . . . . . . . . . 365 impressive. 8.3.1 Passive prevention . . . . . . . . 365 The category heading of ‘soft-tissue rheumatism’ 8.3.2 Active prevention . . . . . . . . . 367 clearly includes many patients suffering from loco- motor system dysfunctions. As a cause of absentee- 8.4 M anipulation as a prophylactic ism from work, it is a sobering fact that locomotor measure . . . . . . . . . . . . . . . . . . 369 system disorders rank second only behind common infections of the upper respiratory tract. However, 8.1 Importance and if we consider only those locomotor system disor- incidence of locomotor ders that are of vertebrogenic origin, we find that system dysfunctions they account for 15 million lost working days. The previous chapter in particular has highlighted Table 8.1 gives official data from the Czech the role of dysfunctions of the spinal column in the Republic. These give a good overview and are sig- pathogenesis of pain involving the locomotor system. nificant economically; they cover only patients who That discussion will enable us now to formulate a missed work because of their symptoms. strategy for their prevention as we remind ourselves that it is possible to apply preventive principles not Impressive though this statistic may be, unfitness only to therapy itself, but also to rehabilitation, the for work is only part of the problem. It is mainly main goal of which is to ward off relapses and com- low-back pain and/or pain in the lower extremities plications. that renders people unfit for work, and ‘unfitness’ also depends on the nature of the work involved. Before going into detail, we first need to con- It is therefore critical to cite data that relate more sider the importance of locomotor system dysfunc- directly to the incidence of locomotor system dys- tions and the sheer scale of the problems they pose. functions. According to Säker (1957), in a survey The patients we see comprise the vast majority of population aged between 60 and 80 years, 440 out all those who suffer from back pain and from pain of 1 000 people questioned stated that they had associated in any way with the spinal column. The experienced at least one episode of low-back pain or statistical data are unreliable because our patients sciatica in their lives. In his 1951 study conducted are recorded under a range of different diagnostic in Stockholm among 1 200 workers from a variety of labels, for example headache, chest pain, vertigo, occupations, Hult (1954) found current symptoms or a history of cervical disk or lumbar disk lesions in 51% and 60% respectively. In a randomly selected

Manipulative Therapy Table 8.1 Numbers unfit for work per 100 000 inhabitants in the Czech Republic and average number of working days lost Disease category Year Average number of working days lost 1968 1979 1989 2004 1989 2004 Locomotor system disease 7898 9451 11 798 11 627 21.9 53.0 Vertebrogenic disease 3763 4895 7338 19.9 * Circulatory disease 3114 3335 2254 35.7 Psychiatric disease 1430 1229 1075 32.0 69.4 Neurological disease 1037 940 732 29.0 68.9 Respiratory infection 36 538 40 203 37 896 9.4 64.0 17.6 *Since 1989 ‘vertebrogenic disease’ has no longer been categorized separately in the statistics issued by the Ministry of Health of the Czech Republic. rural district near Prague, Uttl (1966) found that our dietary habits altered, but we are also exposed to 61 subjects from a representative sample of 100 air and water pollution and to risks from chemicals had a history of vertebrogenic symptoms. and radiation. And the change in our locomotor hab- its has been no less radical: although we have become When older and more recent data are compared, increasingly sedentary, excessive static strain is on the it is evident that the incidence of such dysfunctions increase. It is precisely this that produces the imbal- is increasing year on year and that the number of lost ances described by Janda: our predominantly postural, working days has in fact doubled over the course of phylogenetically ‘older’ muscles become hyperactive 20 years. Locomotor system dysfunctions primarily and contract, whereas our predominantly phasic, phylo- affect middle-aged individuals, that is those in the genetically ‘younger’ muscles grow flaccid. The same most productive years of their working lives. Treat- process is also at work in the deep stabilizers. This ment is frequently time-consuming and costly, and is one reason for the epidemic increase in disorders there is a marked tendency for these conditions to involving the locomotor system and spinal column. become chronic. The cardinal symptom is pain, and this is associated with a burden of suffering that is Instead of walking, or even riding, we sit or stand impossible to quantify. According to Frymoyer (1991, in automobiles and other vehicles in which we are Frymoyer et al 1980), back pain affects 80% of the jolted about. Most work nowadays is carried out general population at some point in their lifetime. in a more or less fixed position, frequently sitting or bending forward. Long hours of working at the 8.2 Principles and goals of computer are especially harmful. And the worst prevention thing about this unfavorable trend is that it begins in early childhood: in front of the TV screen, sit- As locomotor system dysfunctions play a key role ting in school, or playing computer games. Children in the pathogenesis of back pain, it is important to travel to school by automobile, bus, or tramcar, know the circumstances that most frequently pro- even though the distance may be short. Healthy duce them. Major factors here also include muscle children may resist this trend for a while, boister- imbalance, instability, and faulty patterns of mus- ously involving themselves in fun and games, but cle movement, among which incorrect breathing is once they start to grow older they are seduced by probably the most common. the appeal of watching TV, riding motorbikes or sitting in a café or bar. These facts deserve to be No less important is the influence of the modern emphasized because the public gaze is so narrowly industrialized world in which we live: not only have focused on environmental pollution that the harm 364

Prevention of locomotor system dysfunctions Chapter 8 done as a result of changes to our patterns of loco- It is important that the height of the desk or motor behavior is easily overlooked. From this there work table is on a level with the elbows when the emerge two logical approaches to prevention: one is to patient is sitting upright with upper arms verti- minimize excessive static strain as far as possible, and cal. If the chair has forearm rests, these should be the other is to seek to compensate for it by exercise. adjusted to the height of the freely hanging elbows. For work at the computer, it is also important that Our highly-developed technological society is the monitor is positioned so that the patient’s gaze suffering from the twin evils of sedentary lifestyle is not directed up or down or to one side. and excessive static strain. Like forward-bending of the trunk, head and 8.3 Lifestyle factors neck anteflexion can also pose problems in the long term. Care must therefore be taken to ensure that 8.3.1 Passive prevention this head position is avoided if at all possible. If the work surface is horizontal, the plane of the visual Sitting field forces the head into anteflexion. This can be overcome by using a desk with a tilted surface but As most of our time is spent seated, a correct sit- not by raising the height of the desk. A potentially ting position is of great importance. This, how- even more harmful situation arises when simple ever, depends on the chair used: the height of the head and neck anteflexion is compounded by rota- chair is correct if the subject’s thighs are horizon- tion of the head to one side. This is the position tal, with feet resting flat on the floor. The back of typically adopted by keyboard operators as they the chair should provide support where the kypho- copy texts lying flat on the desk. The remedy is for sis peaks in a position of complete relaxation (see the text to be positioned directly in front of the Figure 6.159). When the patient is sitting relaxed, keyboard operator. the peak of kyphosis is more often in the lumbar than in the thoracic region of the back. Under these Standing circumstances it may even be helpful if the sitting surface is tilted backward slightly. If leaning back is If work is performed standing, the goal should be an not possible, then the patient’s elbows and forearms erect posture, because a forward-bending position should be able to rest on the desk or work surface. held for any length of time is always a strain. At this point it is helpful to note that bending forward If the patient is not supported either by the chair slightly, for example over a wash basin while shav- back or the desk/work table, it is better if the seat ing, may constitute more of a strain than maximum slopes up at the back, rather like a saddle, because forward-bending. This is because in the former this tilts the pelvis forward and prevents excessive position the erector spinae is maximally contracted, lumbar kyphosis. Special chairs are now manufac- exerting greatest pressure on the spinal column (see tured with the seat tilted forward and a knee rest, Cyriax’s ‘painful arc’, Section 4.6.1). During for- thus ensuring that the patient sits up straight. How- ward-bending, it is therefore always recommended ever, it is helpful to advise the patient to change sit- to advance one leg while bending the knee at the ting position as soon as back pain is felt, and chairs same time (see Figure 4.72). When standing at the should be recommended that allow patients to vary wash basin, patients should turn to the side slightly their position. Specially-designed wedged cushions and brace themselves with one thigh against the are also recommended. Long periods of sitting can basin. be particularly harmful if they are compounded by jolting, for example when riding on lorries or trac- Lifting and carrying tors (the shock absorption and suspension on such vehicles should therefore be as smooth and efficient If lifting is the cause of symptoms (or relapses), as possible). the patient must be taught how to lift objects cor- rectly. For light objects, the principle is the same as when bending forward: there must be harmoni- ous synergism between the trunk and the advanced leg, and ‘uncurling’ of the trunk is accompanied by 365

Manipulative Therapy co-contraction of the abdominal muscles. Heavy to patients to lie flat. This counsel may be helpful objects should be lifted with a straight back while for a young person who sleeps in the supine posi- bending and straightening the knees and holding tion. However, if the patient sleeps side-lying, it the load close to the trunk to eliminate any lever- should be remembered that the shoulders are wider age effect. Here, too, it would be ideal if everyone than the head. If such a patient sleeps with only obliged to work bending forward for long periods a thin pillow (or no pillow at all), this means that were encouraged to change this position occasion- the cervical spine slopes downward at an angle. The ally, or given a short break in which to do so. patient’s head should be supported so as to keep the cervical spine in a neutral position; this will Sleeping position depend not only on the width of the shoulders but also on the position that the patient adopts. Many Just as important as the position held during the patients demonstrate a side-lying position in which day is the way the body lies at night, in bed. It is no one arm is under their head. While they cannot exaggeration to say that there are few lifestyle fac- sustain this position for long, they are nevertheless tors that affect the spinal column so powerfully – demonstrating their need for a sufficiently thick for good or ill – as the patient’s sleeping position in support. The pillow should be squarish, sufficiently bed. This applies especially in cases where a patient big so that the patient’s head does not slip off it, reports that symptoms are felt mainly during the and firm enough to give constant support. It must night or in the morning on waking up. Question- not be placed under the shoulders and therefore ing about the type of bed slept on is usually fol- should not be wedge-shaped. lowed by advice to use a hard mattress over a firm, unyielding frame. We believe that this is the wrong If the patient has the unfortunate habit of lying approach. The patient should first demonstrate the prone, this should be discouraged, because it is a usual sleeping position and only then should we position that forces the cervical spine into maximum offer advice on how this might be corrected. For rotation. Again, a firm pillow giving the necessary this we need to know, for example, whether the support to allow comfortable side-lying will both patient’s symptoms are mainly in the cervical or encourage this and prove an obstacle if the patient lumbosacral region. tries to turn into a prone position. Specially-designed pillows with a hole for the face and nose can be pur- If symptoms are mainly in the low back we need chased that enable the patient to lie prone with the to know whether the patient sleeps in the supine, head in a neutral position. However, this position side-lying, or prone position. If the answer is supine may produce extreme cervical lordosis. The most or prone, and symptoms occur during the night or suitable compromise for those who cannot drop this on waking, the trouble is usually due to lordosis. We habit is to place a large pillow under the shoulder may then advise the patient either to adopt a side- and chest on the side to which the head is turned, lying position, or – if the patient lies supine – to instructing them to clutch this to them, thus lessen- put a thick pillow under the legs or a rolled towel ing neck rotation. The habit of lying prone usually or blanket under the waist. If the patient sleeps dates from early childhood, when the position has in the prone position, it is usually best to advise a much to recommend it; later in life, unfortunately, different position. If that proves impossible, it can it can give rise to pathological changes. be helpful to raise the pelvis using a pillow. If side- lying produces symptoms, this may be due to scoli­ Even when lying supine, most older people with osis because the shoulders and pelvis are wider a rounded back need a fairly thick, firm head sup- than the waist. In this case a rolled towel should be port to prevent their head falling into retroflexion. placed under the waist. Head retroflexion is not only unfavorable for the cervical spine but may actually jeopardize the blood More often though it is necessary to correct the supply to the vertebrobasilar region, especially if patient’s sleeping position due to symptoms associ- there are already signs of arteriosclerosis. ated with the cervical spine. This is also borne out by the fact that acute wry neck and cervicogenic Summary headache most frequently occur after a night in bed, and radicular pain has a tendency to be worse In each individual case it is most important to iden- when lying down. All too frequently advice is given tify the circumstances that precipitate symptoms, 366

Prevention of locomotor system dysfunctions Chapter 8 so as to prevent further disturbances or relapses. their devotees, their usefulness for prevention of In fact, there is probably no more effective way of disease is highly questionable. Indeed, competitive helping these patients than by judicious advice con- athletes are among the groups who are most at risk cerning workplace organization, leisure activities, and most likely to become our future patients. and sleeping position. It cannot fall within the scope of this book to Our best treatment efforts often go awry give a comprehensive picture of the effect of vari- because we fail to discover that the patient adopts ous types of sport on the locomotor system. It a faulty position when working at the computer, may be useful, however, to give a few examples of or sits incorrectly when driving, or stands without how to approach the question. Take swimming, for proper support. It is therefore a grave omission on example, considered by most people to be a par- our part if, after learning that symptoms occur in ticularly ‘healthy’ sport: all the muscles are brought the morning, we do not ask for a demonstration into play, the body weight does not act on the spi- of the patient’s usual sleeping position – or if we nal column and there is very little risk of injury. On learn that symptoms are precipitated by lifting or further analysis, however, we find that the breast carrying objects and fail to investigate the patient’s stroke and even the crawl make the pectoralis mus- techniques for doing this. Indeed, one of the main cles overactive and taut, so that most swimmers purposes of taking the case history is to investigate become slightly round-shouldered. Moreover, most these matters meticulously. We are of no help to exponents of the breast stroke and the ‘butterfly’ the patient in the long term if we detect a lifestyle tend to develop lumbar hyperlordosis and hyper- error on repeated visits and fail to offer advice as mobility. Elderly swimmers have a habit of holding to how this might be corrected. It also follows that their head out of the water while swimming, keep- prevention of disease or relapse and advice on life- ing the cervical spine in hyperlordosis. All of which style-related issues apply equally to patients and to is not intended to imply that swimming is harmful. the healthy population. Patients who are round-shouldered or who have lumbar hyperlordosis should be advised to swim on 8.3.2 Active prevention their back if they suffer from low-back pain. And because swimming in cold water sends a signal to There are a number of activities – especially lei- the body to form a good layer of insulation, this sure pursuits – that can be used to compensate for particular type of swimming is not recommended the potentially harmful effects of the technological for people wishing to lose weight. society in which we live. Volleyball is one of the most popular and at Sports the same time one of the most dangerous types of sport. As they leap up and land again on the The amount of exercise taken can be easily ground, players at the net must keep their lumbar increased by making minor changes to our habitual spine in hyperlordosis so that no part of their body lifestyle: for example, people might walk to work touches the net. This is most unphysiological and or use the stairs instead of taking the elevator. constitutes a great danger to the low lumbar disks (‘nutcracker mechanism’). High-board diving poses Patients often ask which activities or sports they dangers for the same reason, with spondylolisthesis should take up for prophylactic reasons. The ques- being significantly more frequent among divers than tion seems straightforward, but we are instantly in the population at large (Groh 1972). aware that there is no simple answer. Not only do the various forms of sport and physical exercise As usually taught, gymnastic exercises have a affect our bodies in very different ways, but they tendency to aggravate muscle imbalance, particu- may even be downright harmful. It is therefore larly when the legs and trunk are held straight and essential to analyze each type of sport carefully, at right angles to each other. In order to achieve bearing in mind the patient’s constitution and their this, the gymnast is required to suppress the nor- medical history. Then there is the question of com- mal function of the abdominal muscles, which is petitive sports: in view of the extreme and ever- to approximate the xiphoid process of the sternum increasing demands made by competitive sports on to the pubic symphysis and thus bring the lumbar spine into kyphosis. Instead, the iliopsoas and the erector spinae enable the gymnast to hold the legs straight at right angles to the trunk, the net result of 367

Manipulative Therapy such training being to provoke what Janda defined women’s fashion are particularly harmful.) At the as the ‘lower crossed syndrome’ (see Section 4.16). same time it is also necessary to develop a certain An important protective mechanism is lost, namely degree of resistance or hardening. Thus although it that of curling and uncurling the lumbar spine, to is sensible to protect regions that we know are apt be replaced by unphysiological leverage in the par- to be vulnerable to symptoms, we should aim to ticularly vulnerable lumbosacral region. In terms harden the body as a whole. Nor should it be for- of prevention, therefore, preference should always gotten that the susceptibility to cold of certain body be given to exercises that have become familiar to regions is often due to a clinically latent lesion that us from yoga or Tai Chi. In these traditional exer- is localized there, and that after successful treat- cise systems, movements are smooth, never abrupt, ment cautious hardening may be undertaken. Nev- while at the same time being rounded and gradual. ertheless, the main purpose of wearing clothes is to Muscle contraction and relaxation are alternated protect the body from the cold, but this should be and there is a focus on correct breathing; all these judicious so as to maintain thermoregulation and aspects tend to be absent from European-style gym- the ability to cope with fluctuations in temperature. nastics. Besides clothing, this also applies to the question of when and to what extent we should expose our Apparatus-based gymnastic exercises routinely bodies to the air, water, and the sun. make the upper fixators of the shoulder girdle over- active, leading to the ‘upper crossed syndrome’ (see There is yet another side to the question, some- Section 4.16). The emphasis on very rapid, forceful thing that might be termed the mechanical effect movement here makes safe control of the body dif- of clothing; and the most telling example here is ficult, and it is not easy to avoid (micro-)trauma. the sometimes devastating effect of brassieres that are too tight. Tight brassieres with thin straps cut One leisure activity that can always be recom- deeply into the skin and muscles of the shoulders, mended is regular walking, preferably on soft paths resulting in permanent excessive strain in which and wearing suitable trainers that support and cush- the shoulder girdle and cervical spine are drawn ion the feet; this is the most physiological form of forward. Overlooking this problem in our female locomotor movement. Similarly, cross-country ski- patients may be the root cause of treatment fail- ing has much to commend it because it also exer- ure. Use of shopping bags instead of rucksacks can cises the arms, as does Nordic walking. We should also be harmful. For men, wearing belts that are also not forget that dancing is among the oldest too tight can be a problem, particularly in cases forms of exercise that people have enjoyed through- where there are hyperalgesic zones in the abdomi- out history. Because it can be carried on for hours at nal or dorsal regions. Braces are recommended for a time, its beneficial effects are considerable while obese patients. Wearing pantyhose is not helpful for harmful effects are a rare exception. Dancing can women with weak abdominal muscles; elasticated also be highly recommended as a weapon in the stocking suspenders are far better if an abdominal war against obesity. However, with the high noise support belt around the waist is not necessary. levels generated by modern amplification systems, a warning against auditory damage may not be out Without doubt, shoes are the biggest prob- of place. lem area. High heels do not merely change the position of the feet but also tilt the pelvis for- Clothing ward, thus altering the body’s center of gravity, as well as accentuating lumbar lordosis, which in Although posture and movement, and their correc- turn adversely affects the abdominal muscles and tion, naturally play the principal part in preventing breathing. What is more, the toes are forced into disturbed locomotor function and its sequelae, the dorsiflexion and the great toe is angled away from influence of other important factors such as food the midline of the body, which encourages the and clothing should not be underestimated. development of splay foot and hallux valgus. From the purely physiological standpoint, only walking It has long been known that regions that are barefoot can be termed ‘normal’; footwear should highly susceptible to pain, such as the neck and low therefore be constructed from yielding material back, should be protected from cold and draughts, that allows the foot to adapt well to the walk- especially in situations where the individual is per- ing surface. Hard soles and heels should therefore spiring. (In this regard, many aspects of modern-day be avoided, and they are especially harmful where 368

Prevention of locomotor system dysfunctions Chapter 8 osteoarthritis is already present in the joints of the pain for which the patient is seeking help would lower extremities. shortly recur if we were not to take such action. From this it is evident that the aspect of prevention Obesity must also be taken into account when we are estab- lishing the indications for treatment. We should It is only too obvious that the campaign against therefore ask ourselves whether, and under what obesity common to many fields of medicine is very circumstances, it is justifiable to treat clinically relevant for the correct functioning of the loco- latent lesions in persons without (perceived) symp- motor system. A vicious circle easily develops in toms, purely for reasons of prevention. This needs which pain (due to overstrain and faulty statics) to be considered particularly in cases of non-painful makes the patient reluctant to move and lack of restriction in a motion segment or of latent trigger movement encourages obesity. points (TrPs) that can be easily abolished. It is beyond the scope of this book to deal in So what are the options for treating patients detail with the problem of obesity. However, it is with non-painful dysfunctions, purely as a prophy- important to decide whether obesity is a relevant lactic measure? Given the astronomical incidence factor in any given case. We should remember that of latent dysfunctions, prophylactic manipulative obesity seriously affects the joints of the lower treatment for the population as a whole is probably extremities in particular, less so the lumbosacral an illusory goal. However, it may be entirely reason- spine, and at most has only indirect relevance for able in future to envisage such preventive measures the cervical spine. We frequently encounter sub- for pre-school and school children. Our own expe- jects who have very little fat on their trunk but rience suggests that a locomotor system check-up whose buttocks and thighs are hugely obese; this once a year would be sufficient, to be carried out may be completely irrelevant for the spinal column. exclusively by qualified physicians and/or physio- therapists. This would ensure prevention during the The patient’s somatic type is also important: decisive growth phase. individuals with a stocky, compact (‘pyknic’) build tolerate obesity much better than those with a There are also a number of at-risk groups for graceful (‘asthenic’) build. A stockily-built subject whom preventive manipulation is indeed desir- who weighed about 80 kg at 20 years, increasing able. The first category comprises patients recov- to 90 or even 100 kg at 50 years, may handle the ering from injury, and this group may be further additional weight very well, whereas someone who extended to include those recovering from painful weighed 50 or 60 kg at 20 years, increasing to 80 visceral diseases where spinal column involvement or 90 kg at 50 years, will be decompensated. When is to be anticipated. Surgical patients are another advising weight reduction we must have good rea- candidate group here because the position of the son to think that obesity is a potential cause of the head for intubation is likely to result in dysfunc- symptoms. tions involving the cervical spine. Similar considera- tions are appropriate following tonsillectomy. There 8.4 Manipulation as a may also be some value in advocating preventive prophylactic measure manipulation for certain occupational groups that appear to be at particular risk, although, as we have Having discussed some of the basic principles of noted, this might be seen as including most occupa- prevention, we will now turn to the question of tions in our modern technological society. However, preventive correction of specific disturbances. there is one group in which manipulative treat- ment for preventive purposes is justified, namely Treatment should not be directed only at the site competitive athletes, a fact which throws light on where pain is manifest. Instead we should attempt the effects of competitive sport. One other aspect to target treatment at those structures that appear should be mentioned while we are on the subject of to be key regions for the dysfunction in question, prevention: it is imperative that choice of employ- even though the patient may be experiencing no ment should take into account the individual’s pain there whatsoever, because we are convinced physical constitution. And here we are most con- that abnormal findings in these structures are a cerned with hypermobility; it is the hypermobile source of potential trouble. We do this because the subject who is least able to tolerate static overstrain and jolting. 369

Manipulative Therapy It would of course be misleading to give the carrying bags/satchels, and sitting. I have already impression that manipulation is the only therapeu- made reference to the potentially harmful effects tic measure with a potential role in prevention. It of traditional European-style exercise systems, but forms the subject of this book, and serves to illus- it would certainly also be possible to introduce trate the fact that a therapeutic method can also many elements from yoga into school gymnastics be useful for prevention. The classic method used lessons. However, the greatest obstacle to achieving in a preventive setting is, of course, remedial exer- this is the attitude of many, if not most, physical cise, and this has been accorded due importance in training instructors. Like sports trainers, they are Chapters 4 and 6. Remedial exercise, too, is effec- primarily interested in those children who shine in tive only if it is applied specifically on the basis of sports and gymnastics – those who (perhaps to their a precise diagnosis. However, it must be empha- own detriment) seem promising as future competi- sized that remedial exercise is far more demanding tive athletes. Instead it is the ‘awkward’ children in terms of time and effort than are manipulation who really need more of the teacher’s attention. or TrP treatment. Herein perhaps lies the chief In sports and athletics clubs, the above attitude reason for its limited practicability in a preventive is even more accentuated: in the public interest, context. youngsters deemed not to have what it takes to make the grade at the very highest level are ruth- Remedial exercise has always been used for lessly dropped from the program. children with bad posture, but it has only ever been implemented consistently in a tiny proportion Finally, there are two groups for whom the pre- of those who need it. A more effective approach scription of remedial exercise is obligatory: these would be to introduce the principles of reme- are women after childbirth and, for the same rea- dial exercise into normal physical education in son, patients with weak abdominal muscles after schools: teaching correct techniques for respiration, abdominal surgery. Failure to prescribe remedial bending down, picking up objects from the floor, exercise in such cases constitutes gross negligence. 370

Chapter Nine 9 Expert assessment of locomotor system dysfunctions Chapter contents pathogenesis, leading us to conclude that function is the decisive factor here. Since it is precisely this 9.1 Assessment of (un)fitness for work . . . 371 aspect that must be reflected in any expert assess- ment, the considerable difficulties are obvious. 9.2 A ssessment of trauma and its consequences . . . . . . . . . . . . . . 373 One problem is that patients have often not received either adequate therapy or rehabilitation. 9.2.1 Did an accident happen? . . . . . 373 This scenario will continue for as long as there are only relatively few physicians who understand how 9.2.2 Did the accident cause the to diagnose and treat locomotor system dysfunc- symptoms? . . . . . . . . . . . . 374 tions adequately. In this highly regrettable situ- ation significant lesions may pass unnoticed, and The words ‘expert assessment’ here refer to any this is a particularly serious consequence in view medical evaluation of a patient in terms of fitness of the principal symptom, that is pain. A physi- for work and potential employment and in terms of cian who is unfamiliar with the diagnosis of pain- any insurance-related issues in the particular case in ful trigger points (TrPs), tension, and resistance in question. the tissues has to rely on the patient’s own descrip- tion of the symptoms. The physician then has 9.1 Assessment of the choice of either believing the patient or not. (un)fitness for work When called upon to provide an expert opinion, the physician tends to search for objective criteria, The most numerous category of patients suffer- in the misguided belief that these are supplied by ing from pain originating in the locomotor system X-ray examination findings. However, any changes comprises those with back pain. While their lives detected in that way are primarily morphologi- are not endangered, they may nevertheless not be cal. Because this approach is consistent with con- fit for the work they are expected to perform, tem- ventional, received wisdom it is psychologically porarily or permanently, and in some cases they are advantageous. The patient is informed, more even threatened with invalidity. In addition, there often than not, of the changes found on X-ray and is the question of harm traceable to the type of these are presented as the true cause of the pain, work they do, or to occupational injury, sometimes thus confirming the patient’s own ideas about the involving litigation with claims for compensation. significance and potential duration of the under- All these aspects have to be assessed by an expert. lying condition. It then becomes very difficult to motivate the patient concerning the benefits of an If the assessment is to be scientifically based, arduous rehabilitation program. it must take account of the pathogenesis, evolu- tion, and prognosis of the condition. Our experi- On the other hand, young patients with seri- ence with reflex therapy and with manual therapy ous pain that is often of a radicular nature are in particular has modified our views concerning

Manipulative Therapy considered to be malingerers because their X-rays soon as possible after learning how to perform these show ‘no degenerative changes’. In recent years, activities correctly. despite significant advances made in the fields of computed tomography (CT), magnetic resonance If the symptoms are due to lack of exercise, we imaging (MRI), and ultrasound, not much has should be reluctant to forbid movement, even if it altered; indeed, if anything, the situation has become is perceived to be unpleasant. It should not cause even more complicated. It is beyond the capability of a sensation if a patient who is signed off sick from any imaging technique to demonstrate the relevance work is spotted walking in the countryside or even of morphological changes, that is to show whether moving about on skis so as to get fit. the patient has a herniated disk or ‘merely’ narrow- ing of the spinal canal. If no radicular syndrome is Sometimes unfitness for work is caused not by present, even a herniated disk may be irrelevant. the patient’s work itself, but by how the patient These findings, obtained using the most up-to-date travels to and from work, particularly if the journey and most expensive techniques, divert attention involves being jolted about. away from gross yet highly relevant dysfunctions. Here again it is important to distinguish between It is therefore important to give some indication (low-)back pain, with or without pain referred here of how an expert assessment can and should be to the lower extremities, and true radicular pain. performed with regard to disturbed function. While In the former case, movement (especially walk- we cannot deal with all types of pain caused by loco- ing) is usually very well tolerated and should be motor disturbance, we will focus primarily on back encouraged, while in the acute stage of a radicular pain and radicular syndromes, because these are the syndrome it may be harmful. Patients with degen- commonest causes of unfitness for work that neces- erative joint disease involving the lower extremities sitate expert assessment. Because expert assessment do not tolerate walking (or standing) for long peri- is chiefly called for in conditions with a chronic or ods, especially on hard paved surfaces or concrete. chronic relapsing course, we will deliberately not be considering acute cases. It is also important to There is a specific problem in the case of patients exclude pathological conditions such as ankylosing who have been unfit for work for a long period spondylitis, tuberculosis, osteoporosis, etc. due to a radicular syndrome, particularly where an operation has been necessary. These people are Chronic disease courses without pathomorpho- out of training. If a young athlete, for example, logical findings are characterized by decompensa- were confined to bed for several weeks or months, tion due to dysfunctions of muscles, joints, or soft nobody would expect them to be ready to compete tissues, by faulty statics, or by muscle imbalance. again straight away. However, people with physi- The chief concern must be to correct these, so as cally demanding jobs do not enjoy the same consid- to reverse the pattern of dysfunction, while at the eration, although it should be obvious that a period same time assessing to what extent the work the of adaptation is necessary if they are to train them- patient is expected to perform contributes to this selves up to the same level of efficiency as before. decompensated state. This assessment of the loco- If we do not want to run the risk of relapse, it is motor system has to be performed specifically in helpful if the patient works for a time under some- each individual case. what easier conditions, that is either part-time or omitting some of the more demanding operations For instance, if a patient consistently develops involved, until full work fitness is regained. back pain after sitting for extended periods, there should be a (temporary) ban on sedentary work but Even though they are equally intense, pain in the walking should be encouraged if the patient feels low back and the lower extremities is a more fre- comfortable with this. First, however, a check must quent cause of work incapacity than pain involving be made to ensure that the bad effects of sitting are the neck, head, or upper extremities; this is because not due to an unsuitable chair or to a table at the intense low-back or lower extremity pain may pre- wrong height. Similarly, if the symptoms are pro- vent the patient from standing or walking. Pain of duced by bending down, lifting, or carrying loads, cervical origin may result in unfitness for work if the it must be established whether the patient’s corre- job demands full use of the hands or if the nature sponding movement patterns are at fault – in which of the work considerably aggravates the pain. (As an case these must be corrected. Steps should also be aside, pain is often more bearable if the patient is taken to ensure that the patient returns to work as not alone and resting or ‘taking things easy’.) From all that we have noted so far, it is evident that in terms of function it is possible for the expert 372

Expert assessment of locomotor system dysfunctions Chapter 9 to make a concrete assessment of the demands was due to injury. When someone bends forward to imposed on the patient by a particular type of work lift a heavy object, the force generated in the trunk and to relate these demands to the patient’s symp- on straightening up may amount to several hundred toms and capabilities. In this way the patient can kilograms. If in such a situation a sudden, uncoordi- be helped far more efficiently to overcome those nated, jerky movement occurs, for example if the symptoms produced by locomotor system dysfunc- person slips or unexpectedly lets go of the load, the tions or by adverse circumstances in the workplace. dynamic forces brought to bear on the lumbosacral junction may be even greater. Before turning to the much-discussed question of trauma, it will be appropriate to say a few words It would be illogical not to regard the sudden, about the harmful effects of certain types of work unexpected effect of such a force as an injury. per se. In the preceding chapter we noted the unfa- We know from experience that sometimes it will vorable repercussions on the locomotor system of not be easy to determine with certainty precisely most forms of work in our technologically developed which mechanism actually caused the alleged injury world. Having said that, there are certain occupa- because most injuries affect the spinal column tions that appear to be particularly vulnerable from in­directly. If, therefore, symptoms pointing to spinal this point of view: drivers, particularly those exposed involvement occur after a fall on to the buttocks, to severe jolting, as in a tractor; people whose jobs shoulders, or head, they should be considered as a involve extreme static overstrain, for example long consequence of the trauma, even if the patient is hours of computer work in an ergonomically unsound unaware of the connection. The greater the damage position; and production line workers who have to to the structure directly injured, the easier it will perform rapid hand movements for hours at a time be for indirect spinal involvement to be overlooked. (repetitive strain injuries). Even so, it seems prema- Immediately after fracture of the humerus or pel- ture to regard back pain as an occupational disease. vis, local pain is such that it draws all attention to the major trauma, while the insidious concomitant Frequently, symptoms develop if patients are injury to the spinal column is barely noticed. In engaged in work for which they are clearly unsuited the cervical spine, this same phenomenon is often physically. This should be prevented by screen- seen in whiplash-type injury. After the fracture has ing employees in the workplace when they are first healed, the vertebrogenic symptoms deteriorate taken on. Worst affected are older employees who and often assume a chronic course. It is also not find it hard to adapt and have to move to another sufficiently recognized that a fall on to the shoul- job. They then rightly claim that symptoms appeared der or a blow on the head (e.g. in boxing) can have or got much worse because of their new job. How- an effect similar to that of whiplash injury after a ever, the real fault lies in lack of prevention. classic rear-end automobile impact. 9.2 Assessment of trauma It should be recalled that although a patient’s and its consequences symptoms after trauma are frequently due to dis- turbed function, only relatively few physicians Because an accident, and particularly an accident have the skills needed to accurately diagnose loco- in the workplace, may give the patient the right to motor system dysfunctions. And it can be particu- claim compensation, this is a frequent area for litiga- larly difficult to recognize hypermobility resulting tion and one that requires expert assessment. The from trauma. It may easily happen therefore that expert needs to consider two main questions: (1) Did patients who have suffered injury end up ‘merely’ an accident really happen? and (2) Was the alleged with disturbance of function. If they then com- accident responsible for the patient’s condition, and plain of symptoms, they are dismissed as having to what extent? Both these questions may be conten- ‘no objective signs of illness’, their pain is labeled tious and therefore both will be explored here. as ‘psychological’ and in the worst-case scenario they may even be accused of malingering. Inevita- 9.2.1 Did an accident happen? bly, patients register this and feel a deep sense of injustice. A typical conflict then ensues, in which If a heavy object falls on someone’s toe and causes patients tend to come off worse, eventually react- fracture, nobody would question that the fracture ing in a neurotic and usually inappropriate way, and sealing their own fate. The diagnosis is then one of ‘pain behavior’, although this is often the result of 373

Manipulative Therapy physician ignorance regarding dysfunctions that are again the trauma would have been no more than a eminently treatable. precipitating factor. 9.2.2 Did the accident cause The above reasoning can be criticized point by the symptoms? point, as follows: Where trauma as such has been admitted, the ques- 1. There are conditions under which a disk tion then to be answered is whether the patient’s may prolapse even if intact. This occurs symptoms are indeed the result of the accident. when a force impacts the disk in lordosis or This is a difficult question in some circumstances, hyperlordosis, as is known from those tragic for example if symptoms do not follow immedi- accidents when an adolescent diver’s head ately after the accident and if there is a symptom- strikes the bottom of a pool. Acute herniation free interval of days, weeks, or even months. We of the disk then compresses the spinal cord, know that the immediate result of an accident may resulting in quadriplegia. In this process the be ‘merely’ disturbance of function and that this vertebrae remain intact and the radiological may not become clinically manifest for some time, appearance is normal. being triggered, for example, by a sudden move- ment or by additional strain. 2. Disk degeneration is a very common condition, as confirmed by radiological Another contentious issue is whether the trauma evidence of such in the majority of persons affects a structure that was completely intact, or studied over 50 years of age. Yet relatively whether the structure now affected has previ­ few suffer from any clinical manifestations at ously been injured. This question is frequently put all, let alone from radicular pain. in cases of elderly patients in whom degenerative changes are usually already present. It is reasonable 3. Even if a disk has prolapsed, it may be to argue that trauma impacting an intact structure asymptomatic: disk herniation is often an should cause less harm than if there was previous opportunistic finding at autopsy in subjects damage to the structure. In the first case there is who never suffered radicular pain (McRae ‘merely’ a (reversible) dysfunction that, if treated 1956). Currently, thanks to CT or MRI, we adequately, should recover in time without sequelae. are detecting increasing numbers of herniated In the second case (with the previously damaged disks that are clinically irrelevant, that is the structure), even if the patient was symptom-free patient’s symptoms have cleared up. This prior to injury, there were probably compensatory serves to confirm the commonly opportunistic mechanisms at work that were already functioning nature of this finding, as pointed out by well; the subsequent trauma therefore brings about McRae more than half a century ago. decompensation, which may be (and frequently is) a much more serious condition. It is therefore untenable to argue that particular morphological, mainly degenerative changes are In actual fact, however, most expert assessors necessarily predictive of certain clinical conditions. arrive at the opposite conclusion. They reason that This applies not only to the ‘degenerative’ changes in view of the demonstrable morphological (i.e. themselves but also to the disk lesions associated degenerative) changes, the patient would sooner with them. or later have developed the same symptoms, and therefore the trauma did not produce the symp- In principle, it is wrong to assess the conse- toms but merely caused a clinically latent disorder quences of trauma as ‘less serious’ simply because to become manifest. The same thinking is also used pre-existing degenerative changes have been dem- to explain the clinical manifestation of interverte- onstrated. To follow that line of reasoning may give bral disk herniation. Again the argument runs like rise to a number of potential anomalies, as illus- this: trauma affecting an intact spinal column is trated in the following example. A young injury vic- more likely to result in fracture of the vertebra than tim with an intact locomotor system would receive in disk herniation. If, however, signs of disk degen- extremely generous compensation, even though eration are already present, prolapse with its clinical recovery from the consequences of trauma is nor- consequences would have occurred anyway, so that mally quite straightforward. By contrast, an older injury victim with no symptoms up to the time of the accident (i.e. because of good adaptation to any pre-existing degenerative changes) is likely to show 374

Expert assessment of locomotor system dysfunctions Chapter 9 functional deterioration following trauma. This already had symptoms before the accident and the individual would receive relatively little financial clinical course alternated between typical episodes compensation despite the fact that recovery from and remissions, then the trauma was at most a injury will be far more difficult than in the case of precipitating cause, and even then only if the pain the younger colleague. occurred shortly afterward. And this is irrespective of the presence or absence of degenerative changes The crucial question then is: what are the cri- on X-ray. As most employed persons are registered teria for providing an expert assessment in the with a physician, it is not usually difficult to estab- field of locomotor system dysfunctions? The basis lish how often the patient sought medical help for here should be the clinical examination because pain even before the accident and whether the this offers insight into the significance of any dys- symptoms had previously necessitated the patient functions present and provides a measure of the being signed off sick. intensity of the reflex changes that are the direct expression of the pain or nociceptive stimulus. Trauma impacting a previously damaged but compensated spinal column will have more serious However, the true role played by trauma is repercussions than trauma impacting an intact determined primarily on the basis of the case his- spinal column. The fact that a patient shows tory: according to the criteria set out in this chap- evidence of pre-existing degenerative changes in ter, did the trauma really occur and was the patient no way justifies the assumption that symptoms in fact symptom-free up to the time of the acci- and/or disk herniation would eventually have dent? If the answer is yes on both counts, then the occurred anyway. A useful criterion here is the trauma must be recognized as having caused the presence of similar symptoms prior to the accident. patient’s symptoms. The pain-free interval between the occurrence of trauma and the onset of symp- toms should be relatively brief and not longer than a few weeks. On the other hand, if the patient 375

Chapter Ten 10 The place of manipulative therapy and its future There are two aspects to manipulation. First, it is and of adductors and abductors and of external and an extremely effective form of reflex therapy in internal rotation in the extremities. In addition, many types of pain, a feature that it shares in com- we know that the deep stabilizer system operates mon with many other methods of physical therapy to maintain the otherwise labile equilibrium of the such as massage, electrical stimulation, and local human body in the sagittal plane. The harmonious anesthesia. Second, it is a specific form of treat- associated movement of all soft tissue, including the ment for important locomotor system dysfunc- viscera, is a further important element that should tions, namely for functionally reversible movement not be forgotten, as demonstrated by the role of restrictions involving joints and motion segments active scars in pathogenesis. of the spinal column. And these movement restric- tions can be regarded as a model for locomotor Familiarity with all the above aspects is indis- system dysfunctions in general. pensable if we wish to negotiate the uncharted ‘no man’s land’ of dysfunctions devoid of gross patho- It soon became clear that treatment of restricted logical changes that occupies the indeterminate joint movement had its limits and that passive borderlands between the traditional specialist dis- movement restriction in itself involves not only ciplines of neurology, orthopedics, rheumatology, joints but also muscles. It was this recognition of and physical medicine. We have coined the phrase the importance of trigger points (TrPs) and their ‘functional pathology of the locomotor system’ to role in restricted joint movement and in the patho- describe this no man’s land. The most frequent genesis of locomotor system pain that signaled the clinical manifestation of this pathology is pain, next decisive step forward. Indeed, the close inter- the symptoms of which include TrPs, hyperalgesic relationships between joints and muscles became zones, restricted joint movement, and changes in the starting point for further advances, leading to tissue tension. an improved understanding of active movement and its dysfunctions, and enabling us to identify muscle Manipulative or manual medicine played a major imbalance and faulty motor patterns. role in these developments not only as the initial step toward ‘functional pathology’, but also because No less important than movement are posture as a form of ‘bloodless surgery’ it called for pre- and statics, as demonstrated by the ever-increasing cise palpatory diagnostic skills. While it is relevant practical significance of excessive static strain in in restricted joint movement, this palpatory diag- contemporary technological society. In recent years nostic aspect also serves to enhance understanding we have benefited immensely from progress in the of muscle TrPs, of soft-tissue mobility and relative field of developmental kinesiology made by Vojta & displacement, and ultimately of pathological resist- Peters (1992) and Koláˇr (1996, 2001) and this now ance in the abdominal cavity where active scars are forms the basis of our understanding of upright pos- present. In all these changes, the barrier phenom- ture in humans. These insights relate to the co-acti- enon is utilized to impart a degree of objectivity vation pattern of flexors and extensors in the trunk to palpatory findings. Only a diagnostic approach

Manipulative Therapy that includes all tissues will permit comprehensive it has been found that most chain reaction patterns therapy that is consistent with the pathogenesis of originate in the deep stabilizers of the trunk (which locomotor system dysfunctions. are intimately associated with respiration) and in the feet. For all the importance that has come to be attached to the manipulative treatment of joints, it The key role in stability is played by mono­ is only one method among many. Anyone who uses it articular muscles which are largely under involuntary should never limit themselves to just one method, no control. Dysfunctions of these muscles very often matter how effective it may be. The object of treat- result in intensive chain reaction patterns that man- ment is not any single method but the locom­ otor ifest themselves as pain due to TrPs and movement system and, primarily, its function, and historically restrictions. These lead in turn to faulty movement this has had no specialist discipline of its own. Today patterns that create a kind of compensatory sta- there is a growing tendency to designate this emerg- bility in which the true stabilization system is no ing specialty as ‘musculoskeletal medicine’. longer operative. After successful activation of the deep stabilizers, it is routinely observed that TrPs We should remind ourselves that locomotor and movement restrictions disappear throughout system function is the most complex of all func- the system as a whole. tions in the human body, and this is reflected in the fact that the largest part of the brain is associ- Summarized in the proverbial nutshell, the ated with locomotor system function and control. development has been from joint to muscle, and This control is reflected in motor system programs from an accent on mobilization to stabilization, that are designed to implement function: these which leads automatically to the release of patho- relate to the locomotor apparatus as a whole, and logical movement restrictions, provided that these this explains why dysfunctions only rarely affect a are not caused by viscerovertebral reflex mecha- limited part of the locomotor system but usually nisms or active scars, for example. involve the system as a whole. The clinical expres- sion of this fact is the chain reaction pattern: this Recognition of the importance of muscles and phenomenon was initially understood solely in TrPs has not been without consequences for the empirical terms although we are now beginning to development of manipulative techniques, and of unravel something of the theoretical background too. mobilization in particular. In recent years we have learned to apply neuromuscular techniques that One major difficulty is that although we are make use of the patient’s own muscles to achieve familiar from experimental research with the basic mobilization. TrP relaxation and mobilization go neurophysiology of reflex mechanisms at a spinal hand in hand, serving simultaneously also to abol- level up to and including the brainstem, the same ish pain at the attachment point of the tensed mus- cannot be said for those that encourage the co-acti- cle. And from these techniques that depend on the vation patterns responsible for human upright pos- active cooperation of the patient it is just a small ture and stability. These are reflex processes that we step to self-treatment: every patient should be observe daily when we treat the lower extremities assigned a daily program of home exercises tailored or the trunk and provoke reactions in the cervical specifically to the most recent examination find- region, or conversely when we treat the craniocer- ings. In this way, therapy transitions seamlessly into vical junction and influence function in the pelvic rehabilitation, with the practitioner functioning region. Vojta’s developmental kinesiology has pro- merely to monitor progress and suggest corrections. vided some insight into these situations: his stimu- lation techniques demonstrate these reflex patterns This trend has also had the effect of bringing a in humans in an ‘experimental setting’ as it were. radical change to the relationship between practi­ tioner and patient. In most fields of medicine the Advances made in the theoretical field are the unquestioning patient expects to be cured of suffer- prerequisite for understanding the modern-day ing, whether by drugs, surgery, or miracle. In such development of musculoskeletal medicine. The situations where the practitioner is the authority practical point to emerge from the concept of chain figure, the patient is the object and is not required reaction patterns is that once the relevant link in to do anything, and certainly must not ask (annoy- the chain has been identified, it is then possible ing) questions. In manual medicine, however, the not only to administer treatment with the utmost patient is the subject and, as such, cooperates intel- economy, but also to determine the direction for ligently at every opportunity even while treatment further therapy and rehabilitation. In this context is in progress, increasingly taking responsibility for 378

The place of manipulative therapy and its future Chapter 10 self-treatment and responding to advice designed to patients and how to approach them in a hands-on correct lifestyle errors. If the patient is moved out manner, while already possessing a broad under- of the ‘comfort zone,’ so too is the practitioner who standing of the principles of manipulative therapy. has to face up to the difficult problem of psycho- Because it is indispensable for rehabilitation, the logical motivation. It is illusory to imagine that the functional approach is also more intuitive for the function of the locomotor system, the organ of vol- physiotherapist. untary movement, can be treated successfully with- out the active involvement of the patient. From The division of labor between physician and the very outset the human factor plays a major role physiotherapist will vary considerably, depending on here, as reflected in the intimate hands-on contact the manual skills of the physician and physiotherapist established with the patient. working together in the same team. The physician may initiate therapy in order to be satisfied about At a time when apparatus-based techniques have the correctness of the diagnosis and case analysis, come increasingly to the fore, we must continue to but the physician may also delegate therapy to the rely on our hands and eyes as we strive to acquire physiotherapist; however, as physiotherapy proceeds, those skills that modern medicine has largely the physician will need to assess the results so far neglected in favor of sophisticated (and costly) and then determine any subsequent treatment technology. Only the skilled human hand is capable steps in consultation with the physiotherapist and of sensing the patient’s reactions and of adapting to patient. the patient’s needs. The function of the locomotor system is an expression of personality and therefore It is to be expected that, because of their training, a personal relationship between patient and practi- physiotherapists will on average be better prepared tioner is vital. The logical conclusion to be drawn than physicians for the practice of manual medicine. is that manipulation has its place within the frame- Because manipulative therapy moves naturally and work of physical medicine and rehabilitation, the goal seamlessly into rehabilitation where the activity of of which is to restore function using physiological the patient is crucial, the physiotherapist has an methods. important role to play here. In consultation with the physician, the physiotherapist is also respon- Attainment of this goal is possible only in a team, sible for the application of other physical therapy the members of which are the physician, the physio­ modalities. therapist and the patient. The role of the physician is to form the diagnosis and, most importantly, to As in the past, so too in the future, the training analyze the locomotor system dysfunction. This of physicians and physiotherapists is a decisive necessitates close familiarity with the functional factor, with the functional approach being more approach, and this is as difficult to acquire as a important than mere cramming of facts, which polished manual technique. Because the univer- often simply involves regurgitating what was taught sity education of physicians in mainstream medical during student days and then forgetting it again. schools leaves much to be desired in this respect, In this respect, too, the physiotherapist has things intensive efforts are needed to introduce appropri- easier because, as far as the physician is concerned, ate training for physicians who wish to specialize the functional approach invariably entails a degree in musculoskeletal medicine. The treatment itself of re-learning, and that is always difficult. For should then be implemented in consultation with practical training purposes, a sufficient number of the physiotherapist. instructors is essential in order to guarantee high- quality courses. And if participants are to acquire The problem for physiotherapists today is due the necessary skills, the trainee-to-instructor ratio in no small measure to the fact that their training should be such that one-to-one tuition is possible. lacks uniformity. However, one certainty is that the The foundation stone of good technical training is a future belongs to physiotherapists who, as a mini- hands-on approach. mum requirement, have completed a full univer- sity degree course. This is already largely the case For the reasons enumerated above, it would be in the Czech Republic; on completion of university highly desirable if the basic principles of musculo­ studies, the graduate physiotherapist has a greater skeletal medicine and rehabilitation were intro- knowledge of the locomotor system than a physician duced into the medical school curriculum, with newly qualified from medical school. By that stage the objective of awakening interest in this special- the physiotherapist has also learned how to inspect ist field. Given the enormously high incidence of patients with painful dysfunctions of the locomotor 379

Manipulative Therapy system, every family physician will inevitably come for the more demanding cases where structural up against these conditions on a daily basis but at changes are generally also present. present can do little more than prescribe analge- sics. They should themselves at least be capable The locomotor system, the subject of this book, of adequately treating the more straightforward is the largest and most intricate system in the cases. With the easily learned and safe mobilization human body. We need to learn not only to under- and soft-tissue techniques in current use, it is also stand its function better but also to take better care unlikely that the patient will be harmed in any way. of this precious and perfect instrument that we have at our disposal. In an age when we are learning And this brings us to the ultimate goal of our to use ever-more sophisticated mechanical systems, work. The vast majority of painful disorders desig- we are losing an intelligent understanding of our nated as ‘functional’ and perceived by the patient own bodies. And this applies particularly to those as organic disease have their origin in the loco­ of us who treat other people: we have learned to motor system and its dysfunctions, which simulta- utilize increasingly complicated equipment while neously give rise to innumerable minor painful at the same time neglecting the evidence of our ailments. The techniques described in this book are eyes and in particular of our hands, as well as for- suitable for treating these conditions using physio­ getting how to communicate with our patients. logical methods. It would indeed be a significant However, by comparison with communicating with contribution to modern medicine as a whole if these the patient, observing with our eyes and sensing methods, which are free from side effects, were to with our hands, no piece of high-tech equipment is be judiciously brought into play in such patients. able to yield such a wealth of varied information. Pharmacotherapy, injections, and anesthesia, etc. And all this is heightened by the capacity for feed- (with all their side effects) could then be held in back – indeed empathy – between practitioner and reserve, ready to be deployed at the right moment patient. 380

Glossary Agonist A muscle that causes Eccentric movement against Motor program The sum total of resistance A movement against movements that permit complex a specific movement to occur resistance in which the examining activities; a motor program Antagonist A muscle that acts in practitioner overcomes the comprises memory, triggering, opposition to or slows down the patient’s resistance and combinatory skills and usually specific movement generated by involves the whole locomotor the agonist muscle Facilitation The promotion of muscle system activity Autonomic reaction A reaction of Motor stereotype The sum total of the autonomic nervous system, Gamma system The efferent unconditioned and conditioned particularly involving the internal motor system consisting of fine reflexes that determine a organs (viscera) and blood vessels myelinated motor fibers that chiefly movement pattern or habit innervate muscle spindles and thus Barrier The limit of the range primarily regulate muscle tonus Movement pattern A persistent of motion; may also refer to repetitive sequence of motor soft tissue. Under normal Inhibition (neuromuscular) Reflex actions (posture, movement) circumstances, resistance is felt at inhibition of muscle activity the physiological barrier, whereas Isokinetic resistance A movement Neoarthrosis New joint formation, limitation of movement is felt at constant rate or velocity against a ‘false’ joint at the pathological or restrictive resistance that is set by a machine Nictitating membrane A thin fold barrier or piece of apparatus of skin lying deep to the eyelids; the ‘third eyelid’ Basion A craniometric landmark Isometric Maintaining uniform located at the mid point of the anterior border of the foramen length, that is without positional Nociception Perception of injurious, change or movement usually pain-provoking stimuli magnum Isometric muscle Nutation A slight nodding movement, Capsular pattern Movement contraction Muscle contraction usually in the sense of anteflexion restriction pattern due to an intra- articular lesion of the joint capsule against resistance that permits no and retroflexion movement Cervicomotography A technique Isometric phase The time period Occlusion Locking, a position in which no further joint movement for the graphic analysis of head and during which no movement occurs is possible neck movements, developed by because the forces involved are in Offset Minor mutual displacement Berger (1990) equilibrium of the surfaces of a joint Co-activation, co-contraction The Isometric resistance Resistance Opisthion A craniometric landmark simultaneous contraction of that permits no movement located at the mid point of the antagonist muscles producing a because the forces involved are in posterior border of the foramen stabilizing effect equilibrium magnum Concentric movement against Isotonic resistance Resistance Osteopenia A decrease in bone resistance A movement by the employing a constant force mass below the normal; the term patient against resistance that the includes both osteoporosis and patient overcomes Joint play Movement that can be osteomalacia produced only passively in the Costen’s syndrome A symptom joint, for example distraction, complex involving the translation, and occasionally Panjabi’s neutral zone A region of laxity around the neutral temporomandibular joint (TMJ) rotation resting position of a spinal motion and associated with headache and dizziness Kinematics The science that deals segment that is maintained only with the possible motions of by muscles and not by passive a material body structures de Kleyn test With the patient supine, the head in retroflexion Kinesiology The study of the motion Phasic muscle A muscle, is rotated in both directions to detect vertebral artery of the human body usually an extensor, that has a insufficiency tendency to weaken; in terms of Locus minoris resistentiae A site developmental kinesiology, these of lessened resistance are phylogenetically ‘younger’ muscles Deceleration Slowing down; due Manipulation with Proprioception Perception of to the inertia of the head, sudden thrusting Manipulation employing position and movements of the braking, or acceleration (speeding a high-velocity, low-amplitude body up) may produce whiplash injury (HVLA) thrust Reciprocal inhibition Inhibition to the cervical spine by stimulating the antagonist Mobilization A gentle form of muscle(s) Distraction Separation or drawing manipulation in which release or apart; produces ‘gapping’ of the relaxation is obtained by waiting joint surfaces or by repetition 381

Manipulative Therapy Reflex therapy Therapy involving Segment An area or region of the body Taking up the slack Reaching stimulation of receptors that that is innervated by a nerve root or the point in the range of automatically provoke an efferent a (hypothetical) spinal cord segment movement where initial resistance response is met; engaging the physiological Somatic dysfunction The sum total barrier Relational diagnosis Assessment of reflex changes that take place in of mutual position, especially a dysfunctional motion segment Tonic muscle A muscle, usually of vertebrae in a spinal motion a flexor, that has a tendency to segment Somatic reaction A reflex reaction hyperactivity and shortening; in the locomotor system, primarily in terms of developmental Restriction A functionally reversible in muscle kinesiology, these are impairment of movement phylogenetically ‘older’ muscles produced by a pathological barrier Stabilization system, deep A Trigger point (TrP) A small hardened system of monoarticular muscles or contracted nodule in muscle Rhythmic stabilization A method that maintain the stability of the that is a source of referred pain, in which the patient performs motion segments of the spinal especially when irritated a rhythmic movement in the column, shoulder blades, and direction opposite to alternating bones of the feet resistance, thus causing rhythmic contraction of the antagonist Static posturography A method for muscle(s) recording body sway in a standing subject 382

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abnormalities with those present Funktionsstörung der Wirbelsäule 2001 Morphology and histochemistry in closed head injuries. Archives of als pathogenetischer Faktor bei of myogelosis. Clinical Anatomy Neurology 5:28–35 einem Fall von Überleitungsstörung 12(4):266–271 Travell J G 1952 Ethyl chloride spray mit stenokardischen Beschwerden. Wohlfahrt J, Jull G, Richardson C for painful muscle spasm. Archives Manuelle Medizin 18:79–82 1993 The relationship between of Physical Medicine 33:291–298 Vítek J 1970 Das zervikokraniale the dynamic and static functions Travell J G, Rinzler S H 1952 Myofascial Syndrom des hinteren of abdominal muscles. Australian genesis of pain. Postgraduate Halssympathicus und die Journal of Physiotherapy 39:9–13 Medicine 11(4):425–434 Arteriosklerose des Gehirns. Wolff H G 1948 Headache and other Travell J G, Simons D G 1999 Manuelle Medizin 8:13 head pain. University Press, New Myofascial pain and dysfunction. Vojta V, Peters A 1992 Das Vojta York The trigger point manual, 2nd edn. Prinzip. Springer, Heidelberg Wyke B D 1980 The neurology of low Williams & Wilkins, Baltimore Volejníková H 1992 Studie zur back pain. In: Jayson M I V (ed) The Tuchin P J, Pollard H, Bonello R 2000 Objektivierung der Erfolgsraten nach lumbar spine and back pain, 2nd edn. A randomized controlled trial of der Behandlungsmethode von L. Pitman Medical, London, p. 265–339 chiropractic spinal manipulative Mojžísová bei weiblicher Sterilität Zbojan L 1984 Zum Einsatz therapy for migraine. Journal of infolge von Funktionsstörungen im der Antigravitätsmethode in Manipulative and Physiological Beckenbereich. Manuelle Medizin der Behandlung muskulärer Therapeutics 23(2):91–95 30:96–98 Fehlsteuerungen und Enthesopathien Ushio N, Hinoki M, Hine S et al 1973 Weisl H 1954 The movements of the bei Sportlern. In: Buchmann J, Studies on ataxia of lumbar origin sacroiliac joint. Acta Anatomica Badtke G, Sachse J (eds) Manuelle in cases of vertigo due to whiplash (Basel) 23(1):80–91 Therapie. Report [in German] of injury. Agressologie 6(D):73–82 Whitman J M, Flynn T W, Childs D et the 2nd Joint Conference of the Uttl K 1966 On the incidence of al 2006 A comparison between two Manual Therapy Section of the DDR discogenic disease (vertebrogenic physical treatment programs for Society for Physiotherapy and the disorders) with regard to work patients with lumbar spinal stenosis: Department of Sports Medicine capacity. Review of Czechoslovak a randomized clinical trial. Spine of the Karl Liebknecht University, Medicine 12:116 31:2541–2549 Potsdam, p. 51–67 Vecan T, Lewit K 1980 Plurisegmentale Windisch A, Reitinger A, Traxler H et al

Further reading Abrams A 1912 Spondylotherapy. anatomitscheskich osobenostej Atilla B, Yazici M, Kopuz C et al 1997 Philopolis Press, San Francisco posvonotschnovo kanala na The shape of the lumbar vertebral nischneposvonotschnom urovne canal in newborns. Spine 22: Ackerle J, Tesch K H 1985 Der u bolnych lumboischialgiami (CT 2469–2472 röntgenologische Nachweis klinisch studies of features of the lower diagnostizierter Blockierungen der lumbar spinal canal in patients Aure O F, Nilsen J H, Vasseljen O Halswirbelsäule. Manuelle Medizin with lumbago and sciatica). 2003 Manual therapy and exercise 23:47–50 Vertebronevrologia 2:14–18 therapy in patients with chronic low Anderson B 1980 Stretching. Shelter, back pain, a randomized, controlled Adams H, Bogduk N, Burton K et al Bolinas/California. trial with 1-year follow-up. Spine 2002 The biomechanics of back pain. Angrist A A 1973 Inevitable decline of 28(6):525–531 Churchill Livingstone, Edinburgh chiropractic. New York State Journal of Medicine 73:324–328 Awerbuch M S 2008 The clinical utility Adler D C, Jacobson G 1956 Ardic F, Kahraman Y, Kacar M of ultrasonography for rotator cuff Examination of the atlanto-axial et al 2006 Shoulder impingement disease, shoulder impingement joint following injury with particular syndrome, relationship between syndrome and subacromial bursitis. emphasis on rotational subluxation. clinical, functional and radiologic Medical Journal of Australia 188: American Journal of Roentgenology findings. American Journal of 50–53 76:1081–1094 Physical Medicine and Rehabilitation 85:53–60 Baastrup C 1933 On the spinous Ahlin J A, Atkins G 1984 A screening Arkuszewski Z 1986 The efficacy of processes of the lumbar vertebrae procedure for differentiating manual treatment in low back pain, and the soft tissues between them, temporomandibular joint-related a clinical trial. Journal of Manual and on pathological changes in this headache. Headache 24:216–221 Medicine 2:68–71 region. Acta Radiologica Arkuszewski Z 1986 Involvement of the 14:52–55 Aho A, Vertianen Q, Selo O 1955 cervical spine in back pain. Journal of Segmentary anterio-posterior Manual Medicine 2:126 Babin E, Capesius P 1976 Étude mobility of the cervical spine. Arlen A 1978 Verfahren zur Erfassung radiologique des dimensions du canal Annales Medicinae Internae Fenniae von Statik und Dynamik der rachidien cervical et leurs variations 44:4287–4299 Halswirbelsäule in der sagittalen au cours des épreuves fonctionelles. Ebene. Manuelle Medizin 16: Annales de Radiologie 19:457–462 Airaksinen O, Keikinnen A 1988 Results 25–35 of autotraction treatment for disc Arlen A 1979 Röntgenologische Babin E, Capesius P, Maitrot D 1977 prolapse in a one-year follow-up Funktionsdiagnose der Signes radiologiques osseux des study. Journal of Manual Medicine Halswirbelsäule. Manuelle Medizin variétés morphologiques des canaux 3:129 17:24–32 lombaires étroits. Annales de Arlen A 1980 Mastodynie – pathologie Radiologie 20(5):491–499 Aker P D, Gross A, Goldsmith C H metamérique et statique rachidienne. et al 1996 Conservative mangement Senologia 5(3):230–236 Badtke G, Roderfeld E 1986 of mechanical neck pain, systematic Arslan M 1952 La pathogénie du Muskelfunktionsstörungen bei overview and meta-analysis. British syndrôme sympathique postérieur. gesunden Schulkindern. Manuelle Medical Journal 313:1291–1296 Revue Oto-Neuro-Ophtalmologique Medizin 24:87–90 24:1 Akio S 1995 Somatovisceral reflexes. Ashina M, Bendtsen L, Jensen R et al Baerthold W, Koch H 1972 Journal of Manipulative and 1999 Muscle hardness in patients Leitsymptom Schwindel und die Physiological Therapeutics 18: with chronic tension-type headache, Problematik der Vestibularis- 597–602 relation to actual headache state. Diagnostik in der otologischen Pain 79(2–3):201–205 Sprechstunde. Deutsches Albeck M J, Hilden J, Kjaer L et al Ashraf M 1995 First rib function and Gesundheits-Wesen 27:1227–1231 1995 A controlled comparison of the thoracic outlet syndrome. myelography, computed tomography Journal of Orthopaedic Medicine Bajer A K, Bohrn K, Kamenik M and magnetic resonance imaging 17:56–61 1959 Funktionsproben des in clinically suspected lumbar disc Aspegren D D, Cox J M, Trier K K 1987 Hirnstammkreislaufs mit Hilfe des herniation. Spine 20:443–448 Short leg correction. A clinical trial de Kleyn-Tests. Ceskoslovenská of radiographic vs. non radiographic Otolaryngologie 8:55–61 Alexiev A 1994 Longitudinal procedures. Journal of Manipulative comparative study on outcome of and Physiological Therapeutics Bakke S N 1931 Röntgenologische inpatient treatment of low back pain 10(5):232–238 Beobachtungen über die with manual therapy vs. physical Beweglichkeit der Wirbelsäule. Acta therapy. Journal of Orthopaedic Radiologica Stockholm, Medicine 17:10–14 Supplement XIII Alexiev A, Kraev T 1994 Postisometric Balagué F, Dutoit G, Waldburger relaxation versus high velocity M 1988 Low back pain in low amplitude technique in low schoolchildren, an epidemiological back pain. Journal of Orthopaedic study. Scandinavian Journal of Medicine 16:38–41 Rehabilitation Medicine 20(4): 175–179 Altumbajev R A 1993 Komputerno- tomografitscheskoje issleovanije 389

Manipulative Therapy Balagué F, Nordin M, Skovron M L et Bélager A Y 1996 The pros and cons of Beyer W F, Seyler F, Graf M 2005 ISG- al 1994 Non-specific low-back pain passive physical therapy modalities Befunde bei Schulkindern. Manuelle among schoolchildren, a field survey for neck disorders. Journal of Medizin 43:151–155 with analysis of some associated Musculoskeletal Pain 4:125–134 factors. Journal of Spinal Biedermann F 1954 Grundsätzliches Disorders 7(5):374–379 Ben Eliyahu D J 1996 Magnetic zur Chiropraktik. Haug, Ulm. resonance imaging and clinical Baldry P 1995 Superficial dry needling follow-up, study of 27 patients Biedermann F, Edinger A 1957 at myofascial trigger point sites. receiving chiropractic care for Kurzes Bein, schiefes Becken. Journal of Musculoskeletal Pain cervical disc herniation. Journal Fortschritte auf dem Gebiete 3:117–126 of Manipulative and Physiological der Röntgenstrahlen und der Therapeutics 19:597–606 Nuklearmedizin 86, 75. Banke S L, Jacobs E W, Gevitz R et al 2000 Effect of autogenic relaxation Bendix T 1986 Sitting posture – a Bigos S, Bowyer O, Braen G et al 1994 training on electromyographic review of biomechanic ergometric Acute low back problems in adults. activity in active myofascial trigger aspects. Manuelle Medizin 23:77–81 Clinical Practice Guide Line No 14, points. Journal of Musculoskeletal AHCPR Publications No 95-0642. Pain 8:133–142 Bendtsen L, Jensen R, Olesen J et Rockwell MD, Agency for Health al 1994 Muscle palpation with Policy and Research, US Department Barbor R 1972 Das Schultergelenk. controlled finger pressure, new of Health and Human Service. Manuelle Medizin 10:25–37. equipment for the study of tender myofascial tissues. Pain 59:235–239 Bilkey W J 1991 Involvement of fascia Barbor R 1979 Instabilität der in mechanical pain sydrome. Journal Wirbelsäule. In, Neumann HD, Bendtsen L, Jensen R, Olesen J 1996 of Manual Medicine 6:157–160 Wolff HD (eds) Theoretische Qualitatively altered nociception Fortschritte und praktische in chronic myofascial pain. Pain Birtane M, Calis M, Akgün K 2001 Erfahrungen der Manuellen Medizin. 65:259–264 The diagnostic value of magnetic Konkordia, Bühl, p. 172–181. resonance imaging in subacromial Benini A 1976 Ischias ohne impingement syndrome. Yonsei Barnsley L, Lord S, Bogduk N 1994 Bandscheibenvorfall. Die Stenose Medical Journal 42:418–424 Whiplash injury. Pain 58(3):283–307 des lumbalen Wirbelkanals und ihre klinisch chirurgische Bedeutung. Blomberg S, Svärdsudd K, Mildenberger Baron J B, Bessineton J C, Bizzo G Huber, Bern. F A 1994 A controlled multicentre et al 1973 Correlation entre le trial of manual therapy in low fonctionnement des systèmes Benini A 1984 Der enge Rezessus back pain. Journal of Orthopaedic sensorimoteures labyrinthiques lateralis. 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Williams Berger M 1988 Röntgenologische und & Wilkins, Baltimore biometrische Befunde beim oberen Bogduk N, Jull G 1985 The theoretical Zervikalsyndrom. In: Hohmann pathology of acute locked back, Bayerl J R, Buchmüller H R, Pohlmann- D, Kügelgen B, Liebig K (eds) a basis for manipulative therapy. Eden P 1983 Nebenwirkungen Neuroorthopädie. Springer, Journal of Manual Medicine 2:18 und Kontraindikationen der Berlin, p. 65 manuellen Therapie im Bereich der Bogduk N, McGuirk B 2002 Halswirbelsäule. Der Nervenarzt Berger M, Gerstenbrand F 1986 Management of acute and chronic 56:194–199 Cervicogenic headache. Handbook of low back pain. Elsevier, Amsterdam Clinical Neurology 4:405–412 Beal M C 1982 The sacroiliac problem, Bogduk N, Twomey L T 1987 Clinical review of anatomy, mechanics, and Berger M, Gerstenbrand F, Lewit K anatomy of the lumbar spine. diagnosis. Journal of the American 1984 Schmerzstudien 6, Schmerz Churchill Livingstone, Edinburgh Osteopathic Association 81(10): und Bewegungssystem. Gustav 667–679 Fischer, Stuttart Boline P D, Haas M, Meyer J J et al 1993 Interexaminer reliability Beal M C 1985 Viscerosomatic reflexes, Bergmann G J, Knoester B, Assink N of eight evaluative dimensions of a review. Journal of the American et al 2005 Variation in cervical range lumbar segmental abnormality, Osteopathic Association 85:786–801 of motion over time measured by Part II. Journal of Manipulative the ’flock of birds’ electromagnetic and Physiological Therapeutics Beck E, Thümmler W 1975 Zur tracking system. Spine 30:650–654 16:363–374 Ätiologie und Pathogenese der sogenannten Epikondylitis Berlinson G 1989, 1990, 1991 Boline P D, Kassak K, Bronfort G et humeri. Manuelle Medizin 13: Précis de médicine ostéopathique al 1995 Spinal manipulation vs. 91–96 rachidienne. 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Further reading of Manipulative and Physiological Bewegungsapparates? Was ist Butler D S 1995 Mobilisation des Therapeutics 18:148–154 Rheuma? Funktionskrankheiten des Nervensystems. Springer, Berlin Bonduelle M 1955 Les myelopathies Bewegungsapparates 1:7–21. chroniques par cervicarthrose. Revue Brügger A 1986 Die Caillet R 1993 Pain mechanisms Neurologique 93:83–91 Funktionskrankheiten and management. F A Davies, Bonk A D, Ferrari R, Giebel G D des Bewegungsapparates. Philadelphia et al 2000 Prospective randomized Funktionskrankheiten des controlled study of activity versus Bewegungsapparats 1:69–129 Caillet R 1994 Low back pain syndrome, collar, and natural history of Brunström A A 1962 Clinical 5th edn. F A Davies, Philadelphia whishplash injury. Journal of kinesiology. FA Davies, Philadelphia Musculoskeletal Pain 8:123–132 Buchmann J 1980 Motorische Cairns M C, Foster N E, Wright C Bourdillon J F, Day E A 1987 Spinal Entwicklung und 2006 Randomized controlled trial of manipulation, 4th edn. Heinemann, Wirbelsäulenfunktionsstörung. specific spinal stabilization exercises London Manuelle Medizin 18:37–39 and conventional physiotherapy Bove G, Nilsson N 1998 Spinal Buchmann J, Bülow B 1989 for recurrent low back pain. Spine manipulation in the treatment of Asymmetrische frühkindliche 31:E670–E681 episodic tension-type headache. Kopfgelenksbeweglichkeit. Journal of the American Medical Springer, Berlin Carmichael J P 1987 Inter- and intra- Association 280:1576–1579 Buchmann J, Wende K, Ihracky D et al examiner reliability of palpation Bozzao A, Gallucci M, Masciocchi C 1998 Gezielte manualmedizinische for sacroiliac joint dysfunction. et al 1992 Lumbar disk herniation, Untersuchung der Kopfgelenke vor Journal of Manipulative and MR imaging assessment of natural und nach einer Intubationsnarkose Physiological Therapeutics history in patients treated without mit vollständiger neuromuskulärer 10(4):164–171 surgery. Neuroradiology 185: Blockade. Manuelle Medizin 36: 135–141 313–318 Cassidy J D, Lopes A A, Yong-Hing K Brandt T 1993 Vertigo, its multisensory Buchmann J, Hässler F, Grossmann 1992 The immediate effect syndromes. Springer, London A 1999 Neurologische und of manipulation versus mobilization Brandt T, Daroff R B 1980 Physical manualtherapeutische Befunde on pain and range of motion therapy for benign positional nach Beschleunigungsverletzungen. in the cervical spine. Journal of vertigo. Archives of Otolaryngology Manuelle Medizin 37:321–325 Manipulative and Physiological 106,:484–485 Buerger A A 1980 A controlled trial of Therapeutics 15(9):570–575 Brauer W 1967 Wirbelsäule bei rotational manipulation in low back Kontorsionisten. Medizin und Sport pain. Manuelle Medizin 18:17–24 Cassidy J D, Thiel H W, Kirkaldy- 7:33–40 Bullock-Saxton J E, Janda V, Bullock M Willis W H 1993 Side posture Breig A 1964 Dehnungsverschiebungen I 1993 Reflex activation of gluteal manipulation for lumbar von Dura und Rückenmark im muscles in walking, an approach to intervertebral disk herniation. Spinalkanal. Fortschritte der restoration of muscle function for Journal of Manipulative and Neurologie. Psychiatrie und ihrer patients with low-back pain. Spine Physiological Therapeutics 16(2): Grenzgebiete 32:195–208 18(6):704–708 96–103 Brocher J E W 1966 Die Bullock-Saxton J E, Janda V, Bullock- Wirbelsäulenleiden und ihre Saxton M I 1994 The influence Caviezel H 1977 Torticollis acutus. Differentialdiagnose. Thieme, of ankle sprain injury on muscle Manuelle Medizin 15:67–73 Leipzig activation during hip extension. Brodeur R 1995 The audible Journal of Sports Medicine 15: Chaitow L 1991 Palpatory literacy. release asociated with joint 330–334 Thorsons, Bath. manipulation, a review of the Burke J, Buchberger D J, Carey- literature. Journal of Manipulative Loghmani M T et al 2007 A pilot Chandnani V, Ho C, Gerharter J et al and Physiological Therapeutics study comparing two manual therapy 1992 MR findings in asymptomatic 18:155–164 interventions for carpal tunnel shoulders, a blind analysis using Brodin H 1982 Inhibition-facilitation syndrome. Journal of Manipulative symptomatic shoulders as controls. technique for lumbar pain. Manuelle and Physiological Therapeutics Clinical Imaging 16:25–30 Medizin 20:95–99 30:50–61 Brodin H 1982 Cervical pain and Bush K, Ranjana C H, Hiller S et al Chang H-T 1979 Acupuncture analgesia mobilisation. Manuelle Medizin 1993 The pathomorphologic changes today. Chinese Medical Journal 20:90–94 that accompany the resolution of 92:7–16 Bronfort G, Evans R 2001 A randomised cervical radiculopathy. A prospective clinical trial of exercise and spinal study with repeat magnetic Cherkin D C, Deyo R A, Wheeler K manipulation for patients with resonance imaging. Journal of et al 1995 Physician views about chronic neck pain. Spine 26:788–800 Orthopedic Medicine 19:35–42 treating low back pain. The results Brügger A 1986 Was sind Busquet L 1986 L’ostéopathie crânienne. of a national survey. Spine 20:1–9 Funktionskrankheiten des Maloine, Paris. Chaouat H 1979 Les myelopathies cervicothoraciques. Revue de Médecine 34:1816–1820 Cholewicki J 1993 The mechanical role of lumbar ligaments in lifting. A review article. Journal of Orthopaedic Medicine 15:39–48 Cholewicki J, Panjabi M M, Khachatryan A 1997 Stabilizing function of trunk flexor–extensor muscles around a neutral spine posture. Spine 22(19):2207–2212 391

Manipulative Therapy Chrást B, Korbicka J 1962 Conradi F (ed) 1990 Schmerz Danek V 1989 Haemodynamic Die Beeinflussung der und Physiotherapie. Volk und disorders within the vertebrobasilar Strömungsverhältnisse in der Arteria Gesundheit, Berlin arterial system following extreme vertebralis durch verschiedene positions of the head. Journal of Kopf- und Halshaltungen. Deutsche Coulter I 1996 Manipulation and Manual Medicine 4:127 Zeitschrift für Nervenheilkunde mobilization of the cervical spine, 183:426–448 the results of a literature survey Danenberg H J 1992 Subtle and consensus panel. Journal of gait malfunction and chronic Chrastek J 1968 The harmful effect Musculoskeletal Pain 4:113–124 musculoskeletal pain. Journal of of competitive volleyball on the Orthopaedic Medicine 14:18–26 musculoskeletal system [in Czech]. Coupé C, Mittun A, Hilden J et Acta Chir Orthop Traumatol al 2001 Spontaneous needle Danz J 1982 Gelenkspielbefunde Cechoslov 35:39–48 electromyographic activity in an der Hand bei Patienten mit myofascial trigger points in rheumatoider Arthritis. Manuelle Christiansen H W, Nielsen N 1998 the infraspinatus muscle, a Medizin 20:70 Natural variation of cervical range blinded assessment. Journal of of motion, a one-way repeated Musculoskeletal Pain 9:7–16 Davidoff F A 1998 Trigger points measuring design. Journal of and myofascial pain. Cephalalgia Manipulative and Physiological Cramer A 1955 Lehrbuch der 18:436–438 Therapeutics 21:383–387 Chiropraktik. Haug, Ulm. Davies C G, Fernando C A, Motta A Christiansen H W, Vach W, Manniche Cramer A, Döring J, Gutmann G 1990 1993 Manipulation of the low back C et al 2002 Palpation of the upper Geschichte der Manuellen Medizin. under general anaesthesia, case thoracic spine, an observer reliability Springer, Berlin studies and discussion. Journal of study. Journal of Manipulative and the Neuro-Musculoskeletal System Physiological Therapeutics 25:285–292 Cramer G D, Tuck N R, Knudsen 1:126–132 J T 2000 Effects of side- Christiansen H W, Vach W, Gichangi posture positioning and side- Davis C 1985 Osteopathic manipulation A et al 2005 Manual therapy for posture adjusting on the lumbar resulting in damage to the spinal patients with stable angina pectoris, zygapophysial joints as evaluated by cord. British Medical Journal a non randomised open prospective magnetic resonance imaging, a before 291:1540–1541 trial. Journal of Manipulative and and after study with randomization. Physiological Therapeutics 28: Journal of Manipulative and Davis C G 1998 Rear-end impacts, 654–661 Physiological Therapeutics 23: vehicle and occupant response. 380–394 Journal of Manipulative and Chung S H, Dickenson A 1980 Pain, Physiological Therapeutics 21: encephalin and acupuncture. Nature Crisco J J, Panjabi M M 1991 The 629–639 283:243–244 intersegmental and multisegmental muscles of the lumbar spine. A Davis P T, Hulbert J R, Kassak K M Ciancaglini R, Testa M, Radaelli G biomechanical model comparing et al 1998 Comparative efficacy 1999 Association of neck pain with lateral stabilizing potential. Spine of conservative medical and symptoms of temporomandibular 16:793–799 chiropractic treatments for carpal dysfunction in the general tunnel syndrome, a randomized population. Scandinavian Journal of Croft A C 1993 Cervical acceleration/ clinical trial. Journal of Manipulative Rehabilitation Medicine 31:17–22 deceleration trauma. A reappraisal and Physiological Therapeutics of physical and biomechnical 21:317–326 Cihák R 1970 Variations of lumbosacral events. Journal of the Neuro- joints and their morphogenesis. Acta Musculoskeletal System 1:45–51 Decher H 1969 Die zervikalen Universitatis Carolinae Medicinae Syndrome in der Hals-Nasen-Ohren- 16:145 Croft P R, Macsfarale G J, Papagorgiu Heilkunde. Thieme, Stuttgart A C et al 1996 Outcome of low Clarke J, van Tulder M, Blomberg S back pain in general practice, a DeFranca R G 1996 Pelvic locomotor et al 2006 Traction for low back prospective study. British Medical dysfunction. Aspen, Gaithersburg. pain with or without sciatica, an Journal 316:1356–1359 updated systematic review within Dejung B 1985 Iliosakralblockierungen the framework of the Cochrane Dabbs V, Lauretti W J 1995 Risk – eine Verlaufsstudie. Manuelle collaboration. Spine 31:1591–1599 assessment of cervical manipulation Medizin 23:109–115 vs. NSAIDs for treatment of neck Coenen W 1996 Manualmedizinische pain. Journal of Manipulative and Dejung B 1999 Die Behandlung Diagnostik und Therapie bei Physiological Therapeutics 18:530–536 unspezifischer chronischer Säuglingen. Manuelle Medizin Rückenschmerzen mit manueller 34:108–113 Dalseth L 1974 Anatomic studies Trigger-Punkt-Therapie. Manuelle of osseous craniovertebral joints. Medizin 37:124–131 Coenen W 2002 Koordinations- Manuelle Medizin 12:19–24 und Konzentrationsstörungen im Delitto A, Erhard R E, Bowling Kindesalter. Manuelle Medizin D’Ambroglio K J, Roth G B 1997 R W 1995 A treatment-based 40:352–358 Positional release therapy. Mosby, classification approach to low back St. Louis syndrome, identifying and staging Collard M, Conraux C, Thiébaut M S patients for conservative treatment. et al 1967 Le nystagmus d’origine Dan N G, Sacassan P A 1983 Serious Physical Therapy 75:470–485 cervical. Revue Neurologique complications of lumbar spine 117(6):677–688 manipulation. Medical Journal of Descarreaux M, Normand M C, Australia 10:672–673 Laurencelle L et al 2000 Evaluation of a specific home exercise program 392

Further reading for low back pain. Journal of joint anesthesia/analgesia, a treatment Paterson J K, Burn L (eds) Back Manipulative and Physiological approach for recalcitrant low back pain, an international review. Kluwer Therapeutics 25:497–503 pain of synovial joint origin. Journal Academic, Dordrecht, p. 214 de Sèze S 1960, 1961 Étude sur l’épaule of Manipulative and Physiological Epstein J, Lavine L S 1964 Herniated douloureuse (parts I, II and III). Therapeutics 18:537–546 lumbar intervertebral discs in teen- Revue du Rhumatisme 27,323–327, Dul J C, Snijders J, Timmermann J age children. Journal of Neurosurgery 443–453, 28,85–94 1982 Bewegungen und Kräfte im 21:1070–1075 de Sèze S, Thiérry-Mieg J 1955 Les oberen Kopfgelenk beim Vorbeugen Erdmann H 1967/1968 manipulations vertébrales. Revue du der Halswirbelsäule. Manuelle Grundzüge einer funktionellen Rhumatisme 22:633–650 Medizin 20,51. Wirbelsäulenbetrachtung. Manuelle Deyo R A 1998 Low-back pain. DuPriest C M 1993 Nonoperative Medizin 5,55–63, 6,32–37, Scientific American 279(2):48–53 management of lumbar spinal 78–90. Diakow P R, Gadsby T A, Gadsby J B et stenosis. Journal of Manipulative Eschler J 1967 Das Costen-Syndrom al 1991 Back pain during pregnancy and Physiological Therapeutics aus der Sicht mandibulomotorischer and labor. Journal of Manipulative 16:411–414 Inkoordination. Deutsche and Physiological Therapeutics Durianova J 1985 Objektivzácia úcinku medizinische Wochenschrift 92: 14:116–118 manipulacie a postizometrickej 711–714 DiFabio R P 1995 Efficacy of relaxacie kvantitativnou termografiou Evers W T 1985 Muskeldehnung, comprehensive rehabilitation [in Czech] (Objectifying the effect Warum, wann und wie? In: Frisch program and back school for patients of manipulation and post-isometric H (ed) Manuelle Medizin heute. with low-back pain. Physical Therapy relaxation by means of quantitative Springer, Berlin, p. 157–169 75:865–878 thermography). Bratisl Lek listy Evers E 2004 Zervikogener DiFabio R P 1999 Manipulation of the 83:87–93 Kopfschmerz. Manuelle Medizin cervical spine, risks and benefits. Duus P, Kahlau G, Krücke W 42:99–102 Physical Therapy 79:50–65 1951 Allgemeinbetrachtungen Evjenth O, Hamberg J 1981 Dishman J D, Ball K A, Burke J der Foramina intervertebralia. Muskeldehnung. Remed, Zug/ 2002 Central motor excitability Langenbecks Archiv für Chirurgie Switzerland changes after spinal manipulation, 268:431 Falkenau H A 1977 Pathogenese a transcranial magnetic stimulation Dvorák J 1988 Rotationsinstabilität und Chirotherapie des pharyngo- study. Journal of Manipulative and der oberen Halswirbelsäule. In: ösophagealen zervikalen Syndroms. Physiological Therapeutics 25:1–9 Hohmann D, Kügelgen B, Liebig K Laryngologie, Rhinologie, Otologie Dolan P, Adams M 2000 Biomechanical (eds) Neuroorthopädie 4. Springer, 56:467–469. factors affecting the disc. Journal of Berlin, p. 37 Falla D L, Jull G A, Hodges P W 2004 Orthopaedic Medicine 22:3–9 Dvorák J 1991 Inappropriate indication Patients with neck pain demonstrate Dölken M 2000 Biomechanische and contraindication for manual reduced electromyographic und pathomechanische Aspekte therapy. Journal of Manual Medicine activity of the deep cervical flexor des Humeroskapulargelenks und 6:85–88 muscles during performance of the Auswirkungen auf die Rehabilitation Dvorák J, Dvorák V 1983 Manuelle craniocervical flexion test. Spine der Schulter. Manuelle Medizin Medizin. Springer, Berlin 29:2108–2114 38:242–247 Dvorák J, Orelli F 1982 Wie Farfan H F 1980 The scientific basis Doran D M L, Newell D L 1975 gefährlich ist die Manipulation der of manipulative procedures. In: Manipulation in treatment of low- Halswirbelsäule? Manuelle Medizin Grahame R (ed) Low back pain. back pain. British Medical Journal 20:44–48 Clinics in rheumatic diseases. 2:61 Dvorák J, Aebi M, Baumgartner H Saunders, Philadephia, p. 159–177 Dorman T A 1994 Pelvic mechanisms et al 1991 Functional CT scans for Farrell J P, Twomey L T 1982 Acute and dysfunction. Journal of diagnosis of atlanto-axial rotatory low back pain. Comparison of two Orthopaedic Medicine 16:45–48 fixation. Journal of Manual Medicine conservative treatment approaches. Dorman T A, Buchmiller J D, Cohen R 6:203–204 Medical Journal of Australia 1: E et al 1994 Energy efficiency during Ebbets J 1979 Manipulation of the foot. 160–164 walking. Journal of Orthopaedic Physiotherapy 194:202 Fassmeyer W B 2001 Was man vom Medicine 16:13–19 Eddie G 1995 A series of 43 patients Kiefergelenk des Menschen wissen Downey B J, Taylor N F, Niere K L complaining of shoulder pain who sollte. Manuelle Medizin 39:126–132 1999 Manipulative physiotherapists responded to treatment of the first Fast A, Zinicola D F, Marin E L 1987 can reliably palpate nominated rib. Journal of Orthopaedic Medicine Vertebral artery damage complicating lumbar spinal levels. Manual Therapy 17:62–64 cervical manipulation. Spine 12: 4(3):151–156 Eder M, Tilscher H 1988 Chirotherapie. 840–842 Downing C H 1935 Osteopathic Hippokrates, Stuttgart Feinstein B, Langton J N, Jameson principles in disease. Orozko, San Editorial 1960 Children’s headache. R M et al 1954 Experiments on Francisco British Medical Journal 1154. pain referred from deep somatic Dreyfuss P, Michaelsen M, Horne M Ellis R, Swain I 1990 Frozen wrist, the structures. Journal of Bone and Joint 1995 MUJA, manipulation under contribution of thermography. In: Surgery 36A:981–997 393

Manipulative Therapy Feld M 1954 Subluxation et entorse Fossgreen J 1991 Editorial, Fritz J M, Delitto A, Welch W C sousoccipitales. Leur syndrôme Complications in manual medicine. et al 1998 Lumbar spinal stenosis, fonctionel consecutif aux Journal of Manual Medicine 6: a review of current concepts in traumatismes crâniens. Semaine des 83–84 evaluation, management and Hôpitaux 30:1952 outcome measurements. Archives of Franca G G 1992 Proximal tibiofibular Physical Medicine and Rehabilitation Feldenkreis M 1999 Body awareness as joint dysfunction and chronic 79:700–708 healing therapy. The case of Nora. knee and low back pain. Journal North Atlantic Books, Berkeley/ of Manipulative and Physiological Frühwirth J, Lackner R, Höllerl G 1992 California Therapeutics 15:382–387 Postoperative manuelle Medizin. Manuelle Medizin 30:35–37 Fick R 1911 Handbuch der Anatomie Franca G G, Levine L J 1991 The und Mechanik der Gelenke. quadratus lumborum and low back Fryette H H 1954 Principles of Teil III. Spezielle Gelenk- und pain. Journal of Manipulative and osteopathic technique. Academy Muskelmechanik. Bardeleben, Physiological Therapeutics 14: of Applied Osteopathy, Carmel/ Handbuch der Anatomie des 142–149 California Menschen. Fischer, Jena. Fredrickson J M, Schwarz D, Kornhuber Fullenlove T M, Justin Williams A 1957 Figar Š, Krausová L, Lewit K H H 1976 Convergence and Comparative roentgen findings in 1970 Plethysmographische interaction of vestibular and deep symptomatic and asymptomatic Untersuchungen bei manueller somatic afferents upon neurons in back. Radiology 68:572 Behandlung vertebragener the vestibular nuclei of the cat. Störungen. Acta Neurovegetativa Acta Otolaryngologica 61: Fusek L 1970 Príznaky a operacní 29:618–623 168–188 nálezy pri výhrezech bederních meziobratlových plotének u Fischer A A 1986 Pressure tolerance French S D, Green S, Forbes A mladistvých [in Czech] (Symptoms over muscles and bones in normal 2000 Reliability of chiropractic and surgical findings in herniated subjects. Archives of Physical methods commonly used to detect disk lesions in adolescents). Medicine and Rehabilitation 67: manipulable lesions in patients Ceskoslovenská Neurologie 33: 406–409 with chronic low back pain. Journal 199–202 of Manipulative and Physiological Fischer A A 1990 Application of Therapeutics 23:231–238 Gaizler G 1973 Die Beurteilung der pressure algometry in manual Ruhehaltung der Halswirbelsäule – medicine. Journal of Manual Friberg O 1987 Lumbar instability, eine erledigte Frage? Fortschritte auf Medicine 5:145 a dynamic approach by traction- dem Gebiete der Röntgenstrahlen compression radiography. Spine und der Nuklearmedizin 103:566 Fischer A A 1998 Algometry in 12:119–129 diagnosis of musculoskeletal pain. An Gaizler G, Madarász J 1979 evaluation of treatment outcome, an Fricton J R 1993 Myofascial pain. Funktionelle Röntgendiagnostik der update. Journal of Musculoskeletal Clinical characteristics and diagnostic Halswirbelsäule. Manuelle Medizin Pain 6:5–32 criteria. Journal of Musculoskeletal 17:82–84 Pain 1:37–39 Fisk J W 1986 The low back problem. Gallinaro P, Cartesegna M 1983 Three The 1982 Menell-Travell Lecture. Fricton J R 2002 Masticatory myofascial cases of lumbar disc rupture and Journal of Manual Medicine 2: pain, an explanatory model of one of cauda equina associated with 32–132 regional muscle pain syndromes. spinal manipulation (chiropraxis). Journal of Musculoskeletal Pain Lancet 8321:41 Fitz-Ritson D 1991 Assessment of 10:131–150 cervicogenic vertigo. Journal of Galm R, Rittmeister, Schmitt M 1998 Manipulative and Physiological Fried K 1966 Die zervikale juvenile Vertigo in patients with cervical Therapeutics 14:193–198 Osteochondrose. Fortschritte auf spine dysfunction. European Spine dem Gebiete der Röntgenstrahlen Journal 7:5–8 Fjellner A, Bexander C, Faleij R et al und der Nuklearmedizin 105:69 1999 Interexaminer reliability in Gambardino M A, Affaitati G, Lezzi S physical examination of the cervical Friedrich M, Tilscher H, et al 1999 Referred muscle pain and spine. Journal of Manipulative and Liertzer H 1985 Segmentale hyperalgesia from viscera. Journal of Physiological Therapeutics 22: Wirbelfunktionsstörungen bei Musculoskeletal Pain 7:436–438 511–516 stationär aufgenommenen Patienten mit spondylogenen Schmerzen. Garzillo M J, Garzillo T A 1994 Does Foreman S M, Croft A C 1988 Manuelle Medizin 23:38–42 obesity cause low back pain? Journal Whiplash injuries, the cervical of Manipulative and Physiological acceleration/ deceleration syndrome. Frisch H 1985 Manuelle Medizin heute. Therapeutics 17:601–604 Williams & Wilkins, Baltimore Springer, Berlin Gassin R 1999 Low back pain Forestier J, Lagier R 1971 Hyperostoses Frisch H 1996 Programmierte Therapie during pregnancy. Australian vertébrales ankylosantes. Médecine am Bewegungsapparat. Springer, Musculoskeletal Medicine 4:16–23 et Hygiene 29:668–670 Berlin Gassin R, Masters S 2001 Spinal manual Fortin J D, Aprill C N, Ponthieux B et Fritsch C, Jeangros P 1994 Die therapy – the evidence. Australian al 1994 Sacroiliac joint, pain referral Dehnung der neuromeningealen Musculoskeletal Medicine 6:26–31 maps upon applying a new injection/ Strukturen bei Adhäsionen nach arthrographic technique. Spine lumbalen Diskusoperationen. Gatcheva J, Boykikev N, Damyanova 19:1483–1489 Manuelle Medizin 32:159–172 J et al 1986 Der vertebrale Faktor in der Pathogenese eines erhöhten 394

Further reading Augeninnendruckes und dessen American Medical Association Gorman R F 1978 Cardiac arrest after Beeinflussung durch physikalische 259:81–83 cervical spine mobilization. Medical und manuelle Therapie. Manuelle Geyer K H, Bücheler E 1967 Zur Journal of Australia 2:100–103 Medizin 24:105–108 vaskulären Genese des synkopalen Gatterman M I 1995 Foundations of zervikalen Vertebralissyndroms. Gottfrýd O 1973 Príspevek k patogenezi chiropractic subluxation. Mosby, Nervenarzt 38:270–275 syndromu canalis intervertebralis St Louis Ghia J N, Mao T, Twomey T C et al [in Czech] (A contribution on the Gay J R, Abbott K H 1953 Common 1976 Acupuncture and chronic pain pathogenesis of the intervertebral whiplash injuries of the neck. Journal mechanisms. Pain 2:285–299 canal syndrome). Rozhl Chir 52: of the American Medical Association Gibbons P 1997 Coupled motion, 100–103 152(18):1698–1704 relationship to joint assessment. Gaymans F, Lewit K 1975 Journal of Orthopaedic Medicine Govind J, Bogduk N, Lau P 2005 Mobilisation techniques using 19:66–71 Headache and the cervical pressure (pull) and muscular Giles L G 1986 Lumbosacral and zygapophyseal joints. Australian facilitation and inhibition. In: cervical zygapophyseal joint Musculoskeletal Medicine 10: Functional pathology of the motor inclusions. Journal of Manual 108–110 system. Rehabilitácia Supplement Medicine 2:89–92 10–11,47–51. Giles L G F 1989 Anatomical basis of Graber-Duvernay J 1972 Coxarthroses Geerinckx P 1979 Vorlaufphänomen der low back pain. Williams & Wilkins, mineurs et réactions ostéophytiques. Rippen. Manuelle Medizin 17:41–44 Baltimore Rhumatologie 24:123–133 Geiger T, Gross D 1967 Therapie Giles L G 1992 Paraspinal autonomic über das Nervensystem Volume 7 ganglia distortion due to vertebral Gracovetsky S, Farfan H 1986 The Hippokrates, Stuttgart body osteophytosis, a cause of optimum spine. Spine 11: Geiser M 1972 Rückenuntersuchungen vertebrogenic syndromes? Journal 543–573 in einer Infanterie-Rekrutenschule. of Manipulative and Physiological Schweizer medizinische Therapeutics 14:551–555 Gracovetsky S, Kary M, Pitchen I Wochenschrift 102:1301–1309 Giles L G 1994 A histological 1989 The importance of pelvic tilt Gelb H (ed) 1977 Clinical management investigation of human lower lumbar in reducing compression stress in of head, neck and TMJ pain and intervertebral canal (foramen) the spine during flexion–extension dysfunction. Saunders, Philadelphia dimensions. Journal of Manipulative exercises. Spine 14:412–441 Gelb H, Bernstein I 1983 Clinical and Physiological Therapeutics evaluation of 2000 patients 17:4–14 Granata G I, Agarwal G G 1995 The with temporo-mandibular joint Giles L G, Kaveri M J 1991 influence of trunk muscle coactivity syndromes. The Journal of Prosthetic Lumbosacral intervertebral disc on dynamic spine loads. Spine Dentistry 49:234 degeneration revisited, a radiological 20:913–919 Gemell H A, Jacobson B H 1990 and histological correlation. Journal Incidence of sacroiliac joint of Manual Medicine 6:62–66 Granges G, Littlejohn G 1993 dysfunction and low back pain Gill K P, Callaghan M J 1998 Prevalence of myofascial pain in fit college students. Journal of The measurement of lumbar syndrome in fibromyalgia Manipulative and Physiological proprioception in individuals with syndrome and regional pain Therapeutics 13:63–67 and without low back pain. Spine syndrome, a comparative study. Gerstenbrand F, Tilscher H, 23:371–377 Journal of Musculoskeletal Pain Berger M 1980 Radikuläre und Gläser O, Dalicho A W 1962 1:19–35 pseudoradikuläre Symptome Segmentmassage. Thieme, Leipzig der mittleren und unteren Glover J R, Morris J G, Khosla T 1974 Grant R (ed.) 1988 Physical therapy Halswirbelsäule. In: Kocher R, Gross Back pain, a randomized clinical trial of the cervical and thoracic spine. In: D (eds) Schmerzstudien 3. Fischer, of rotational manipulation of the Clinics in physical therapy, volume Stuttgart, p. 82–90 trunk. British Journal of Industrial 17. Churchill Livingstone, New York Gerwin R D 2002 Myofascial and Medicine 31:59–64 visceral pain syndromes, visceral- Goddard N J, Stabler J, Albert J S 1990 Grave-Nielsen T, Arend-Nielsen L, somatic pain representation. Journal Atlanto-axial rotatory fixation and Svensson P et al 1997 Experimental of Musculoskeletal Pain 10: fracture of the clavicle. Journal of pain, a quantitative study of local and 165–175 Bone and Joint Surgery 72(B):72–75 referred pain in humans following Gerwin R D, Shannon S, Hong Z 1997 Good A B 1985 Spinal joint blocking. injection of hypertonic saline. Journal Interrater reliability in myofascial Journal of Manipulative and of Musculoskeletal Pain 5:49–71 trigger point examination. Pain Physiological Therapeutics 8:1–8 69(1–2):65–73 Goodridge J P 1981 Muscle energy Green D 1959 Vascular accidents to Getzendanner S, Johnson K B 1988 1. technique, definition, explanation, the brain stem associated with Permanent injunction order against methods of procedure. Journal of the neck manipulation. Journal of the AMA. 2. Statement from AMA’s American Osteopathic Association American Medical Association General Counsel. Journal of the 81:249–254 170:522–524 Greenman P E 1979 Verkürzungsausgleich – Nutzen und Unsinn. In: Neumann H D, Wolff H D (eds) Theoretische Fortschritte und praktische Erfahrungen der Manuellen Medizin. Konkordia, Bühl, p. 333–341 Greenman P E 1984 Eingeschränkte Wirbelbewegung. Manuelle Medizin 22:15–18 395

Manipulative Therapy Greenman P E 1984 Schichtweise phantom limb and stump pain. Pain Wirbelsäule und ihre tatsächliche Palpation. Manuelle Medizin 13:313–320 klinische Bedeutung. In: Manuelle 22:46–48 Gross D, Kobsa K 1984 Medizin heute. Springer, Berlin, Polymyographische Untersuchungen p. 61–89 Greenman P E (ed) 1984 Concepts und Rückenschmerzen. Manuelle Gutmann G (ed) 1985 Arteria and mechanisms of neuromuscular Medizin 22:74 vertebralis, Traumatologie und functions. Springer, Berlin Guechev G, Guechev A 1994 Clinical funktionelle Pathologie. Springer, and electrophysiological changes Berlin Greenman P E 1985 Die osteopathische in neurological deficit of patients Gutmann G, Biedermann H Untersuchung des Haltungs- und with lumbosacral radiculopathy 1984 Allgemeine funktionelle Bewegungsapparates in 10 Schritten. undergoing traction therapy. Journal Pathologie und klinische In: Frisch H (ed) Manuelle Medizin of Orthopaedic Medicine 16: Syndrome. In: Gutmann G (ed) heute. Springer, Berlin, p. 43–50 80–83 Funktionelle Pathologie und Gunn C C, Milbrandt W E 1976 Klinik der Wirbelsäule. Vol. 1, Die Greenman P E 1986 Innominate shear Tennis elbow and the cervical spine. Halswirbelsäule (part II). Gustav dysfunction. Journal of Manual Canadian Medical Association Fischer, Stuttgart Medicine 2:114–121 Journal 114:803–809 Gutmann G, Biedermann H 1992 Gunn C C, Chir B, Milbrandt W E Funktionelle Pathologie und Klinik Greenman P E 1990 Clinical aspects of 1978 Tenderness at motor points. A der Wirbelsäule, Volume 3, Die sacroiliac function in walking. Journal diagnostic and prognostic aid for low Lenden-Becken-Hüftregion, Part 1. of Manual Medicine 5:125 back injury. Journal of Bone and Joint Fischer, Stuttgart Surgery 58A:815–825 Gutmann G, Roesner J 1979 The Greenman P E 1991 Grundlagen der Gurfinkel V S 1973 Muscle subforaminal stenosis headache. Acta myofaszialen Entspannungstechnik. afferentation and postural control in Neurochirurgica 50: Manuelle Medizin 29:67–71 man. Agressologie 14C:1–8 201–215 Gutmann G 1953 Die Gutzeit K 1956 Anamnese und Klinik Greenman P E 1991 Principles of obere Halswirbelsäule im der vertebragenen Erkrankungen. In: manipulation of the cervical spine. Krankheitsgesehen. Neuralmedizin 1 Wirbelsäule in Forschung und Praxis, Journal of Manual Medicine 6: Gutmann G 1955 Schädeltrauma und Volume 1. Hippokrates, Stuttgart, 106–113 Kopfgelenke. Deutsche medizinische p 22–28. Wochenschrift 41:1503–1505 Haas M, Nyiendo J 1992 Lumbar Greenman P E 2003 Principles of Gutmann G 1956 Einführung motion trends and correlation manual medicine, 3rd edn. Lippincott in die statisch-funktionelle with low back pain. Part II. A Williams & Wilkins, Philadelphia Röntgendiagnostik der Wirbelsäule roentgenological evaluation of unter besonderer Berücksichtigung quantitative segmental motion Greenman P E 2006 Non-operative der Kopfgelenke und der in lateral bending. Journal of management of spinal stenosis. Halswirbelsäule. In: Wirbelsäule in Manipulative and Physiological American Academy of Osteopathy Forschung und Praxis, Volume 1. Therapeutics 15:224–234 Journal 16(4):18–20 Hippokrates, Stuttgart, p. 70–72 Haas M, Peterson D 1992 A Gutmann G 1962 Halswirbelsäule roentgenological evaluation of the Gregg G 1974 The commonest lumbar und Durchblutungsstörung in der relationship between segmental disc – L3! British Journal of Sports Vertebralis-Basilaris-Strombahn. In: motion and malalignment in lateral Medicine 8:69–73 Wirbelsäule in Forschung und Praxis, bending. Journal of Manipulative Volume 25. Hippokrates, Stuttgart, and Physiological Therapeutics Grieve G P 1981 Common vertebral 138–155 15:350–360 joint problems. Churchill Gutmann G 1963 Das cervico- Haas M, Nyiendo J, Peterson C et al Livingstone, Edinburgh diencephale Syndrom mit synkopaler 1992 Lumbar motion trends and Tendenz und seiner Behandlung. In: correlation with low back pain. Part Grim M, Rerábková L, Carlson B M Wirbelsäule in Forschung und Praxis, I. A roentgenological evaluation of 1988 A test for muscle lesions Volume 26. Hippokrates, Stuttgart, coupled lumbar motion in lateral and their regeneration following p. 112–132 bending. Journal of Manipulative intramuscular drug application. Gutmann G 1968 Das cervical- and Physiological Therapeutics Toxicologic Pathology 16: dienzephal-statische Syndrom des 15:145–158 432–442 Kleinkindes. Manuelle Medizin Haas M, Taylor J A, Gillette R G 1999 6:112–119 The routine use of radiographic Groh H 1972 Wirbelsäule und Gutmann G 1983 Verletzungen der spinal displacement analysis, a Leistungssport. Selecta 14:324 Arteria vertebralis durch manuelle dissent. Journal of Manipulative Therapie. Manuelle Medizin 21:2 and Physiological Therapeutics Gross A R, Hoving G L, Haines T A Gutmann G 1985 Die 22:254–259 et al 2004 A Cochrane review of funktionsanalytische Hack A 2002 Therapeutische manipulation and mobilization for Röntgenuntersuchung der Ergebnisse mit der muscle mechanical neck disorders. Spine 29:2108–2114 Gross A R, Goldsmith C, Hoving J L et al 2007 Conservative management of mechanical neck disorders. Journal of Rheumatology 34:1083–1102 Gross D (ed) 1974 Funktionelle Störungen des Bewegungsapparates. Therapie über das Nervensystem Volume12. Hippokrates, Stuttgart Gross D 1982 Contralateral local anaesthesia in the treatment of 396

Further reading energy technique nach Mitchell musculoskeletal pain in patients Heilig D 1981 The thrust technique. beim Bandscheibenvorfall der receiving spinal manipulative Journal of the American Osteopathic Lendenwirbelsäule. Manuelle therapy. Journal of Manipulative and Association 81:244 Medizin 40:141–145 Physiological Therapeutics 16:47–50 Hack A 2002 Wirbelsäulenschonendes Haldeman S, Kohlbeck F G, Hellsten W 1969 Epikondyläre Heben (parts 1–5). Manuelle McGregor M 1999 Risk factors Schmerzen. Manulle Medizin 7:59–61 Medizin 40,276–278, 279–281, and precipitating neck movements 282–285, 286–288, 289–290. causing vertebrobasilar artery Hemborg B, Moritz U, Hohnström Hack A 2003 Die Klavikula – der dissection after cervical trauma E 1985 Lumbar spinal support Schlüssel zum Schultergelenk. and spinal manipulation. Spine and weightlifters belt. Effect on Manuelle Medizin 41:199–204 24:785–794 intra-abdominal and intra-thoracic Hack G D, Koritzer R, Robinson W L Hamann A 1974 Massage in Wort und pressure during lifting. Journal of et al 1995 Anatomic relation Bild. Volk und Gesundheit, Berlin Manual Medicine 2:86–92 between the rectus capitis posterior Hammer W I 1999 Functional soft minor muscle and the dura mater. tissue examination and treatment by Hensell V 1976 Neurologische Schäden Spine 20:2484–2486 manual methods, 2nd edn Aspen, nach Repositionsmaßnahmen an Hadler N M, Curtis P, Gillings D Gaithersburg der Wirbelsäule. Medizinische Welt B et al 1990 Der Nutzen von Hanten W P, Dawson D D, Iwata M 27:656–658 Manipulationen als zusätzliche et al 1998 Craniosacral rhythm, Therapie bei akuten Lumbalgien, reliability and relationships with Henssge R 1984 Intermittierende eine gruppenkontrollierte Studie. cardiac and respiratory rates. vertebrobasiläre Insuffizienz. Manuelle Medizin 28:2 Journal of Orthopaedic and Fahrradergometrie als Hadley L A 1957 The covertebral Sports Physical Therapy 27:213–218 Provokationstest. in, Buchmann J, articulations and cervical foramen Hargrave-Wilson W A, Sherry J H 1966 Badtke B, Sachse J (eds) Manuelle encroachment. Journal of Bone and Cervical spondylosis and vertigo. Therapie. Report [in German] of Joint Surgery 39A:910–920 Lancet 7449:1262–1263 the 2nd Joint Conference of the Hagbarth K E, Hägglund J V, Nordin Harrison D E, Harrison D D, Manual Therapy Section of the DDR M et al 1980 Thixotropic behaviour Troyanovich S J 1997 The sacroiliac Society for Physiotherapy and the of human finger flexor muscles with joint. A review of anatomy Department of Sports Medicine accompanying changes in spindle and and biomechanics with clinical of the Karl Liebknecht University, reflex responses to stretch. Journal of implications. Journal of Manipulative Potsdam, p. 196–199. Physiology 368:323–342 and Physiological Therapeutics Haig A J, Tong H C, Yamakawa K S et al 20:607–617 Hermachová H 1995 Dysfunkce 2006 Predictors of pain and function Hartman L S 1983 Handbook of svalu pánevního dna [in Czech] in persons with spinal stenosis, low osteopathic technique. N M K, (Dysfunction of the muscles of the back pain and no back pain. Spine Hadley Wood pelvic floor). Rehabilitace a Fyzikální 31:2950–2957 Hasner E, Schalimtzek M, Snorrason E Lékarstvi 2:32–34 Haldeman S 1977 Why one cause of 1952 Roentgenological examination back pain? In: Buerger A A (ed) of the function of the lumbar spine. Hermachová H 1998 Jaké boty? [in Approaches to the validation of Acta Radiologica 37:141–149 Czech] (Which shoes?). Rehabilitace manipulative therapy. Charles C Hausamann E 1971 Hüftschmerz und a Fyzikální Lékarstvi 5:29–31 Thomas, Springfield, p. 87–197 Sakroiliakalgelenk. Manuelle Medizin Haldeman S 1984 Manipulation and 9:73–75 Hermachová H 1999 O svalovém napetí massage for the relief of pain. In: Hautant H 1927 L’étude clinique de a jeho ovlivneení ve fyzioterapii [in Wall P D, Melzack R (eds) Textbook l’examen fonctionel de l’appareil Czech] (Muscle tonus and how it of pain. Churchill Livingstone, vestibulaire. Revue Neurologique is influenced by physiotherapy). London, p. 942–951 34:909–997 Rehabilitace a Fyzikální Lékarstvi Haldeman S 1990 Presidential address. Hawk C, Long C, Azad A 1997 6:108–110 North American Spine Society, Chiropractic care for women with Failure of the pathology model to chronic pelvic pain, a prospective Hermachová H 2001 O kožním predict back pain. Spine 15: study. Journal of Manipulative and vnímámí, jeho zmenách a ovlivnení 718–724 Physiological Therapeutics 20: [in Czech] (Tactile perception Haldeman S (ed) 1992 Principles and 73–79 through the skin and how to modify practice of chiropractic. Appleton & Head H 1893 On disturbances of it). Rehabilitace a Fyzikální Lékarstvi Lange, East Norwalk sensation, with especial reference to 8:182–184 Haldeman S, Dagenais S 2008 the pain of visceral diseases. Brain Supermarket or science for chronic 16:1–133 Herrschmann H 1975 Ein Beitrag zur back pain. The Spine Journal Heidsieck C H 1990 Der Kreuzschmerz Behandlung des Sudeck-Syndroms. 8:1–278 und das Sakroiliakalgelenk in der Zeitschrift für Physiotherapie Haldeman S, Rubinstein S M 1993 Schwangerschaft. Manuelle Medizin 28:143–144 The precipitation or aggravation of 28:59 Hertel R, Ballmer F T, Gerber C 1999 Lag sign in the diagnosis of rotator cuff rupture. Journal of Orthopaedic Medicine 19:73–76 Herzog W, Read L J, Conway P J et al 1989 Reliability of motion palpation procedures to detect sacroiliac joint fixations. Journal of Manipulative and Physiological Therapeutics 12:86–92 397