Manipulative Therapy in Rehabilitation of the Locomotor System, Third Edition

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Dedicated to my wife Butterworth-Heincmann L i n a c r e H o u s e , J o r d a n Hill, Oxford O X 2 8 D P 225 W i l d w o o d A v e n u e , W o b u r n , M A 0180-2041 A division of R e e d E d u c a t i o n a l and Professional Publishing Ltd A m e m b e r of the R e e d Elsevier pic g r o u p

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First published 1985 R e p r i n t e d 1987, 1988 Second edition 1991 R e p r i n t e d 1996, 1997 T h i r d edition 1999 © R e e d E d u c a t i o n a l and Professional Publishing Ltd 1999 Line drawings: © G e r d a Istler 1985 P h o t o g r a p h s : © Jaroslav Cmi'ral 1985 British Library Cataloguing in Publication Data A catalogue record for this b o o k is available from t h e British Library Library of Congress Cataloguing in Publication Data A catalogue r e c o r d for this b o o k is available from the Library of Congress ISBN 0 7506 2964 9

P r i n t e d and b o u n d in G r e a t Britain






1 Introduction

Pain - especi al ly in the locomotor system - is man k ind

suffered.

It

a

curse

been

control is

b ased

largely on reflex action, precise

the

information about wbere, how and w hy we should

commonest reason for his calls for hel p , answered

app ly one or the other method may be very useful

has always

of diverse treatments . To

and give us better insight into the various method s ,

the ortbodox the cure. it seems, can often be 'left to

as well as more reliable p ractica l results. As these

by a bewildering

m ul t itude

has

nature', sometimes assisted by rest in bed and the

methods are most

mixed blessing of pharmacotherapy, but there are

conditions, it may be useful to begin with the reflex

frequently applied in painful

many other methods (all si n cerely held by some to

response to nociceptive (painful) stimulation.

be singularly effe ctiv e ) that belong mainly, although

Any localized painful stimulation will act in the

not exclusively, to the realm of physical therapy.

segment to which the stimulated structure belongs.

These

In this segment there is usually a byperalgesic zone

include

local

anaesthesia

and

needling,

massage, electrotherapy, manipulation, local cold or

in the skin, muscle spasm (trigger point TrP), painf u l

hot applications, more recently the laser and the

periosteal points, movement restriction of the spinal

magnet, remedial exercise, hypnother a py, counter

segment

irritative poultices and even leeches. All of these are

visceral organ (Figure

used for mor e or less the sa me type of disorder, and

both of recogni z i ng clinically which of these changes

and

(perhaps)

some

1.1).

dysfunction

of

a

Th.is provides a means

we may ask if any one of them should be prefe rred ,

is present and of using some of the methods avail

especial ly since in practi ce we very often find that

able either upon the skin, the musc les (periosteal

the therapist uses the method he or she knows best.

points), the spinal segment or the visceral organ

The common feature of all these methods is that

involved. We may also try to find out which of these

they act reflexly, that is they act on sensory recep

structures is the source of the painful stimulus, in

tors - usually in the region where the pain is felt or.

which structure the changes are more intense, and

even better, where it originates - to produce a reflex

so on.

re s p onse . They may thus be te rme d 'methods of

However, these reflex changes are not confined to

reflex therapy'. Assuming the reflex nature of the

a single segment. A vis ceral disturbance is accom

action of this type of treatment, we may then ask

panied by viscerovisceral reflexes: for example, pain

which receptors are acted up on and w hic h structures

in the region of the gall bladder causes anorexia;

are

subserved

by

those

rec e p tors.

As

nervous

pain in the region of the h eart ,

viscus

t

I I I I I skin

I

.- -------------------------

Figure 1.1 Reflex relalions within the segment


a

sense of oppression,


1l1froduclion

3

lively by post-isometric relaxation, by warmtll or by

atic fashion and, as we would do when making

infiltration. Periosteal points may be reached by soft

neurological examination, start at the peripheral

a

tissue techniques, deep massage, by needling, or, if

level and work up to the central, applying treatment

they are the insertion points of muscles, by post

according to our findings,

isometric relaxation of the muscle. The most suitable

At times, however, the results fall far below what

treatment for joint or spinal segment movement

we might expect from our premises. One of the chief

restriction is manipulation: that for disturbed motor

reasons why this happens in this type of therapy is

patterns is remedial exercise.

the

presence

of a lesion

which

causes

intense

Furthermore, we must decide which of the affected

nociceptive stimulation and so dominates the clinical

structures is the most important and which less so;

picture without the patient being aware of it. The

which is likely to be primary and which secondary.

German literature uses the term

The severity of the change may be significant. Even

of disturbance. This is frequently an old scar after

Siorungsj(!ld,

focus

at the segmental level, however, there is a sort of

injury or operation, often a tonsillectomy scar. This

hierarchy: there may be a primary visceral disorder

focus-scar is usually tender on examination, with

and there may be blockage of a spinal segment.

pain spots, and surrounded by a hyperalgesic zone.

Changes in muscle can be secondary and in the skin

If the 'normal' therapy fails, the existence of such a

this is the rule. But in the locomotor system itself,

scar acting like a 'saboteur' must be considered;

and in the spinal column, there are regions of greater

treatment by local anaesthesia or simply by needling

and of lesser importance, regions in which

primary

the pain spots or stretching the scar tissue by soft

lesion occurs more readily than in others. It is vital

tissue techniques can be most rewarding. Another

a

to recognize those faulty central motor patterns

reason for poor results in patients treated for pain

which, if significant, will cause relapses at the peri

may be undiagnosed masked depression, which must

phery. In this connection psychological factors play

then be treated as such.

a major part, as motor patterns are to a certain degree expressions of the state of mind: anxiety,

Disturbed

function of the

locomotor

system,

together with the reflex changes it produces, may

depression and an inability to relax will greatly

aptly be called the 'functional pathology of the loco

influence motor patterns: no less important is the

motor system'. [n this connection the unfortunate

subject's psychological attitude to pain, as it is the

but frequent use of the term

most frequent symptom in our patients.

synonym or euphemism for 'psychological' is most

'functional'

as a

In addition to the importance of the changes

regrettable - it implies a grave underestimation of

diagnosed, there is also a practical or technical

the importance of function and changes of function

aspect to be considered, as not all of the methods

consequent on pathological changes. In rehabilita

used are equally effective or 'economical'. Thus

tion we are primarily concerned with the restoration

needling of a periosteal pain spot (or infiltration) is

of impaired function even in those conditions where

usually more economical than periosteal massage

there is underlying structural pathology, This is

(deep friction), but wherever possible it is prefer

understandable because structural lesions neces

able to use post-isometric relaxation of the muscle

sarily produce disturbances of function. Indeed, so

(if the periosteal point is a point of muscle insertion)

fundamental is the distinction between morphological

soft tissue techniques because they are painless

lesions and function, that it can aptly be compared

or

and the patient can usually be taught to do it him

to that between computer hard- and software.

self. The attractiveness of manipulation techniques

The greatest obstacle to the practical application

lies mainly in the fact that they are effective and not

of these apparently simple principles is a general

time consuming.

lack of clinical understanding of functional disorders

We can see from this that the choice of treatment

of the locomotor system or even of their reflex

is very broad. We can decide which to use by

manifestations, which are, in fact, the most typical

diagnosing each lesion in turn, and from this make

clinical manifestations of pain. The lesions that are

calls the palhogenelische

the most frequent, as well as being the object of

Alwwiiliilsdiagnose, the diagnosis of the lesion that

what

Gutmann

(1975)

manipulative therapy, are those affecting the spinal

is the most important link in the chain of pathology

column; the term vertebrogenic lesion is often used

at a given moment. We must do this, otherwise we

to describe them, but this is now believed to be not

may, for example, apply a method which acts on skin

quite

receptors when there are no signs of a hyperalgesic

include

zone, act on a muscle when there is no change in

spondylitis, osteoporosis, tumours, etc., while our

appropriate: such

vertebrogenic

pathological

states

disorders as

also

ankylosing

tension, manipulate a spinal segment with normal

main concern is with disturbed function. However,

mobility,

function is not confined to the spinal column but in

or give

remedial

exercise

for

normal

movement patterns. Such very varied methods of

volves muscles, nervous control and very frequently

treatment should be applied only after full clinical

the extremities. It is therefore more appropriate to

examination and analysis, and with careful testing of

speak of disturbed function of the locomotor system,

the results of treatment. We must act in a system-

rather than of vertebrogenic disturbance.


4

Manipulative

Therapy in Rehabilitation of the Locomotor System

What is the present place of reflex therapy? This question is as difficult to answer as the question of

should be applied to all other methods of reflex therapy.

the place of pharmacotherapy. Whereas pharmaco therapy has developed into an exact and sophisti cated science, methods of reflex (physical) therapy

History

have for the most part remained empirical, with largely overlapping and even chaotic indications.

It might be as well to say something of the history

From what has already been said it is possible to

of manipulative therapy in order to explain the

formulate

anomalous position it holds in p resent-day medicine.

one

important principle:

we

do

not

prescribe treatment for a particular disease, but for

I will also consider its prospects and take the oppor

those changes that are of pathogenic significance in

tunity to warn against some of the worst pitfalls.

the dis e a se. If, for example, headache is due to

It seems that some forms of manipulative therapy

muscular tension alone, then muscular relaxation by

are as old as the history of mankind, and it was, and

whatever may be the most effective method is the

is to this day, part of folk healing in Europe and

correct treatment. However, if this muscular tension

elsewhere. However, it is noteworthy that the father

is due to blockage of a motor segment of the cervi

of European medicine, Hippocrates, saw 'rhachio

cal spine, manipulation will be more suitable; if

therapy' as one of the cornerstones of medicine, on

faulty posture is the cause, remedial exercise may

a par with surgery and drug the r a py. According to

be the answer. However, the great advantages of

Waerland (1950), Hippocrates repeatedly pointed

this type of therapy over pharmacotherapy are that

out the imporlance of knowing all about tbe spinal

(I) the mainly physiological methods used cause a

(2)

column, since so many disorders are related to it.

minimum of side-effects if properly applied, and

Hippocrates is quoted as saying that manipulation

as most methods of reflex therapy act immediately,

of the spinal column was an old art, and that he

their effectiveness can be checked at once.

thought highly of those who first discovered its

It is worth saying a few words here about the role

importance and who would follow him in furthering

of pharmacotherapy in those lesions that mainly

the art of natural healing. Writing about articula

affect the functioning of the locomotor system. It

tions, Hippocrates described 'pararthremata " similar

would be difficult to conceive of a drug that could

to slight dislocation or subluxation, in which the

restore a specific motor function, but drugs may alle

vertebrae are only slightly shifted, and went on to

viate spasm, influence pain and damp down some of

say that the 'eyes and hands of the experienced

the reflex reactions involved, and thus facilitate the

physician should not miss anything which could be

restoration of function. Additionally, they are of

helpful in adjusting the shifted vertebra without

course necessary for the treatment of depression and

harming the patient .

anxiety symptoms.

. if treatment is performed lege artis, the patient can come to no harm'. .

There are numerous relief carvings and other

To sum up, neither the clinical diagnosis nor our findings in themselves suffice as the basis for decid

illustrations

ing the most appropriate therapy. O nly an analysis

traction as performed in classical antiquity (see

showing

manipulative

therapy

and

of pathogenesis enables us to determine the lesion

Frontispiece). The patient was usually prone on a

that is the most important at a given moment. After

specially constructed table while traction was applied

treatment the patient must be re-examined to gauge

to both the head and the feet. The physician then

any immediate effect, and from this we can see at

dealt with a specific vertebra. Galen, too, knew that

once whether our hypothesis about the pathology

nerves originated from the spinal column and could

was correct and can adjust treatment accordingly.

be

If treatment has been effective, then at the next

description of his treatment of the philosopher

examination

the

picture

should

have

changed

and again we have to determine which lesion has

damaged

Pausanius.

at

this site,

as we see

from

the

But while treatment with herbs dev

eloped into modern pharmacotherapy, and surgery

become the most important. Thus therapy is never

became

a monotonous routine; at the same time it is always

manipulation remained unchanged throughout the

the

In

field

of

specialized

practitioners,

verifiable, which encourages the therapist to take an

centuries.

objective scientific approach.

manipulations was a 'bonesetter': in France he was

Manipulative th e ra p y which is one of the most ,

England

the

layman

performing

'Ie raboteur'.

effective and important of tbe various methods of

The first important school teaching manipulation

reflex therapy, is concerned with impaired function

on a professional basis in modern times was the

of the locomotor system. Because we can define its

osteopathic school founded by Andrew Sti ll

purpose (treatment of blockage) it serves to show

1828): he served as a surgeon in the American Civil

(born

that methods of reflex therapy are more effective it

War and then worked as a general practitioner. He

we know exactly on which type of lesion they act,

founded his school in Kirksville in 1897, and trained

and that they are improperly used if this is not

lay manipulators.

known. This is fundamental to our approach, and it

lasted for 2 year s


Initially, courses at the school ,

but

later the curriculum was

IntroduClion sCllools,

extended to 4 years, and is now the same

study in time

university faculties osteopathic schools were private institutions,

in

recent years Colleges of Osteopathic Medicine have

been established at some American universities, the

less, for some

5

generation of

willlI1g to co-

chiropractors not

have been

operate with the

encouraged to refer patients to specialists when

advisable.

Chiropractic

colleges now

teach

and

undertake research on a modern scientific basis, are

first being that of the Michigan State University at

consistently overcoming their cherished ideology,

these colleges give full medical training and gradu ates are recognized in most of the states of the USA

system considering themselves specialists of the

istration; this entitles them to carry on medical practice.

pharmacotherapy

East Lansing. In addition to osteopathic techniques,

as DO (doctor of osteopathy) by the state admin

Soon after S till founded

grocer

(D. D.

practic'.

Palmer)

Born in

and limit their activities to problems of the locomotor 'neuro-musculo-skeletal system'.

The fact that chiropractors are taught neither

greater adherence manipUlation is

nor

wrote that it was a

they also prescnbe and use soft-tiSSUe

indeed - only a

chiropractors arc,

were trained. At first

being set up in

dollars! By 1911 courses lasted I year, and now schools

also

give

students a 4-year course of training.

their

There are to this day some differences between osteopaths and chiropractors. The former have full medical training plus manipulation training, and are entitled to work not only as general practitioners but

also as gynaecologists, surgeons, eye specialists, etc. In this way they have become part of the medical profession and the

little,

if at all, to manipulal

are

who remain faithful

something of an elite

physthrust

icians. They rely much

techniques

in

much

so that than

certainly rely mOle

lI:ik"

chiropractic

results

by osteopaths.

College of Chiropraclic

American

surgery

day,

than

tech II iques,

preferring mobilization active (,muscle energy')

sophisticated, they

form the most active and numerous body of manip

ulating physicians. The development of modern medicine in Europe,

in particular, has shown that an uncompromisingly

negative attitude to manipulation is not shared by

the whole of the medical profession. The discovery

of the mechanical role of disc prolapse in root

syndromes made doctors aware of the possibilities of traction and even of other methods of mechanical

treatment, including

somewhat paradoxical the osteopaths and

by the medical prolession ing sophisticated doctors began to

lation, even employing It is no coincidence

a common aim or denominator: to obtain myotascial release.

men who devoted themselves La the an at malllpuiation were

profession has been crossed only gradually. To quote

Naegeli, who used very effective traction manipula

The rift between chiropractic and the medical

a typical example: ' Chiropractic flourishes where

ignorance

prevails.

Chiropractic

will

Europeans. One of the first was a Swiss doctor,

tion on the cervical spine, which was particularly

disappear

effective in the treatment of headache. His book

and common sense. Testimonials are but hypnotic

lished 1954, 1979) makes good reading to this day.

because its time has come. Chiropractic defies logic multiples of zero in an empty vacuum .. .' (Angrist, 1973). Today chiropractors.

which he also is in a way

nor surgery. In fact,

Cyriax, whose

American Medical

iated Medical Societies

IIh:mbcrs to

cooperate with

chiro-

'llIegal

practors took the rnatte I

conspiracy', and won their case

III

! 01::;:; the AMA is

now obliged by law to allow cooperation between chiropractors.

The most important pioneer of medical manipula tion, however. was J. A. MennelJ (1952, 1964), an

outspoken protagolJlsl

curriculum enabling I their students are

doctors and

Nervenleiden lind Nervenschmerzen (1903, repub

It should be

noted,

however, that in the past the chiropractors themselves showed little interest in such cooperation. Neverthe-

techniques physloti1aapists. It

his

disciple Medicine

(1977,1978) remains

assessment of molOl

decessor in

This gap was

also graduated in medicine and whose Manual of Osteopathic Technique remains the classic in its field

(Stoddard, 1961). The London Coll ege of Osteo

pathy (now the London Co.I.lege of Osteopathic Medicine) was the first institution where osteopathic


6

i?chohlill£iliol1 of

Manipulative

qualified

techniques originally

the Locomotor System doctors,

of this College

have plaYfil

obvious reasons a rift

Poland

medicine, or between

an

of manipulattve medicine throughout Europe and

school of thought, was not likely to develop in all exclusively State-run

prominent. Working under De Seze he succeeded in

tbe interest of some members of his staff at the

medical practitioners (mainly specialists in physical

system, and in the potential of 'unconventional'

the development

particularly in France, where Maigne is the most

giving courses in manipulation at the Medical Faculty of the University of Paris, attended by medicine) but not by physiotherapists.

At the same time, i.e. shortly after 1945, a group of

German doctors became interested in manipulation, mainly under !\merican-trained chiropractors SCllldberg). Unlike Maigne, doctors in private

service.

Neurological. broad field of

Professor

Henner

rehabilitation

of

encouraged

the locomotor

methods, among them manipulation. Svehla, Obrda,

Stary, Miratsky, Jirout and the present author, and later Janda and Vele, worked on these lines. Here the of the most prominent country, and it is in

the Czech Republic

were

team-work in research in

manipulation

doctors): the MWE

economy of manipu

Extremitalcntherllpie]

bv Sell and the FAC

practice;

groups

medical

III

mg and teaching

formed wl1h

[(Gesellscilal!)

(Forschungs

Wlrbelsaulen-

und

und Arbcitsgemeinschaft fOr Chiro

therapie) with Biedermann, Cramer, Gutmann and

H.-D. Wolff.

Unlike

France and Great Britain,

where courses for doctors lasted months or even a year. in Germany doctors were given weekly courses at intervals, arranged in a series of at first 4 and later

8 separate weeks. With this system it has been

progress.

Ministry

curriculurn ot the lll�tllutes of Postgraduate Train

ning which run refresher courses tor specialists in all

fields of medicine. Doctors are thus trained in each of the fields, the 'teachers' receiving additional preparation. Teaching began in Czechoslovakia in 1961, and on the same lines in East Germany in 1965 (three courses of 2 weeks each, at 6-month

possible to teach manipulation techniques to far

intervals).

Austria, Holland

ment of

more doctors in Germany, and also in Switzerland,

into hundreds. united to Medicine,

heir numbers run

German groups

There is another striking feature of the develop-

with rehabilitation of

particular with techniques

developed

on high-velocity thrusts gentler osteopathic

aroused a

being overCClmc,

mcdicine in Czechoslovakia -

As';(xlation of Manual

simpler chiropractic

have been formed

outside the predominant

the Czechoslova k

incorporate it in the

which is only slowly 1113ny counlries of Western

improved muscular

were in turn greatly

addition of neuro-

Europe important groups of medical men have

inhibition techniques, it became obvious that team-work by qualified doctors

performed by

cal necessity for maximum effectiveness. Therefore.

promoted the idea that manipulation should be

exception of

qualified doctors only.

Maigne in France they

With

the

bave not,

however, succeeded in adding manipulative tech

niques to the medical curriculum at universities and

teaching hospitals. They thus belong to what we may call 'unofficial' trends in medicine;

remains rather

support of (NonnenbruclL Schuler and 01

of the univt:r'dl outside

some of the

manipulation

'outsider's' method, despite the German professors

together with trained physiotherapists was a practi

with the exception of high-velocity thrusts, manipu lative techniques are now being taught ever more

widely to physiotherapists who work with doctors.

During the 1980s great interest in mal1!pulative therapy also appeared in the former Soviet Union.

ZUCk,c!lwc:rdt, Junghanns,

Collea:'l1es frol11 Czechos!mJkia. the GDR and Bulgallign of h a r m f u l f u n ct i o n i n g w h i c h s h o u l d

o f pa i n w i t h o u t a s pe c i fi c d ia g n osis, a n d t re a t -

T h e m os t t e n s io n .

7 . Pa i n i n

i m p a i r m e n t of m o tor

I

b e c o r r e c t e d i n t i m e b e fore i t c a u ses p e rm a n e n t

m e n t o f t h e p a i n a s s u c h , w i t h ou t a t h o ro u g h

d a m a g e . I t i s p r o b a b l y t h e m o s t freq u e n t t y p e o f

c l i n i c a l u n d e rs t a n d in g o f t h e f u n c t i o n i n g o f t h e locomotor s y s t e m , i s c o u r t i n g fa i l ur e .

p a i n t h ro u g h o u t t h e orga n i s m .

S . I f t h e p a t i e n t i s a b l e to d e s c r i b e a n d l o c a l iz e t he p a i n , a n d we fi nd some c h a n ge s

in

a

9 . T h e complex o f c h a n ge s i n f u n c t i o n o f t he l oco

of t h e t y p i c a l reflex

c orrespo n d i n g

are a

and

h a ve

e x c l u d e d gross p a t h o l o g y , t h e n i t is o u r t a s k t o


motor s y s t e m a n d t h e res u l ti n g r e fl e x c h a nges c o n s t i t ute w h a t may be ca l l e d the ' fu n c t i o n a l p a t h o l ogy of t h e m o t o r syst c m ' .

3 Functional anatomy and radiography of the spinal column

Without a good un dersta nding of fu nctional anatomy as p rese n ted by X-rays, i t is almost impossi ble to u n d e rstand i m p a i red function and t h erefore to i n terpret correctly w hat we have fe lt with our h a n d s d uring examinat i o n . I t is, o f course, not t h e pu rpose of this chapter to dea l with a n a tomy in detai l , but to present those featu res that a re essentia l for a n und e rsta nding bot h o f t he w a y i n w h ich function may be imp a i red, a n d of the mech a n isms involved. Basically X-ray d i agnosis o f the s p i n a l col u m n serves t h ree pu rposes: (1) d i agnosis o f c h a nges i n structure, (2) assessme nt o f locomotor function (ki nema tics) a n d (3) assesme n t of static function (spina l c u rvature, position o f i n d i v i d u a l vertebrae ) .

Diagnosis o f structural changes Classic X-ray d i agnosis is concerned mainly with cha nges in structu re, and this type of d i agnosis is essentia l in ord e r to avoid serious e rror; methods aimed a t correcti n g fu nction are out of p l ace in cases where the u nder l y i n g condition is structura l pathology . Our specia l i n te rest i n t h i s fie ld, however, l i es i n such cha nges of st ruct u re as ma y have a d i rect influence o n fu nction, such as various a n omal ies, i n particular in the shape of j o i n ts, asymme try o f t h e vertebrae, spinal c u rva t u re, etc. Not o n l y is the shape or deformity o f some vertebrae t h e ca use o f asym metrica l function ( e .g. in sco l iosis), but it can itself bc the result of asymme t r ica l function (e.g. rota t i o n of the lower cerv i c a l spine ow ing to dom i n a nce of one h e m isphere a n d asymmetrical loading of the upper extremities, as Jirout (1980) has shown). Diagnosis of structur a l c h an ge can be fou n d i n the classic tex tbooks both o f a n a to m y a n d of radiology, and t h e refore need not be dea l t w i t h i n detail here.

Diagnosis of disturbed function (mobility studies) The X-ray examination of d i sturbed fu nction i n v o l ves exa m i n a tion o f the s p i n al col u m n in vario u s, usu ally extreme, positions such as a n te- and retroflexion (exte n s i o n), side-bend i n g or even rotation. This type of examina t i o n und o u b t e d l y p rovides some d i rect information about mobility; as a routine examination, howeve r, it i s very time consu ming and uneconomica l a nd i ts practical v a l u e is t h u s limited to complicated cases w h e re specia l information is required, o r to cases invol v i n g l i tiga tion. It is advisable to use X-ray exa m ination in cli nica lly re l e v a n t positions, e . g. i n retroflexion in cases o f ve rtigo ca used by ben d i ng the head back. Doctors familia r with manu a l diagnosis of d i s t u rbed funct i o n a re accustomed to assessi ng mobi lity by cli nica l examination; neve r theless X-ray exa m i nati on of mobi l i ty is extre m e l y i mporta n t for res e a rch p u rposes, as i t gives insight into the mechan i s m s u nderlyi ng mobility and i ts d i s turbance, an ins i g h t no othe r m ethod can provide.

Diagnosis of disturbed static function (spinal curvature and 'malalignment') Mobi l i ty is what is usua l l y m e a n t by 'spi n al function', yet static function is no less importa nt, a n d X-rays of the s p i n a l co l u m n with the p a t i ent standing or s i t t i n g (ta ken und e r standard conditio ns) ca n, a n d should, be eva l u a ted f o r static function. As is s h own in more d e t a i l below, spi n a l curva tu re sho uld be such as not to upset b a l a nce. Thi s goes not only for t h e sagittal b u t also for t h e coronal plane, in which every obliq u i t y (e.g. i n w a lki ng) p roduces a scoliotic 35


Manipulative Therapy in Rehabilitation

36

of the Locomotor Systan

c u rva t ure with the correspo n d i ng rotatio n . Curva

posture. To d etermine the p os i tio n of the ce rvical

ture may be smo o t h, or less so; in

segments

spine, the base o f the skull mus t be v i s i b l e , as we l l

kyp h o tic ,

a s the whole o f t h e cervical .

t h e re

may

b e a s harp bend

ce r t ain

(scolio tic ,

l ord otic) or even som e rotatio n or shift ('offset' ) .

The imp orta nce of the se s ig ns of m al a l ignm e n t is highly controversial, es pe cial l y in v i ew of t h e dis c r ed ite d sublu x at i o n tb e ory. The controversy is f u e ll e d by t he d oub t fu l impor ta n ce of asy m m e try, as, in fact, asy mmetry i s t h e rule rat her t h an the exce ptio n . Yet Jir o u t (1978) has shown that alt h oug h

to assess the shape of the l umbar sp i n e we need to se e at le a s t the t h oracolu m b a r j u n ctio n , the ilia, the p u bic sy m physi s and both hip joints on a sin gl e AP picture. This gives a suf fi c i ent n u m ber of l a n dmarks by which to assess correct focusing and t o com p are successive p ictu r e s if a stan dard te c h n iq u e is used .

Th e id e al method f o r X-ray exami n a t io n o f t h e

asymmetry of the positi o n of the atlas in rela t i o n to

sp i n a l column i s t o s h ow the whole column o n a

t h e axis is the rule, i ts i n cidence incre ases with age.

s i n g l e pi cture. An AP a n d

This is e qua lly true for t he a sym m etrical shape of

patie n t st a n ding are required: the on ly condition to

a

l a t e ra l vie w with the

the sp i nous p r o cesses. He conc l u de d that t his is

be obse rved for the AP vi e w is t h a t both feet must

pro b a bly the r e s ult of a s y m m e tr ica l pull due to the

be place d sy m m e t r ic ally in relation to the X-ray

d ominance o f o n e c e r eb ral h e mi sp h e re .

scre e n , and t h at the patie nt be re qu este d to d istri b ute

F r o m this it appears reas o n a b l e to deduce tha t

his weight e q u all y be t w een his t w o feet, keep ing his

asymmetry and irregu l a rity of ' alig n m ent ", while not

legs straig h t . In the lat e ral view, the feet s h o u l d be

in themselves p at h o l og i cal , can be the exp ress i on of

place d so that the ankles are about a fing er' s breadth

example,

. behind the v e r ti ca l to the flo or. from the mid-po i nt

the axis is rotat ed in n eutral posi tion , not only will

of the horizontal edge of the cass ette; the head s h o u ld be n eith e r bent Lo the side no r rotated, the p a tien t fixing s o m e o bj ec t at eye -le v e l in ord er to

asym metry or a n om a l y in fu n c tion.

If, for

it ro tate asym m e t rically d u ring side-bending, b u t the

rest of the cervical spine will follow suit (see p.

65).

retroflexion

Without j u m ping to c o n cl u sio n s , marked asymmetry

avoid a n te tlex i o n or

or 'm alalig nment' in the X-ray pic ture sho uld be

p atie n t holds his arms crossed ove r t h e chest and his

c orrel ated to the c l inical find ings. Marked irregularity

h a n d s on his shoulders.

of t h e head; the

of the r ela t ive p osi tion of vertebrae in the X-ray can be regard ed as a warning signal that there may al.so be some fu n c tio n al anomal y or at least su s cept i b i l i ty to dis t urbe d fun c tio n.

X-ray of the lumbar spine and the pelvis

One obvious ad v a n tage of t h e exam ination of static fun c tion is its e c o n omy: on ly t w o X - rays are

Th e pat i e n t mus t be standi n g if X-ray p i c ture s that

re q ui r e d , t h e anteroposterior (AP) view and the side

can

view. Sta n d a rd c o n d itions must be adh e red to. As

obtained. He is therefore p l ac ed before the X-ray

individual posture is highly characteristic, i.e. constant,

s c re e n as when pictures are take n of the who l e spinal

co m pa r a b l e pi c tures can be e x pe c ted on rep e tition .

column. To acquire in f or m a t i o n about the sta t ics of

be

e v alua t e d

Gutman n a n d Vele (1978) h ave ve ry a ptly s u mmed

the spinal column

up the i m p o r ta n ce of static function: 'The d o minat i ng

Gutman n

fo r sta t ic function are

as

a whole,

a

to be

dev i ce described by

(1970) is used , in which a plumb-line

p rincip le of the sp i nal colu m n is body s t a t i cs '. All

indicates the vertical line from the head. A lin e

ot h e r func tions are subordinate to the requirements

which c o rr es po n d s to the centre of the scre e n is the fl oo r: for the AP vie w the patie n t

of u p right posture on two le gs . Loss of m ob i lity and

draw n on

p a i n ful i m pi nge m e nt of nerve roots is pr e ferred to

places o n e f o o t symmetrically o n each sid e of the

sacrifice of the e re c t p o sture .

line. A movable pl u m b - li n e of m etal wire is attached to the scre e n . The s c re e n is fi r st raise d to t h e l evel of the p a t i e n t ' s oc ci p u t and the metal wire m ove d

Techn i c a l require m e nts The

be

take n

to in

a

posit i o n

a

point

c o r resp o n di n g

to the

o u t er occ ipit a l

that

protuberance. In this way the plumb-line sh ows the

c o rresp o n ds to t h e pa t ie n t ' s natural posture, either

head position. The screen is the n adj ust e d to the

X-ray sh ould

standing or sit ti ng (with the e x c e p t i o n of the AP

he i gh t re quir e d to t ake a picture of the lum bar spine

view o f the cer vical spi n e , which is taken with t h e

and the p e lvis (with the cen tral b eam and the cent r e

p a t ie n t su pi n e ) .

There s h ould ,

therefore, be

no

artificial correction of the patient's p os ture. Distortion must be avoided and f ocusing m ust be s cru pu l ous t o

obtain clear pi c tures t ha t can be used s u c cess i v e l y

of the screen roughly at the h e igh t of the n avel ) . The wire should n ow be taped to the lower edge of t h e

screen a n d th e patie nt l eans aga i n st t h e screen s o as n o t to bl ur the p ict u re (Figure 3.1 ) .

fo r com par i s o n . To ac h i e ve this, some corre c tion is

For t h e lat e ral vie w t h e patie n t p u ts his feet as

u n avoid ab l e , for insta n c e to prevent d i s t o r tion or

desc ribed for t h e X-ray of t h e whole spi ne: the

tilt, b u t t h e nat ural posture must be r e gis t e r ed. It is

scree n with the p l um b -l i ne is raised to the

also esse n t ial to v i sual i z e

suflkiently lo n g section

the h ead in o rder to place the p l u m b - l in e at a point

of the spinal column t o make it p ossible t o assess

correspon ding to the outer meat us acousticus, and

a


l evel

of

Functional analOmy and

radiography of {he spinal co/ul11n

Figure 3.1 X-ray technique of the lumbar spine with the patient standing. (a) Positioning of the moveable plumb-line: the device prepared For X-ray, AP view: (c) positioning of plumb-line: (d) the device prepared for X-ray, lateral view (After Gutmann, 1970) (b)


37

38

Manipulative Therapy

in

Rehabiliratioll of rhe Locomoror

Sysrern (Figure

3.2).

lumbar

sp ine is o v er-exposed or the lumbosacral

With

the normal t echniq ue , either the

j unc tion is t ube to

under-exposed. The dis ta n c e of the X-ray the fi l m should be as great as possible,

depending on t he power of the apparatus a n d the corpulenc e of

the

patie nt , the ideal dista n ce b ein g

2 m.

X-ray evaluation of lumbar spinal statics As

we

h a ve al rea d y seen, X-ray examination of t h e

p a t ie n t st a n di n g serves mainly for d ia gnosis o f static fu n c tion and i ts disturbance. It should be borne i n mind tha t clinical examination alone can ascertain the position of the outer occipital prot ub e rance , t h e spinous processes, the intergluteal line and

the

mid

point be tween t he heels in rela ti on to a p lumb-line. In the sagittal plan e , clinic al examination can show the position of the sh oulders, the great troc hante rs and the heels in relation to a plum b -l ine from t h e external aud itory meatus. Clinical exa min a t ion,

ever,

how

cannot provide information about the position

of the sacrum

and L5, i.e. the true base of the s pinal column, information which is essential for the under s tan ding and evalua tio n of spinal statics. This e xplai n s why clinicians in t e r e ste d in body

s t a tics have d e v o t e d t h e i r a t ten tion mainly to the question of bo d y equilibrium as a whole, studyin g d eviation of the head and dev iation from the line of g r a vit y by means of sta tove ctography. Rash an d Burke (1971) p oin te d out that 'in s tationary

the

c e n tre of

g rav i t y

be ver tically above the area of preferably n e ar

Figure 3.2 Lateral view of the lumbar spine using the technique illL:strated in Figure 3.1: perfect visualization of the innominate and the femoral heads, and of the lumbosacral j u nc ti o n. The rest of the lumbar spine is neither over-exposed not distorted

its

posture

of eac h bod y segment sbould

centre.

If

the

supporting base,

persistent gravitation a l

torques are bei ng borne by ligamen ts . or if ex c e s s i ve m uscular c o n traction is r e qui red to m a intai n balance, this p r i nci p l e is being viola ted'. X-ray exa m ina t i o n u n der sta t i c

conditions prov ides pertinent informatio n

on this type of s t a tic disturbance . The me ch a n is m of balance differs a nd the sagitt al p la n es .

This

is

in readily

the coro nal un d erst ood

if the effe ct of a heel-pad is consid ere d. An arti

with the p lumb-lin e in place the screen is t h en

the

ficial difference of m o re t h an 1 cm in leg length

this

the coronal plane ; it is felt and resented by the subject, wh ere as ra isin g (or lowerin g ) both h e els is hardly noticed. T his is because in the coronal plan e the lin e of gra v ity lies between the two hip joints and the heels, guaran t eein g ( r ela t i v ely ) stable equili bri um . Purely mechanical sta t i c chan ges a re t h e re for e much more readi l y felt in the coro n al than in th e sagittal plane . In the l a tter the tru n k is in a state of labile equilibrium above th e two perfectl y round sur faces

tec h nique is that it giv e s an u n disrort e d view of the

of the hip joi n ts. Ba l a n ce in this pla n e canno t be

pelvis and the hip j oin ts and correct exposure of

maintained by static forces alone ; dyna m i c m uscul ar

bo t h t h e lumbar s pin e and the l umb osa cra l junc tio n,

forces mus t be brought i n t o pla y , but should be kept

and yet there is no disto r t ion of the lumbar spine

at

lowered to

level requ i red for t h e latera l v i e w of

the lumbar spine (the centre of the screen at the level of the

navel

or slight ly above ) . The p l umb- line

must a g ain be ta ped to

the lower edge

of

the screen

and the p a t i e n t must le a n aga inst the screen to avoid blurring. In the la t e ral view it is an adva n tage not to focus t h e central beam o n th e mid dle of the pic tur e but eccentric ally mi d way between the i l i a c

cre s t a nd th e greater t ro chan te r , i. e. level of

the sa cral

roughly

a t t he

promontory. The advantage of

changes t he balanc e in

i m med iat ely


a

minimum.

FunClionai analomy and radiography of the

Lumbar spinal statics i n the coronal pla ne

Under 'ideal' cond i tions the pelvis a n d sacrum in the AP view a re s t r a ight and a l l vertebrae a re symmetrical: the outer occi pi ta l protru berance is i n the mid-line a n d s o are all the spinous processes down to the sacrum, as well as the coccyx and the p u b ic s ym ph ysi s. Not only is such a s p i n a l colu m n the exception but it is o f l ittle i n te rest. N o bod y ever sta nds n atu ra l l y sy m metrica l l y o n both feet. a n d du r i ng move m e n t the p e l vi s con s t a n t ly s w i n g s f r o m one side t o the oth e r. The pro b l e m is thus not obliquity in i tse l f b ut correct or fa u l ty reactio n to obliquity, and the crite ria by which this reaction c a n b e j udged. This can be stud ied physiologically i f one creates obliquity of the base i n a he a lt h y s u bject b y lengthe n i ng one le g (Figure 3.3). The pe lv is shifts to the h igh e r side while the lumbar s pi n e bends to the same s i d e , if bo t h l egs are stra ig ht and the p a t i e n t re l a x e s. Tn X-rays the same shift to the side. sco li o si s a n d rotation to t h e lower s i d e can b e observed. The summit of th e scoliotic curve i s us ua l ly at the mi d lumbar reg i o n , so that the tho racol u m b a r junctio n comes to stand above the sacrum. The d egree o f rotation i n l u m b a r scoliosis d e p e n d s on lordosis: if this is prese nt, rotation is norma l l y fo und. If th e r e is no lordosis - as in acute l u m bago or sci a tica, for example - there is a l so no rotation; if t here is kyphosis there may even be rotation to the o p po s i t e side. The c rit e r ion of norma l stat i c function of the lumbar spine mllst therefore be its reactio n to obliquity at the base - this base not necessari l y being only the sacrum but also the l ower l umbar vertebrae up to U. If the ob liq u ity is not due to a sho rt l e g (pelvic i n cl i n a t i o n ) but o n l y to inclinati o n of the base of the s pi n e . i t will persist w h e n the p a tie nt is seated, and therefore correction of the sitting pos it i on should be cons i d e red . Reaction to o b l iquity at the base is normal if (1) t h e r e is s co l io s is to t h e lower s id e; (2) there is rotation to the same s i de , p rov ided th at lordosis is present; (3) t he th oracol umbar junction stands vertically above the sacrum; and (4) the pelv i s shifts to t h e higher side . Tho racic scoliosis is always in the opposite d i r e c t io n to l u m b a r scol i osis (Figu re 3.4). These facts reflect the physiology of bala nce a n d

Figure 3.3 Body statics with the subject standing: with his weight equally on both feet. the body axis corresponds to the plumb-line between the heels: (b) with a heel-pad, the weight again equally on both feet. the pelvis shifts to the higher side; (c) w i t h the weight on the right foot the whole body deviates to the right. the head deviating furthest (a)


spinal

column

39

40


in

Rehabilitation of the

Locomotor System

Figure 3.4 Normal reaction of the lumbar spine and pelvis to a short right leg (pelvic obliquity): static dextroscoliosis with dextrorotation of the lumbar spine, deviation of the pelvis to the left from the mid-line (arrow)

affect the whole question of difference in leg length.

that while clinically we determine pelvic tilt,

This in itself is of no significance if it does not cause

cannot determine the position of tbe

sacrum

we

nor that

obliquity of the base of the spinal column. There

of the lumbar vertebrae that constitute the base of

fore, the age-old dispute over how to measure this

the spinal column, as the pelvis may be straight while

difference is beside the point. What is important is

the sacrum is tilted, and vice versa. Only by X-ray


Functionrd anatomy

and radiography of the spina! column

41

Figure 3.5 Pelvic obliquity. (a) Pelvis lower on the right (short right leg) with a horizontal sacrum, the lumbar spine with a right heel-pad the pelvis is horizontal, but sacral obliquity appears, with deviation or the lumbar spine to the left and slight dextroscoliosis

straight: (b)

examination can the true b a s e of the s pinal col umn and the reaction of the s p i n a l col u mn to incl i n ati on b e determined (Figure 3.5). The principa l pathological fi nd i n g s a r e : 1. Obliquity

without scol iosis or w ith insu ffic i e n t scoliosis, so that the thoracolumbar j uncti o n is n o t above the lumbosacral. 2. No pelvic shift to t h e hi g he r side. 3. No rotation whe n there is sco l iosis and lordosis or ro t a t i o n i n the opposite d irectio n from t h e scoliosis, or even sco l i osis to t h e h igh er s ide . Co rre ct i n g disturbance of st a t ics by me a n s of a heel - p ad is the pra c t i ca l a pplica tion of these cr ite r i a . This is, of cou rse, always a c l i n i cal q uestion whi c h can ne v er be decided b y X-ray alone. Neve rtheless, it is X -ra y examination that prov id e s the m ost i m p or t a n t information. What do we expect to a ch ieve by usi ng a hee l-pad to reduce obliqu ity? 1. If

scol iosi s is

sufficient to bring t h e above the lumbosacral, or if sc o li o s i s is abse n t , the th oracolumbar j unc tion will be b ro ugh t to stand above the lu mb o sac r a l , or to a ppro a c h t h is p os i t i o n . 2. If the pelvis is shifted, usually to t h e h i g he r side, it wil l return to the mid-line. not

thoracolumbar j unct i o n

3.

Even if the scoliosis (scoliotic c urv e ) has been b a l a nced, it will decrease a fter o n e h e e l h a s b e en r a is e d .

All this m u s t be c h ec k e d again b y X-ray. With each of these p ossi bi l i ti es we obse rve a p os i t i v e or a negative r e a c t i on , t h e spi nal column e i ther ' a cce pt ing' or ' rej e c t ing' the c o rrection . In cases of 'rejection' i t would b e wro n g t o 'force' c o rrec t i o n upon the patient, be c a us e t h is wo uld only in cre ase the s t r a i n a t t h e b a s e (F i g ure s 3.6 and 3.7). D e v i a ti on fr om t he p l u m b - li ne c a n us u a l l y be i n te rpr e t ed as a s i gn t h a t the p a t i e n t p u t s m o re weight on the leg towards w h ic h the plumb-line i s s h i fted . The tra d i t i o n a l reacti o n t o o b l iqu i t y has been studied by Ill i (1954) a nd Biederma n n and Edi n ge r (1957), w i th t h e s ubj ect ma r ki ng time i n fro n t of a n X -r a y screen . A t every step ob l iqu i ty appeared a t t he b a s e and with i t sco l iosis to th e lower side; the s u mmi t of the scol i o tic cu rv e ap p e a r ed at L3 a nd the thoracolumbar junction was b ro u g ht above the s acrum. A bove T12 the thoracic s p i ne made a (co m pe nsatory) scoliosis to the opp o site side, but it was le ss marked, like a d a m ped w a v e . A cc o rding to Biedermann and E di ng e r (1957), the thoracolumbar jun ct i o n forms a k i nd of fixed p o i nt which s h o u l d n o t swing more than 4 c m fr o m o ne s id e to t h e o t h e r.


42

Manipulalive Therapy

in

Rehabililation of the Locomotor

System

Figure 3.6 Pelvic aDd sacral obliquity due to a short left leg. (a) Left scoliosis with eleviation of the thoracolumbar the right; (b) normal l um ba r statics after application of a left heel-pael

junction to

Figure 3.7 Pelvic and sacral obliquity elue to a short left leg. (a) Left scoliosis with deviation of the thoracolumbilr (b) l e s s pelvic obliquity after application of a left heel-pad, but 110 improvement in lumbar statics

jun ction to the le ft :


rudiographr

FllncJjoJloi [!i1alorny The relation of scoliosis to rotation under the influence of lordosis has been studied by Lovett ;!ccording

whom the

spine'

ares

is lordosis, but direction oC scoliosis if lhe opposite side in kyphosis. This call be

43

'iff! spinal

there is an increased difference between L5 and T 12, the latter being more than 4 cm dorsal to L5 (Figure

1 is

l'labby' llnualance

the

lypical

to

reaction

the rnuscles conlrolling poslure of the

explained by the relative mobility of the vertebral

lumbar spine and pelvis; it may be the result of weak

bodies and the arches during side-bending. If there

abdominal and gluteal muscles, but equally well of

is

the

in

sagittal

proeesse" which an, ?lre locked

therefore rccsist

side-bending; the vertebral bodies, however, arc lice

4).

hack

hip

muscles

Lumbar splltal curvature

J�

(see

clearly dependent

to bend sideways. Hence, there will be more lateral

on pelvic tilt which, in turn, varies according to

flexion of the vertebral bodies than of the arches,

the 'type' of pelvis, as is shown in the following

"Ide of scoil()slS will resuit, the and ro(;ltion to spinolls processes rnnaining in mid-line

IO!1. can, therefore\ be concluded that

spinal

On the other hand, if there IS kyphosis the joints

curvature is adequate if in the sagitta! plane the

are much freer to move, as the joint facets are in

thoracolumbar junction is behind the lumbosacral

loose apposition. The vertebral bodies, however, are

junction and there is no excessive anteposition of

pre,;scd against antt:nor edge, and as

other, pcnticularly therefore

as free

tbeir bend

lordosis. Side-bending of the arches will tllus

sdcral promolltory, and L5 (not

T12 is

far

the most important

coronal

average). In

100

which is double the

than

be the same as, or even exceed, lateral flexion of

criterion is also that the thoracolumbar junction

the vertebral bodies. The result will be either no rotation at all, or rotation in opposite direction from scoliosIs. can be in X-ray

should be vertically above the lumbosacral. If there

of (Figure

3.8).

with acute lumbago, taken slandll1g

obliquity

base

normal redetion is

scoliOSIS and rotal!on shift of

pelvis to

lordosis

present)

higher side.

This can also be ascertained clinically

If curvature of the spinal column subserves these

if a subject with a marked lumbar kyphosis when

rules, i,e. the rules of body statics, then it is physio-

sitting relaxed is told to side-bend: while in lordosis his in

spinous processe:; Ime, in

the,

remain airnost form a

; I am not 8ware of any other criteria of spinal be infern:cI that the

curvature. Furthermore, it column

scoliotic arch.

only helps

maintain equilibrium

the whole body but also determines the relation ship between the various parts of the body under

Lumbar spinal statics in plane

the influence of gravity. Wc

sagittal

therefore speak of

equilihnum' subservcd accordance

38).

the spimil column

the criteria of Rash

Burke

In the sagittal plane we are concerned with what are

(1971) (see p.

called 'normal' curvatures, generally held to comprise cervical lordosis, thor8cic kyphosis, lumbar lordosis

recumbent or if the position of the pelvis and the

and sacral kyphosIs. (1961

have the

Sollmann and Breitenbach for clisproving this

Curvature cannot be evaluated if the patient is spine

to at

cannot

seen on

the thoracolumbar single radIOgraph.

accepted view, on the basis of 1000 X-rays of the entire spinal column. They came to the conclusion

'flat' spine) goes hand in hand with hypermobility

that there is only an 'individual norm': they do not,

anrllack of stahilitv, while greater curvature (in both

however lay down thai

is a con,llInt correlation between the ti It of L5 and that of T12, and more important still, that the T12 vertebra lies 4 cm behind L5 (150 measurements were taken). I in 200 mysI'lf ccmfirmecl ,ewit,l lind also showed that plumb-Ililc from the external acoustic meatus passes exactly through the scaphOlds at its base. The sacral promontory lies 4 mm behind and the axis of the hip joints 12 mm in front of this changed in distllrb plumb-11IIe. These cI1I1ditions anct' dynamics, of muscular function. IS wrote

most eVident in muscle spasm due to acute sCl3tica

It is important to realize that a slight curvature (a

sagittal and and

coronal

corrcsponds to

rnobility.

The pelvis pelvis

the spinal column constitute a

functIOnal entity, the pelVIS being the base of the column and the point of connection with the lower extremities. The pelvis transfers motion from the extremitit" [he ilia,

and acts

a shock absorber.

muscles dnd Iigarllcills attach

themselves to the spine as though to a mast. The

or lumbago in disc lesions, when there is a forward

sacroiliac joints and the pubic symphysis allow

thrust posture (Figure

for some mobility (springing) while guaranteeing

whieh

3.9)

or in flabby posture in

he sacral promontory

forwa

and


44

Manipulalive Therapy in Rehabiliralion of lhe LocomOlOr System

Figure 3.8 Typical posture in acute disc lesions with deviation of the plumb-line and the (straight!) pelvis 10 the side: 'paradoxical' scoliosis vith slight rotation to the opposite side: lumbar kyphosis can be deduced from the shape of the pelvis

Pelvic types

There are frequent anomalies of the lumbosacral

The function of the pelvis and its influence on body

region: the last lumbar vertebra is a 'transitional'

statics depend largely on its type. We owe this

vertebra and shows by definition that there is harclly

concept to Erdmann (1956) and Gutmann (1965).

any 'norm' and that variation is the rule. ff the


Functional anatomy

and radiography

of Ihe spillal column

45

forward thrust posture, in an acute radicular syndrome

Figure 3.10 Lateral view of the lumbar spine in 'flabby' posture - a fo rw a rd shift of tbe pelvic promontory - in this case due to a shortened iliopsoas muscle

variations are asymmetrical, the result may be obli

pe l v ic gird l e, the sacroiliac j oin ts having the d ec isi v e

quity of the sacrum, c a us in g the c hanges in statics

role.

Figure 3.9 Lateral view of the lumbar spine with

a

d ist ing u is h

The sacr u m is wedge shaped in two directions: (1) the w h ole structure tapers like a p y ra m id in the caudal direction; and (2) the upper part (S1-S2) t apers in a d orsa l d i r e c ti o n ( accord ing to Solonen, 1957), while the lower p art may taper in either

three p elvic types with far-reaching d ifferences in

direct i o n . There is a tuberosity on the i nn om inate

already dealt with. If, h oweve r , there is symm etric a l variation,

the

most important

con s eq uence is a

change in the length of the sa cru m , a ffec t ing the postion of the sacral promontory. Gutmann (1965) and E r d m a n n

(1956)

fun c t i on and possible pathology. The first pr es ents a

bone

long s a crum and high sacral p romon tor y , the second

su r fa c e,

the average or intermediate ty p e , and the third

a

low

p elvic inclination,

a pp r ox i m ately

in

t he

mid d le

of the joint

fitting into an impression on the joint surface of the sacrum at the lev e l of S2, but there is

For greater cl arity the d iffe re nt criteria are s h ow n

grea t variability and this is not the only t u be r os i t y . In the AP X-ray there is a d o u bl e contour owing to the wedge sha p e described above, but this varies from case to case and is frequently asymmetrical. It

in Tabl e 3.1 and F i gure 3.11.

is of some i m p or tance that the greater the distance

promontory

and

considerable

which the authors call Hohes Assimiliationsbecken, Normal Becken and Uberlastungsbecken, respectively .

when

between the two contou rs of the j o i nt , the greater

evaluating X-ray findings: the type of pel vis will

the d iv erg ence (or convergence) a n d the na rr ower

All

of

this

sh o ul d

be

b or n e

in

mind

determine the d egre e of lordosis to be expe cte d ,

the joint space appears. C o n ve rsel y , if th e r e is no

while the height of the last intervertebral disc will

con verge n ce and we see only o ne contour, the j oint

de termin e the mobility of the se g men t.

space appears to be wide.

Greater c o nv ergence

(wedge sh ap e) g i v es more stabi li t y , whereas little convergence accom p a ni e s hypermobility.

The sacroiliac joints

It is

impor ta n t to poin t out that, d espite its

Thanks to the s acroilia c joints an d the p u bi c sym

unusual shape and the fact that t h e r e are no muscles

phy s is there is some m obili t y of the otherwise firm

moving

the


sacrum against

the innominate,

t he

46

Manipllimnc

Rehllhiillalion of Ihe Locomotor Syslem vertical from the promontory

the outer and to the

(b) vertical from

(a)

Figure 3.11 Pelvic types. (a) High promontory: (b) average type: (c) increased pelvic (sacral) inclination (After Gutmann, 1965)


(c)

vertical from the outer meatus

Fun Clional

analOmy

radiography of the

and

spinal column

47

Table 3.1 Pelvic ty pes Crilerion

Typ e

High I n c l i n a t i o n of s acr u m

Interm ediate

Low

50-70

35-50

1 5-35

\ 5 -30

3 0- 50

50-70

p rom ontory

prom o n t o ry

( degrees) I nc l i n a t i o n of u p p e r

s u r fa ce of S l (degrees) Pos i t i o n o f L4 disc

Above t h e l i n e of t h e i l iac

cres t s

At the

h e i g h t o f the

l i n e o f the i l i a c d iscs Posi t i o n of the .

At

Ecce n t ric ( d orsa l )

pro m o n t o r y i n t h e pe l v i c

t h e c e n tre

At t h e ce n t re o r eve n

r i ng

Rec t a n g u l a r

Wedge s h a pe d

S h a p e of L5 d i sc

R e c t a n g u l a r a n d h ig h e r t h a n L4

Wedge shaped a n d l owe r t h a n

W e d ge s h a p e d

L4

LS-S I

L4-- L 5

L i t t l e fi x a t i o n of L5

G ood fi x a t i o n of

m o b i li t y R o l e of i l i o l u m b a r

Wed ge s h a pe d a n d lower than

L4

L4-- L S L5

l i ga m e n t W e i g h t - b e a r i n g s t ru c t u re

l i n e of t h e

v e n t ra l

S h a p e of L5 v e r te b r a

Level o f m a x i m u m

B e l ow the i l iac c r e s t s

G oo d

fi x a t i o n o f LS

a n d e v e n o f L4

End p l at e of L5

E n d p l a te of L5

A poph ysea l j oi n t s u r face of

SI , s a c ro i l i a c

j oi n t Spi n a l c u r v a t u re

Flat

Average

I nc r e a s e d

X-ray statics

H i p j o i n ts in fro n t o f p r o m o n t o ry : t h e p l u m b - l i ne from t h e o u te r acoustic m e a t u s coi ncides w i th the ve r t i c a l

A s fo r h ig h

The p l u m b - l i n e from

p ro mo n t or y t y pe

f r o m the os n a v icu l a r e a n d l i e s b e h i n d t h e h ip j o i n t , sl i gh t l y b e h i n d

the

lies

i n fro n t o f t h e h i p

j o int

H y p e r m ob i l i t y , d e ge n e ra t i o n o r pro l a p s e o f

fro n t o f

the pro m o n t o ry , w h i c h

p romo n tory Clinical c o n s e q u e n c e s

the o u t e r aco u stic mea t us l ies i n

B lo c k a g e , d i s c l e s i o n

LS d isc: l i g a m e n t p a i n

sacroi l i ac joint is a true dia rthrosis w ith its own mobility ( M e n neIJ, 1 952; Weisl, 1 954; Co lachis el al., 1 96 3 ; Duckworth, 1 970) . A ccord i n g to Duckworth, ' the normal movemen t that occurs is rota tion of the sacrum a ro u n d the s h ortest and strongest part of the i n terosseus sacro i liac l i game nts, w h i ch run from t he i l iac tube rosities to the transverse tu bercles of the second sacra l vertebra ' . Th is move m e n t can be described as nutation, a n d the weight o f the spinal col umn d u r i n g walki ng w i l l le nd to rotate the sacr u m forward w i t h each step, t h e sacroi l i a c j o i n ts p l a y i n g t h e part of spri nging shock-absorbers. This rotational move ment o f the sacrum against the ilium ca n be palpated and is fa m i l i a r to gy naecologists i n the manageme n t of labour. However important i t i s that there should be some mobi l i t y o f the sacro i l i a c j o i n t , it should b e very lim ited a n d l ax i ty is u n d esirable. A t t h e e n d of t h i s section on t h e function a l anatomy o f the p e l v i s some re m a r k s a re re q u i red

o f L 4 disc

A rt h ro s i s : l u m b o s a c r a l,

s a cro i l ia c and

o f the h i p

about a cli n ically very stri king p h e n o m e n o n w h ich m a y be called ' pelvic d istorti o n ' . I f the most promi nent points of t h e bony pelvis are palpate d , a peculi a r a pparent d iscrepa ncy e merges: whereas the posterior spi n a il iaca superior (PSIS) i s higher on one side, us u a l ly t h e right, the reve rse is fou n d on palpating the a n terior s p i n a i l i aca superior ( A S I S ) . T h e i l i a c crest may be l a tera l l y a t t h e same level, o r t h e r e may be a slight d iffe re nce. O n p a l p a t i o n o f t h e posterior part o f the i l iac crest a s i m i l a r d i ffe rence will be fel t to t h a t observed o n the posterior spinae i l i a cae, confirm ing the fi n d i ngs. This might give the i m pressio n t h a t one i nn o m i n a te was rota ting against the oth e r o n a horizo n t a l axis. This cannot be so beca use we should then find a considera b l e s h i ft of the pubic bones a t the symphysis. These c l i n ica l facts may best be i ll u strated a n a tomically by Cra m e r 's d i agram (Figure 3 . 1 2 ) . This s h ows a one-sided n u tation a n d there fore a l so sl ight


48

Manip u lative Therapy ill Rehab ilitation

of the

Locomotor System

has been foun d t h a t p a l p a t i o n fi n d ings of a in the l e v e l of the p u b i c b o n e s a t t h e s y m p h y s i s a n d a t t h e ischia l tube ros i ties do not co r r e s p o n d to X-ray fi n d i ngs (see Chapter 4 , p a l p a tory i l l u s i on , p . 1 00 ) . It

d i ffe r e n c e

The lumbar spine A l t h o u g h o n l y a l i t t l e s h orter t h a n t h e t h o ra c i c spine, t h e l u m b a r sp i n e i s u s u a l l y fo r m e d o f fi ve vertebrae. H ow e ve r , m o b i l i t y i n a n t e - a n d retro fle x i o n as well a s i n l a te r a l be n d ing e ns u r e s most o f the m o bi l i t y of the t r u n k . In a d d i t i on t o t h i s i m po rt a n t

a spect, the lumbar s p i n e h a s t o c a r r y m o s t t h e trunk. The vertebral bod ies as w e l l a s the a r ch e s a re t h ere fore m o re r o b u s t . The a p o p h y s e a l j oi n t s give b o t h m o b i l i t y a n d s t a b i l i t y . They a re v e r t i c a l , t h e ( l a r g e r ) l a te r a l p a r t

of

FiglJfe

3.12 The

mechan ism

of pelvic distortion ( A fte r

Cra m e r , ( 965)

the

w e i g h t of

i n the s a g i ttal pla ne a n d t h e ( s m a l le r ) m edia l p a r t i n

the

coro n a l p l a n e . T h e two p a rt s m a y t h u s t y p i ca l l y

form a n a n g l e : howe v e r ,

t h e sacrum between the i Ji a , p ro d uc i n g r o t a t i o n o f o n e i n no m i n a t e rou n d a horizo n t a l a x is a n d o f t h e ot h e r roun d t h e ve r t ic a l . A l t h o u g h m a n y a t t e m p ts h a v e b e e n m a d e to v i s u a l i z e by X - r a y so m e of the a s y m m e tr ica l ch a n g es to be ex p e c t e d . X - r a y d i a g nos i s of t h i s co n d i tion rema i ns unsat isfactory . T h e re is one c h a n ge , however. that do es a p pe a r in the X - ra y p i c t u r e , and that i s a ch a ng e in the statics of t h e l u m b a r spi n e , co n si s t i n g c l i n i ca l l y i n a s h i f t of t h e p e l v i s to t h e s i d e o f t h e h i g h e r pos te r i o r i l iac s p i n e , w h i c h m a y p rod u ce static decompe nsa t i o n of the l um b a r s p i n e , v is i b l e i n t h e X - r a y p i ct u re t a k e n s t a n d i n g ( F i g u re 3 . 1 3 ) . ro t a t i o n of

( a)

a n a rc h ,

the

freq u e n t ly

t h e y o n l y form

l a te r a l part po i n t i n g i n to ( h e s ag i t t a l a n d

i n t o t h e c o ro n a l p l a n e . I f there is the joi n t is e a s i l y v i s u a l ized by X - r a y , b u t t h i s is not t h e c a s e i f i t is a rch e d . The l u m b o sa c ral j o i n t , h o w e v e r . i s m a i n l y i n t h e coro n a l p l a n e . As t h e fi n a l s h a p e of the j o i n t is formed d u r i n g o n to g e n e s i s , a nom a lies a n d a s y m m e t ry a r e v e ry fre q u e n t . T h e s h a pe o f the a r t i c u l a t i o n determ i n es t h e f u n c tion o f the lum b a r s p i n e ; i t a l l o w s f o r m uch a n t e a n d r e t ro fl e x i o n a n d p r a c t i c a l l y e xc l u d e s a n y a x i a l rota t i o n as l o n g a s t h e l u m b a r s p i n e is e re c t . I t l i m i t s .l a tera l fl e x i o n as l o n g a s l o r d os i s i s p rese n t , a s h as a l re a d y b e e n e x p l a i ne d (see p p . 42 a n d 43). It the

medial

a n g u la rity

( b)

( c)

Figure 3.13 D i s t u r bed sta t ics i n p e l v i c d i s t o r t i o n . (a) Pelvis s t r a i g h t . o b l i q u i t y at L4 w i t h d e v i a t i o n of t h e l u m b a r s p i n e t o t h e l e f t a n d s l i g h t s i n i s t rosco l i o s i s . ( b ) N o i m p ro v e m e n t a ft e r a p p l y i ng a l e ft h e e l - p a d . ( c ) A ft e r trea t m e n t o f a b l oc k e d a t l a n t o - o c c i p i t a l ( ! ) j o i n t . n o r m a l s t a t i c s a o d no p e l v ic d i s t o r t i on


( ollimn

Functional ana /amy and shou l d , however, be

v e r t e b r a e . A l t h o lJ {' h

caps u l es a re v e r y w i d e

i n t e rv e r t e b r a l fora m e n

a p p o s i t i o n o n l y i n l or d o s i s

the rest o f t h e l u m b a r

i n n e u t r a l a n d k y p h o t i c pos i t i o n s .

im p or t a n t

T h e i n te rv e r t e b r a l d i scs a re t h ic k e s t i n t h e l u m bil r

to bear

49

t h ick, tbe n a rrower t h a n fo r a m i n a . I t i s

in

m i nd

that

the

i liolumbar

m ob i l i ty . T h e i r t h i c k n e ss

l ig a m e n t i s a t t a c h e d t o t h e t r a n s v e rs e p ro c e s s o f L5 s o t h a t the fift h l um b a r v e r te b r a t r a n s m i ts i m p u l s e s

i nc r e a s e s from Ll down t o L4; h e n c e , m a x i m u m

t o t h e l u m b a r s p i n e b o t h f r o m t h e s a c r u m a n d from

mob i l i t y i s u s u a l l y fou n d a t t h e L4/5 s e g m e n t . O n l y

the i l i a , p l ay i n g the r o l. e of a s h oc k - a b s o r b e r as w e l l . ;\ s t h e u p p e r s u r f a c e o f t h e s a c r u m i s u s u a l l y con

spine

a n d a l l ow g r e a t

i n t h e p e l v i c t y p e w i t h a h i g h s a c r a l p r o m o n to r y i s m a x i m u m t h i c k n e s s a n d m o b i l i t y fo u n d b e t w e e n L5

s i d e r a b l y i n c l i n e d , t he p os i t i o n o f the l u m bo s a c r a l

and S 1 .

a p o p h y s e a l j o i n ts i n a m a i n l y c o ro n a l p l a n e m a y a c t fo rw a r d g l i d in g

as a preven t i o n Some of the

X-ray a nato m y T h e w h o l e o f t h e v e rt e b r a l

h a v e a l re a d y b e e n cases o f transi t i o n a l

in Figure

d i ffi c u l t t o dete r m lll c

3. I 4 ;

the oval

e n c o u nt e r e d types. I n i t may be vertebra

( r a d i x a rc u s ) a re m o s t p r oj ects o n t o t h e u p p e r

i s a l u m ba r i z e d

t h e fi ft h v e r t e b r a a n d

i liac crests: i f an

most p r o b ab l y a t t r i b u t a b l e [ 0 l

t h e vertebra beJo\\

of t h e v e rt e b r a l c a n a l i n t h e l o w e s t p a r t

l i n e passes t h rough t h e m i d d l e o f a verte bral body,

I

The m o s t

r e l i a b l e r e fe r e n c e

l u m b a r s p i n e From the p e d i c l e w e may fo l l o w t h e b r o a d s h a d o w o f t h e l a m i n a i n t h e d i re c t i on o f t h e .

the two t h a t l i ne

,

however, t h i s

i t m a y b e i m poss i b l e t o d e t e r m i n e t h e t ra n s i t i o n a l

s p i n o u s p r o c e s s . La t e r a l t o a n d a b o v e t h e p e d i c l e

v e r t e b r a , i n p a r t i c u l a r i f t h e re a p p e a r to be s i x l u m b a r v e r t e b r a e , w i t h o u t t a k i n g a n X - r a y of t h e

we c a n fi n d t h e u p p e r a r t i c u l a r p ro c e s s ; f r o m t h e

t h orac i c s p i n e . I n s t e a d o f a t r a n sv e r s e p ro c e s s , a

l a m i n a downwards and below the ped icl e , t h e l o w e r

t r a n s i ti o n a l l u m b o s a c r a l v e r t e b r a m a y h a v e a m a s s a

a r t ic u l a r p rocess c a n be t r a c e d i n a c a u d a l a n d l a t e r a l

l a te ra l i s w h i c h ( o nu s a

d i rectio n towards t h e p e d i c l e ( a n d t h e u p p e r a rt i c u l a r

m a s s a l a t e r a l i s o f t h e s a c ru m , a n d m a y e v e n c a u s e

process) o f t h e n e x t ( c a u d a l ) v e r t e b r a . B e t w e e n t h e

s y m p to m s

a rc h for m e d b y b o t h l o w e r

and

.

T h e m ost i m por t a n t

t h e s p i n o u s process 01

a b l y a n a rr o w s p i n a l

v e r t e b r a it i s poss i b l e t o

n a rrowe r a s a res u l t

i . e . t h e c a n a l i s n o t coveTed

e a s i l y recog n ized

i n d i c a to r o f t h e e ffe c t i v e

p ro p o r t i o n b e twe c: 11 s h o r t t h i c k p e d ick"

i n t h e A P proj e c t i o n . W h e re

m i n a a n d the s t e e p

m e e t ( c l os e a bo v e t h e space ( i f p a r t o f t h e

pse u d o a rt h ro s i s w i t h t h e

, i s probbecome e v e n r e l a t i ve l y t h e d i s body a n d I m e rv e r t ebra l

fo r a -

A P v i e w , a l th o u g h IS

I n t he s a g i t t a l p l a n e ) .

th i s co n d i t i o n s h o u l d n e v e r b e a s s e s s e d a c c o r d i ng

T h e re i s s l igh t d i v e rgence o f t h e a p o p h ys e a l j o i n t i n

to t h e i n te rpe d ic u l a r d i sta n c e , b u t by t h e d i s t a n c e

a c ra n i a l d i rect i o n .

b e t w e e n t h e t w o l o w e r a rt i c u l a r proces s e s , i . e . t h e

T h e l a t e r a l v i c w (Figure 3 . 1 5 ) a ls o s h o w s t h e t h i c k

w i d t h of t h e t ra ns l u c e n c y corres po n d i n g t o t h e s p i n a l

p e d i cl e s , from w h i c h t h e a r t i c u l a r p r o c e s s e s a ri s e .

c a n a l . I n s u c h c a s e s t h e a rt i c u l a r processes p rese n t a

H e r e , t o o , we m a y s e e t h e j o i n t s p a c e i f p a r t o f t h e j o i nt i s i n t h e coro n a l p l a n e . B e t w e e n t h e u pp e r a n d

s w a l l o w - t a i l s h a p e on X-ray T h e a r t i c u l a r processes

l o w e r a r t i c u l a r p r o c e s s e s l ie s t h e p a rs i s t h m i c a , t h e s i te w h e re s po n d y l o l y s i s m a y b e s o u g h t . B e l o w t h e

p i ct u r e i s s e e n i n b o t h v i e w s we m a y in fe r t h a t t he s p i n a l ca n a l i s trefoi l i n h o r i z o n ta l section. ( Ho w e v e r

ped i c l e s w e s e e t h e i O lc n e rt e h r a l l ie a l m o s t e x a c t l y i n t h e

sca n n i n g v i s u a lizes

\\ h i c h

.

a r e v e ry t h ic k and the j o i nts c l e a r l y v i s i b l e . If a t y p i c a l

r a d i o l o gy CT

s i g n i fi c a n t t he s e It

is,

,

of course.

zon t a l d i a m e t e r a l m o s t post e r i o r w i d t h o f t h e

criteria for a s s e ss i n g

c ov e re d b y t h e a r t ic u l a r

d i s c ; i t s h o u l d be b o r n e

t h e se p rocesses o n ly t h e

h y po p l a s i a i s a c o m n l O l 1

p rocess ca n be see n . T h e I

w i t h d is c d e ge n e r: 1 1

sound

I

on to t h e a r t i c u l a r p rocess

fou n d p a r t i c u l a rl y

sm a l l t h i c k s h a d o w .

( w h e r e a n o m a l ie s m o s t o fl e n occ u r ) . T h e r e fo r e i f

T h e l a s t l u m b a r v e r t e b r a d i ffers fro m t h e r e s t i n many ways: i n t h e side view i t i s wedge shaped a n d

t h e l a s t v e r t e bra s h o w s m a r k e d s i g n s o f be i ng a t ra ns i t i o n a l v e r t e b r a a n d t h e r e are n o s i g n s o f

w i t h powerfu ll y d e v e l oped t r a n sv e r s e processes i t

m a rg i n a l s cl e ro s i s , b o n e s p u rs o r i nc r e a s e d l a x i ty

s ho w s a t r a n s i t i o n a l s h a pe i n r e l a t i o n t o t h e s a c r a l

( s h i ft ) a d i a g n o s i s of d e ge n e ra t i o n i s u nfo u n d e d . A ,


50

Manip u lative Therapy in

Rehabilitation of the Locomotor System

10

2

11 12

3 4 5 6 7

13

8 9 14

(a) (b)

( i)

( ii )

� 1

(e )

( iii )

0

o

/

(d )

Figure 3.14 Com p a r i s o n of t h e a n a to m i c a l s t r u c t u r e s i n t h e d o rs a l a s p e c t of t h e l u m b a r s p i n e a nd t h e s a c r u m (a) w i t h t h e a n t e ro poste r i o r X - r a y ( b ) a n d t h e v e n t r a l a s p e c t ( e ) . 1 , S p i n o u s process; 2 , u p p e r a r t i c u l a r process; J , l a m i n a ; 4 , p a r s i n t e r a r t i c u l a r i s ; 5 , j o i n t s p a c e ; 6 . low e r a r t i cu l a r process; 7 . s p i n a l ca n a l ; 8 , posterior s p i n a i l iaca supe rior: 9 , dorsal p a r t o f t h e s a c ro i l i a c j o i n t; 1 0 , disc: 1 L t r a n s v e rse p rocess: 1 2 , v e r t e b r a l bod y ; 1 3 , p e d i c l e ; 1 4 , v e n t r a l p a r t o f t h e s a c ro i l i a c j o i n t . ( d ) D e Seze ' s d i a g r a m v i s u a l i z i n g t h e A P X - r a y o f l u m b a r ve rtebrae: ( i ) t h e v e r te b r a l bod y , (Ii) t h e v e r t e b ra l a r c h , ( iii) t h e p e d i c l e s , ( i v ) t h e e n t i re v e r t e b r a


Functio l / a l a l / atomy a n d radiography of th e sp inal

column

51

7 6 5 Ij. 7 2 3

Figure 3.15 Co m pa ri s o n of t h e a n a tomical s t ru c t u re s in the l a te r a l v i e w of t h e l u m b a r spine (model) a n d t h e X-ray. 1. Ped icle: 2, p a rs i n t e ra r l i cu l a r i s ; 3 , lowe r a rt i cu l a r p rocess; 4 , up p er a r t i c u l a r p roce s s : 5 , joint space ; 6 , i n te rverte b r a l fora m e n : 7 , t ra n s verse p r ocess

v a l u a b l e s ig n of d i sc h y p o p l a s i a i s r e d u c e d wi d t h o f bot h v e r te b r a l margins a dj a c en t to th e h y p o p l a s t i c disc . A l t h o ug h w e u s u a l l y r e l y o n la teral v i e ws fo r

t i o n s h o u l d be p rop o r t i on a t e to scoli o s i s a n d c a n be modi fi e d by t he degree of lordosis ; if rota tion is d is proportiona te, o r l i m i ted to one or two i n terverte b r a l

t h e assess m e n t of d i sc s , marke d asy m metry in t h e

segmen ts o n l y , i t c a n be a s ign o f d istu rbed fun c t i o n .

AP v i e w m a y be o f s o m e i m por t a n c e , p a rti c u l a rl y at the LS-S 1 i n ters p ac e , as here assess m en t may be d i ffi c u l t in view o f t h e fre q uen c y of a n oma l i es . A

process a n d the ped i c l es i n t h e d ir e c t i o n opp o s i t e to

marked nar rowing on one s i de m a y t h e n poin t t o

becomes w i d e r a n d t h e ar t i c u l a t ion is better vis u a l

d isc d e gen e ra t ion ( Fig u r e

ize d ; t he t r a n s v e rse p rocess i s sh o r t er ( F i g u re 3 . 1 7 ) .

3 . 1 6) .

R o t a t i o n is recognized

by

a

s h i f t of th e s p in o us

t h a t of rot a t ion . On t h e sid e of ro tation t h e p e d i c l e

Rotati on sho u l d never b e eval u a t e d o n t h e basis o f o n e s i n g l e sign

E v a l ua t i o n o f fu nct i o n F o r eval uation o f fu n c tion and

(such

a s devia tion o f t h e s p i n ou s

p roces s ) . T h e a s s ess m e n t of lateral fl e x i o n ( scolios i s )

its

possible d i s

t u r b a n c e s , p ictures m u s t b e ta k e n u n d e r standa rd

cond itions (see pp. 36-3 8 ) . A ssessment of r o t a t i o n is of value, because rota-

i s ca r r i e d out a c cord in g t o the p rin c i p l e s o f bod y sta tics .

In the lat e ral v iew we assess lord osis or k y p h o sis a forwa rd or bac kward s h i ft . A l oca l

a s wel l as


52

Manip uia live Therapy in

RehaiJililGlion of Ihe LocomOlor System

Figure 3.16 The a n t e rior lower edge o f the verte b r a l b o d y o f L5 i s lower on the l e ft s i d e (artTow) in re l a t i o n t o t h e s a cr u m , h e n ce t h e L 5 d i s c is n a rrowe r on t h e l e ft : com p e n s a t o ry l u m b a r sco l i osis w i t h l e ft ro t a t i o n

i n te r r u p t i o n o f t h e l o rd o t i c l i n e

or of kyphosis,

b e t w e e n t w o v e r t e b ra e , c a n be a s i g n

of

d i s c l e s ion .

A s h i ft ( f o r w a r d s or b a c k w a r d s ) m a y be a s i g n o f i n c r e a s e d m o b i l it y - l a x i t y . T h i s m a y be p a r t i c u l a r l y c o n s p i c u o u s d u ring a n t e - o r r etr o fl e x i o n . V e ry s l i g h t p r op o r t i o n a l s h i fts in a n te- o r r etr o fl e x i o n i n youn g p a t i e n t s , see n a t X - ray e x a m in a t i o n , c a n be rega rded a s n o rm a l . Tw o d i a g n o s t i c p itfa lls must b e s t r e s s e d . The fi r s t i s t h e i n c o n gru o u s s u rfa ces o f two a dj a ce n t v e r te b r a e , o cc u r ri n g m o s t fr e q u e n t l y betwe e n L5 a n d t h e sacru m ; th e u p per s u r f a ce of S l in such c a s e s i s u s u a l l y s l i g h t l y l o nger t h a n the l o w e r s u rface o f

L 5 , a n d look i n g

at the

edge of t h e adj a c e n t o f a n a n t e r i o r s h i ft the a n t e r i o r e d ge) of a posterior pos terio r

ve r t e b ra e o n e gets t h e i m pre s sion

o f L 5 , or ( l oo k i n g at s h i ft of L5 . The second p i t f a l l i s s l ig h t rota ti o n : h e re the p os t e r i o r a n d a n t e r i o r m a rg i n s of the v e r t e b ra e fo rm a d o u b l e co n t o u r w h i ch c a n be m i s t a k e n for a s h i ft .

to h y p e r m o b i l i ty m u s t , o f c o urs e , from true spo n d y l o l isthe s i s ( w i t h s p o n d y l o l ys i s ) a n d fro m degenerative spon d y l o l i s t h e s is ( t he p s e ud o s p o ndy l o l i s t h e s i s o f J u ngha n n s , 1 930) d u e to d e fo r m i ty . t h e b e n d i n g fo rwa rd o f a n These s h i fts

due

be d i s ti n g u i s h ed


Func/ional a n a /amy

and ra diography of (he sp inal co/limn

53

Figure 3.17 R o t a t i o n o f l u m b a r v e r t e b r a e with l a t e r a l s h i ft o f t h e s p i n o u s processes a n d p e d i c l e s i n re l a ti o n t o the v e rte b r a l bodies

u p p e r a r t ic u l a r p rocess ( m ost freq u e n t l y w h i c h t h e v e rt ebra a b o v e gl i d es fo r w a rd

L5 )

over

m a y be d e s c r i b e d a s a s o r t of l e v e r a ge (J i r o u t , 1 95 6 ) .

N a r rowing o f a n i n te rv e r t e b r a l d i sc, c a u s e d b y

.

d egeneration , m a y some t i m e s be v i s i b l e o n l y i n a n t e or re trofle x i o n . I n s u c h c a s e s we see exagge ra ted

X - ray studies of move m e n t X - r a y p i c t u re s

in

the

upright

posi t i o n

a n te r i o r n a rrow i n g of the d i s c ( w i t h o u t compe n s a t o r y may

not

p os t e r i o r w i d e n i ng) i n a n t e fl e x i o n a n d e x a gge r a t e d

provide a n y c l u e s t o d i s t u rbed f u n c ti o n ; t h ose t a k e n

poste r i o r n a r r o w i n g ( wi t h o u t c o m pe n s a t o r y a n te r i o r

i n a n te- o r retrofle x i o n o r l a t e r a l fl e x i o n m a y t h e n

w i d e n i ng ) i n retrofle x i o n .

reve a l s o m e i r re g u l a ri t y . W e m a y d i s t i n g u i s h seg

M o b i l i ty s t u d i e s a r e u s u a l l y m a d e w h e re t h e re i s

m e n t s o f i n c re a s e d o r l ow e r e d m o b i l i t y . In a n te - a n d

a c l i n i c a l rea s o n f o r d o i n g s o , i . e . i f move m e n t i n

retrofle x i o n i ncreased m o b i l i t y m a y t a k e t h e fo r m o f

some speci fic d i recti o n c a uses s y m p t o m s . A cond i t i o n

v e n t r a l o r d o rs a l s h i ft , respect i ve l y ( ' d isc r o l l i n g ' ) .

i n w h ic h t h is t y p e o f e x a mi n a t i o n i s p a r ti c u l a rly

A s has a l re a d y b e e n p o i n te d o u t , v e r y s l ig h t pro

i m po r t a n t i s s p o n d y l o l is t h e s i s , beca u s e i t i s a d v i s a b l e

port i o n a l s h i ft i n g m o v e m e n t s in all se g m e n ts may b e

to asce r t a i n w h e t h e r t h e s p o n d y l o l i s t h e s i s is fi x e d o r

cons i d e red n o r m a l , p a r t i c u l a r l y i n y o u n g s u bj e c t s

m o b i l e ; i t i s t h e l a t t e r t h a t c a uses s y m p t o m s a n d h a s

(J i r o u t , 1 95 6 ) . The re is o n e i n te r e s t i n g exce p t io n : i n

a te n d e n cy to d e t e r i o r a t e .

t h e l u m b osacra l segm e n t t h e re s o m e t i m e s o c c u r s

a

I n l a t e r a l fl e x i o n i t i s m o s t i m p o r t a n t to corre l a t e

' p a ra d o x i c a l ' s h i ft , i . e . a d o r s a l s h i ft d u r i n g a n te

t h e d e g re e o f fl e x i o n a n d rota t i o n w i t h rega rd t o t h e

fl e x i o n a n d a v e n t r a l s h i ft d u r i n g r e t r ofl e x i o n . w h i c h

degree o f lordosis (see p.


43 ) .

54

Manip uialive Therapy in Rehab ililOlioll of !he Locomo!or Syslem

The thoracic spine

coro na I p l a n e as if o n the p e r i p h e r y of a cylinder w hose cen tre is i n front of t he ve rtebral b o d y T h i s s h ape would a l low for considera b le r o ta t i on w e re it n o t fo r the r i bs and the i n terve rtebral d iscs. S i d e a n d fo rward-bendi ng, too, a re l i m i te d m a i n l y by rh e ribs, a l t h oug h t h e l a tter movem e n t is a l s o h e l d i n check b y t h e i n te r- a n d s u p r a s p i n a l l iga m e n ts. B ack bending i s l i m i ted m a i nly by a p p o s i t i o n locking of the articular a n d t h e s p i nous processes. Because of t his relativel y l i m i ted m o b i lity, t ru n k r o t a ti o n was ,

.

Fun ctional a n atomy

The thoracic s p i n e (Fig u re s 3 . 1 9 a n d 3 . 20) is the long est part of the s p i n a l col u m n a n d that which e n j o ys the least m o b i l i t y The main reason for th i s i s i ts c l ose re l a t i on s h i p to the thorax but i t is a lso related to t h e t h i n ness o f th e i n te rve rtebra l d iscs. Th e apophyse a l j o i n ts a re a l m ost ve rtical a n d s h o w a s l i g h t t i l t i n the .

Figure 3.18 The t h o ra co l u m b a r ( sJde �exion) begi nning a t LS

spi n e d uri n g t r u n k ro t a t i o n with the pe l v i s fixe d : t h e re is both rot a t i o n a n d s c o l iosis


FlinCl iulla! anatumy and be l i eved

to take

p l a ce m a i n l y i n t h e l o w e s t t h or a c i c

55

the

l o west p a rt o f t h e t h o r a ci c spi n e ( l h e t h o ra co l u m b a r j u n c t i o n ) w a s refu t e d by S i n g e r a n d G i l e s ( 1 9 90 ) .

Fu n c t i o n a n d i ts d i st u r ba nces a re of p a r t i c u l a r

thoraco l u m b a r j u n c t i o n . T h is m a y b e b e c a u s e i n t h i s re g i o n moveme n t c h a nges fro m o n e l y p e 1 0 a n ot h e r w i t h i n a s ing l e s e gm e n t . as c a n b e d e d u c e d fro m t h e s h a pe o f t h e a p o p h ys e a l j o i n ts : on a s i n g l e vertebra t h e u p p e r a r t i c u l a r pr oc e s s e s m a y be i n t h e co r o n a l p l a n e a n d t h e l o w e r m os t l y i n t h e s a g i t t a l p l a n e ( Fi g u re 3 . 1 9 ) . As we h a v e a l re a d y s e e n (see p . 4 3 ) , w i t h t h e p a t i e n t m a r k i n g t i m e t h e t h o ra co l u m b a r j u n c t i o n fo rms a re l a t i ve l y f ix e d poi n t w h e re l u m ba r sco l iosis to o n e s i d e cba nges to thoracic s c o l i os i s to t h e o p p o s i t e s i d e . T h e t h o raco l u m ba r j u n c t i o n i s a l s o t h e o n l y tra n s i t i o n a l regi o n w here t w o v e ry m o b i l e s e c t i o n s of t h e s p i n a l c o l u m n m e e t : d y s f u n c t i o n i n t h i s r e g i o n t h e refore re s u l t s in w i d e s p r e a d s p a s m .

coil l m n

T h a t t r u n k ro t a t i o n ta k e s p l a c e m a i n l y i n

segm e n t s , t h o s e l e a s t fixed b y t h e r i b s . s i g n i fi c a nce a t t h e

radiog raphy oj Ihe spinal

Th e y de m o nstra t e d

by

s o m e ro t a t i o n o f

fe w d e g r e e s t a k e s p l a ce

a

CT d u r i n g t r u n k r o t a t i o n t h a t

both i n thro u g h o u t a l l t h e seg m e n ts To e x p l a i n the poss i b l e m e c h

t h e l ower t h o r a c i c a n d

of t h e l u m b a r sp i n e . a n i s m , I e x a m i n e d t ru n k r o ta t i o n by X - r a y ( L e w i t ,

1996) a n d d e m o n s t ra t e d th a t s i d e fl e x i o n d o e s i n deed t a k e p l a c e d u r i n g t r u n k r o t a t i o n , i . e . t h ere i s a c o u p l e d m o v e m e n t w h i c h i s v e ry s i m i l a r to w h a t w e see d u ri ng s i d e - b e n d i ng ( Figure 3 . 1 8 ) . A n o t h e r re g i o n o f t ra n s i t i o n a n d i n c r e a s e d v u l n e ra b i l i t y is t h e c e r v i c o th o r a c i c j u n ct i o n d o w n to T3-4 , b e c a u s e i t is h e re t h a t m o v e m e n t s of t h e h e a d a n d n e c k e n d , a s a r e m o s t c l e a r l y s e e n i n ma x i m u m a n t e - a n d re t r o fl e x i o n . T h e s a m e i s t r u e fo r s i d e be n d i n g a n d r o t a t i o n i f t h e c e rv i c o t h o r a ci c j un c t i o n

Figure 3.19 C o m p a r i s o n of t he a n a t o l1l i c a l s t ru c t u res in t h e d o rs a l v i e w of t h e t h o r a c i c s p i n e ( s k e l e t o n ) w i t h t h e a n l c ropos t e r i o r X - r a y . I , S p i n o u s p rocess: 2, p c cl i c l e s : 3 , r i b s ; 4 , t ra n sve rse process: S , t r a n s v e rsocos t a l j o i n t



56

is held

upright

.

ill

Rehabili llltion of the

Function is partic u l a r l y

Locom otor System

v u l n e ra b l e

h e r e , beca u s e t h e v e ry m o b i l e c e r v i ca l s p i n e m e e t s

the m uc h less with i ts

g i rd l e

,

mob

ile

t h oracic s p i n e . T h e s h o u l d e r

p o w e r fu l m u sc l e s , i s

a lso

a ttached

to

t h is j u n c t i o n .

A l l t r a n s i ti o n a l

r e g i o n s a re r i c h i n a n o m a l i e s . m a y be a r u d i m e n t a r y t w e l ft h r i b or a ( r u d i m e n tary) l u m ba r L 1 ; r e ma r k a b l y , a c e rv i c a l r i b (C7) i s q u i t e com m o n , w h e r e a s w e r a re l y fi n d a r u d i m e n ta ry fi r s t r i b .

T h e re

The ribs

r i b s a re attached t o t h e vertebrae a t t h e tra nsversocost a l a n d costoverte b r a l j o i n t s . The h e a d of the r i b a r t i c u l a te s w i t h t h e u p p e r m a rgin o f t h e b o d y of t h e corresp o n d i n g v e r t e b ra a n d w i t h t h e

The

l ower m a rg i n o f

t h e n e x t v e r t e b ra l boel y a b o v e . T h e of t he h e a d o f t h e ri b (crista capitu l i ) i s a t t a c h e d to the i n te rverte b ra l el i s e b y l iga m e n ts. The firs t rib is a n exce p t i o n in t h a t i t a r t ic u l a t e s e x c l u s i v e l y w i t h t h e b o d y o f t h e fi rs t thoracic verteb r a . The n e c k o f the r i b fi xeel b e t w e e n the costove r t e b r a l and costotra n s v e rs a l a rticu lation fo r m s a n a x i s f o r r i b m o v e m e n t . Th i s a x i s i s h o r i z o n t a l i n t h e t ru e ( v e r t e b roste r n a l ) r i bs and p rod uces a m o v e m e n t by w h i c h t h e s t e r n u m is l i fteel a n d at the same ti me t h e thorax broa d e n s . In the fa lse ( v e r t e b roc h o n d ra l ) r i b s the a x i s is o b l i q u e , l a terodo rso ca u d a l , a nd p ro d u c e s a w i n g- l i k e move m e n t . T h e l a st two r i bs ( free r i b s ) a re a t t a c h e d t o r u d i m e n ta ry c e n tre

t r a n s v e rse processes by c o n n e c t i v e t i s s u e o n l y ( s y n d e s m os i s ) .

Co n se q u e n t l y ,

t h e re

n o j o i n t move m e n t re s t r ic t i o n

is no j o i n t a nd can a r ise h e r e .

h e nce

Figure 3.20 C o m p a rison o f t h e a n a t o m ica l s t ructu res i n t h e l a t e r a l v i e w o f t h e s k e l e t o n o f t h e t h o r a c i c s p i n e w i t h t he X - ra y . I , L o w e r a r t i c u la r p rocess; 2, j o i n t space; 3. u p p e r a rt i c u l a r p rocess: 4. i n t e rverte bral fo r a m e n : 5, pe d i c l c s : 6. ri b : 7 , t ra n sve rse process


Fl lnctional anatomy alld d e fo r m i t y ,

The X-ray picture

coillmn

w hi c h

I

the

the

1 11

osteo-

t ho r a c i c spine a s

I n t h e A P v i e w , v i s u a l izm l () o

57

v e r t e b r a l a rc h is m u c h l ess d e t a i l e d t h a n i n t h e

c h o n d ro s i s . In a s y m m e t r i c a l move m e n t r e s tr i c t i o n of the ribs

l u m b a r s p i n e . I n a d d i t i o n t o t h e v e r t e b ra l bod i e s a n d

t h e re may b e a s y m m e t ry of the d i s ta n c e be tw e e n the

i n t e r v e r t e b r a l d i sc s , w e s e e t h e s p i n o u s processes

a rc h e s o f the r i b s .

a n d t h e p e d i c l e s (see F i g u re

3. 19).

It s h o u l d be b o r n e

i n m i n d t h a t fro m a b o u t T 4 t o T l O t h e t i p o f t h e s p i n o u s p rocess i s s e e n a t t h e l e v e l o f t h e b o d y o f

The cerv i c a l sp i n e

t h e n e x t v e r t e b ra b e l o w . T h e c h a ra c te r i s t i c fe a t u re is the c o s t o v e r t e b r a l j u nc t i o n , the h e a d of t h e r i b agaJ llst t he i n te rv e rt e b ra l d is c a n d t h e o v e rl a p p i ng s h a d o w o f t h e costa l cess. A s t h e facets o f t h c

I

pro

t i l t e d from d o rsoe r a n i ,l l

T h e c e r v i c a l s p i n e i s th e m o s t m o b i l e s ec t i o n o f t h e w h o l e s p i n a l c o l u m n . T h e c r a n i oc e r v i c a l j u n c t i o n i n pa rticu l a r is the their repercussi o n s

t h e vertica l p l ane) t h e

m u s c u l a t u r e ; d i st a re , t h e refore,

ized i n t h e A P v i e w

a d e q u a te t re a t m e n t

rc ll e x e s w i t h 1f1

pos t u ra l t h i s region and

t he i r

t h oracic r i b s , i f t h i s t i l l I n t h e l a te r a l v i e w

v c rte b r a l

a r c h e s a re p a r t l y o ve r l a p pe. d

X -ray tech n i q u e I n o r d e r to o b ta i n p i c t u re s t h a t c a n b e e v a l u a t e d fo r

t h e p i c t u res a re c l e a r , w e g e t a g o o d v i e w o f t h e i n t e rv e r t e b r a l fo r a m e n a n d e v e n o f t h e j o i n t f a c e t s

f u n c t i o n , a d e q u a t e s ta n d a rd

( a r t i c u l a r process e s ) . T h e t h o r a c i c s p i n e a bo v e T 3

a d h e re d to. The u s u a l t e c h n i q u e , w h i c h v i s u a l izes

i s u n fo r t u n a t e l y h i d d e n b y t h e s t r u c t u re s o f t h e s h o u l d e r g i r d l e a n d m us t be v i s u a l i z e d e i t h e r b y o b l i q u e v i ews o r b y t o mogra p h y . I t m a y b e d i ft1 c u l t t o n u m be r t h e v e r t e b r a e i n t h e

t e c h ni q u e s m us t

be

the cra n i o ce r v i c a l j un c t i o n p oo r l y in t h e s i d e v i e w a n d n o t a l a l l i n t h e A P v i e w , i s n o t e v e n a d e q u a te to s h o w t h e a n a to m i c a l d e t a i l s p ro p e rl y a n d i s c o m p l e tely u s e l e s s for t h e e v a l u a t i o n o f fu n c t io n .

l a te r a l v i e w , a s T l c a n n o t b e s e e n a n d i t i s h a rd t o

I n t h e A P v i ew t h e e n ti re c e rv i c a l s p i n e s h o u l d b e

re cog n i ze T 1 2 . I t i s t h e refore usefu l t o r e m e m b e r

v i s i b l e , from t h e c ra n i oc e rv i c a l j u n c t i o n ( fora m e n

t h a t t h e lowe r a n g l e o f

m a g n u m w i th t r h '

u s u a l ly

at t h e h e i g h t o f T7 , t h e

the

t h o ra c i c v e r te b r a e .

fo r k o f t h e t r a c h e a

the

s u ffic i e n t , b u t 1 5

d i a p h ra g m a t T91 1 0 .

1 t o t h e fi r s t

the upper thoracic p a ti e n t i s p l a ce d a s ro l 1 95 6 ) : fi r s t he i s t h e e x t e n d e d l eg :,

Eva l uating X - r a ys As i n a l l pa r t s o f t h e

li re i s

i m p orta n t h e re from t h e p o m ! o f v i e w o f fU li c t i o n , the

m o s t s i g n i fi c a n t c h a n g e s b e i n g sco l i os i s a n d i n c re a s e d k y p h o s i s . H e re a ga i n i t m u s t b e p o i n t e d o u t t h a t i t i s esse n t i a l for u s t o k n ow w h e th e r t h e

each side of the

one on a s ke d t o

l i e d o w n , w i t h o u t u s i n g h is a rm s , i n t h e p os i t i o n t h a t i s m o s t n a t u r a l t o h i m ( t h e pos i t io n m a y b e c h e c k e d b y r e pe a t i n g t h e p ro ce d u r e ) . I f t h e h e a d r eg u l a r l y

yet

d e v i a te s f r o m t h e m i d - l i n e t h i s m us t n o t be c o r r e c t e d , b e c a u s e t o d o s o w o u l d e i t h e r correct o r

a n o t h e r I m p o r t a n t a s p e c t o f c u r v a t u r e : t h e m o re

p ro d u c e c e r v i c a l sco l i o s i s a nd a t t h e s a me t i m e

m a r k e d it i s , t b e l e s s m o b i l e t h a t s e c t i o n of t h e s p i n a l

i n d uce a x i s r o t a t i o n a n d l a tera l d e v i a t i o n of t h e a t l a s .

c u rv a t u re

is

in

s t a t i c e q u i l i b ri u m .

T h e re

is

co l u m n w i l l b e , a n d c o n v e rs e l y , a fl a t t h o r a c i c s p i n e

I t i s t h e r e fo r e n e c e s s a ry to s h i ft t h e fi l m a n d t he

i s accom p a n i e d b y h y p e r m ob i l i ty , w h i c h i s o f c o n s i d e r a b l e c l i n ic a l s i g n i fi c a n c e

X - r a y t u b e a c c o rd i n g l y . The p a ti e n t n o w o p e n s h i s mout h as wide is placed 1 0 u n ti l t h e between his teet h ,

seen i n t h e u p p e r t h or a C i C

g l a be l l a a nd t h e 1 1

C h a nges i n f u nc t i o n

h o r i zo n t a l h e a d i s o ft e n

s i g n s of s u d d e n r o t a t i o n

plane. For this a

or w i t h a s u d d e n d e v i a t i o n

n e ce ss a r y .

toge t h e r w i t h s i g n s o f d i a g n ose d b y a s h i ft o f

W e a re n o w ce n t r a l r a y m us t

o n e fi n ge r

a nd t h e p e d i c l e s i n t h e

b e l o w t h e upp e r

a b ove t h e

o f rota t i o n .

poster i o r m a rg i n o f t h t: oCCi p i t a l lor a m t: n ( F i g u re

S h i fts a re h a r d l y e v e r s e e n i n t h e l a te r a l v i e w o f the t h o r a c i c s p i n e , n o r i s k y p h o t i c a ng u l a t i o n b e t w e e n

3.21 ) .

tube. The

I f t he pa t i e n t h a s no t e e t h t h e c e n t ra l r a y

p a s s e s t h ro u g h a p o i n t o n e fi n g e r b e l o w t he u p p e r

t w o v e r t e b r a e t h a t i s s i mp l y a tt r i b u t a b l e t o c h a n ge s

g u m s to t h e pos t e r i o r ma rgi n o f the foram e n m a g n u m .

i n fu n c t i o n . A n g u l a t i o n m a y , h o w e v e r , b e d u e t o

T h e d is t a n c e fro m foc u s t o fi l m s h o u l d b e 1 m .


58

Manipulative Therapy in

Rehabilitation of the Loconwlor

Syslem

Figure 3.21 X-ray tech n i q u e of the ce rvica l spine accord i n g to S a nd b e rg ( 1 955). (a) F oc u s i n g the ce n t r a l r a y in t h e a n t e ropos t e r i o r v i e w w i t h t h e aid of a s t r i n g , the h e a d in a horizon ta l p o s i t i o n ; (b) foc u s i n g t h e X - r a y t u be i n the l a t e r a l v i e w a t t h e m a s to i d process

F i n a l l y , we correct a n y rotatio n o f the pati e n t ' s

e y e s o n s o m e obj e c t at eye- l e v e l , to kee p the h e a d

h ead , b eari n g in m i n d t h e possib i lity o f as y m m e try

in a

(th e u p p e r tee t h are a u s e f u l l a n d m ark) .

fl e xion m us t be c o r r e c te d .

I t is poss.ib l.e to proceed in an a nal ogo u s m a n n e r

s ta n d ard

position; h ead

rotation

o r l a te ra l

T h e ce n tra l ray i s foc used not a t t h e m i d - cervical (c e n tre

of

t he

fil m )

but

at

wit h t h e patie n t s e a te d , w h i c h is m ore di fficu l t b u t

region

has t h e a d v a n tage of being perfor m e d u n d e r t h e

proc e s s . Th is yields an u n d is t orted view o f th e base

the

mastoid

i n fl u e nce o f bod y s tatics . N e v e rt h e l ess, t h e re can b e

o f the sku l l a n d y e t ca uses no d i s t o r t i o n of the l o wer

diag n o s tic advan tage if t h e sid e view, which m ust

cervica l spine ( b ecause the base o f the skull is w ide,

a l ways be take n w i t h the patie n t seate d , reve a l s

w hi l e t h e cervical v e r te b r a e are n a rrow) . In additi o n

d i screp a n cies w h e n c o m p ared with t h e

AP

v i ew

take n w i t h the patie n t s u pin e . In s u c h cases t h e

AP

we ac h ie v e correct e x posure of b o t h t h e base o f t h e sku l l a n d t h e cranioce rvical j u nctio n a n d

of the

v i ew c a n a l w a y s be repe a t e d in t h e si t ting pos i t i o n .

c e rv ic a l v e rte brae . The distance from foc u s to fi l m

S o m e a ut h ors d is l i k e t h e o p e n - m o u t h t ec h n i q u e

s h o u l d b e .1 5 0 c m o r more . W i t h t his tech n i q u e

because t h e man d i b l e overlaps t h e mid-cerv i cal s pin e ,

pict ures o f t h e cra n i o cervical j u n c t i on are so cl ear

a n d prefer to t a k e t h e picture w h i l e t h e patie n t

th a t tomogra p h y is s e l d o m n e ce ssary.

r h y t h m ic a l ly o p e n s a n d s h u t s h i s m o u t h ; i n t h is w a y t h e shadow o f t h e m a ndib l e is bl u rred. The tec hniq u e , h owever, pres e n ts t h e danger of a s l i g h t s haki n g o f t h e h ead , w h i c h w i l l cau s e bl urrin g o f t h e image o f t h e a p o p hyseal j oi n t s o f t h e cranioce rvical j u n c t io n . I n t h e l atera l view t h e patient i s s eated re l ax e d i n

Asses s m e n t of the q u a l ity of X - r a y p i ctu res B e fore e v a l u a t i n g an X -ray o f t h e c e rvica l spin e , partic u l a r l y w h e re fun ctio n i s co n c e r n e d , we m us t

cm or

3.22 ) . I n t h e A P v i e w we fi r s t m a k e sure that we c a n s e e b o th

2 4 x 30 c m , a n d m u s t be p lace d s o t h at t h e X -ray

occipital c o n d y l e s , t h e a t las a n d t h e ax i s with both

fro n t o f a vertic a l X -ray casse t te ; n o Potte r - B u c k y d iaph r a g m i s n e e d e d . T h e fi l m may be

1 8 x 24

assess i t s q u a lity a s a p i c t u r e (Fig u re

s h ows t h e base of the sku l l wit h t h e s e l l a turcica , t h e

tra n s versocostal fo ramina (fora m i n a o f the verte bra l

h a r d p a l a te a n d t h e cervical s p i n e d own to C7 , if

artery) , a n d at t h e c a u d a l e n d , t h e (irst t h o r a c i c

possib l e with t h e first two th ora cic v e r t e b ra e . T h is ,

v ertebra. I f t h e v i e w i s co rrec t we see t h e c l e f t

howev e r , i s poss i b l e o n l y i n s u bj ects ( u s u a l l y w o m e n )

b e tw e e n t h e u p p e r and l o w e r fro n t te eth in mid - l ine ,

with v e r y tapering s h o u l d e rs . The patie n t nxes h i s

toge t h e r w i th t h e ce n tre of t h e o d o n toid p rocess and


Functional anatomy

and

radiography of the

59

spinal colLlmn

Figure 3.22 A n a t o m i c a l s t r uctures o f the c r a n i o c e r v i c a l j u n c t i o n , a n t e ropos t e r i o r v i e w . 1, L o w e r edge o f the c l i v u s ; 2, fo ra m e n m a g n u m ; 3 , occi p i t a l co n d y l e : 4 , l o w e r e d g e o f t h e a n t e r i o r a r c h of t h e a t l a s ; 5 , l a t e r a l t r i a n g l e ; 6 , fo r a m e n t r 3 1l s v e rsa r i u m of t h e a x is: 7 . l o w e r con t o u r o f t h e s q u a m a occipi t a l i s ; 8 , m e d i a l t ra n s l u ce ncy o f t h e a t l a s ; 9 , t r a n s v e rse p rocess o f t h e a t l a s : 1 0 , l o w e r e d ge o f the p o s t e r i o r a rc h o f the a t l a s : 1 1 , ped i c l e of the axis: 1 2 , l a m i n a of the a x i s

o f t h e ch in. T h e cervica l spi n e as a w h o l e must lie be t w e e n the two halves of th e man d ibu l a . E v e n i f each of these structures is asym metrical there a re suffi cient la ndm a r ks by w h ich to recogni ze dis tor tion. A pict ure without the cra nio ce rvical j u ncti on and the fi rst thoracic verte b r a with the thoracic outlet is insuffici ent fo r o u r purpose .

s y m metr ica l l y

T n the l ate r a l view w e need t o see the base of t h e s k ull w i th the sella turcica , the c l i vus d o w n to the ba si on , t h e

p o st e rio r

margin of the

fora men

magnum, the hard p a l ate , the odontoid process and

If po s s i b l e even the fi rst thoracic verteb ra s hou ld be see n, but in heavily

the cervical spin e down to

C7 .

bui l t pati ents it m a y be impossible

to

vi suali ze

C7

in the l a teral vie w . It is imp o rta nt tha t the hard palate

should be

lordos i s

horizontal

or kyphosis)

(fo r

assess m e n t

and tha t the two halves

of

of the

m a ndibula should be e x actly ove rlaid, showing tha t

( Figure

there is neither side -be nding nor rot a tion

3 .23 ) .

Fine m a n et al.

of only

( 1 963 )

show ed that

10 degrees in incli na tion

of

a

d i fference

the

head

is

su fficien t to c h ange lordotic to linear posture, and vice versa.

T h e o b l iqu e view serves m a i nly to show

the

intervertebral fora min a , wh i ch in the ce rvical s p i ne

a re not visualize d at al l in the side vie w a nd


poorly

60

Manipulative Therapy in Rehabilitation of the Locomotor System

Figure 3.23 La t e ra ] X-ray o f t h e e e l'viea l p l a n e of t h e fora m e n magnum. t h e a t l a s a n d the a x i s i n d ica ted : t h e c l i v u s a n d t h e pos t e ri o r e d g e o f t h e v e r t e b r a l c a n a l a r e a ls o shown s p i n e with t h e

i n the A P view. I t should be t a ken with the p a t i e n t s i t ti ng o n a c h a ir t u r n e d a t 45 degrees to the casse tte ; the p a t i e n t u s u a l l y sits with h i s back to i t , b u t l i ke G u t m a n n I p r e fer t h e p a t i e n t to face the cassette a n d t o h o l d the h e a d in retrofle x i o n , because if t h e patie n t faces t h e cassette i t i s t h e fo r a m e n n e a r e r t o i t t h a t is visualize d , a n d na rrowing o f t h e fora men is o fte n v i s i b l e o n l y i n re t ro fl e x i o n ( Figure 3 .24) . O b l i que views a re p a r t i c u l a r l y i m po r t a n t i n cervical radic u l a r synd romes a n d i n cases of the v e rtebra l artery syndrome. because of the close re l a t i o n s h i p betwee n the i n terve rtebra l fo rame n , the n e rve roots and the verte b r a l artery. F u n ct i o n a l a n atomy of t h e cervi ca l spi n e

The cervical s p i n e h a s two very disti n ct sect ions: the cra n i ocervica l j u nction between the occi p u t and C2. and the section from C2 to C7. Most of the move m e n t s i t pe rforms start a t t h e cra niocervica l j unction,

and the mov e m e n ts of the head a n d neck a re u s u a l ly i n i tiated by eye moveme n ts . I therefo re b e g i n w i t h a s h o r t a na t o m i c a l descri ption i n w h i c h t h e t w o pa rts a re t re a te d separa t e l y , w h i le t h e fu nction of t h e ce rvical s p i ne is dea l t w i t h a s a w h o l e . F u n ct i o n a l a n ato m y

C2-C7

As in o t h e r pa rts o f the spi n a l co l u m n , the cl egree o f move m e m t i n the cervic a l s p i n e is d e t e r m i n e d m a i n l y by t h e th ick ness o f the i n terverte b r a l d isc; t h i s is usua l l y greatest in the segme n ts C4/5 a n d C5/6 , w h e re mobi l i t y i s a lso greatest. T h e c h a r acteristic fe a t u r e o f t h e ce rv ica l verte b r a l bodies is a latera l ridge the u n ci fo r m process . Its sign i ficance fo r cervica l fu nctio n is t h a t the s h a pe of the vertebral body l i mits l a te r a l fl e x i o n while encouraging a n t e a nd la tera l fl e x i o n . T h e a po ph y se a l j o i n ts a re al most p a ra l l e l o n b o t h sid es and a re t i lted f r o m v e n t rocra n ia l to


,

Fun Cliona/ aJ1a lOmy and radiography of

Ihe sp inal co/u /1 / 11

ol

a d u l t s , a r e l e s s m a r k e d i n h i g h e r a g e g ro u ps . I t i s i m p orta n t to r e a l i ze t h a t t h e y a r e p h y s i o l o g i c a l i f th e y a re p roportion a te . a n d t h a t t h e sh i ft i s grea test a t t b e C2/3 s e g m e n t ( s e e F i g u re 3 . 30) It m u s t be a l so b o r n e in m i n d t h a t d u ri n g a n te fl e x i o n t b e ce r v i c a l v e r t e b ra l ca n a l l e n g t h e n s c o n s i d er a b l y . shorte n i n g d u r i ng retrofl e x i o n . T h i s p rod uces a s i g n i fi ca n t m o v e m e n t of t h e m e n i nges w i t h t h e i r root s l e e v e s , a n d a l s o o f t h e s p i n a l cord , wh i c h c a n be s e e n i n p n e u m o m y e lographs to g e t l o n g e r a n d t h i n n e r i n a n t e fl e x i o n a n d s h o r t e r a n d t h ic k e r i n re t r o fl e x i o n . A n o t h e r h i g h l y s i g n i fi c a n t fe a t ure i s the cou rse o f t h e v e r te b r a l a rtery, w h i c h e n te rs t h e b o n y c a n a l a t t h e tra n sv e rsoco s t a l fora m e n of

C6

a nd r u n s

u pw a rd s , cro s s i n g t h e i n te rv e r t e b ral c a n a l s i n c l ose c o n t a c t w i t h the a r t i c u l a r p rocesses a l m o s t at ri g h t a n g l e s to t h e cou rse o f t h e n e r v e r o o t s . T h e r e fo re , a s the i n te rv e r t e b r a l fo ra m e n ( c a n a l ) n a rrows i n retrofl e x i o n , t h i s m a y a ffec t the n e rv e r o o t a n d t h e ve rte bra l a r tery.

F u n cti o n a l a n atomy of the cra n i ocervica l j u n ction S t u d y o f t h i s m o s t i m porta n t j u n c t i o n i s co n ce r n e d w i t h t h e m o b i l ity o f e ac h o f i ts j o i n ts a nd t h e b o n y s t r u c t u res a n d l i g a m e n t s t h a t l i m i t i t . T h e r e a re n o i n te rv e r t e b r a l d i scs. T h e upper a rt i c u l ar fa cets o f t h e a t l a s are o v a l wi t h t h e l o n g a x i s r u n n i n g o b l i q u e l y , c o n v e rg i n g p o s t e r i o r l y a n d m e d i a l l y l i k e a sect i o n o f t h e s u rface

Figure 3.24 O b l i q u e v i e w

of

of a sphere w i t h t h e c e n tre loc a t e d above

lhe cerv i c a l s p i n e i n

both

a r t ic u l a r s u rfaces . The m a i n m o b i l i ty i n t h e a t l a n to

ret ro A e x i o n s h ow i ng a n a r ro w e d i n t e rv e r t e b r a l fo r a m e n

occi p i t a l

of C213 on t h e r i g h t

j o i n ts

d e g re e s ( Fi g u r e

i s a n t e - a n d r e t r o fl e x i o n , a b o u t 15

3.25).

There is poste r i o r gli d i n g o f

t h e occ i p i t a l c o n d y l e s d u r i n g a n te fl e x i o n a n d a n te r i o r d o rsoca u d a l . Th i s t i l t v a r i e s co n s i d e r a b l y ( a b o u t 4 5

gl id i ng d u r i n g retro fle x i o n . S l i g h t rota t i o n i s poss i b le .

d egrees ) . b e i n g g r e a t e s t a t C2/3 a s a r u l e . A t t h i s

w h ich J i r o u t ( 1 98 1 a ) h a s s h o w n to be a v e r y l i m ited

l e v e l t h e j o i n ts a re freq u e n t l y n o t p a ra l l e l b u t a s i f

l a t e ra l fl e x i o n , rota t i o n b e i n g c o u p l e d w i t h s i d e

o n t h e s u rface o f a cy l i n d e r w i t h i ts c e n tre b e h i n d

be n d i n g to t h e o p p o s i t e s i d e .

the s p i n a l c o l u m n ; i t i s t h e refore n o t p a t h o l o gical i f t h e a r t i c u l a t i o n C213 i s n o t we l l v i s u a l i zed i n t h e s i d e v i ew ( u n l i ke t h e o t h e r cerv i c a l a po p h y se a l j o i n ts) . The s h a p e o f t h e cerv ica l a p o p h y s e a l j o i n ts is best s u i t e d t o a n te - and re t r o fl e x i o n . O n l a t e r a l flex i o n t h e t i l t o f t h e j o i n ts produces rota t i o n t o t h e s i d e o f in c l i n a ti o n a n d d u r i n g h e a d ro t a t i o n i n c l i n a ti o n

The

a t l a n toax i a l

j oi n ts

com p r i s e

the

a t l anto

o d o n to i d a s w e ll a s the j o i n ts b e t w e e n t h e m as s a e l a t e r a l e s a n d t h e a x i s , a n d th e i r m a i n f u n c t i o n i s a x i a l r o ta t i o n . T h e j o i n t fa cets r u n a n te roposte r i o r l y a n d a re concave on t h e m a ss a l a tera l i s of t h e a t l a s a n d convex o n t h e a x i s . I n a d d i t i o n , t h e re i s t h e a t l a n t o -

re s u l ts fo r t h e s a m e reaso n . D u ri ng a n te fl e x i o n t h e re is freq u e n t l y a s l i g h t s h i ft of t h e c ra n i a l v e r t e b r a , a n d i n r e t r o fl exi o n a sl i g h t b a c k w a rd s h i ft w h ich is a lso i n a c c o r d a n c e w i th t h e t i l t o f t h e a r t i cu l a r face t s . Accord i n g to Pe n n i ng

( 1 968)

cra n i a l

t h i s fo rward a n d b a c k w a r d move m e n t of t h e vertebra

i s l i k e a rota t i o n

of the upper

vertebra i n t h e s a g i t t a l p l a n e r o u n d a n a x i s s i t u a ted

at the d o rs a l part of the l ow e r verte b r a l bod y . It s h o u l d be po i n te d o u t t h a t t h e se s h i ft i n g m o v e

Figure 3.25 A n t e - and retrofle x i o n bet w e e n occi p u t a n d

m e n t s . w h i c h a re t h e r u l e i n c h i l d r e n a n d yo u n g

atlas


62

Manip uialive Therapy in

RchabililaliOI1 of the

Locomotor

o d o n t o id j o i n t between t h e a n terior a rc h of t h e a tl.a s a n d t h e odon toid process a n t e r i o r l y . w h i l e t h e p o s t e r i o r s u rface of t h e od o n t oi d p rocess is l i n e d by c a r ti l a g e and in c o n t a c t w i t h t h e t r a n sv e r s e l i g a m e n t . T he p ossi b l e movements a re a n te- and retro flexion and r ot a t i o n . D u r i n g a n te - and r e t r o fl e x ion t h e a n terior arch of t h e a t l a s g l i d e s u p a n d down o n t h e odon toid a n d i f t h e t r a n s v e rs e l i ga m e n t i s fi r m t h e space between t h e s e t w o structures d o e s n o t w i d e n . The range o f m ovm e n t h ere is a g a i n a bo u t 1 5 degrees.

The m ost i m p o rta n t m o v e m e n t , h o w e v e r , i s r o t a t i o n , i n w h i c h a l l j o i n ts t a ke p a r t ; w h i l e t h e re i s rota tion rou n d t h e o d o n t o i d , the m assa l a t e r a l i s of t h e a t l a s g l i d es on t h e axis p os te ri o r l y o n the side of rota t i on a n d a n t e ri o r l y o n t h e o pp o s i t e s i d e . Rotation i s l i m i te d b y th e j o i n t c a p s u l e a n d the p o w e r f u l alar l iga m e n ts w hi c h are a t tached t o t h e m a rgins o f t h e forame n m a gn u m a n d t o t h e atlas. R o t a t i on a m o u nts o n ave rage to 2 5 d e g rees to e a c h side, the m a x i m u m b e i n g 40 d e g r e es ( F i g u re s 3.26 and 3 .27) . D v o r a k ( 1 988) h a s sh o w n b y a xi a l c o m p u t e d tomo gr a p h y that the ra nge o f mo v e m e n t between a t l a s a n d a x i s m a y b e e v e n gre a t e r : h e fo u n d ave rages o f 4 1 . 5 d e g r e e s t o t h e r i g h t and 44 d e g r e es to t h e l e ft w i t h a m ax i m u m o f 50 d e g re e s ( ' ) to o n e s i d e , a nd i n a d d i t i o n a n a v e r a g e of 4 . 5 d e g r e e s be t w e e n o c c i pu t a nd a t l a s to t h e r i g h t , a n d 4 . 1 d e g r e e s to t h e l e ft . H ug u e n in a n d H o p f ( 1 993 ) u s i n g m a g n e t i c reson a n ce, on t h e o t h e r h a n d , fo u n d t h a t t h e ra nge o f motion c o r r e s p o n d s m u c h m o r e to o u r e a r l i e r fi n d i n g s .

K i n e s i o l o g y of t h e cerv i c a l spi n e as a whole Rota tion

D u ri n g ro t a t i o n , m ov e m e n t sta rts b e tw e e n the a tlas a n d the axis a n d t a k es p l ace m a i n l y t h e re until the range of motion is e x h a u s te d , i . e . to about 25 d e g rees to e ac h side, o n a ve r a ge . U p to t h i s p o i n t the re i s pure a x i a l rotat ion i n t h e hor i zon t a l p l a n e . From this p o i n t o n w a rd s rotation t a kes place fro m C3 to C7 in s u cc e s s i o n j f there i s fl e x i o n a t t h e c e r v i c o t h o r a c i c j u n ct i o n , a n d as fa r as T3 if t h e cervicothoracic j u n c t i o n i s s t r a i g h t e n e d up. Th ere i s sti I I s o m e a d d i t i o n a l pa s s i v e r o t a tion be t w e e n t he o c c i p u t a n d t h e at l a s . T h e m o m e n t rotation t a k e s p lace i n t h e c e rv i c a l s p i n e b e low t h e a x i s ; s i d e - b e n d i n g a u t om a t i c a l l y occurs a t t h e s a m e t i m e , u n less d e l i be r a t e l y a v o i d e d . Side-bending

System

u p p e r cervica l a rea (Figu re 3 .28). T h i s shows t h a t l a t e r a l fl e x i o n sta rts w i t h rota t i o n of t h e a x i s i n t h e d i re c t i o n o f s i d e - b e n d i n g a n d a t t h e s a m e t i me t h e re is sy n k i n e s i s o f t h e a t las, s h i ft i n g re lative to the o cc i p i t a l c o n d y l es and to t h e a x i s , i n the d i rection o f s id e - b e n d i n g . O n l a t e r a l flexion of t h e w h o l e of t h e c e rv i ca l s p i n e we see s i d e - b en d i n g a n d r o t a t i o n i n t h e d i r e c t i o n o f l a te r a l flex i o n , b e i n g g r e a t e s t a t t h e a x i s . As J i rout ( 1 968) h a s s h ow n , t h i s rota t i o n usua l l y e nd s i n t h e l ow e r c e r v ica l s p i n e d u r i n g s i d e - b e n d i n g to the r i g h t . b u t d u r i n g l a te ra l !kx ion to t h e l e ft ca n be fo l lowed d o w n i n t o t h e u pper t h o r ac i c re g i o n . (This he e x p l a i ns as t h e result of s t ro nger p u l l o f the m u s c l e s o f the shou l d e r g i rd l e a t t a c h e d t o t h e s p i n ou s processes on t h e r i g h t s i d e . ) T h i s co m b i n a ti o n o f s i d e - be n d i n g a n d rotati on is, o f cours e . i n ac c o rd a n c e wi t h the t i l t o f t h e c e r v i c a l a po p h y s e a l j oi n ts b u t n o t a d i rect c o n s e q u e n c e o f the t i l t , as i s u s u a l l y t h o u g h t , as t h e movem e n t sta rts a t t h e c r a n i o c e r v i ca l j u nction a n d rot a t ion o f t h e a x is c o m e s fi rs t , fol lowed by r o t a tio n of t h e l o w e r c e r v i c a l v e rte b r a e in success ion . A s i s s h ow n i n d e ta i l l a te r , i f ro t a t io n o f t h e a x i s does not t a k e p l a c e , t h e re i s n o ro t a t i o n o f t h e rest o f t h e c e r v i c a l s p i ne . J i rollt ( 1 97 1 ) h a s d e p i c t e d t h e force c a u s i n g rot a ti o n d u r i n g s i d e - b e n d i n g (Figure 3 .29) . I t c a n eas i ly be seen t h a t s o m e a n te fl e x i o n m i g h t t a k e p l a ce w i th r o t a t i o n d u r i n g s i d e - be n d i n g , and these s y n k i n es e s in the sagi t t a l p l a n e h a v e , i n fa c t , been co n fi r m e d b y J i ro u t ; t h e y const i t u t e j o i n t p l a y i n t h e c e rv i c a l s p i n e ( see F i g u re 3 . 4 6 ) . H o w e v e r , the exact m e c h a n i s m t h a t fo rces t h e a x i s to rotate , t h e moment t h a t l a t e r a l fl e x i o n s t a rts ( w h i c h c a n e a s i l y b e p a l pa te d ) , re m a i n s u n k now n . A n te flexion a n d retro flexion A n te fl e x i o n can be carried out i n d i ffe re n t ways: w e can e i t h e r draw the c h i n i n , or l e t t h e h e a d d ro p fo r w a r d , o r b r i n g t h e c h i n to t h e chest. which is a c o m b i n a t i o n of t h e fi rst two m ov e m e n t s . In r e t rofl e x i on t h ere a re no s u c h d i ffere nces. T h e two m e c h a n i s m s o f a n t e fl e x i o n a re s o m e w h a t ;r. com pe t i t i o n : u n l ess there i s h y p e r m o b i l i t y , if w e d r a w t h e ch i n i n w e c a n not d ro p t h e h e ad fa r f o rw a r d a n d if we d r o p i t fo rw a rd , we c a n not d raw t h e ch i n i n . Th e e xp l a n a t i o n l i e s i n t h e m e c h a n i s m o f a t l as ti l t , w h ich must b e u n d e rs tood i n order to assess c e r v i c a l a n te- and retro fl e x i o n . T h e fo l l ow i n g c h a n g e s c a n b e o bs e rved i n X - r a y s t u d i e s i n t h e s a g i t t a l p l a n e ( s e e F i g u r e s 3 . 30 a n d 3.3 1 ). 1.

S i d e - b e n d i n g can be studied o n l y by X-ray, a n d t h e re fore i s d e a l t w i t h u n d e r X-ray m o b i l i t y s t u d ies. Like rota t i o n , i t b e g i n s a t the cra n i ocervical j u n c t i o n . T h i s c a n b e s t be s t u d i e d d uring p a ssiv e s i d e - t i l t i n g m o v e m e n t l o ca l i zi n g l a t e ra l fl e x i o n m a i n l y i n t h e

Wi t h t h e p a t i e n t i n t h e e r e c t p o si t i o n t h e p l a n e s of t h e fora m e n m a g n u m and the a x i s r u n a l m o s t p a r a l l e l . t h e atlas b e i ng t i l t e d b a c k w a rd s a t a n a v e r a g e a ngle of about 6 degrees. 2 . W h e n t h e p a t i e n t draws i n t h e c h i n , a n t e fl exi on b e t w e e n occi p u t a n d atlas i n c rease s o n l y s l i g h t l y :


FI /llction al ana lOmy and

b

f Figure 3.26 A n te ropos t e ri o r X · rays of an i s o l a t e d a x i s : t h e p i c t ure s a re use fu l f or grad i ng rota t i o n

mdiogmphy of the

spinal column

63

c

h

9 (a)

i n n e u t r a l pos i t i o n a nd ( b-h ) in ro t a t i o n from 5 to 40 d e g r e e s :

Figure 3.27 R o t a t i o n o f the a x i s i n rela t ion t o t h e a t l a s ( h e a d ) : t h e h e a d i s fi x e d i n n e u t r a l pos i t i o n , th e b o d y i n m a x i m u m rota tion ( h e re a t 4 0 degrees axis r o t a t i o n : cf. Figure 3 . 26 (h))

t h e m a i n m o v e m e n t i s a n t e fle x i o n b e t we e n a t las and a x i s , t h e fo r m e r b e i n g now t i l t e d fo r w a rd w h i l e t h e rest of t h e c e r v i c a l s p i n e re m a i n s a l m o s t s t ra i g h t . 3 . In m a x i m u m a n le ll e x i o n t h e c e r v ic a l s p i n e i s a l m o s t h o r i zo n t a l : t h e re i s p ro p o r t i o n a te v e n t r a l

s h ift of the ce rvical v e r t e b r a e u p t o C2/3; there is m a x i m u m a n tefle x i o n between Cl/2 b u t , c o n t r a ry to pos i t i o n s ( I ) a n d (2) ,

a n t e fl e x i o n

of t h e o cc i p u t

a g a i n s t t h e a t l a s h a s now d isappe a r e d , i . e . t h e re

is

r e t ro fle x i o n

of the h e a d a g a i n s t t h e a t l a s o r

for w a rd t i l t o f t h e a t l a s . Conseq u e n tl y , the a n gl e


64

i'vl a l f ip u lati ve Th erapy

il7

Rehab ilitOlion of the Locomotor

S )'stem

Figure 3.28 A n te r o p o s t e r i o r X - r a y of t h e c e r v i c a l spine of a h e a l t h y s u bj e c t . i n n e u t r a l posi t ion . d u r i n g a c t i ve l a t e r a l fl e x i o n . and p a s s i v e l a t e r a l Ikx i o n l i m i t e d to the upper c e r v ica l re g i o n . ( a ) In n e u t ra l pos i t i o n the a t l a s is t o the r igh t i n r e la t i o n to the co n d y l e s. a n d t h e p l a n e of the c o n d y l e s a n d the axis c o n v e rge o n t h e righ t . t h e a x is be i n g ro t a te d a b o u t 5 d e grees to t h e l e f t . (b) At a c t i v e l a t e ra l fl e x i o n t o t h e l e ft t h e a t l a s i s s t i l l t o t h e r i g h t o f t h e c o n d y l e s a n d the p l a n e o f t h e cond y l e s a n d t h e a x i s con verge a l i t t l e t o t h e r i g h t . t h e a x i s n o w b e i n g ro t a te d about l O degr e e s to t h e l eft . (c) Passive l a t e ra l fl e x ion o f t h e upper c e r v i c a l s p i n e t o t h e l e f t : t h e a t l a s i s n o w c l e a r l y t o t h e le ft o f t h e c o n d y l e s il n d the p l a n e o f t h e co n d y l es i s para l l e l t o t h e a x i s w h i c h is ro t a t e d a b o u t 1 0 d e g rees


Fl Il1clional anatom v and

radiogmphy of the spinal cO/limn

fo r a m c n m a g n u ln Th e c o n d y l e s

u( u l a te

65 the

l a te r a l m a s s o f t h e a t l a s , t h e a t l a n lo occ i p i l a l j o i n t s b e i n g v i s i b l e o n b o t h s i d e s , t h e i r p l a n e s m e e t i ng a t an

o f Cl b o u t

co n d v l e s we

1 25 -110

on

degrees . B e n e a t h the

bot h sides

t h e ocl o n to i d

process t h e l a te r a l m a s s e s o f t h e a t l a s , w h i c h a rc w e d ge s h a p e d , t a pe r i n g t o w a rd s t h e m e d i a l b o rd e r . Cl ose

t h e h o rd e r we o ft e n

translucency

be t a l.. e ll for o s te o l y s i s . L a t e ra l l y

which should

t h e re a re t h e t r a n s v e rse proces s e s . F r o m o n e t r a n s v e rse p rocess t o t h e o t h e r , o n e c a n fo l l o w t h e c o u rse of t h e poste r i o r a re h w h i c h i s l i ke a t its c e n t re .

spindle, broader

l a t e r a : l r i a n g l t: s o f t h e m d s s a e

l a t e r a l e s p roj ect b elow t h e s h a d o w of the p o s te r i o r arch.

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t h e o d o n to i d .

B e low t h e m a s s a e l a t e r a l e s o f t h e a t l a s w e s e e t h e

Figure 3.29 M e c h a n ism or l a t e ra l rl e x i o n o f the cerv i c 8 1 s p i n e ll Ccord i n g J i r o u t ( I (7 1 ) . D u r i n g s i d e - b e n d i n g the h e a d tO ta tes a sag" a xi s ( x ') s i l uated a n t e r i o r c r a n i a l fos s a . The diagram s h o w s h o w the base of the s k u l l . w i t h t h e c o n d y l e s , s h i ft s in the o p p o s i t e d i re c ' l o TI o f l a r c r 2 1 fl e x i o n " c a i n s t t h e 2 t l a 5 . a n d h o w t h e axis w i t h t h e ce rv i c a l v e r t e b r D e b r o u g h l mto rO l a t i o n a n d t h e ,pi n o Ll s process o f the a x i s i s l i l t e d for w a rd by c r a n i a l p u l l

b e t w e e n t h " c l i v u c; a n d t h e o d o n t o i d ,

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t h e a b d o m i n a l m u scles a n d t h e e re c t o r s p i n a e , m o re p a r t i c u l a r l y t o t h e r i g h t . Pos t u re a n d m u s c l e t e n s i o n w e re n o r m a l i z e d a ft e r p r e s s u re a p p l i e d to t h e r i g h t g l u te u s m a x i m u s , a n d H a u t a n t ' s t e s t be c a m e n e ga t i v e . M o ve m e n t re s t r i c t i o n a t

T h S-6 w a s t re a t c d b y speci fi c m a n i p U l a t i o n .

T h i s very com p l icated c a s e is i n teresti ng fo r m a n y reasons - a l i v i ng e x peri m e n t . T h e s a m e t y p e of h ea d a che a n d d i zz i n e s s w a s caused b o t h by move men t restriction a t t h e c ra n i ocervical j u nction , a n d b y spasm o f t h e masticatory m u scles. A s lon g a s t h e u n derlying d i s t u rbance a t the pe l v is re m a i n e d u n t reated, w i th i ts conseq u e n t fa u l t y sta nce and s i d e deviation , re l a pses were freq u e n t . Tr e a t m e n t b y sp e c i fi c ' repos i t i o n ma noeuvres' g a v e t h e s a m e re s u l ts as soft t i s s u e t e c h n i q u e s a i m e d a t t e n s i o n i n t h e gl u t ea l m uscles, w h ic h revea led ' p a l patory i l l us i o n ' d u e t o cha nges i n t e n s i o n o f t h e so ft tissues ove r l y i n g the b o n e . Ex a m i n a t io n a n d treatme n t o f the w h o l e motor system i s s h o w n to b e n eces s a r y i n comp l i ca t e d re l apsing c a s e s . When q u e s t i o n i n g t h e patient, i t i s esse n t i a l to make it q u i te c l e a r w h a t h e o r she m e a n s by 'd izziness ' , for the word is u s e d to d e s cribe the fee l i ng or fe a r o f fa l l i n g from a h e i g h t , a n a ttack of fa i n t i ng or w e a k n ess d u e to c i rc u l a t or y d i sord e r , or eve n for i n toxication (cerebe l l a r d i stu r b a n ce ) a n d ata x i a . W h e n t h e p a t i e n t com p l a i n s o f d i zzi.ness, t he n cross-exa m i na t i o n m u s t first e l icit more explicit i n fo r m a t i o n : d o e s t he w o r l d seem t o be t u r n i n g c l oc k w i se o r a n t i-c l oc k w i se ro u n d h i s h e a d ? Does he fe e l p u l led to one s i d e , o r to the ot her?

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C l i n i ca l signs O n l y i f it is poss i bl e to e x a m i ne t h e p a t i e n t d ur i n g a classic a t t a c k of t r u e v e r t i go c a n w e obs e rve t h e typic a l s i g n s o f l a b y r i n t hin e disorder, s u c h a s n y s t ag m u s to the ri g h t w i t h d e v i a t ion to t h e l e ft , a n d d e v i a t i o n to t h e s i d e of t h e w e a k e r la b y ri n th - i . e . d u r in g R o m b e rg's t e s t , s ta n d i n g w i t h eyes closed with t h e h e a d i n n e u tral posi t i o n , t he re is d e v i a t i o n to t b e s i d e ; w i t h t h e head t u rned to t h e s i d e o f t h e w e a k e r l a byrin t h t h e t ru n k mo v es backwa rds, w h i l e i t m o v e s fO lw a r d i f t h e h e a d i s t u r n e d to t h e oppos i t e s i d e . I f, however, we e x a m i ne the pa t i e n t i n b e t w e e n a t t a c k s , a n d t h e re a r e n o pathologic a l neurological fi n d i ngs, t h e re i s l i t t l e to observe u n less we carry o u t H a u ta n t ' s t e s t a s descr i b e d i n C h a p t e r 4 ( p. 1 1 9) . U s i n g t h i s a s a rou ti n e e x a m i n a t i o n m e th o d a c h a racte ristic p a ttern emerges i f t h e r e is a cervi c a l fa ctor, rega r d l e s s o f t h e t y p e of d i s t u r bance o f e q u i l i b r i u m . 1 n 7 2 exa m i n a tions of 69 p a t i e n t s I fo u n d t h e m os t con s t a n t p h e n o m e n o n was i ncreased d e v i a t i o n o f t h e fo r w a r d - s t r e t c hed arms a t head retroA e x i o n and a t rota t i o n o f the head in the o p posi te d i rection to that o f d e v i a t i o n , and less or n o d e v i a t i o n o f the a rm s at head rotation in t h e d i rection o f d e v i a tion , o r a t a n t e A e x i o n . I n 6 9 cases t h e re w er e on l y t wo excep t i o n s , and in n e ither o f t h ese d i d the ce rvica l s p i ne p l a y a n y p a r t . I n w h a t m i gh t be c a l l e d ' t y p i c a l cases ' , d e v i a t i o n i nc r e a s e d i f t h e ' p a t hoge n ic ' head pos i ti o n coincide d with the d i rection o f moveme n t restri c t io n , as was t h e c a s e i n 5 0 e xa m i na tions (70 p e r ce n t ) . I n m a ny cases s i d e devia t i o n is prov o k e d o n l y if t h e head i s rota t ed a n d /o r be n t bac k , but d e v i a t i o n of the arms is i n t h e o p p o s i t e d i rection to t h a t o f h e a d rota t i o n . I t i s a lso sign i fi c a n t that d ev i a ti o n d is a ppe a rs a fter tre a t m e n t o f moveme n t rest rict i o n , or a t least becomes m u c h less m a r k e d , t h e effect being v i s i b l e a fe w m i n u tes a fter treatment. The same a p p l i e s to d i s t u rbed f u n c t i o n o f t h e orofa c i a l muscles i n c l u d i n g t h e d i gastricu s . I t i s i m p orta n t t o stres s h e re t h a t a cervical fa ctor may be p rese n t i n all forms o f v e r t igo a n d d izzi n e ss; this was as t r u e in a group o f typica l vert igo patie n ts ( 5 4 p a t i e n ts ) as in 70 p a t i e n t s w i t h cervica l. a n d m ix e d - type v ertigo, t h e res u l ts of t re a t m e n t s ho w i n g l i t t l e d i fference ( t h e figu re fo r i m p rov e m e n t i n b o t h was 90 pe r ce n t ) . The t y p e o f vert i go t h a t reacts least t o t re a t m e n t o f the ce rvica l sp i n e a p p e a rs to b e po si tio n a l v e r t i g o ; t h i s is a less freq u e n t for m . Disturbed a ud i tio n , t o o , i s a ffecte d by m a n i p u la t i o n o n l y i n a few c a s e s . D i s t u rb e d cervical fu nction i s u s u a l l y fo u n d i n a l l forms, m o s t fr e q u e n t l y i n t h e cran ioce rvical j u nc t i o n , i n c l u d ing C2/3 . I n C h a p t e r 2 I s e t o u t some of t h e t h e o re t ica l reasons for the i m p o r t a n ce of t h e s p i n al co l u m n a n d i n particu l a r of t h e c ra n i ocerv ica l j un c t i o n . C l i n i ca l evid e n ce corroborates t h is : t he p a t t e r n d esc r i b e d a bove , i n w h ic h movi n g t h e h e a d i n t h e d irec t i o n o f movement restriction aggra v a tes d e v i a t i o n , a n d t h e


274

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fact t h a t t h e nystagm u s ch a nges ( N oITe e l al. , 1 976), in the r h y t h m provi d e a d d l l, I O Ii;,l l role of rece p to rs i n j o i n ts a n d m uscles I n t h e m a i n te n a nc e o r d i s t u rb a n ce o f eq u i l ib r i u m . I n two o f m y cases t h e re w a s o n l y s p a s m o f t h e short e x t e n sors a t t h e cra nio cervica l j u nc t i o n , and by s i m p l e PIR o f these m uscles d e v i a t i o n was a bo l i s h e d . N o l ess i mp o r t a n t a re t he m a s ti c a tory m us c l e s . I t i s i m portan t to n o t e t h a t d is t u r ba nce o f e q u i l i b r i u m , w i t h a d i ffere nce o f more t h a n 4 kg i n w e i g h t d i s t r i b u t i on o n t w o sca l e s , a n d t h e c e r v i c a l p a t t e r n s h o w n by o m I I a ma n t 's test, i s m u c h more fre q u e n t v e r t igo. T h e forme r s i gns a re t h e d i s t u rbed craniocervica l m uscle functi o n , They poi n t to w h e t h er I h e c ra n i ocervical o n t h e post u r a l j u n c t i o n , i.e, m uscles. A s Il l wa y s d i sa p p e a rs dysfuncti o n , t h i s type of d is t ur b a nce o f e q u i li bri u m w i t h o u t d izzi n e ss c a n no t be of l a by r i n t h i n e ori g i n . I t i s n o t o n l y by a ffe re n t s ti m u l i f r o m j o i n ts a n d m uscl e s t h a t t h e ce rvical s p i n e m a y c a use d is t u rb a nce of e q u i li b ri u m , however; i t can a ffect i n tracra n i a l s t r u c t u res, i nc l u d i n g t h e l a b y r i n t h , by i m pi n g i n g o n t h e v e r t e b r a l artery . I n fact, t h e re i s a ten d e n cy t o ascribe m o s t disturba nces o f e q u i l i b r i u m o f cervical origi n to S (Hll t of a rtery, w h i c h i n my v I e w I S I t i s t h e re i n w h i c h cases o f d i s t urbed o f the v e r te b r a l a il e ry l.

I n p a ti e n ts a re o t h e r (ce r v i c a l syncope ) . 2. If t h e re 3 . I f b a c k - be n d i n g o f t b e h e a d cou p l e d w i th rot a t i on h a s a m ar k e d e ffec t on d izzi n ess, p a r t ic u l a rly i n t h e absence o f m o ve m e n t restriction , o r i f d izzi ness persists a ft e r m a n i p u l,l t i o n ; a posi tive d e K l e y n ' s test i s a l so s uggest i v e , 4. Ce r ta i n X - r a y fi n d i ngs - re t r o l i s t h e s i s , i n particu Iil r i f o b l i que p i c t u res o f the cervica l s p i n e i n head retroflex i o n show a n a rrowed i n terve rte bral foramen (see Fi"me 1 '"}1 , p . Ii 1 ) d i fference i n t h e obli q u i t y o f a po p h y se a l j o i n ts at one p . 82) o r m a rked m d i rect signs, the ; I r l e riogra p h y o r b y o n l y proof Dopp l e r a re certainl y Cerv ica l syncopes proo f o f i sc h a e m i a a n d a re most fre q ue n t ly pro v o k e d by s u s t a i n e d h e a d retroflexion d ur i ng w o r k . If cere bra l i sc h a e m i a i s m a r ke d , e v e n e p i leptic seizures c a n occu r . T h e i m po r t a nce of ce rvi c a l

syncope u nd e rra t e d , as i t i s ce rta i n l y t h a n the AdamsStokes So fa r i t mig h l see m o n l y d q uest i o n o f d i ffere n t i a l d i agnosis, w h i c h i n i tse l f i s a d i ffic u l t m a t te r i ll d i s t u r b a nces o f t h e e q u i l i b r i u m . Howe v e r , i n t h c l a rge m aj o ri t y o f cases w i t h i nvol veme n t o f t h e vertebral a rt e r y t h e re is a l so i n v o l v em e n t o f t he cervical s p i n e . Th i s is not j ust coi n c i d e nce : t h e re i s n o t o n l y a dose a n a to m i c a l re l a t i o n s h i p , w h i l e t he a v erage age o f p a t i e n t s suggests a degree o f a rt e r i o scl e rosis, but a sclerotic a r t e ry i s i tse l f much more i r r i t a t i o n than i s a normal susce pl complications a t a r t e riovesse l . graplw in cases w i t h arteriosderosis i n t u m o u r p a t i e n ts. A " p i n e w i l l t h e re fore b e p:l t i e n t w i t h a sderotic ; i pa tie n t w i t h n o r m a l a rten e". The g r e a t a t p d ti e n t s wi t h v e r t e bra l a r t e ry i n v o l v e m e n t a lso s u ffe r from d i s t u rba n ces o f t h e cervica l s p i n e , a s i s borne o u t by c l i n i c a l experie nce a n d b y t h e l i terat ure ( Ba rr e . 1 926; B a r tschi - Rocha i x , 1 949). Both a u t h o rs describe a comb i n a ti o n o f ce rv i c a l h e a dache a n d d is t u r b a nce o f e q u i l i b r i u m due to verte b r a l a rtery i nvolve m e n t e v e n w i t h poss i b l e m in o r n e u ro l ogica l sy m p toms, V ite k ( 1 970) m a d e t h e poi n t t h a t h e a d a c h e i n a rk r i osclerosis is as a rule patienh c a u se d i n v o l ve m e n t of the cervica l rel a ti o n s h i ps becau se consequence s i n volved . e ffect of m e c h a n ica l verte bra l artery by d i s t u r b a nce In ;; kes a d e q u a te t re a t m e n t N e v e r t h eless t h is i s of t h e s p m :iI t h e s u bj e c t o f con s i d e ra b l e con t roversy because o f poss i b l e com p li c a t ions d u e to d a mage t o t h e v e rt e b r a l a rtery b y m a n i pu l a t i o n ( s e e p. 1 49). C l e a r l y , such complications are not t h e res u l t o f m a n i p u l a tion as such, b u t o f gmve tec h n ical m istakes. Leav i ng d is t ur b ed fu n c t i o n unt reill e d is t a n ta m ou n t t o l e av i ng mechan ica l i rr i t a t i o n free to e n ci a nger the v e r t e bral a rtery u nc h e c k e d . A ga i n , i n the gre a t m aj o r i t y o f ('nsf'S t h e d i st mba nce i s a t t he cra n i o i m port a n t because t h i s i s cervica l I II regul a r l y gives rel i e f. the s; n o r m a l fu nctio n i n g o f t h e loops o f t h e verte b ra l h e a d rot a t i o n w i t h o u t a rl e ry; a n d ( 2 ) i f h e a d h a s to t a k e p lace be low rota t i o n C2 , i . c . �Htery runs t h rough i ts c a n a l , ex posed to s h e a r i n g forces i f rota t i o n t a kes p l ac e , Th i s i s borne out by c l i n ical p ract ice. I n a group o f 7 0 patie n ts w i t h d i zzi n ess, v e r t igo o r bot h , 2 1


Clin ical aspects

s h o wed t h e s i g n s g i v e n a rt e ry i n volve m e n t : a r t e r i a l i n v o l ve m e n t ( t h e res u l ts w e r e s i m i l a r to t h os e i n t h e l a rge r gro u p a l ready q u o t e d ) , i n t h e gro u p w i t h i n vo l v e m e n t o f t h e v e rt e b r a l a r t e r y t h e re w e re 2 8 . 5 % f a i l u re s , b u t 38';;, e x ce l le n t a n d 3 3 .5% good re s u l t s . The l e s i o n t r e a t e d was. for t h e m o s t p a r t , a t t h e c r a n i o c e r v i c a l j U ll c t io n . These resu l t s a r e a l s o s i gn i fi c a n t for d i a g n o s i s . I f n o i m p rov e m e n l o f t h e c on d i t i o n fo l l ows o n n o r m a l iza t i on o f t he f u n c t i o n o f t h e c e r v i c a l s p i n e , I lI v o i vc m e n t i t c a n be s u r m i s e d t h a [ ! o f t h e v e r t e bra l a rt e r v or by gross d e for m i ty i n t h , m a y req u i re s u r g i c a l not 1 972). Ade q u a t e no o n l y g i v e s s a t i s factory o t h e r n o n - s u rgica l b ut e n ab l e s us t o s i n g l e p u t a rt e riog r a p h y i s i n d i c a t e d w i th a v i e w to s u r g i c a l treat m e n t . P . F.. ( 1 93 4 ) . li rsl secn 2 1 A u g u s t 1 98 6 . c o m p l a i n e d o f v e rt i go w h i c h w a s w o r s e w h e n s h e l a y d o w n . g i v i ng a

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