Musculoskeletal Manual Medicine: Diagnosis and Treatment

Copyrighted Material

uccessor tl) the renowned Manual Medicine: Diagnostics and Manual Medicine: ·Inerapy. this richly illustrated. logically organized book. while clinically oriented. presents both the theory and practice of the expanding field of musculoskeletal medicine. Its aim is to fully integrate and coordinate the relatively young firld of manual medicine with classic medical school teaching, based on currenL biomechanical and evidence-based knowledge. Without pleJudice the book includes the posillve aspects of osteopathic and chiropractic examination and treatment tpchnique within the context of a functionally meaningful musculoskeletal managpment approach. _

Whllt> the particular examination and related treatment techniques are described in detail. tile layour facl1itate both a quick overview and sufficient detaJi, when needed. The accom­ panying text describes and correlates possible pathologic findings. Other chapters cover the history of manual medi ine, examination and Lreatment principles. and the application of biomechanics and muscle physiology La the variolls non-surgical hands-on approaches, including myofascial trigger point treatmtnt. Emphasis is given to anatomical descriptions of muscles Jnd their palpatory assessment as well as techniques to treat shortened muscles. The concept of muscle imbalance is presented. Relationships between pain and specific variables are juxtaposed Jnd graphically represented. Rarionaltreatmenl approaches are deScribed. ranging from "wait-and-see" recommendations to further medical work-up and indications for surgery. SpecifiC musculoskeletal disorders Jre reViewed in detail.

Highlights: •

•

•

•

•

•

•

Systematic presentation, from three-dimensional anatomy to function and pain Over 1000 illustrations. dispenslllg with [he need for lengthy text passages LogICal presentation of speCific disorders "Action" photographs for examination and treatment Full-color drawings and photographs with superimposed graphics clearly depicting lhe joints and areas of each body region Physiological explanations and further requirements substanliclting the use of m;mipulative medicine Well arranged examination techlllques for the entire person

Muscu/oskeleral Manual Medicine will be indispensable to professionals who treat the person

with acute and chronic musculoskeletal problems, providing access to the broadest possible cumamentarium based on today's knowledge and insights.

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Important note: Medicine is an ever-Changing science undergoing

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continual development. Research and clinical experience are contin­ ually expanding our knowledge. in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application. readers may rest assured that the authors. editors. and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book.

Parts of this book are an authorized and revised translation of the 5th German edition of Manuelle Medizin: Diagnostik and the 3rd German edition of Manuelle Medizin: Therapie. published and copyrighted 1997 by Georg Thieme Verlag. Stuttgart. Germany. This book also includes revised and updated material taken from the 1 st edition of Manual Medicine: Therapy and the 2nd edition of Manual Medicine: Diagnostics. published and copyrighted 1988 and 1990. respectively. by Georg Thieme Verlag. Stuttgart. Germany.

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IV

Copyrighted Material

List of Contributors Hubert Baumgartner, MD

Carl Granger, MD

Former Chief of Rheumatology

Professor of Rehabilitation Medicine

Schulthess Clinic

University at Buffalo

Zurich, Switzerland

School of Medicine and Biomedical Sciences

Daniel Buehler

Uniform Data System for Medical Rehabilitation

Physiotherapist

Amherst

Fluntern High School Sports Center

New York, USA

Executive Director

Department of Physiotherapy Zurich, Switzerland

Dieter Grob, MD

Douglas Chang MD, PhD

Head of Spine Surgery

Professor ,

Assistant Professor

Schulthess Clinic

Chief, Physical Medicine and Rehabilitation

Zurich, Switzerland

Department of Orthopedic Surgery University of California, San Diego San Diego, CA, USA

Norbert Gschwend, MD Professor and Former Chief Surgeon and Chairman Schulthess Clinic

Jill Chomiak, MD, PhD

Zurich, Switzerland

Associate Professor Head of Pediatric Orthopedic Department

Jochen F. Loehr, MD, FRCSC

University Hospital IPVZ and 1 st Medical

Professor of Orthopedics

Faculty of Charles University

ENDO-Clinic

Hospital Na Bulovce

Hamburg, Germany

Prague, Czech Republic Chetan Malik, MBBS Beat Dejung, MD, PhD

Clinical Instructor

Physical Medicine Specialist

Rehabilitation Medicine

Rehabilitation and Rheumatic Diseases

Department of Physical Medicine and Rehabilitation

FMH Swiss Medical Association

University at Buffalo

Winterthur, Switzerland

School of Medicine and Biomedical Sciences

Tomas Drobny, MD

Amherst

Orthopedic Surgeon, Lower Extremity

New York, USA

Uniform Data System for Medical Rehabilitation

Schulthess Clinic Zurich, Switzerland

Anne Frances Mannion, MD, PhD

Toni Graf-Baumann, MD, PhD

Research and Development

Professor

Schulthess Clinic

Managing and Scientific Director

Zurich, Switzerland

Head of Department

German Society of Musculoskeletal Medicine Managing Director

Urs Munzinger, MD

German Society for the Study of Pain

Orthopedic Surgeon FMH

German Pain Society

Head of Orthopedic Surgery. Lower Extremities

Teningen. Germany

SChulthess Clinic Zurich, Switzerland

Copyrighted Material

v

Manohar M. Panjabi, PhD

Wolfgang Trautmann

Professor Emeritus

Physiotherapist

Former Director Biomechanics Research

Director of Physiotherapy

Yale University School of Medicine

Sports Medical Center Bern

New Haven, Connecticut, USA

Permanence Clinic Bern-Hirslanden Bern, Switzerland

Bogdan P. Radanov, MD Professor

Beat Waelchli, MD, DC

Head of Pain Center

PRISMA Spine Surgery Zollil<erberg

Schulthess Clinic

Center for Chiropractic Zurich

Zurich, Switzerland

Zollikerberg, Switzerland

Pascal Rippstein, MD

Barbara Weber Schneider, MD

Chairman of Foot and Ankle Department

Dietlikon, Switzerland

Schulthess Clinic Zurich, Switzerland

Richard D. Weissmann, PT, OMT I

Beat R. Simmen, MD, PhD

Head of Faculty

Physiotherapy Practice and Clinic Chairman Upper Extremity and Hand Surgery

David G. Simons Academy

Schulthess Clinic

Winterthur, Switzerland

Zurich, Switzerland

Acknowledgements

As editors of a textbook with a history of 25 years and a

In this respect we thank Thieme Publishers for assigning

track record of five editions in German and two editions in

two such skillful collaborators to assist in the project from

English, Japanese, Spanish, and Italian respectively, we

beginning to end.

have been supported, in particular, by Mr. Brian Scanlan,

We would like to thank the Schulthess Clinic Zurich for

President of Thieme Publishers. The idea and concept for

offering

the current, completely reworked book Musculoskeletal

Li.itscher, head of the documentation center of the Schult­

its infrastructure.

In particular, Mr. Andreas

Manual Medicine was strongly supported by the Executive

hess Clinic, who supported us since 1986 and who contrib­

Director, Dr. Clifford Bergman, who saw the advantage of

uted in a major way in the production process while chang­

the new concept.

ing from the classical style to complete digital desktop

Fusing the previous two books, introducing several new

publishing. Those who went through the process greatly

chapters, and enhancing the layout and presentation of the

appreciate such professional help. A special thanks also

material was quite an undertaking. We would therefore

goes to the research assistants from the Schulthess Hospi­

like to extend our special thanks to Mrs, Annie Hollins,

tal, Mr. Dave O'Riordan and Mr. Charles McCammon, who

Editorial Assistant, and Ms Elisabeth l(urz, Production Edi­

helped us with the references and coordinated contacts

tor, from Thieme Publishers, who did more in the course of

with all of the collaborators.

the translation and production of the book than anyone

We, as editors, experienced that a project of this nature

would expect from a publishing house. Both ladies now

is not just an individual effort. It requires a tremendous

understand the concept of musculoskeletal manual medi­

amount of teamwork to produce a textbook such as this.

cine as they not only contributed to the production of the book but also used their intellectual capacity to identify and eliminate mistakes that occurred in the fusion process.

The Editors

VI

Copyrighted Material

Preface on the Occasion of the 25th Anniversary

The current textbook Musculoskeletal Manual Medicine has,

two authors influenced immensely how we would learn to

in terms of medical publishing, a long and interesting his­

think about and approach new research projects that

tory. Although this book has a new format, completely

would investigate principles of mechanisms and how they

reworked and reorganized, the original ideas presented

relate to clinical signs and symptoms. This resulted in a

25 years ago still hold true. To the surprise of many-both

wonderful friendship and thoughtful scientific collabora­

within and outside the field-probably no other back pain

tion, and nearly 50 papers in peer-reviewed journals.

treatment interventions have been studied as exhaustively

Knowing the quality ofThieme Publishers, we presented

in biomechanical studies and randomized clinical trials as

them with our hand-made book for consideration. In 1983,

manual medicine procedures.

Thieme Publishers courageously published a book which at

During the past 25 years, interest in the field has steadily

that time appeared to be quite an exotic project: the first

increased, both on the part of the public and patients, and

German edition of Manual Medicine: Diagnostics. We think

on the part of orthodox medicine. Manual medicine has

that this important decision served everyone well.

gone from having an "outsider" role to being a logical part

Soon after the first edition, and being educated within

of the armamentarium of today's musculoskeletal physi­

the framework of the rather young Swiss Medical Associa­ tion for Manual Medicine, we visited well-established edu­

cian. Again, history is a good teacher. In the mid 1970s, cr, M RI, SPEcr, and PET scans capable

cational institutions of osteopathic medicine in the USA

of investigating structures and tissues potentially respon­

that already held university status, as well as those colleges

sible for primary symptoms such as pain and altered struc­

of chiropractic accredited by the Swiss health system to

ture and function were not available to patients presenting

educate Swiss chiropractors. The close exposure and col­

with musculoskeletal disorders. However, with the increas­

laboration with experts of osteopathic manual medicine

ing interest in and fascination of applications of technology

such as Philip Greenman, Myron Beal, and Bob Ward, and

in patient care, the physician's hands as a diagnostic and

from the chiropractic profession, Scott Haldeman, not only

therapeutic tool were commonly neglected, particularly in

offered us new dimensions and aspects of manual medicine

the assessment of such musculoskeletal disorders as so­

but also taught us to respect and collaborate equally with

called nonspecific or mechanical low back and neck pain.

doctors of osteopathic medicine and doctors of chiroprac­

In the late 1970s our attention was attracted by a small

tic.

group of Swiss physicians successfully using manual med­

Wolfgang Gilliar, DO, currently Professor at the New

icine approaches, both diagnostically and therapeutically.

York College of Osteopathic Medicine of the New York

We became students of the prominent Swiss rheumatolo­

Institute of Technology, translated the book, and it was

gist, Dr. Max Sutter, who taught us one-on-one how to use

presented to the English-speaking market in 1984.

our hands to palpate the changes of different tissues in the

Following the experience gained from our exposure to

human body such as the skin, subcutaneous tissues,

osteopathy and chiropractic on the occasion of the 7th

muscles, and tendons. The principle idea was to try to

International Congress of the FIMM (International Federa­

identify the anatomical structures and relationships re­

tion of Manual Medicine) in Zurich in 1983, we invited the

sponsible for pain and altered function in a joint or spinal

leaders in their particular field to what is now known as the Fischingen Conference. There, within 1 week, the common

region. The first two authors, together with the orthopedic

denominators of manual medicine, osteopathy, and chiro­

surgeon Dr. Tomas Drobny, set down their experiences of

practic were openly and collegially discussed. We realized

the nearly 3-year educational process in the first German

that many of the diagnostic and therapeutic approaches

edition of Manual Medicine: Diagnostics (Manuelle Medizin:

appear similar or deviate only slightly from each other-as

Diagnostik), with a print run of a total of 10 copies of a book

far as the biomechanical model is concerned-and their

based on our own hand colored drawings, the starting point

approach and applications may have been shaped, at least

of a long medical journey. Many of the original drawings

in part, by their professional context and philosophy.

from this very first edition in 1980 are still used in the

In the 1980s relationships between exponents of manual

current textbook, now redrawn and following a layout

medicine and classical orthodox medicine were somewhat

that was created, yes, with sophisticated publishing tech­

tense. In other words, traditional universities. at least in

nology. At that time we were already impressed by the

Europe, seemed rather reluctant to integrate the diagnostic

seminal research papers and textbook on clinical bio­

and therapeutic aspects of manual medicine within the

mechanics by Augustus White and Manohar Panjabi. These

framework of what could be best medical practice. Around

Copyrighted Material

VII

Preface

the globe, the trend of and call for evidence-based ap­

in Switzerland, which offers postgraduate teaching to doc­

proaches became more important, not only in academic

tors and physiotherapists in the field of musculoskeletal

practice but in medical practice altogether. In this regard,

manual medicine.

we received quite a strong message from one of the most

The current English edition, Musculoskeletal Manual

prominent and respected pioneers in spine research, Pro­

Medicine, has been completely reworked and integrates

fessor Alf Nachemson from Giitheborg, Sweden. After send­

the newest aspects of clinical biomechanics. clinical prac­

ing him the first edition of the English bool< for review, his

tice. and evidence-based approaches to diagnose and treat

answer was swift and to the point: "I will not read your

musculoskeletal disorders conservatively. including the

bool< unless it has been scientifically proven." Our first

preventive programs.

reaction was quite human, but giving Dr. Nachmeson's

For this new book. we invited Wolfgang Gilliar.

O.

comments a second thought, we were markedly influenced

meanwhile close friend and exponent of osteopathic med­

by them, as was our further development. The first author

icine and well-known not only in the USA but also in

returned from clinical practice and started his residency in

Europe. to be coauthor. Having translated our initial texts

neurology to obtain education and particularly scientific

(Manual Medicine: Diagnostics and Manual Medicine: The/'­

tools to investigate and fulfil Nachemson's request. In this

apy). being a physiatrist. and ever interested in furthering a

respect, the close collaboration with Manohar Panjabi and

meaningful understanding of principles and mechanisms.

his research team, as well as the opportunity to perform

he developed his own personal approach and expertise

cadaveric experiments in the highly sophisticated labora­

from the start. His contribution to the new English edition

tory of the Moris MUlier Institute in Bern was a lucky

has been major and the editors are very thankful that

coincidence to the advantage of the development of Mus­

Wolfgang accepted the invitation to help shape and signifi­

culoskeletal Manual Medicine, which further contributed to

can tly contribute to the current book.

our personal improvement of understanding and clinical

As editors and authors. we are highly satisfied with the

skills. We realized, thanks to Nachemson's hard lesson, that

several editions in different languages, with the first and

a good starting

current edition spanning 25 years. The new edition. which

point-is not enough, and actually carries a risk of being

clinical

experience-while

serving as

now has become an entirely new book. reflects our per­

led in the wrong direction.

sonal development as physicians. and at the same time is

The scientific approach, which we as authors of the

witness to the growing acceptance of this form of medicine

current book implemented in the framework of our think­

within the medical community. We realize this brings with

ing, dominated our next steps with the intention to search

it the responsibilities we editors need to take into account

for evidence of those phenomena which we felt by using

when presenting new teaching material.

our hands for diagnosis and treatment. The exposure as

Truly this book has become a "trans" book: transconti­

active members of the leading spine societies such as the

nental and transdisciplinary. integrating neurology UO).

International Society for the Study of the Lumbar Spine, the

internal medicine (VO). physical medicine and rehabilita­

Cervical Spine Research Society, and the Spine Society of

tion (WG). rheumatology (WS). sports medicine (HS). and

Europe, also influenced our development and, being con­

physiotherapy

fronted with spine surgery in particular, we learnt the

contributors. it is our sincere wish that the reader is stimu­

(TI).

With the invaluable input from all the

limits of conservative approach including those of manual

lated to move beyond professional boundaries and look at

medicine. We respected the limits and, while understand­

the "soul" of the topic at hand.

ing the great advantages of modern spine surgery, we dis­

This may be a topic-hopefully with more research re-

cussed and recommended surgical procedures to our pa­

suits. ideally with its own new ideas and forms of inves­

tients when necessary to reduce pain and improve func­

tigation- in a book in another 25 years from now.

tion. In 1997 we completely reworked and restructured the books and invited three new editors to enhance and im-

Jiff Dvorak

prove the fifth German Edition with their experience and

Vac/av Dvorak

expertise.

Wolfgang Ci/liar

In this form the book became a major educational tool

Werner Schneider

within the Swiss Medical Association of Manual Medicine,

Hans Spring

one of the most successful and active medical associations

Thomas Tritschler

VIII

Copyrighted Material

Contents 1 Manual Medicine-An Overview .......

Historical Perspective ..................... .



Somatic Dysfunction and Tender Points .... ......

126

The Spondylogenic Reflex Syndrome .......... ,.

127

Recent International Perspective ...............

Effectiveness, Outcomes, and Open Questions .....

,

2

7 The Structural and Functional

Neuro-Musculoskeletal Examination ... 135

2 Definitions and Principles of Manual

Medicine Diagnosis and Treatment.....

4

.

4

Techniques.......................... .

16

Definitions and General Principles ............

,

Treatment Principles of Various Manual Medicine

3 Biomechanlcal Principles of the Spine

and JOints .........................

135

Observation ("LOOK") . ... .. ... ... ... ......

137

Palpation ("FEEL").... ... ..... ... ..... ....

137

Motion Testing ("MOVE") .......... ..... ....

140

Functional Examination of the Muscles and Myofascial Structures ... . . ... ... .. ....

142

Provocative Tests .... ... ........ ..... ....

144

Rational Selection of the Appropriate Laboratory 41

General Biomechanical Principles...............

41

Clinical Biomechanics of the Spine............. .

41

Biomechanics of the Upper Cervical Spinal joints

(CO-C1-C2) ..........................

44

Biomechanics of the Lower Cervical Spine (C3-C7)....

54

Vertebral Artery ........................ .

61

Biomechanics of the Thoracic Spine .............

64

Biomechanics of the Thorax and Ribs ............

65

Biomechanics of the Lumbar Spine ............ .

66

Biomechanics of the Pelvic Girdle ..............

69

JOint Motion and Biomechanical Correlations

78

4 Neurophysiology of the Joints

and Adjunctive Diagnostic Studies. .. .........

81

Neuropathophysiology of the Apophyseal joints .....

81

Articular Neurology .......................

81

Functional Pathology of Muscle............... .

87

What's on the Horizon - When Manual Medicine 98

144

8 Rational Selection of Appropriate

Low-Risk Treatment Interventions.....

145

Introduction .......... ..... ... .........

145

Examination Levels in Relation to the Diagnosis and Treatment of Musculoskeletal Disorders. .....

148

Correlation of the Various Clinical Parameters .. ....

149

9 Indications and Contraindications for

Conditions with Potentially Increased Risk of Treatment . ................. Diagnosis: Lumbar Disk Herniation .... ... . . ....

and Muscles ...................... .

and Molecular Medicine Meet .............. .

Introduction .. .. ... ... ..... ... .........

160

160

Diagnosis: Lumbar Spinal Stenosis (Central and/or Foraminal Stenosis) .

.

.

•

... ....

161

Diagnosis: Cervical Disk Herniation . ... ..... ....

161

Diagnosis: Cervical Spinal Stenosis... ... ........

162

Diagnosis: Acute Soft-Tissue Injury to the Cervical Spine

162

Diagnosis: Chronic Phase of Soft-Tissue Injury to the Cervical Spine . .... ... ... ..... ....

163

Diagnosis: Cervicogenic Vertigo

5 The Pharmacologic and Psychologic

Treatment of Chronic Pain ........... . 99 B. D. Radanov Understanding Pain Mechanisms. ... ..... .... ..

in the Lumbar Spine. ........ ... .. ... .... 99

Pharmacologic Treatment of Chronic Pain ...... ... 102

Psychologic Aspects of Pain Treatment ......... "

(Including Cervical Migraine) ... ... ...... ...

110

163

Diagnosis: Spondylolisthesis with Spondylolysis 164

Diagnosis: Bony Malformations of the Vertebral Column, Malformations of the Spinal Cord. ... .. ... . . ..

164

Diagnosis: Osteoporosis (in the Presence of Pathologic Vertebral Fractures) . ..... ... .... ........

164

Diagnosis: Ankylosing Spondylitis (Bechterew Disease):

6 Nonradicular Pain: Spondylogenic

and Myofascial Pain Syndromes . .. . ... 113

Referred Pain............. ... ........ ... 114

Myofascial Pain Syndromes .... ... ........ ...

118

The Postural Pseudoradicular Syndrome .... ... ...

122

Acute Inflammatory Changes ... ... ..... ....

165

Diagnosis: Ankylosing Spondylitis (Bechterew Disease)

without Clinical Signs of Acute Inflammation "

Copyrighted Material

...

165

IX

Contents

Neurologic Disorders Associated with Back Pain. . .... 222

Diagnosis: Inflammation of the Vertebral Column in Association with Chronic Rheumatoid Arthritis.... 166

Cervicogenic Vertigo and Headache ............. 226 Degenerative Disorders of the Spine.

Diagnosis: Abnormal Segmental or Regional Spinal Hypermobility (Congenital or Acquired) ......... 166 Diagnosis: Patient on Anticoagulation Medication..... 166

.

.

.

.

.

.

•

..... 231

Metabolic and Rheumatologic Disorders Affecting the Spine...................... 232 Organ-related Pain and Pseudo Spine Pain ......... 238 Orthopedic Spinal Disorders.................. 240

10 Evidence Base in Manual Medicine for the Treatment of Back Pain Syndromes:

Spondylosis, Spondylolysis, Spondylolisthesis,

Background, Status, and Practice ..... 167 A. F. Mannion, j. Dvorak, W. Gilliar Brief Historical Background. .................. 167 Effectiveness and Cost Considerations: Evidence and Recommendations.................... 167 Requirements for Successful Manual Medicine Management: The Individual Practitioner......... 170

and Spinal Stenosis........ .............. 241 Spinal Deformities........................ 243

Clinical Disorders and Syndromes of the Upper Limb. 252 B. R. Simmen, W. Gilliar General Comments ..... . ... . ............. 252

The Shoulder. .......................... 252 Common Shoulder Disorders ................. 252

The Elbow. ............................ 268 Surgical Interventions: A Brief Overview . .......... 268

11 Informed Consent, Complication

Elbow Disorders ......................... 270

Assessment, Quality Control, and Documentation ................ 171

The Wrist.......................... , .. 276 Wrist Disorders.......................... 276

Clinical Disorders and Syndromes of the Lower Limb. 287

T. Graf-Baumann, W. Gilliar Informed Consent within Patient Care.......... .. 171

The Hip .............................. 287

Complication Assessment ................... 171

j. F. Loehr, W. Gilliar

Quality Control in Manual Medicine; Continuing Education..................... 172 Documentation Requirements................. 173

Disorders of the Hip....................... 287 Hip Disorders in Childhood .....

.

.

•

.

.

.

.

.

.

.

•

.. 289

Hip Disorders in Adults..................... 296

The Knee ............................. 301 T. Drobny, U. Munzinger, W. Gilliar

12 Patient Outcome and Follow-Along Measures. ........................ 174 C Granger, C Malik

Patients Younger than 45 Years...........

.

.

•

.. 302

Patients Older than 45 Years ............. . , .. 307 Disorders of the Itu- )

1,I ''''I

+

LFI

I / /' '/.) , 'J I' " ,\il,.I 1/. / Ii "

r.':\

,,-,"\\ f ""

" -" ., 1--r " ,:',

/ "

I

, -

Rl /,'

J

.,



'B ::::J

Set-up phase/"taking out the slack"

Time

Fig,2.26 Mobilization-without-impulse technique. Distance-time diagram,

18

Copyrighted Material

Treatment Principles of Various Manual Medicine Techniques

Mobilization- with-Impulse Technique

Joints of the limbs

(MWITH) (Classic Thrust Technique,

•

The affected peripheral joint (limb joint) is guided to its

•

The operator's hands are placed as close to the joint as

"Manipulation")

present neutral (resting) position.

The mobilization-with-impulse technique is also known as

possible. Usually it is the proximal joint partner that is

the classic "thrust" technique, often referred to in the liter­

fixed (held stationary). The direction of impulse force is

ature simply as a "manipulation."

perpendicular to the plane of treatment.

The following principles apply to the mobilization-with­

•

The mobilization-with-impulse technique progresses from level II mobilization to level III mobilization.

impulse technique (MWITH).

Spine (Apophyseal or Facet Joints)

The force-time diagram (Fig.2.28) demonstrates that dur­

•

Slack is taken up in the facet joints above and below the

ing the positioning of a synovial joint. the forces introduced

incriminated vertebral segment; that is, the spinal seg­

to the particular joint are relatively small.

ments adjoining the restricted spinal segment are car­ ried to their respective barriers. •

The distance-time diagram (Fig.2.29) demonstrates that the mobilization-with-impulse techniques involve

Positioning of the patient and preparation for the tech­

very brief but precise maneuvers (high-velocity, low­

nique should be performed carefully so as not to intro­

amplitude) in which the applied force moves the joint

duce or exacerbate the patient's pain.

beyond its particular or actual pathologic barrier but with­

•

Mobilization proceeds in the pain-free direction.

out exceeding the anatomic barrier.

•

The direction of the mobilization forces is determined by carefully dosed provocation testing. The direction of mobilization is that in which the patient-reported pain and the nociceptive reactions decrease (Fig.2.11 a, b,

Zl

Fig.2.27). •

The mobilization-with-impulse technique in which the spinous process or the articular process of the inferior

\

partner of the spinal segment is utilized will introduce vertebral rotation in the same direction as the irritation zone. •

Thus, the inferior vertebra undergoes rotation away from the irritation zone. The opposite is true for the superior vertebral partner, which undergoes a rotation toward the irritation zone (Fig.2.27).

•

Z

+0Y

The force of the impulse should be carefully dosed so as

+0Y --�-------+--�---+�- X --

not to introduce motion beyond the anatomic barrier (mobilization level III. Fig.2.13). •

Mobilization-with-impulse should be performed care­ fully and with great caution so as not to exacerbate the patient's pain in the incriminated joint, or spinal region.

•

When using the mobilization-with-impulse technique, the affected segment should be treated no more than once during the treatment session. Fig.2.27 Mobilization-with-impulse (MWITH). MWITH-via the superior vertebra MWITH-via the inferior vertebra x', Z1

+0Y

=

Pathologic motion barrier

=

Pathologic rotation to the left of the superior

=

Irritation zone

vertebral joint partner

IZ

Copyrighted Material

19

Definitions and Principles of Manual Medicine Diagnosis and Treatment

QJ U '­

o L.&..

Impulse

CLo

! 2

j

QJ I: o N U '.;:0

QJ I: o N u '.0

WJ

c::

2

I

oil

Vl ro

"'

Set-up phase/"taking out the slack"

Position

Time Fig.2.28 Mobilization-with-impulse technique. Force-time diagram.

QJ U c: "'

t; i5

Distance gain

Impulse



Myofascial Pain Syndromes

Muscles of the Shoulder and Arm

Muscles of the Head and Neck Sterno­

Splenius capitis

Infra­

Supraspinatus

spinatus

cleidomastoid

Temporalis

Masseter

Trapezius

Tra pezius

Supinator

Extensor carpi radialis

Levator scapulae

Rectus capitis

posterior maj or

Interosseus

Adductor pollicis

119

Copyrighted Material

Nonradlculor Poin: Spondylogenic and Myofascial Pain Syndromes

Muscles of the Chest and Back Pectoralis major

Pectoralis major and minor

· ;i/

+

(,4f \ J )

:'::.

)( Trigger point

Fig. 6.4

,,fir' . !li'

i:: "".,/ .:;';'. Pain pattern

(cont.)

120

Copyrighted Material

Muscles of the lower Extremity

Myofascia/ Pain Syndromes

Myofascial Trigger Points and Pain Referral

Myofascial Trigger Points:

Patterns

Treatment Options

Referred pain, in the presence of either an active or a latent

In general, and in addition to standard pharmacologic care

MTrP, is usually very well-localized by the patient. Using

(e. g., nonsteroidal anti-inflammatories [NSAIDS], analge­

palpation, the painful muscle or part of the muscle ("myo­

sics), the activity of the MTrP can be addressed specifically

tenone", for definition see below) can be demarcated. The

in three ways: (1) introduction of maximal stretch with or

MTrP is described as a "palpable band" (Simons, 1975,

without a cooling spray; (2) injection or "dry-needling" of

1976b), which should be palpated perpendicular to the

the trigger points; and (3) specific manual medicine tech­

direction of the incriminated muscle fibers (similar to the

niques applied to treat the MTrP to the incriminated

"myotendinoses" also defined below). Palpation often

muscle or muscles.

causes a local, painful twitch response in the muscle in­ volved (Simons, 1976a; Travell, 1952).

The "spray-and-stretch" method is commonly used to treat the MTrP (Travell, 1981). With the help of a cooling

A MTrP may cause pain in one or in several reference sites (Fig. 6.4).

spray (e.g., fluoromethane), afferent nociceptive impulses of the skin can be invoked, which in turn appear to reflexly

The induction of several so-called satellite MTrPs by a

reduce the muscle's resistance to stretch, thereby facilitat­

primary MTrP is described by Travell (1981). For instance, a

ing the lengthening of the shortened muscle in the direc­

MTrP in the sternal region of the sternocleidomastoid

tion of the normal resting length. This "stretch stimulus"

muscle can cause satellite MTrPs in the sternalis muscle,

appears to be able to reduce the activity of the MTrP,

pectoralis muscle, and the serratus anterior major muscle.

presumably via the reflex pathways within the spinal

MTrPs can be found in any skeletal muscle; in orthope­

cord, or possibly in higher central nervous system (CNS)

dic practice, a set of common muscles has been regularly encountered and described (Rachlin, 1994):

centers. The MTrP activity can be reduced or even extinguished by injection of local anesthetics such as procaine or lido­ caine. The muscle that harbors the incriminated MTrP

1. Posterior neck muscles 2. Sternocleidomastoid muscle and scalene muscles

should be carefully stretched passively during the injec­

3. Trapezius muscle (the most commonly encountered

tion. Another form of treatment entirely avoids the need

MTrP in general)

for any injectant by approaching the MTrP simply using an

4. Infraspinatus muscle

injection needle, a course of treatment known as dry nee­

5. Supraspinatus muscle

dling.

6. Levator scapulae muscle, rhomboid muscles, and tho­ racic erector spinae muscles

Recent reports of the use of botulinum toxin (botox) injections have shown some promising results, but further

7. Lumbar paraspinal muscles and quadratus lumborum muscle

studies are needed to substantiate the use of this rather costly procedure. Currently, the use of such injections is

8. Gluteal muscles (minimus, medius, maximus muscles), tensor fasciae latae, piriformis muscle

considered as "off-label" due to diagnostic restrictions. Efforts are under way to determine further specific indica­

9. Rectus femoris muscle and vastus medialis muscle

tions and contraindications for the use of botox in muscle

10. Flexor and extensor muscles of the forearm ("golfer's

"spasms" and painful myofascial syndromes. Due to the reported duration of up to 3 months, a possible therapeutic

elbow" and "tennis elbow" syndromes) 11. Pectoralis minor and major muscles

window is being opened for patients with recalcitrant myo­

12. Interossei foot muscles.

fascial pain syndromes, as it would not be reasonable to inject local anesthetics for prolonged or even open-ended

Other muscles have also been identified as occurring more

periods, especially when there is lack of anticipated func­

commonly in the presence of headaches and facial pain.

tional progress.

In addition to causing referred pain, the active MTrP can

The manual approach to the treatment of various myo­

influence autonomic functions in the reference site, includ­

fascial trigger points is detailed in Chapter 18. A recent

ing cooling by local vasoconstriction or via increased per­

monograph (Dejung et aI., 2003) provides an exhaustive

spiration and amplified pilomotor activity.

and well-organized treatise of these methods and the dry­

Occasionally, hyperalgesic skin regions have been ob­

needling techniques.

served (Travell, 1981).

121

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Nonradicular Pain: Spondylogenic and Myofasaal Pain Syndromes

path of movement. Remember that a reflexly contracted

The Postural Pseudoradicular

pectoralis major muscle can easily mimic the substernal or

Syndrome

parasternal pain caused by organic heart disease (Fig. 6.6).

Brugger (1962,1977) coined the term pseudoradicular syn­

Brugger considers the "effort syndrome" as indicative of

drome to differentiate it from the neurologically based

the sternal syndrome, representing an abnormal head­

radicular syndrome. The pseudoradicular syndrome is ex­

forward posture.

plained on the basis of the reflex interactions between the

In the cervical spine, the reflexly hypertonic neck

various joint structures and the muscles. Of particular in­

muscles may cause a secondary spondylogenic cervical syn­

terest is the potential interaction of some of the somato­

drome. Abnormal sternocostal and sternoclavicular stimu­

motor nociceptors that apparently come into play when

lation can also "spread" further to reflexly involve some arm

the soft tissues are irritated or become painful, such as the

muscles, which may eventually result in myotendinosis. The

joint capsule or the tendon attachments (Brugger, 1977).

reflexogenic changes in the muscles and tendons (myoten­

Brugger believes that the painful reflex nociceptive re­

dinosis) can be demonstrated by having the patient assume

sponses can affect not only the associated muscles and

the upright, erect posture position and then the abnormal

their corresponding tendons but the skin as well. The re­

slouched position. The patient may spontaneously report

gion where the muscle-tendon junction has become pain­

that the slouched posture (that is,the patient's stereotypical posture) is more comfortable than assuming the normal

ful is referred to as a "myotendinosis." Myotendinosis is described as a reflex change in or

upright position. This can be explained by the mechanisms

alteration of muscle and tendon function in response to

of involving the mechanoreceptor and nociceptor reflexes

pain. These reflex reactions can be initiated by nociceptor

as described by Wyke (1979b).

stimulation following: (1) abnormal posture: (2) muscle

When the acromioclavicular joints are involved, reflex

(3) direct or

myotendinoses have been characteristically noted in the

(4) a combination of these.

serratus anterior muscle, the trapezius muscle, the biceps

and tendon overuse and strain syndromes: indirect soft tissue injury: or

Brugger (1977) divides the various pseudoradicular syn­

brachii muscle, the coracobrachialis muscle, and the exten­

dromes according to body regions. Upper body involve­

sors of the wrist and fingers (Brugger,1977).

ment includes the sternal syndrome and the thoracic spine

It should be noted that the sternal syndrome does not

syndromes. Lower body involvement is comprised of the

only affect the musculature of the shoulder, neck, chest,

lumbar syndrome and the symphyseal syndrome. They are

and arm but may also present with paresthesias and tro­

described in greater detail below.

phic skin changes. Furthermore, and equally important, Brugger (1977) emphasized that any primary brachial syn­ drome, including the carpal tunnel syndrome and the var­

The Sternal Syndrome

ious upper limb overuse syndromes, can all lead to a sec­ ondary sternal syndrome on a reflex basis (Brugger, 1977:

The sternal syndrome is usually the result of a slouched,

Gerstenbrand et aI., 1979).

trunk-forward-bent posture that is maintained over a pe­ riod of time. Due to abnormal mechanical loading condi­ tions, the sternocostal and sternoclavicular articulations are continuously subjected to ever increasing stress and strain (Fig. 6.5), in particular when abnormal loading forces are introduced to the thoracic spine and the ribs along with their connections to the sternum. As a result of these abnormal loading conditions at the sternocostal and sternoclavicular joints, the muscles in this region are increasingly called into action. This can ulti­ mately lead to reflex muscular contraction in many re­ gional muscles including the intercostal, pectoralis major and minor,sternocleidomastoid, scalene, and the posterior neck muscles. The involvement of any of these muscles can relatively easily be assessed by careful palpation. Starting with the patient in the seated or "normal" up­ right position and requesting him or her to adopt a slouched

b

a

posture will provide valuable feedback to the examiner

Fig. 6.5

about which muscles are engaged at what point in the

tion. (After Brugger,

122

Copyrighted Material

a

Slouched trunk position. b Erect (straight) thorax posi-

1977.)

The Postural Pseudoradicular Syndrome

c

Fig.6.6a-d Overview of pain radiation patterns when the sternoclavicular joints

(a,

b, c,

d)

and different sternocostal joints (c, d) are

stimulated through puncture (after Brugger, 1962).

and their related myotendinous junctions, particularly in

Reflex Syndromes Associated with the Trunk

the pelvis, the abdomen, and the lower limbs. Based on

and the Viscera

reports by Fassbender and Wegner (1973) and Fassbender (1980), Brugger further believes that some of the lumbo­

Functional disturbances of the trunk and disorders of the

pelvic dysfunctions can ultimately precipitate new reactive

viscera can both result in myotendinoses and articular

inflammatory changes and swelling at the tendinous in­

somatic dysfunction syndromes via somatosomatic and

sertions to bone, the tendon sheaths, and the interstitial

viscerosomatic reflex interactions. respectively (Brugger,

muscle tissue.

1965).

Thus, the confluence of the many somatic sources and

It is known that a primary segmental dysfunction aris­

their secondary reflex interactions at the spinal cord level.

ing from somatic structures can cause pain referral to the

at least as seen with the various nociceptive reflex pain

inner organs (Schwarz, 1974), that is, via the somatovisceral

patterns, and possibly even at the brain level, may reduce

reflex path. The reverse is also well described, that is.

the individual's overall functional capacity, by diminishing

diseases of inner organs can reflexly induce myotendinotic

the performance of the entire musculoskeletal system in

changes via the viscerosomatic reflex (Korr, 1975; Beal and

general and the other interrelated systems. This, in turn, may explain the variability of the many pain syndromes

Dvorak. 1984). Proficiency in palpation of the muscles, the fasciae, ligaments and tendons. and, where possible, the nerves,

when they involve the back, the lower limbs. and the pelvis (e. g., shortening of the iliopsoas muscle).

requires solid knowledge of and experience in the func­

Subcutaneous inflammatory processes, hemorrhages,

tional. three-dimensional anatomy. A detailed structural­

and scars can also cause pain that involves the various

functional analysis of body posture and movement patterns

articular,

along with appropriate application of local infiltration of

1981). In clinical practice it is often difficult to differentiate

anesthetics in the incriminated spinal joints (apophyseal or

between the secondary reflex changes and a presumed

muscular,

and

fascial

structures.

(Reynolds,

facetjoints) or the costovertebral joints can help distinguish

primary musculoskeletal disorder. A detailed and function­

whether the pain arises from a particular musculoskeletal

ally oriented structural examination is therefore often a

structure or from a visceral source (Wyke, 1979a, b).

logical place to start in order to assess the current states of the different structures, at the time of presentation in the office. The assessment should include a detailed evaluation

Syndromes of the lower Body

of the incriminated muscles, the tendons. ligaments, fas­ ciae. and joint capsules.

According to Brugger (1965). the functional unit of the

Stimulation or irritation of the apophyseal joints in the

lower body consists of the thoracolumbar spine, the pelvis,

thoracolumbar and the lumbosacral junctions can cause

and the lower limbs and the corresponding regional back

particular myotendinotic pain patterns in the muscles

muscles and the abdominal muscles.

and tendons associated with the spine, the abdomen, and

Abnormal mechanical stress to the lumbosacral junc­

the lower limbs (Fig. 6.7).

tion. for instance, may preferentially affect certain muscles

123

Copyrighted Material

Nonradlwlar Poln: Spondylogenlc and Myofascial Pain Syndromes

,:. "

'

•

. ...:. . .: '. . .' . .... : " " 00'

"I

•

•

•

. :I

"

:..

"

"I

::

.,'•.

. ·

'

:

.

r';;,t . :

..

.

·

· · .

'

. . .

"

I , I I I I

l

Fig.6.7 Pain radiation pattern when different apophyseal joints are stimulated through puncture. (After Brugger,

Symphyseal Syndrome

1962.)

femoris muscle, sartorius muscle, tensor fasciae latae muscle) (Brugger,

1962, 1977) (Fig. 6.8).

In the slouched sternosymphyseal posture as described by Brugger (Fig.

6.9), the synergism between the paraspinal

extensors and the abdominal wall muscles is displaced in favor of the abdominal muscles, which in turn may further exacerbate the already present irritation at the symphysis. It is often impossible to distinguish on clinical grounds only a primary symphyseal disturbance from the many possible painful secondary and adaptive reflex changes invoked

by

the

various

ligaments

and

the

tendon­

periosteum interface at the symphysis, when the cause may be due to disturbances in the thoracic spine, for in­ stance.

Fig.6.8

Pain radiation when the symphysis pubis is stimulated

through puncture. (After Brugger,

1962.)

To recognize a true radicular syndrome and to be able to differentiate it from other sources that can' mimic it, the clinician should at least be aware of that articular or so­

It has been reported that the infiltration of the symphysis

matic dysfunctions, e, g., in symphysis pubis, can lead to

pubis with local anesthetics can lead to the immediate

pain due to reflex myotendinotic reactions. Thus, even a

disappearance of symptomatic pain in the pelvis or the

"simple" slouched posture may precipitate an adaptive or

legs. This would indicate that both the symphysis and the

compensatory "downward spiral" cascade that may cause

pelvis are potential pain generators. Dysfunctions involving

pain easily mimicking a true radiculopathy (Fig. 6.10),

the symphysis pubis or the entire pelvis may ultimately

When involved in the symphyseal syndrome, the por­

lead to painful myotendinotic reactions in the lumbar para­

tion of the longissimus thoracis muscle that spans between

vertebral muscles ("symphyseal lumbago"), in the muscles

the sacrum and the mid-thoracic spine may become painful

of the pelvis and the abdomen (symphyseal abdominal wall

and refer pain not only to the spine itself but also to the

pain), or in the muscles of the lower limb (e. g., quadriceps

interscapular region due to the reduced tone ("hypotoni­

124

Copyrighted Material

The Postural Pseudoradicular Syndrome

city") and the subsequent associated myotendinotic reac­ tions. To counteract the backward tilt, the iliopsoas muscle must be recruited and may then be continuously con­ tracted. The tensor fasciae latae, sartorius, and rectus femoris muscles act synergistically. The hamstring, calf muscles, and the fibular (peroneal) muscles may become painfully hypotonic, or reflexly weak. It is therefore not surprising that a myotendinotic pain syndrome that devel­ ops in this fashion can easily be mistaken for a lumbar radiculopathy. The palpatory and functional examination of the various muscle groups should be performed with the patient as­ suming a slouched posture and in the upright-erect posture as well as the supine position. Interestingly, some of the myotendinotic reactions often seem to disappear when the patient assumes an upright posture, especially when the examiner supports such a posture by broad hand place­

a

b

ment on the patient's posterior trunk for stability. However, as mentioned, a number of patients may find the erect

Fig.6.9

posture as less comfortable.

patient is in the slouched sternosymphyseal position.

Figure 6.11 provides an overview of some of the possible nonradicular pain radiation patterns encountered with ir­

a

A torque acting in the posterior direction when the

b Disappearance of the torque in the pelvic region when the patient is sitting erect. (After Brugger, 1962.)

ritation of various joint capsules.

a

Fig.6.10 Muscles that are involved in extension of the trunk (red) and muscles involved in the slouched position (blue). (After BrLigger, 1962.) a

SloLiched, sternosymphyseal position.

b

Erect position.

_

Muscles responsible for trunk extension.

_

Muscles participating in perpetuating the sternosymphyseal slouched position.

125

Copyrighted Material

Nonradicular Pain: Spondylogenic and Myofascial Pain Syndromes

Fig.6.11 Pain radiation pat­ tern when different joint cap­ sules are stimulated by way of puncture. (After Brugger, 1962.)

The goal of the practitioner is to detect abnormal joint

Somatic Dysfunction and Tender Points

function with regard to asymmetry in range of motion,

In the osteopathic manual medicine literature and practice,

and tissue alterations such as "bogginess" (thickness, in-

the central consideration for diagnosis and treatment of the

creased consistency), heat, and perspiration, among others.

usually that of hypomobility rather than of hypermobility,

nonradicular pain syndromes of spondylogenic and myo-

Although these findings are typically associated with local-

tendinotic origin is the somatic dysfunction (Korr, 1975;

ized tenderness or palpatory pain, pain itself is not the

Mitchell et aI., 1979; Jones, 1981; Greenman, 1996).

"sine qua non" in the osteopathic understanding of the

Somatic dysfunction is defined as impaired or altered

somatic dysfunction.

physiological function of related components within the

The diagnosis of a segmental vertebral dysfunction or

somatic (body framework) system including the skeletal.

somatic dysfunction is based on a targeted structural and

arthrodial, and myofascial structures, and the related vas-

functional musculoskeletal examination that expands upon

cular, lymphatic, and neural elements. This definition,

the standard neuro-orthopedic examination. The structural

which replaces the antiquated term "osteopathic lesion,"

and functional examination, in essence, represents a thor-

was registered with the International Classification of Dis-

ough and at the same time refined assessment of the

eases under the number 739.

various components of the axial and peripheral articular

126

Copyrighted Material

The Spondy/ogenic Reflex Syndrome

system, looking for relevant asymmetries in form and func­

they may be compared to the latent phase of the interver­

tion, which may be amenable to manual medicine treat­

tebral insufficiency, as described by Schmorl and Jung­

ment procedures or specific rehabilitative exercise rou­

hanns

(1968).

tines. The goal of the structural-functional examination is

The results of the positional examination dictate the

to arrive at a germane segmental diagnosis that is of suffi­

direction of the manual therapeutic approach for the ten­

cient clinical significance within the entire clinical presen­

der points. After careful localization of a particular tender

tation to be treated in one form or another. While many

point, the patient's limb, or head, neck, trunk, or pelvis is

practitioners may base their findings on the presence of

positioned such that the initially reported tenderness is

localized pain, such as that associated with a tender point

significantly reduced in a specific position (at least

(described below), the convention in osteopathic practice is

intensity reduction), The examiner may find that in re­

to determine motion restrictions and soft-tissue abnormal­

sponse to proper treatment the initially palpated soft­

70%

ities first and to treat those without "chasing the pain"

tissue "tension" is also reduced accordingly, and the tender

1983), A second, but

points should no longer be painful or be only minimally

equally important, diagnostic goal is to determine the po­

painful to the patient. Again, there are a number of sim­

(Greenman, personal communication

tential relationships of various findings in different spinal

ilarities with the definition of the tender points and the

regions and the limb joints and muscles, and if possible to

entity called the "irritation zone."

ascribe the findings to adaptive or compensatory mecha­ nisms.

The growing understanding of the somatic dysfunction complex as such and the particular attention paid to the

One of the neurophysiologic postulates about the occur­

detailed soft-tissue examination using refined palpatory

rence of segmental motion restriction with soft-tissue

techniques, for instance, prompted the introduction of a

changes is that of the "facilitated segment." which is

number of new treatment concepts in osteopathic medi­

thought to explain some of the chronic changes noted in

cine, such as the "muscle energy technique" (MET) (Mit­

the affected spinal section and at the segmental level (Korr,

chell et aI.,

1975),

(jones,

One of the possible, but not universally required, clinical manifestations of a somatic dysfunction is the presence of what Jones

(1964, 1981), and before him Kellgren (1938),

refers to as the tender point. Such tender points can provide

1979), the "strain and counterstrain" technique

1964, 1981), and the myofascial release technique

(Ward and Clippinger,

1987). Similar to, yet different from,

these techniques are the muscle facilitation and inhibition techniques introduced by Lewit

(1981). While the "cranio­

sacral" techniques have been described in early osteopathic

clinically relevant information for the diagnosis of abnor­

literature, and despite their ever-increasing popularity,

mal joint function arising from either the apophyseal or the

they remain controversial, even within the circles of man­

peripheraljoints and can guide the palpatory evaluation of

ual medicine practitioners (Greenman,

1996).

the associated reflex changes in the incriminated soft tis­ sues. The tender points described here, and which are to be

The Spondylogenic Reflex Syndrome

differentiated from tender points associated with fibro­ myalgia syndrome, are usually painful upon palpatory

Numerous empirical reports in the literature give an ac­

pressure, The patient may characterize the pain upon pal­

count of apparent relationships between the axial skeleton

pation as a stabbing type of pain, Typically, and unlike a

and the peripheral soft tissues that are difficult to explain

myofascial trigger point, these tender points do not refer

solely on the basis of neural or radicular, vascular, or en­

pain spontaneously, They can be palpated as enlarged or

docrine mechanisms.

"boggy" tissue changes. The points, while typically located

Following

his

clinical

observations,

Sutter

(1975)

at specific regions that have been found to correspond to

presented a concept he termed "the spondylogenic reflex

specific articular levels, are usually in close proximity to the

syndrome" (Greek, spondylos

affected joint. They are mostly to be found in the deeper

genic reflex syndrome (SRS) is thought to arise from an

=

vertebra). The spondylo­

muscle layers, and their size does not normally exceed 1 cm

articular dysfunction involving either the facet joint (apo­

in diameter.

physeal joint) or a peripheral joint when it affects a limb.

With spondylogenic dysfunction, they often appear

Due to the associated motion restriction, e. g" hypomobility

multiply, primarily in the paravertebral region, often at

or abnormal functional position or dysfunction of the facet

the same level as the related articular processes. They are

(apophyseal or zygapophyseal)joint, certain reflex changes

also found on the anterior side of the trunk (Fig. 6.12).

can be invoked that may eventually lead to anatomically

Tender points have been described for a number of joint

localizable, noninflammatory changes in the soft tissues

dysfunctions. Even with subclinical disturbances, they have

associated with the incriminated joint. The articular dys­

been reported to be detectable by careful palpation, Thus

function is thus believed to be a disturbance at the "internal

127

Copyrighted Material

Nonradicular Pain: Spondylogenic and Myofasdal Pain Syndromes

5

b

a

Fig.6.12 Localization of selected posterior tender points (exam­

Note: There are cu rrently over 200 such points considered as

ples). (After Jones, 1981.)

tender points (after Jones).

a

b Anterior.

Posterior. 1

(1

1

Acromioclavicular joint

2 3 4

T2

2 3 4

(7

5

Tl-Tl2 L1- L3

6

T3 Ribs

functional" level of the vertebral spinal unit of the affected

Sternoclavicular joint Tl-T6

perpetuating the controversy about its very existence.

facet joint. The vertebral spinal unit, also Imown as the

Again, the articular or somatic dysfunction should be

spinal motion unit, consists of the two vertebral joint part­

viewed as the expression of a reversible motion restriction

ners and their joints with the intervening intervertebral

with possible soft-tissue changes in the incriminated spinal

disk. In the articular dysfunction, there is a disturbance of

segment or spinal region, the objective clinical detection of

both the static and the dynamic balance between the in­

which is accomplished through the process of specific

dividual bony parts that make up the axial skeleton such as

static tissue and dynamic motion palpation.

the skull, the vertebrae, and the pelvis, and the related

The primary afferent sources of the SRS are the inter­

muscle-tendon system. Maigne (1970) refers to these dis­

vertebral or facet joints (apophyseal or zygapophyseal

turbances as "derangements intervertebrales mineurs."

joints). When the joint-associated mechanoreceptors and

The osteopathic literature refers to similar entities as the

nociceptors in the joint capsule, ligaments, and muscles are stimulated above their normal threshold for a prolonged

somatic dysfunction complex. As the individual motion restriction may be rather

period, the invoked reflex pathways (CNS) will bring about

small, but nonetheless potentially clinically relevant, the

valuable soft-tissue changes that can be clinically observed

"faulty vertebral position" associated with a particular ar­

and correlated within the particular clinical presentation

ticular

dysfunction

cannot usually be identified or detected

(Waller, 1975; Wyke, 1979b).

on adjunctive diagnostic studies such as standard radiog­

One of the first demonstrable clinical manifestation of

raphy or MRI. This is in stark contrast to the easily recog­

the spondylogenic reflex syndrome is the so-called irrita­

nizable structural changes seen with even very minimal

tion zone (Caviezel, 1976). Other authors have referred to

The

similar changes as the segmental points (Sell, 1969), para­

difficulty of demonstrating an articular dysfunction on

vertebral points (Maigne, 1970), or the previously men­

radiographs, for instance, may partly have contributed to

tioned tender points Uones, 1981).

scoliosis

or anterior-posterior spinal deformities.

128

Copyrighted Material

The Spondy/ogenic Reflex Syndrome

may mean many things to different people, including the

Irritation Zone

description of tightness, hypertonicity, and even normal,

The irritation zone represents small. painful soft-tissue

albeit increased, muscle tone. Within the context of this

changes that, when palpated, can be quite tender even

text, the description by Rachlin (1994) is adopted to de­

when the applied pressure is minimal. It averages between

scribe myospasm: myospasm is a clinical description of

0.5 and 1 cm in size. The irritation zones are located in

increased tone affecting an entire muscle that has become

topographically well-defined areas or regions at the level

painful due to an involuntary contraction. In addition to the

of the muscular and fascial tissues. The main characteristic

pain, the myospasm usually causes the muscle to be short­

is the direct relationship between the temporal and qual­

ened, limiting the associated range of motion. In the Ger­

itative response of the irritation zone and the severity of

man literature this phenomenon is described as "myosis"

the associated articular dysfunction. That is, as long as the

(Myose), but there is no equivalent term in the English

articular dysfunction is not eliminated or effectively cor­

literature. The muscle that is affected by myospasm is

rected, there will be a clinically identifiable irritation zone.

palpated perpendicularly at its belly, whereas it is palpated

However, once the disturbance has been corrected, the

longitudinally at its origin and insertion.

irritation zone disappears quite promptly. This is of clinical

A generalized increase in muscle tone in the absence of

significance, in particular in the patient management pro­

muscle pain (either spontaneous or upon palpation) is

cess while monitoring patient response.

known in the German literature as Hartspann, which trans­

Again we emphasize that when we speak of an irritation

lates as "hard tension." Thus, we may use the term muscle

zone we refer to a clinical entity on the palpatory expres­

tension (or increased muscle tone or hypertonicity) simply

sion of joint function through the various soft tissues. To

as a description of a change in muscle tone while the

date, no anatomic or histologic substrate has been identi­

muscle is contracted, while not necessarily being painful.

fied that would be pathognomonic for the irritation zone.

A relaxed healthy muscle, when palpated, displays a

Among the most important causes of an articular dys­

characteristic firmness, consistency, and plasticity. The in­

function are previous trauma, muscular imbalance and

dividual muscle bundles usually cannot be differentiated

uncoordinated or inappropriate movement patterns, acute

from each other by palpation except than when separated

and chronic mechanical overload of the vertebrae, and

by the various fascial septa. When the muscle is affected

osteoligamentous insufficiency. Secondary articular dys­

and shows signs of prolonged increased tone, it is often

functions in response to inflammatory or degenerative

said to be "in spasm." When "in spasm," that is, it is con­

joint disorders, including microfractures, or those associ­

tracted for some period of time, the muscle reveals in­

ated with space-occupying lesions, should routinely be

creased "bogginess" (thickness,

considered in the comprehensive management of the var­

often associated with increased resistance to allow stretch,

ious painful syndromes (Northup, 1966).

and diminished plasticity. Either the entire muscle or only a

increased consistency)

Thus, in the authors' view, the term articular or somatic

few muscle bundles in the longitudinal direction can be

dysfunction may represent a more specific and potentially

affected. On palpation perpendicularly to the muscle fibers

clinically more relevant diagnosis than the current usage of

with average pressure, the myospasm may become painful

"sprains and strains" so commonly "diagnosed" in conjunc­

and can be relatively easily differentiated from the sur­

tion with the various spinal pain syndromes.

rounding area of the same muscle portions that are not

Noteworthy sequelae associated with the various artic­

directly affected. A myospasm can be followed with palpa­

ular or somatic dysfunctions arising from reduced facet

tion from the origin to the insertion of the involved muscle

mobility are the noninflammatory "tendinoses" and the

in a longitudinal manner. "Nervous misinformation" from

"myotendinoses," which, in our understanding, represent

the involved muscle bundles (Fassbender, 1980) has been

abnormal soft-tissue changes of the tendons and muscles

proposed as the mechanism underlying the reflex path­

respectively. They are identified by specific and carefully

ways responsible for the origin of the involuntary isometric

performed palpation.

increase in muscle bundle tone (Fig. 6.13).

Myotendinosis and Myotenone

Myospasm and Myotendinosis

When there is continued increased muscle tone in the form of long-standing myospasm, the involved muscle-tendon

Myospasm

unit can undergo myotendinotic changes. The myotendi­

While commonly used in clinical practice, the term "muscle

notic changes affecting the muscle and/or tendinous inser­

spasm" or "myospasm" has not been specifically defined as

tions can be caused by uncorrected segmental dysfunc­

to underlying pathophysiologic changes. As used, the term

tions. In the field of rheumatology this has often been

129

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Nonradicular Pain: Spondylogenic and Myofascial Pain Syndromes

referred to as noninflammatory soft-tissue rheumatism Segmental dysfunction

(Fig. 6.14).

l

Again, myospasm is a clinical term used to describe a state of painfully increased tone in muscle that can be elicited by palpatory pressure or that may appear sponta­

Stimulation of mechanoreceptors

neously. Painful myospasm is principally found in the

and nociceptors

muscle belly, while the associated changes can involve

l

the entire length of muscle

Reflexes via eNS

"Misinformation"

-

or

where the muscle fibers

change their direction. They are also found at the free muscle borders such as the trapezius muscle, and pectoralis

l

major muscle, for instance. With continued, nonphysiologic

Myotendinosis

creased tone, it is plausible to assume that the muscles

excitatory impulses and in response to a continuously in­ compensate as long as possible, to the point of overcom­

Fig.6.13 Development of increased muscle tone (hypertoniCity). (AFter Fassbender,

1980.)

pensation until the inherent adaptive mechanisms fail and the muscle actually starts to decompensate (Fassbender and Wegner, 1973; Fassbender, 1980). The decompensation then ultimately leads to muscle tears and overt rupture,

L

=-

====--==

potentially resulting also in significant damage to the af­ fected myofascial components associated with the partic­

1

ular muscle (Fig. 6.15).

Attachment tendinoses represent localized swelling of

a

tendons at the respective origin and insertion. They can

.. t ...."";: ' 1 :=:'::-- ' 1 -1' _ 'l :':.'--=-:::: : :ti",==-- ........--

; ;,

-")l·-'; .::

' :':':: T

___

'.

b

sure. The hallmark is their mirror-image appearance: that is, presence at both the muscle's origin and its insertion. In addition to the characteristic points at the respective at­ tachment, the tendinoses can also be found at the muscle­

Fig.6.14

tendon junction of the incriminated muscle.

Schematic representation of a normal muscle.

a

be extremely painful upon even minimal palpatory pres­

b Muscle that has become painful with increased tone (myo­ spasm).

Morphologic studies have revealed that due to the pre­ sumed relative hypoxia in the involved muscle there is anomalous development of the mesenchymal connective­ tissue cells (Fassbender, 1980; Fassbender and Wegner,

L

P ermanently increase tonus

+ 0, req ui e

r m ent

1973) (Fig. 6.15).

Myotendinosis

Tendinoses and painful myospasm as a rule do not occur

in the muscle

unexpectedly as they take quite some time to develop enough to be noted clinically. One mechanism is thought

but

normal 0, supply

J

to be the result of various reflex interactions. Correspond­

Overload at the tendons

ingly, once the causative disturbance has been eliminated, the tendinoses and myospasm are expected to disappear

Relative hypoxia

Degenerative fiber damage

a

] [ I

after a certain latency period (referred to as "latent zones" Localized lack of 0,

by Sutter). This helps in differential diagnosis to set it apart from the presence of the irritation zone. Also, clinically, they must be differentiated from other secondary trau­

Progressively degenerative tendon changes

b

Fig.6.15 Pathogenesis of noninFlammatory soft- tissue rheuma­ tism. (After Fassbender and Wegner a

Myospasm.

b Tendinosis (tendonopathy).

1973.)

matic myospasms and myotendinoses. Each muscle or muscle part can independently undergo myotendinotic changes. Such a clinical muscle-unit with the corresponding tendons is referred to as myotenone. Slender muscles represent a single myotenone. Broad, flat, and fan-shaped muscles comprise several myotenones (Fig. 6.16). Clinical experience has shown that certain axial skeletal components

130

Copyrighted Material

are correlated

with specific myotenones.

The Spondy/ogenic Reflex Syndrome

L3 Rectus capitis

O bliq u us

posterio r

capitis

minor

superior Gluteus medius

(1 --'-<E:

___

(2

IE'--- 0 bliquus c a pi t is inferior

TlO

b

a

Fig.6.16 a

Individual myotenones.

b Myotenones in a fan-shaped muscle.

which can be objectively verified by palpation. A functional disturbance in one vertebral unit usually brings about myo­

The Postural Spondylogenic Reflex Syndrome:

tendinotic changes in the empirically correlated myo­

Clinical Correlation with Reflexes linked to

tenones. Since the spondylogenic-reflexogenic myotendi­

Nociceptors and Mechanoreceptors

noses can be routinely identified. they are collectively termed systematic myotendinosis (Sutter and Frohlich.

The clinical symptom of pain in muscles and other soft

1981; Travell and Rinzler. 1952). The primary articular or

tissues. be it spontaneous pain or pain elicited with palpa­

segmental (somatic) dysfunction of a vertebral segment.

tory pressure. has been termed the spondylogenic reflex

when followed by myotendinotic changes. represents the

syndrome by Sutter (1974.1975). Likewise the authors have

primary SRS.

been able to observe the various systematic myotendinoses

Under certain circumstances additional secondary. ter­

in response to an articular/somatic dysfunction involving

tiary. and other SRSs can develop in a chain-reaction se­

the individual apophyseal. occipito-atlanto-axial. and sa­

quence. Thus. many factors can play a crucial role in the

croiliac joints. We have observed that many systematic

development of the spondylogenic reflex system. These

myotendinoses improve during the course of therapeutic

include spinal deformities. abnormal or stereotypic motion

intervention in the individual patients. It was therefore

patterns. muscle and proprioceptive imbalance. loss of

assumed that. in addition to other helpful physical and

muscle strength. and inherent articular dysfunction. In

therapeutic procedures. the mechanical and functional cor­

clinical practice. many of these factors may be in play

rection of the spinal motion unit according to Schmorl and

together and in simultaneous combination represent a

Junghanns (1968) can play a significant role. if not the most

rather complex clinical picture.

crucial role in treatment.

Therefore. and almost routinely. it is not possible to

Wyke's observations (Wyke. 1979a. b) and research in

determine the causative primary SRS. especially in patients

the new field of articular neurology have brought signifi­

with chronic conditions. The primary SRS may actually

cant insight into some of the principles underlying the

have "resolved" only to give way to the secondary SRSs.

diagnostic and therapeutic approaches in the field of man­

which should then be considered the new primary syn­

ual medicine. In a clinical study of adolescents. we found

dromes (Travell. 1981). The characteristic features of the

that the absence of pain does not automatically mean lack

irritation zone are listed and compared with the spondylo­

of soft-tissue findings. It is well known that localized pal­

genic myotendinosis in Table 6.1. Careful examination tech­

pable muscle bands or systematic myotendinoses can be

niques and precise anatomic knowledge are necessary for

elicited upon careful palpation in many individuals who

establishing the correct diagnosis and initiating the appro­

have no subjective pain complaints. According to the au­

priate therapy.

thors' understanding. this situation is to be considered as pathologic and correlates with the latent state of interver­

131

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Nonrodicular Pain: Spondylogenic and Myofascial Pain Syndromes

Table 6.1 Important characteristics for the zone of irritation and spondylogenic myotendinosis in the context of the spondylogenic refiex syndrome Irritation Zone Changes

III]Jltt.'j[tIlh

Skin, subcutaneous tissues, tendons,

t}{:,IllfIUII

Muscles, ligaments

muscles, joint capsule Localization

In area of the disturbed spinal segment,

Muscles. ligaments (referred pain?)

topographically defined in region around spinous or articular processes Time course (latency)

Immediate reaction to a segmental

Apparent after a certain latent period

dysfunction Qualitative palpatory findings

Decreased ease of skin displacement,

Increased resistance, less resiliency.

increased tissue tension, localized pain

tender upon pressure with radiation (trigger?)

Quantitative palpatory findings

Related to the degree of abnormal

Dependent on the duration of seg­

segmental function

mental dysfunc tion

Changes observed with successful

Immediate decrease in quality and

May disappear after a certain latency

treatment

quantity

period (possibly reflexively)

tebral insufficiency according to Schmorl and Junghanns

receptors. This may occur by release of endorphins from

(1968). Applying the work of Wyke for comparison, this

cells in the gelatinous substance of the dorsal horns.

could be explained on the basis of the tonic reflexogenic

In our assessment. then. it would plausible to propose

influence of the type I mechanoreceptors upon the motor

that these and probably other related neurophysiologic

neurons of the axial or peripheral musculature. It has been

mechanisms may play at least as important a role in the

shown that pain-inducing nociceptors have significantly

manual therapeutic treatment as the pure "mechanical"

higher thresholds than pain-inhibiting mechanoreceptors.

correction of one or several segmental dysfunctions. Fig­

This may explain the delay with which the individual may

ures 6.17 and 6.18 attempt to present this model schemati­

perceive his or her pain. Again. the nociceptive stimulation

cally. Figure 6.19 represents the major tendinoses and irri­

can be inhibited presynaptically when there is sufficient

tation zones in the lumbar spine and the pelvis.

stimulation of the mechanoreceptors. mainly the type II

132

Copyrighted Material

The Spondylogenic Ref/ex Syndrome

Fig.6.17 Model for the re­ Correct anatomical

Normal physiological pressure

position of vertebra(e)

and tension on fibrous

ceptor activity in the normal, nondysfunctional state (no abnormal vertebral position

joint ca psule

or particular hypomobility or hypermobility).

Resting muscle tone; equilibrium between synergists and antagonists

Abnormal position

Irritation of fibrous joint

Stimulation of mechanoreceptors

of vertebrate) Segmental dysfunction

capsule

of type I

Tonic- reflexogenic influence on motor neurons of neck, limb, jaw, eye muscles (myotendinose s)

Additional impulses (mechanical, chemical)

___

Stimulation of nociceptors

Pain perception

Manipulation

Correction of segmental

or mobilization

dysfunction

Stimulation of mechanoreceptors type II; inhibition of afferent fibers; release of enkephalins

Less pain, normalization of receptor activity Change toward normal muscle tone

Fig 6.18 Model for receptor activity as a result of vertebral se g me n tal dysfunction (abnormal vertebral position and/or somatic dysfunction with pain, hypomobility, etc.).

133

Copyrighted Material

Nonradlcular Pain: Spondylogen/c and Myofascial Pain Syndromes

ToT9. T10

)

I

TOT5.T6

1

Inferolateral quadrant of the transverse process and inferior margin of the rib from the tubercle to the angle

Part of the long issimus thoracis

JjfJ'it....--..../

Part of the longissimus lumborum

Origin tendinoses at the inner lip of the iliac crest

ToT7.T8

Iliolumbar ligament to costal process of L4 Origin tendinoses of the gluteus medius

_

Tip of the spinous process of 51

Anterior inferior iliac spine

Zone of irritation of 51 and 52 Posterior sacroiliac ligaments (short)

rrs'1J�\�\\��& I::

....

iii

B

A

}}. e "e",.,s>C'

o

2

3

4

'

:'

7

PAIN INTENSITY

156

Copyrighted Material

8

9

10

Correlation of the Various Clinical Parameters

Segmental Hypermobility and Pain Intensity

painful. and rather impressive decompensated clinical presentation. Hypermobility in patients with rheumatoid arthritis or

Mobilization-with-impulse techniques are contraindicated

patients who have sustained significant cervical spine

for a hypermobile segment. Surgery is indicated in the area (-III only when there are no known psychosocial or behavioral issues (major depres­ sion. axis II personality disorders. for instance).

trauma always requires a thorough

clinical

work-up.

When a patient with known and Clinically relevant hyper­ mobility reports an increase in or significant new pain, it

If there is little pain. despite significant hypermobility as

may reflect a progression of the previously known insta­

in the field (-I. surgical intervention is usually not indicated.

bility. It is therefore of great importance to serially follow

However in the B-1I1 area. trigger point therapy and other

the patient over the entire course of his or her disease.

appropriate interventions for pain control should be applied

When attempting to treat the patient by means of

with the caveat that the chosen interventions must be se­

mobilization. it is paramount to first use a carefully dosed

lected rationally from those therapies that are expected to

trial

reduce the nociceptive reactions. Lastly. a good home exer­

mobilization-without-impulse techniques may reflexly in­

cise and aerobic conditioning program should become part

hibit the usual nociceptive-associated impulses. It must

of the comprehensive management approach (Fig. 8.11).

treatment.

Most

mobilization-with-impulse

and

always be remembered, however, that mobilization into the plastic zone can lead to an increase of the neutral zone, thereby worsening the already existing instability.

Example Instability may develop in the cervical spine as the result of

"Clinical Pearl"

rheumatoid arthritic changes affecting the intervertebral

The presence of hypermobility or instability may be sus­

disk and the apophyseal (facet) joints. In the authors' ex­

pected clinically when the following is observed:

periences. a number of patients may have an underlying. clinically silent segmental hypermobility for many years.

•

Initial pain reduction, in response to mobilization-with­ impulse or mobilization-without-impulse techniques.

often with little or no pain whatsoever.

A "simple" mechanical overload situation or a flare-up

•

of the rheumatoid arthritis may then lead to a sudden.

Return of the original pain one to three days after the manual medicine treatment intervention.

Fig.8.11 Correlation of pain in­ tensity and segmental hypermo­

Segmental hypennobility on radiographs and reported pain level

bility.

III

II

Surgical

c

intervention

B

I

Diagnostic worl(-up Absent

e .F. 1;: ..,.s

0

2

3

4

5

\.

7

8

9

10

NSITV

PAl

Fig.8.13 Correlation of pain in­ tensity and muscular endurance.

Endurance and reported pain level

III

II

c

B

A

o

2

3

4

:"

7

8

9

10

159

Copyrighted Material

9

Indications and Contraindications for Conditions with Potentially Increased Risk of Treatment

This chapter provides an overview of the indications and

for a given diagnosis. As always, the selection of the most

contraindications based on the various primary diagnoses

meaningful treatment(s) of choice should be based on

related to spinal pain or disorders associated with the

multifactorial considerations, including objectively verifi­

spine.

able findings, rational, realistic, and time-contingent treat­

It is assumed that the appropriate diagnostic work-up,

ment goals with specific medical end points in mind, pa­

medically and surgically, has been performed, and the in­

tient response to previous similar or different treatment,

dividual patient's clinical situation has been evaluated as to

patient and physician expectations, and pote ntial barriers

candidacy for the specific manual medicine treatment.

to successful treatment, among others.

The following listings are meant to be general guides rather than specific prescriptions for a particular treatment

Diagnosis: Lumbar Disk Herniation Mobilization-with­ Impulse (Thrust) Almost always this tech­

Mobilization-without­

This technique is

Appropriate stretch­

nique is contraindicated

impulse may be at­

often not indicated as'

ing of the incrimi­

often the only mao

for an acute lumbar disk

tempted when:

it may exacerbate the

nated shortened

nipulative treat­

herniation; if this tech­

•

This technique is

Relatively pain- free

patient's pain.

tonic muscles has

ment possible in

pOSitioning is possible.

Optimal isometric

been found to be

the acute state.

The mobilization ma­

contraction beyond

quite beneficial.

Exact localization

neuver does not exac­

the pathologic barrier

Muscle stretch

and careful fixation

following criteria should

erbate the patient's

is often impossible

should be done

(stabilization) are of

be fulfilled:

symptoms.

secondary to pain in­

carefully. however.

utmost impor­

hibition.

so as to avoid any

tance.

nique is nevertheless considered by the indi­ vidual practitioner. the

It

•

should be possible

•

potential mechani­

to position the patient so that the pain is

cally induced stretch

reduced to a mini­

at the nerve root

mum.

Prior trial treatment

•

using mobilization­

without-impulse has

been successful.

Other treatment mo­

•

dalities have thus far

been unsuccessful.

The patient has been

•

informed about the

potential risks of this

therapeutic proce­

dure.

Rather than manipulative treatment alone, the initial man­

elude interventional spine care with epidural steroid in­

agement of choice for the acute or subacute lumbar disk

jections, for instance (B ush and Hillier,

herniation should be based on a rationally chosen conser­

the standard texts and the latest literature with regard to

1991).

We refer to

vative approach, including medications and the appropri­

the indications for surgery or other interventional spine

ate physical therapeutic regimens. Treatment may also in-

care.

160

Copyrighted Material

Diagnosis: Cervical Disk Hemiation

Diagnosis: Lumbar Spinal Stenosis (Central and lor Foraminal Stenosis) Mobilization-with­

Mobilizatlon-without­

Impulse (Thrust)

Impulse

NMT Type 1

NMT 2 techniques

Mobilization techniques are not able to correct/reverse

the permanent structural changes associated with a

may be particularly

have limited lasting influence. if any. on long-term

ment of associated

tion.

changes associated

address associated secondary segmental or regional

stenosis. The goal

useful for the treat­

stenotic process. and they are therefore expected to

secondary muscular

improvement of the associated neurogenic claudica­

with the spinal

Both of these techniques. however. can be used to

here would be to

dysfunctions and soft tissue changes.

improve overall pos­

As always. the indications and contraindications must

be weighed against each other. particularly when there

ture and/or to reduce

bony abnormalities.

lumbar lordosis.

is evidence for or suspicion of osteoporosis or other

abnormal (excessive)

Treatment of spinal stenosis in a patient with known neurogenic claudication is typically conservative or

interventional. including epidural steroid injections. etc. If clinically indicated. and in particular when the

stenosis is advanced. surgical decompression (e. g

.•

foraminotomy) may be the treatment of choice.

Diagnosis: Cervical Disk Herniation Mobilization-with­ Impulse (Thrust)

Mobilization-without­

In the presence of a

Contraindicated in the

niation. this technique

chronic state treatment

known acute disk her­

is contraindicated in the

cervical spine; there is a

cervical spine. In the

may be attempted if: •

Patient positioning

•

The mobilization

reduces the pain.

potential risk of spinal

cord compression sec­

ondary to the possibility

of a disk prolapse (es­ pecially if there is

NMT Type 1

Impulse

technique does not exacerbate pain.

Stretching of the

This may be the only

particular the suboc­

ment procedure ap­

motion barrier is

prove to be of some

state.

significant pain in­

Muscle stretch should

careful localization

Often not useful

because optimal

isometric contrac­

tion beyond the

impossible due to

hibition.

shortened muscles. in cipital muscles. may benefit.

be done carefully so

as to avoid any pull at

the nerve root.

underlying disk disease or an existing disk her­

manipulative treat­

plicable In the acute Exact fixation and

and optimal isometric

contractions are of paramount impor­ tance.

This technique ad­

niation that has not

dresses the paraverte­

been asymptomatic or

bral muscle ·spasms."

one that has not been

demonstrated thus far).

Rather than manipulative treatment, the initial manage-

techniques, when considered, should be applied extremely

ment of choice for the acute cervical disk herniation should

carefully and gently without much force. Regarding the

be based on a rationally chosen conservative approach,

indications for surgery and/or interventional spine care,

including pharmacologic and appropriate phYSical thera-

we again refer to the standard texts or the most recent

peutic regimens. In general, treatment can be initiated with

evidence-based literature.

the NMT type 3 techniques. Mobilization-without-impulse

,

Copyrighted Material

161

Indications and Contraindications for Conditions with Potentially Increased Risk of Treatment

Diagnosis: Cervical Spinal Stenosis Cervical spinal stenosis, when severe enough, may result in

NMT type 3 technique or manual cervical traction may be

myelopathy and thus may present in the medical office

indicated as long as both are done very carefully and after

with signs and symptoms characteristic of such changes.

the indications and contraindications have been weighed

The stenosis may be the result of congenital malformations

in the individual'S presentation. If such manual treatment

or of progressive spondylotic changes. Due to the pre­

were to be undertaken it would only be done to address the

sumed risk of spinal cord injury, mobilization techniques

secondary changes such as associated "muscle spasms."

would be contraindicated. Possibly the application of the

Diagnosis: Acute Soft- Tissue Injury to the Cervical Spine The techniques outlined may be utilized assuming there

•

No radiologic signs of instability.

exist:

•

No objective neurologic deficit(s).

Mobilization- with­ Impulse

(Thrust)

Mobilization- without­

NMT Type 1

Impulse

Mobilization procedures are typically not the tech­

After the acute phase

In the acute phase,

NMT type 3 proce­

nique of choice in the first 4-6 weeks follOWing an

(i. e., after 4-6

NMT type 2 treat­

dure can be utilized

accident that involves major mechanical trauma.

weeks), the NMT type

ment is typically con­

soon after the trau­

1 technique may be

traindicated.

ma as long as local­

well indicated for

However, in practice,

ization and fixation

soft- tissue treatment

the NMT type 2

are performed care­

of the cervical spine

technique may be

fully.

as long as a detailed

applied by an experi­

structural examina­

ence practitioner

tion reveals that:

while assuring opti­

•

•

There is no seg­

mal fixation (stabili­

mental instability,

zation) to the

and

incriminated spinal

No exacerbations

region.

occur within hours of the provided treatment.

Rest and medical and phar macologic treatment with ap­

in the first 2-6 weeks in trauma-induced cen;ical spine

propriately dosed and carefully applied passive physical

injuries, and as long as there are no objective neurologic

therapy are the initial treatment interventions of choice

and/or radiographic findings.

162

Copyrighted Material

Diagnosis: Cervicogenic Vertigo (Including Cervical Migraine)

Diagnosis: Chronic Phase of Soft- Tissue Injury to the Cervical Spine The techniques outlined may be utilized assuming there

•

No radiographic signs of instability.

exist:

•

No objective neurologic deficit(s).

Mobilization-with­

Mobilization­

Impulse (Thrust)

without-Impulse

NMT Type 1

Mobilization techniques may prove to be benefi­

This technique may

The NMT type 2 pro­

May be only neces­

cial. if:

serve as a good pre­

cedure may be one of

sary for acute exac­

• A prior trial treatment with NMT type 1 was

paratory technique for

the treatments of

erbations during the

the mobilization tech­

choice in cases where

chronic phase.

successful. • The findings are clearly limited to a specific segmental or particular region (I). • Patient positioning can be accomplished with­ out difficulty.

niques with and with­

there is significant

out impulse as well as

muscular imbalance.

for an individually tail­ ored home training or exercise program.

Instability may be present if the patient continues to report

matism" may develop with various diagnostic entities de­

symptoms, especially if there has been an initial trial treat­

scribed in the literature ranging from regional myofascial

ment using manual medicine procedures tailored to the

pain syndromes to cervical "sprain/strain syndromes,"

patient's individual clinical situation. It should be recalled

among many others. While some of the manual medicine

that standard radiographs often may not be able to detect

techniques may be distinctly helpful in the treatment of the

pathologic motion barriers or restrictions that are due to

various tissue injuries, one should be very careful about

muscle dysfunction, for instance. They may therefore be

their long-term use or potentially open-ended manage­

interpreted as "normal," clouding the clinical picture, po­

ment using manipulative techniques. There always exists

tentially leading to the false interpretation that there is no

the risk of psycho-social-emotional problems including the

instability.

patient's potentially becoming dependent on manipulative

In response to a soft-tissue injury to the cervical spine a number of signs and symptoms typical of "soft-tissue rheu­

procedures, for instance, or other possible psychological changes.

Diagnosis: Cervicogenic Vertigo (Including Cervical Migraine) Mobilization- with­

Mobilization­

Impulse (Thrust)

without-Impulse

NMT Type 2

Mobilization procedures with and without im­

This is a well-suited

This may be a very

pulse are indicated. as long as:

technique for pre­

useful technique es­

used in situations in

• The dysfunction is unequivocally segmental or

liminary treatment

pecially in chronic

which vertigo is exacer­

regional. • Neurologic signs do not become apparent upon provocative testing (positioning. palpa­

This technique may be

and for teaching a

situations in which

bated by different posi­

home exercise pro­

there is demonstrated

tioning. The reciprocal

gram.

pronounced muscle

inhibition may be of

im balance.

tory pressure). • Trial treatment using NMT type 1 was suc­

benefit but exact local­ ization and fixation are

cessful.

to be performed with utmost care.

Evaluation of vertigo often proves to be rather difficult. It

Mobilization techniques and NMT type 1 and type 2

may be necessary to consult a specialist who is familiar

techniques are contraindicated when the vertiginous epi­

with functional disorders of the cervical spine as well as

sodes are due to blood flow abnormalities in the vertebro­

neurologic and otologic disorders.

basilar area.

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Indications and Controindicatlons for Conditions with Potentially Increased Risk of Treatment

Diagnosis: Spondylolisthesis with Spondylolysis in the Lumbar Spine Mobillzation- with­

Mobilization-without­

Impulse (Thrust)

Impulse

NMT Type 3 I

Mobilization to the incriminated spinal segment is

This is often of bene­

Muscle stretch tech­

contraindicated. Neighboring segments and/or the

fit for the neighbor­

niques can be of

be helpful in the

adjoining sacroiliac joints. however. may benefit

ing spinal segments.

some use when

acute phase so long

from treatment using mobilization techniques.

as well as the sacroil­

treating patients with

as motion testing

depending on the individual presentation and

iac joint. Exact local­

diagnosed spondylo­

reveals a soft end­

ization and fixation of

listhesis.

feel.

specific structural examination findings.

This technique may

the restricted joint partners are neces­ sary.

Manipulative therapy concentrates primarily on the seg­

ments may include orthotics or stabilizing surgery, when

ments neighboring those involved in the spondylolisthesis

indicated. We refer to the standard texts of the orthopedic

and is more of a supplement to other treatment procedures

literature.

than the primary management choice. Additional treat­

Diagnosis: Bony Malformations of the Vertebral Column, Malformations of the Spinal Cord A thorough orthopedic and neurologic knowledge is nec­

pathologic findings, one is then able to determine whether

essary to diagnose malformations in the spinal cord or the

and which manipulative techniques are indicated or con-

vertebral

traindicated in the individual case.

column.

With this together with

functional

Diagnosis: Osteoporosis (in the Presence of Pathologic Vertebral Fractures) Mobilization-with-Impulse

Mobilization­

(Thrust)

without-Impulse

NMT Type 1

NMT Type2

Both techniques are contraindicated until medical

This technique is

Stretching of the

Often the only

treatment has restored an acceptable level of mineral

contraindicated in

shortened tonic

technique possible

content of the bones.

the acute phase.

muscles is often nec­

in the presence of

It may be of benefit

essary for postural

acute fractures in

as trial treatment

physical therapy

the affected verte­

before mobiliza­

training and exercises

bral area.

tion-without­

to be successful.

Mobllization-wlth- impulse may be applicable. as long as: •

The mineral content of the bone is adequate.

•

Mobilization-without­

impulse.

impulse has been per­ formed successfully. •

The patient is informed about the increased risk including that of possible rib or vertebral fractures.

Medical and pharmacologic (pain) treatment is the major

be complemented by postural physical therapy training

treatment approach in addition to well-delineated passive

exercises. For advanced osteoporosis without pathologic

physical therapy and orthotics at least in the acute fracture

fractures, the same considerations apply.

situation. In a chronic state, manipulative therapy should

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Diagnosis: Ankylosing Spondylitis (Bechterew Disease) without Clinical Signs of Acute Inflammation

Diagnosis: Ankylosing Spondylitis (Bechterew Disease): Acute Inflammatory Changes Mobilization-with­

Mobilization-without­

Impulse (Thrust)

Impulse

NMT Type 1

This is a technique

This technique is abso­

Mobilization-without-impulse and NMT type 1

Muscular imbalance

lutely contraindicated

procedures can be utilized to improve localized or

should be treated

well suited for re­

in the following spinal

regional motion, but only if it is possible to guide

with the NMT type 2

laxing the patient

areas:

that takes advant­

the patient to a relatively pain-free position, and if

procedure even in

•

Sacroiliac joint

mobilization does not lead to immediate or longer

the acute inflamma­

age of reciprocal

•

Thorax, especially

lasting exacerbations of the pain.

tory state in order to

inhibition.

prevent further dete­

during acute exacer­ bation of inflamma­

rioration of postural

tion.

imbalance. The func­ tional pathologic findings, however, must be clearly iden­ tified.

Manipulative therapy should be applied very ca ut iou s ly

procedures, especially when tr ea ting patients with known

wben dealing with inflammatory processes affecting the

rheumatoid arthritis.

cervical spine. Segmental and regional instability in the

Similar considerations apply to the various seronegative

atlanto- OCCipital joint must always be considered and

spondyloarthropathies including psoriatic arthritis, ulcer-

clinically excluded if one is to apply manual medicine

ative colitis, and Crohn disease, among others.

Diagnosis: Ankylosing Spondylitis (Bechterew Disease) without Clinical Signs of Acute Inflammation Mob ilization- with­

Mobilization-without­

Impulse (Thrust)

Impulse

NMT Type 1

This technique is of

Mobilization-with­

Successful trial treat­

This technique can be

This technique is of

impulse should only

ment utilizing NMT

very effective and

great benefit when

rather limited bene­

be applied if the trial

type 1 is a good tech­

specific, especially as

dealing with muscular

fit, if any, in the

treatment utilizing

nique employed before

introduction to an

imbalances of the

treatment of anky­

mobilization-without­

mobilization-without­

indiVidually tailored

tonic cervical spine

losing spondylitis.

impulse was unequivo­

impulse is initiated.

home exercise/train­

muscles, muscles in

ing program.

the shoulder girdle,

cally successful.

and especially in cases in which there is pro­ gressive loss of flexi­ bility of the thorax,

These techniques are absolutely contraindicated for those

occurred. This is also true for hyperostotic spondylosis as

spinal areas and the sacroiliac joint where bony growth has

well as spondylopathy in association with psoriasis.

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Indications and Contraindications for Conditions with Potentially Increased Risk of Treatment

Diagnosis: Inflammation of the Vertebral Column in Association with Chronic Rheumatoid Arthritis If the cervical spine is affected, mobilizing techniques

equivocal clinical or radiologic examination findings, ma-

should be applied only in the rarest of instances and then

nipulative treatment to this region should be considered as

only with the greatest caution. If there is atlantoaxial in-

absolutely contraindicated.

stability suspected or demonstrated objectively by un-

Diagnosis: Abnormal Segmental or Regional Spinal Hypermobility (Congenital or Acquired) Mobilization- with­ Impulse (Thrust) Mobilization techniques and NMT type 1 techniques are contraindicated.

NMT type 2 techni­

NMT type 3 utilizing

Occasionally, mobilization techniques may be of benefit when there is acute

ques are often the

reCiprocal inhibition

segmental or regional motion restriction, especially in the presence of a

treatment of choice

is well suited for

demonstrated soft end-feel. In these situations, however. the mobilizing force,

to address any mus­

regional therapy to

as well as the total number of treatments ("dosage") should be chosen very

cular imbalance or

limber up or to "re­

carefully.

before stabilizing ex­

lax" the muscles.

ercise training pro­

These techniques

grams can be started.

should be supple­ mented by appro­ priate stabiliZing exercises and a well-deSigned training program. however.

Diagnosis: Patient on Anticoagulation Medication Mobilization­ with-Impulse (Thrust) This technique is contraindi­

Mobilization can be per­

These techniques are relatively safe to apply to treat the

cated for the spine due to the

formed as long as the forces

segmental or regional functional disturbances in patients who are on anticoagulants.

potential risk of epidural or

that are being introduced

subdural hematoma. espe­

are relatively small and

cially when the patient is on

carefully chosen (appropri­

anticoagulation therapy.

ate dosage. appropriate di­ rection of force introduction).

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10

Evidence Base in Manual Medicine for the Treatment of Back Pain Syndromes: Background, Status, and Practice

Brief Historical Background

Zurich can matriculate in a course on manual medicine diagnosis and interest is high. In the same year, the medical

The use of the hands as a diagnostic and therapeutic too.1

faculty of Otago in Christchurch, New Zealand, started a

has a long history in the treatment of disorders affecting

program that leads to a diploma in manual medicine. A

the spine and the limb joints. Ever since the introduction of

similar course of education was created in 1993 in Aus­

osteopathic and chiropractic medicine in the late 19th

tralia. In a number of European countries, the medical

century. the use of the hands as a major component in

student of the classical medical curriculum is exposed to

patient management was considered as an "outside"

manual medicine (in the Czech Republic, Austria, France,

method, one that would not be acceptable to the allopathic

and Germany, for instance).

medical profession for most of the 20th centul)' as well.

According to our own survey, 640 000 manual medicine

Manual medicine, even when practiced by medical doctors,

procedures are performed annually by physicians in Swit­

was routinely labeled as unscientific. In the past, the dis­

zerland, approximately 5 million manipulations in Ger­

course between medical doctors (M.O.s), chiropractors

many, and 340 000 in Austria. According to the survey,

(O.Cs) and osteopathic physicians (O.O.s) may often have

manual medicine treatment for low back pain is applied

been based on personal and emotional exchanges and

805 times per year, and 3 50 times per year for treatment of

preconceived notions "along professional lines," rather

cervical spine syndromes (unpublished data from Swiss

than engaging each other in constructive discussions that

Medical Association of Manual Medicine SAMM). Depend­

would help establish a common language and understand­

ing on the medical specialty, manual medicine treatment

ing.

comprises between 20-50% of all medical treatment. The

In the 1960s and 1970s, however, the interest in and

number of treatments applied for each patient depends not

study of manipulative procedures as one of the ways to

only on the medical specialty but also on the clinical sit­

address pain syndromes grew steadily among allopathic

uation overall. Whereas the general practitioner applies

physicians, both in Europe and the United States and in

manual medicine techniques in 1.4 treatments per patient,

other parts of the world. While there may be several rea­

the specialist may treat the patient between four and five

sons for such a development, three major factors seem

times. One explanation for the greater utilization of manual

stand out: (1) an ever-increasing body of "successful" cases

medicine by specialists is that often the patient has a

that had previously been recalcitrant to other forms of

chronic situation whereas the primal)' care physician may

treatment;

treat primarily acute presentations or exacerbations.

(2) the growing interest among patients to be

treated within an individualized and hands-on "holistic" approach: and (3) the growing realization that surgical intervention (introduced by Mixter and Barr in 1934) for

Effectiveness and Cost Considerations:

painful back disorders has limited success and application.

Evidence and Recommendations

[n 1958 the Swiss rheumatologist John-Claude Terrier, M.D. founded the International Federation of Manual Med­

A growing number of published reports have investigated

icine (F[MM, Federation Internationale des Medecins Man­

the effectiveness and cost considerations of spinal manip­

uels), which has grown since to a physicians' organization

ulative procedures either alone or in comparison with

of more than 6 000 members and representing 29 coun­

other treatment interventions (Fig. 10.1 ). Most of the studies have concentrated on studying the high-velocity!

tries. During the past 30 years, there has also been a signifi­

low-amplitude (HVLA) thrusting maneuvers ("spinal ma­

cant growth in the numbers of graduates from osteopathic,

nipulation," or simply "manipulation," or "thrust," or also

chiropractic, and physical therapy institutions in the United

mobilization-with impulse-techniques: see Chapter

States.

definitions).

Since the mid-1 980s, there has been less resistance by

These studies typically

do

not

2 for

make

a

distinction between the thrusting maneuvers and the

the orthodox branch of medicine to manual medicine ap­

low-velocity mobilization techniques (www.backpaineu­

proaches. Since 1992 students at the medical school in

rope.org). The entire manual medicine armamentarium,

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Evidence Base in Manual Medicine for the Treatment of Back PaIn Syndromes

which includes the thrusting as well as the non-thrusting

Number of studies

soft-tissue (or other) techniques. has been referred to as a • Orthoses

• Acupuncture

single "spinal manipulation package" (Harvey et aI., 2003). Two UK BEAM (Back pain Exercise and Manipulation)

D Behavioral therapy • Traction • TENS o EMG/biofeedback

trials published in 2004 and one major review (ECRDG. 2005) provide a detailed basis for our current understand­

• Back school

ing of manipulation within the context of the effectiveness

D Bed rest

of the treatment and the associated cost-effectiveness.

• Exercise

The UK BEAM trials studied 1287 participants (from 1334 recruited) in 181 practices around 14 centers across the United Kingdom (Brealey et aI., 2004a), The goals of these two studies were to estimate the effect and cost­ effectiveness of treating low back pain patients by adding

Acute

Chronic

exercise classes. spinal manipulation offered by the Na­

Fig. 10.1 Schematic representation of the number of different

tional Health Service (NHS) or private practitioners. or

interventions included in the systematic review by van Tulder et

manipulation followed by exercise to "best care" in general

al. (1997). The authors reviewed 150 articles, of which 81 dealt

practice. The UK BEAM trial (2004b) addressed specifically

with chronic pain, 63 with acute pain, and one article with both. The specific distribution was as follows: Interventions for acute pain

Number of studies

other trial (Brealey et al.. 2004a) studied the cost-effective­ ness of delivering manipulation with and without exercise,

Pharmacologic intervention: NSAIDs

19

Muscle relaxants

14

Analgesics

the effectiveness of physical treatments for back pain in primary care. including exercise and manipulation. and the

left- hand column:

The results and the authors' conclusions regarding the effectiveness of manipulation and exercise are as follows

6

(UK BEAM Trial. 2004b):

ESI Nonpharmacologic intervention (physical and cognitive/behavioral therapies): Manipulation

16

Exercise

10

Bed rest

6

Back school

4

TENS

3

Traction

2

•

by a smaller but still statistically significant margin at 1 year, irrespective of location (and irrespective of treat­ ment - whether manipulation took place in a private practice or NHS.

Behavioral therapy

•

The exercise program improves back function by a small

•

Manipulation followed by exercise improves back

Right- hand column: Interventions for chronic pain

NSAIDs

but significant margin at 3 months but not at 1 year.

Number of studies

Pharmacologic interventions:

The spinal manipulation "package" improves back function by a small to moderate margin at 3 months and

function by a moderate margin at 3 months and by a

6

smaller but still significant margin at 1 year.

Muscle relaxants Analgesics

1

ESI

6

Antidepressants

4

Nonpharmacologic intervention

The authors of the effectiveness study (UK BEAM trial team 2004b) conclude that combined treatment (manipulation

(physical and cognitive/behavioral therapies):

and exercise) improves back function by a moderate mar­

Manipulation

9

gin at 3 months and a small but significant margin at 12

Exercise

16

Bed rest

0

months. Generally this combined treatment achieves little

Back school

10

EMG/biofeedback

5

TENS

3

Traction Behavioral therapy Acupuncture

more than manipulation, except for increased understand­ ing of back pain and fear avoidance. The results and the authors' conclusions regarding the cost-effectiveness of manipulation and exercise are as fol­

11

lows (Brealey et al.. 2004a):

6

Orthoses

•

Spinal manipulation. exercise classes. and manipulation

NSAIDs: nonsteroidal anti- inflammatory drugs

followed by exercise all increased the participants'

ESI: epidural steroid injections

quality of life

TENS: transcutaneous electrical nerve stimulation

"best care" in general practice.

EMG: electromyography

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(QOL) over

12 months by more than did

Effectiveness and Cost Considerations: Evidence and Recommendations

•

Adding spinal manipulation to best care in general

definitions of chronic low back pain patients were in­

practice is effective and cost-effective for patients in the United Kingdom. •

consistent across reviews. 2. In many of the randomized controlled trials (RCTs) upon

If the NHS can afford at least approx. US $ 20 000 for

which the conclusions of the Cochrane review (Assen­

each quality-adjusted life year (QALY) yielded by phys­

delft et al.. 2004) were based. the study sample included

ical treatments. manipulation alone can probably offer

mixed populations of patients with subacute and

better value for money than manipulation followed by

chronic neck. thoracic. and low back pain. Although this

exercise.

was not necessarily compatible with their own general criteria for these recommendations. it was difficult to

These conclusions are maintained even if the NHS has to

extract those studies that only deal with chronic low back pain and therefore probably reflect the treatments

pay for spinal manipulation from the private sector. One of the three established working groups (Working Group 2 - Chronic Low Back Pain) of the European Com­ mission Research Directorate General (ECRDG. 2005) sys­

given in the offices of chiropractors and manual thera­ pists. 3. The best systematic reviews stated that the general

tematically reviewed the literature. including prior reviews

quality of RCTs on spinal manipulation is low. making

and meta-analyses dealing with spinal manipulation/mo­

it difficult to draw proper conclusions. although recent

bilization using established evidence-based guidelines.

additional trials appear to be of higher quality. 4. Most of the manipulation/mobilization treatments were

Their summary of the evidence is as follows:

administered by personnel who were considered •

•

•

•

•

There is moderate evidence that manipulation is supe­

"qualified" within their own medical specialties (oste­

rior to sham manipulation for improving short-term

opathy. chiropractic. manual medicine. and physiother­

pain and function in chronic low back pain (level B).

apy). although the qualification requirements differ

There is strong evidence that manipulation and G.P.

markedly among these professions. The study that

(general practitioner) care/analgesics are similarly ef­

showed no difference between manipulation and sham

fective in the treatment of chronic low back pain (level

manipulation was carried out by third-year and fourth­

A).

year medical students in the process of completing an

There is moderate evidence that spinal manipulation in

additional year of training devoted to osteopathic

addition to G.P. care is more effective than the G.P. care

theory and practice (Licciardone et al .. 2003). The au­

alone in the treatment of chronic low back pain (level B).

thors of the study conceded that "it was possible that

There is moderate evidence that spinal manipulation is

the predoctoral fellows may not have had sufficient

no less and no more effective than physiotherapy/exer­

practical experience to provide the treatment with the

cise therapy in the treatment of chronic low back pain

same efficacy as more seasoned practitioners or to

(level B).

provide nontherapeutic sham manipulation." However.

There is moderate evidence that spinal manipulation is

the failure to identify any difference between sham and

no less and no more effective than back-schools in the

real manipulation may also have arisen as a result of the

treatment of chronic low back pain (level B).

small. size of the control and sham groups. Further. the study had a relatively high drop-out rate. especially in

The same working group makes the following recommen­ dation:

the manipulation group. In general. it would seem pru­ dent to recommend that the treatment only be carried out by suitably qualified/trained practitioners within

•

Consider a short course of spinal manipulation/mobili­

the given medical specialty.

zation as a treatment option for chronic low back pain.

5. The manipulative/mobilization treatments used in the

Perhaps as important as their conclusions and recommen­

per week (range one to seven times per week). and most

dations are this working group's comments. paraphrased

commonly for a period of two to three weeks (range two

RCTs to date were most commonly administered twice

here. which are based on the detailed analysis not only of

to nine weeks). There is no evidence to suggest that

the randomized trials but also of the published results from

long-term manipulative treatment contributes any ad­ ditional benefit.

various meta-analyses:

6. Most of the systematic reviews on effectiveness in­ 1. The studies considered in the various systematic re­

cluded RCTs on spinal manipulation and spinal mobili­

views included patients with and without referred

zation. and in fact considered both as the same treat­

pain. All studies considered included a substantial pro­

ment. As such. it is impossible to determine the relative

portion of "chronic" low back pain patients. although

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Evidence Base in Manual Medicine (or the Treatment of Back Pain Syndromes

effectiveness of spinal manipulation or mobilization. Nonetheless, in practice, they are usually used together as part of a treatment package (Harvey et aI., 2003). 7. One recent study sought to examine whether a mobi­

Requirements for Successful Manual Medicine Management: The Individual Practitioner

lization technique selected by the treating physio­ therapist is more effective in relieving low back pain

First and foremost, the individual practitioner of manual

than a randomly selected mobilization technique. There

medicine must be familiar with the appropriate indications

was no suggestion that this was the case (Chiradejnant

and contraindications of the proposed approach or partic­

et aI., 2003).

ular technique(s). The physiCian who utilizes manual medicine in the

A recent systematic review and meta-analysis of random­

management of acute or chronic pain syndromes should

ized osteopathic manipulative trials (Licciardone et aI.,

also be familiar with the limitations associated with this

2005) concluded that osteopathic manipulative therapy

form of treatment. Thus, it serves well if the medical record

(OMT) significantly reduces low back pain. The level of

clearly states the physician's projected goals of anticipated

pain reduction is greater than expected from placebo ef­

outcomes over a well-prescribed timeframe, taking into

fects alone and persists for at least 3 months. The same

consideration patient expectation, structural and func­

authors, not surprisingly, sum up the status of OMT re­

tional diagnoses, existing co-morbidities, and previous suc­

search by stating that additional research is warranted to

cess of treatment or lack thereof.

show mechanistically how OMT exerts its effects, to deter­

Just as does any surgical procedure, manual medicine

mine whether OMT benefits are long-lasting, and to assess

maneuvers require a high level of skill of the practitioner.

the cost-effectiveness of OMT as a complementary treat­

Thus, continued updates on techniques and actually seeing

ment for low back pain.

patients is very important to keeping one's skills main­

Further research in the field of manual medicine is ex­

tained at the highest level. Manual medicine examination and treatment proce­

pected to continue along three lines:

dures are best employed when rationally integrated into 1. Outcome studies.

the overall diagnostic and treatment management. Undis­

2. Mechanisms of action (e. g. physiologic and biomechanic

ciplined treatment (open-ended, indiscriminate treatment

phenomena).

based on symptoms alone, for instance) that does not

3. Approach to the patient.

reflect appropriate monitoring against expected outcomes and does not take the above factors into account will most

There is currently a paucity of literature that has looked

likely lead to greater healthcare costs, increased risk to the

into the "approach to the patient" component. The under­

patient, and unnecessary procedures. This not only in­

lying question here is whether the additional information

creases the risk of greater patient dissatisfaction but also

that the practitioner of manual medicine obtains through

gives this form of medicine a bad name. Monitoring of

his or her hands in the patient examination and treatment

outcomes in the individual treatment should include fac­

process is able to provide a basis (albeit yet "uncharted" as

tors such as medication use (e,g., reduction in medication

to specifics) for more effective, more efficient, and thus

dosing), increases in vocational and nonvocational abilities,

more successful patient management (Greenman, personal

and improvement of function, while always monitoring the

communication, 2005, as quoted in www.com.msu.edu/

patient's pain perception.

communique/Summer98/Greenman.html).

Like virtually every research article that has been pub­ lished about this topic, this chapter closes with the obser­ vation that more research is needed because the important questions answers.

170

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already asked are awaiting some insightful

11

Informed Consent, Complication Assessment, Quality Control, and Documentation

Informed Consent within Patient Care

•

A working or presumed diagnosis.

•

Differential diagnoses.

Obtaining informed consent from the patient is an impor­

•

Th.e purpose and risks of any planned tests.

tant process within the patient-doctor relationship. The

•

Options to treatment recommendations.

goal of the informed consent is to educate the patient about

•

Prognosis.

potential complications or side-effects. Informed consent is

•

An estimate of the current level of severity of the

necessary in situations where a reasonable patient would

patient's condition,

not be aware of the potential consequences of a given tr'eatment decision without obtaining specific information

In order to fulfill the above obligations, one of the points in

from the treating physician (Mock, 2003).

the discussion of providing informed consent is the ques­

The requirement that physicians obtain informed con­

tion of what is "sufficient" or what is "going overboard."

sent from their patients before treatment codifies a belief

While in theory many of these considerations can be im­

predominant in Western culture that people have a basic

plemented, in the end-and in the "real world"-it is prac­

right to control their own lives and bodies (Howard, 2005).

ticality and the availability of time that may be the overall

However, there are distinctions between countries with a

deciding factors.

legal tradition based upon civil law ("Roman" law) and

Howard (2005) provides a rationale for full and com­

those with common law ("English"). What follows is dis­

plete disclosure, a disclosure that informs the patient of

cussion based upon a common law perspective.

"everything." This recommendation is based first on the

The requirement for informed consent not only varies

premise that patient autonomy "means that the values that

from state to state but is also inherently dependent on the

lead to the patient's decision must be respected." He states

nature of the work the physician performs. Furthermore,

secondly that in preparing a comprehensive list only the

not every patient assesses the risks and potential out­

most obscure possibilities are excluded. "A conscientiously

comes, including the disastrous ones, in the same manner.

prepared list excludes only a few risks that are highly unlikely

Some patients may find any risk whatsoever unacceptable

and occur in fewer than 1 per 100 000 cases. Therefore, the

and will not proceed with having the procedure or treat­

chances of such an event both occurring and being absent

ment performed. Another patient may feel. in his or her

from the list is much less than 1 per 100 000 cases". Docu­

assessment of the overall possibilities, that the risks should

mentation of the informed consent is more than crucial.

be taken as a matter of "trust," no matter what could

The ideal is for the physiCian herself/himself to obtain the

happen.

informed consent, review it with the patient, and docu­

In order to obtain informed consent that is acceptable to

ment any questions the patient has and how comfortable

the courts and that meets the ethical obligations, the fol­

the patient felt signing the consent form. The best docu­

lowing information must be provided (AMA, 1998):

mentation is that provided to the patient and reviewed with the patient, with documentation that the review ac­

•

The nature of the disease and the proposed treatment or

tually took place and what steps were taken to make cer­

surgery.

tain that the patient indeed felt fully informed.

•

The chances of success based on medical knowledge.

•

The risks of the proposed treatment.

•

Adverse effects of the proposed treatment or procedure.

•

Reasonable alternatives and their chances of success, risks, and adverse effects.

In the field of manual medicine, similarly to other medical

•

The consequences of deciding not to proceed with the

specialties, the provision of informed consent varies not

recommended course of treatment.

only from state to state or from country to country but also

Complication Assessment

from profession to profession. While, generally speaking, The process of informed consent requires that ultimately

the side-effects of manual medicine procedures are rather

the patient be provided with the following (Howard,

minimal and typically transient, they can in rare situations

2005):

be quite disastrous and life-threatening and may poten­ tially reduce a patient's function to a state of complete

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Informed Consent. Complication Assessment. Quality Control. and Documentation

dependency. The potential major complications include the

complex and very careful review is indicated in such an

following entities:

unfortunate event.

1. Spontaneous dissection of the vertebral artery.

According to the literature review by Ernst (2002) with

2. Disk herniation.

regard to adverse events after cervical spine manipulation,

3. Phrenic nerve paresis/palsy.

large and rigorous prospective studies of cervical spine manipulation are needed to accurately define the true

These complications are often cited in the literature by

risks, and the incidence of these events is unknown.

various medical professionals, who seem to come into contact with the patient only

after

the patient has experi-

Disk Herniation

enced an adverse event. This in itself may raise the possi-

Based on today's scientific knowledge, there is no indica­

bility of an inherent "post hoc ergo propter hoc" fallacy.

tion that a correctly performed manual medicine proce-

In 2003, a symposium in Frankfurt, Germany, consid­

dure would cause a disk herniation. It should be noted that

ered quality control in manual medicine and the above

a manipulative procedure in the presence of an already

clinical entities. The representatives and speakers came

damaged but asymptomatic disk may bring about a new

from varied specialties such as orthopedics, neurology,

set of radicular symptoms. There is no indication from the

anatomy, family practice, physical medicine and rehabili­

literature that would substantiate claims made by various

tation, occupational medicine, and legal medicine. The con-

people that their "disk" was caused by manipulation. Cor­

c1usions were as follows, based on current knowledge then

rect execution requires that the slack in the joint neighbor-

available.

ing the incriminated joint be positioned in the correct

Spontaneous Dissection of the Vertebral Artery

while the entire body should be relaxed.

barrier position, from which manipulation can proceed, There is no indication that an appropriately applied and executed manual medicine procedure would cause a pri-

Phrenic Nerve Paresis/Palsy

mary dissection in a healthy, nonpredisposed artery system.

Again, if the execution of the technique was within the

Spontaneous dissection of the vertebral artery is espe­

standards set by the various manual medicine societies,

cially important to consider in patients who report a par-

there is no indication in the literature that manual medi­

ticular set of symptoms. A manipulative procedure applied

cine procedures lead to phrenic nerve paresis or paralysis.

to a patient who has recently had a spontaneous dissection can indeed be very dangerous. The etiology is essentially unknown. Clinically, it should be noted that the patient typically is not the older person but rather the healthy­

Quality Control in Manual Medicine; Continuing Education

appearing 35-year-old executive. It has been documented that approximately 20% of patients who have had a stroke

In addition to the recommendations made for manual

experience a spontaneous dissection under subsequent

medicine procedures at the Bingen Conference (Graf­

manual medicine treatment. In such cases, the internal

Baumann and Ringelstein, 2005), the following summary

carotid artery is affected 75% of the time and the vertebral

in regard to quality control can be provided:

artery 25% of the time. It is important to remember that a dissection may be the

1. The application of manual medicine approaches and

manifestation of a constitutional disorder. Here, the follow­

techniques using sound principles requires cognitive

ing two conclusions can be drawn:

education and skill development that is in addition to

1. A detailed patient history is very important so as to

art of such practice requires ongoing clinical activities as

the standard allopathic medical school curriculum. The construct a valid differential diagnosis that includes the possibility of constitutional dissection. Thus the physician should investigate whether there is dizziness,

well as continued (typically postgraduate) medical education. 2. It is important when there is sufficient suspicion or

vertigo, or significant change in the patient's headache

supportive information that the treating physician

quality and intensity (e. g., sudden appearance of uni­

should query the patient with regard to a known past

lateral "shooting type" pain to the right posterior parietal-occipital region).

medical and/or family history. 3. Better understanding of spontaneous dissection and

2. A dissection may have a temporal correlation with a manipulative procedure but should not necessarily be causally associated with it. Again, the issue is very

early recognition of warning signs is required. 4. Treatment should be performed only on the relaxed patient.

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Documentation Requirements

5. Thorough medical documentation is an important component of the patient-physician encounter.

1. Treatment must be considered within accepted standards in current medical practice, with measures as specific and effective as possible.

2. Procedures that require the performance or supervision

Documentation Requirements

of the physician and that are considered reasonable or necessary.

It cannot be overemphasized how important it is to main-

3. The treatment provided must not be palliative or of

tain a record that can be read by anyone. Initial consent

maintenance type unless specific functional parame-

should be obtained and this should be reflected in the

ters are being addressed and reviewed or monitored on

record. The consent should state that the patient has

a timely basis, so as to maintain the highest level of

been informed about the potential side-effects, risks, and

functioning. An example of this would be the reduction

outcomes of treatment. Again the goal of the informed

of medication use, a decrease in emergency visits, or the

consent is to appropriately assure and inform the patient,

reduction from two personal assistants to one, when a

and not to exacerbate any preexisting anxiety.

patient receives appropriate manual medicine man-

Furthermore, in today's "litigious society," it is important to maintain the patient's records in as impeccable an order with as much relevant clinical/management informa-

agement at an acceptable level of frequency. This must be clearly documented.

4. There should be a reasonable expectation that the pa-

tion content as possible. This is becoming a balancing act as

tient's condition will improve significantly over a certain

the goals of communication and good record-keeping

projected period.

should be just that: documentation should not be undertaken for documentation's sake nor should one try on

5. The plan of care or treatment must contain reasonable goals to be achieved over a specified period.

principle to include as much information as possible-one Naturally, these can only be broad recommendations or

risks "losing sight of the forest for the trees." A necessary component in the medical chart or elec-

guideline suggestions, as each profession and locale will

t\'onic record IS the information that determines the overall

determine the individual applications of the law according

relevance of the individual findings, their apparent se-

to the specific statutes and the "standard" practice for

verity, and further treatment considerations:

locally.

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12

Patient Outcome and Follow- Along Measures

Introduction

The purposes of Rasch analysis are to maximize the homogeneity of the trait and to allow greater reduction

Neck and back pain are common disorders around the

of redundancy with no sacrifice of information by decreas­

globe. According to the National Health Information Survey

ing items and/or rating levels to yield a more valid and

of 2002 in the United States, over a 3-month period prior to

simple measure.

a survey, 26% of surveyed individuals experienced lower

To develop a scale to measure the performance of a

back pain and 14% experienced neck pain (Lethbridge­

particular task, we need to break down the task into its

t;:ejku et aI., 2004). Some 5-6% of patients with back pain

principal components. Successful completion of a task de­

develop chronic disability. These patients consume 80% of

pends on two factors: the person's ability and the difficulty

health care resources spent on treating back pain (Hashemi

of the task. If the person's ability exceeds the difficulty of

et aI., 1998). The need to develop effective treatment op­

the task, then the person will successfully accomplish the

tions for patients with chronic pain conditions is a major

activity. In order for an observation to have contextual

challenge for health care professionals involved in muscu­

meaning, the concepts of a person's ability and the diffi­

loskeletal/pain management. Good and accurate outcome

cUlty of the task must each have independent directions;

measures are critical for evaluation of treatments for neck

otherwise, an observation is devoid of meaning. It is within

and back pain.

the context of direction that ability and difficulty become

Chronic neck and back pain results in multidimensional dysfunction

relevant.

involving physical function, affective and

Having independent directions of the two factors per­

mood state, activities of daily living, patients' satisfaction

mits quantification and comparison with other independ­

with life in general, quality and quantity of pain, and sleep

ent observations. Criteria may be established to determine

and fatigue. These result in significant decrement in a

whether there is sameness

patient's quality of life (QOL). The outcome measure should

difference, in what direction along a latent variable or how

be able to evaluate all these aspects of a patient's function­

much distance along that direction.

or

difference; and if there is

ing. In addition, the measure should be able to track these

Only after replication of observations of people with

over time. Tracking allows comparison of how treatment or

different abilities doing tasks of different difficulties can

life events impact a patient's function and quality of life.

the variables of ability and difficulty be used to calibrate a yardstick related to performance of a particular task. Both can be measured along the same hierarchy. This is known

SM The lIFEware System

as conjoint additivity.

The main purpose of the LlFEwarSM system (Granger et aI.,

tions-expressed as Bn

1995; Baker et al., 1996) is to measure QOL in patients from

logarithm of the probability (log odds). Rasch measure­

teenage through adult life. The domains measured in the

ment is based on probability rather than certainty. In other

The only tool for achieving conjoint additivity specifica­ -

OJ (ability minus difficulty)-is the

example that follows are physical function, mood and af­

words, a person-rating can be achieved in a number of

fective state, and pain. The measures were developed using

different ways. However, depending on the item of hier­

Rasch analysis (Wright and Stone, 2004). To understand the

archy, only one-way is expected. Rasch analysis measures

LlFEware measures, it is important to review key concepts

the degree of expectedness.

of Rasch analysis.

Rasch analysis proposes a model for measurement. Data collected are tested against that model to determine whether the data fit the model. If the data are judged to

Rasch Analysis

fit the model then the data form a measure.

Usually items are rated with numbers to indicate more or

based on a latent trait and accomplishes stochastic (prob­

less of the trait that is presumed to be homogeneous. Rasch

abilistic) conjoint additivity (measurement of the item dif­

analysis permits the rating of a limited set of attributes that

ficulty and the person ability on the same metric).

In summary, Rasch analysis is a mathematical model

are representative of the underlying trait. Whether ob­

Rasch analysis transforms ordinal scales into equal-inter­

served or self-reported, the sum rating of the attributes

val measures that may be used in parametric statistical ana­

represents how much of the trait has been mastered.

lyses. Those measures are one-dimensional and have pre­

174

Copyrighted Material

LlFEware System Domains

dictable hierarchies of item calibrations that span the range

measure. Effort is an ordinal scale that asks the respond­

of difficulty within a domain of assessment. Patient meas­

ents to rate the most strenuous activity they can perform

ures and calibration of individual item values are meas­

for at least 2 minutes. Effort is measured with a 6-point

ured on the same metric and are locally independent

scale. Effort is also transformed into an equal-interval

(Wright and Stone. 2004).

measure using Rasch analysis. The converted measure

The Rasch modeling provides a philosophical and mathematical foundation for the theory of objective meas­

also ranges from a to 100. where 100 represents the upper limit of effort.

urement. It is operationalized by the WINSTEPS software (Linacre and Wright. 2000).

Mood and Affective State

LlFEware System Measures

Mood and affective state are measured using the Placid measure and a satisfaction with life question. Respondents

The L1FEware measures for musculoskeletal conditions

rate if they feel lonesomeness or isolated; pessimistic about

were tested as the Medical Rehabilitation Follow Along

the future; uptight. tensed. stressed; are having panic at­

(MRFA) (Granger et al., 1995; Baker et al.. 1996). The reli­

tacks; are easily irritated or annoyed; have morbid or

ability of MRFA was established in a study of 47 patients.

gloomy thoughts; or have self-blaming/guilty feelings.

The patients completed the musculoskeletal form of the

The respondents rate their feelings on a 5-point ordinal

MRFA instrument on two occasions separated by an inter­

scale. The raw data is transformed to a a-lOa-point scale

val of 1 -7 days. Responses were examined using the intra­

using Rasch analysiS. with 100 representing absence of

class correlation coefficient (ICC) and kappa. ICC values for

listed mood disturbance. The satisfaction with life question

the sections of the MRFA instrument examining quality of

asks the respondents to report how satisfied they are with

daily living and physical functioning ranged from 0.74 to

life in general on a 4 -point scale. The responses are trans­

0.97. ICC values for items assessing pain and feeling of well­

formed into a lOa-point scale variable using Rasch analysis.

being were more variable. ranging from 0.36 to 0.93. The

with 100 representing being very satisfied with life in

kappa values displayed a similar pattern. The reliability of

general.

the MRFA instrument was found to be adequate for gather­ ing screening information in outpatient settings. The va­ lidity of the measure was confirmed by comparing it to the

Pain

SF-36 (Ware, 1993). comparing pre- and post-treatment ratings and comparing the scale ratings with therapists'

There are two pain measures: Painfree and the L1FEware

ratings of improvement. The scale includes within it ele­

Visual Analog Scale (LVAS). The Painfree is a lO-item meas­

ments of the Functional Assessment Screening Question­

ure used to assess the qualitative dimension of pain. It is

naire (Granger and Wright. 1993). Oswestry Scale (Fairbank

derived from the McGill Pain Questionnaire (Melzack

et al.. 1980). short form McGill Pain Questionnaire (Mel­

1987). Respondents rate their pain using pain descriptors:

zack. 1987), and Brief Symptom Inventory (Derogatis and

throbbing. sharp. aching, tender. tiring and exhausting. hot burning, fearful. splitting pain. punishing cruel pain. and

Melisarotos. 1983).

cramping. Each item is measured on a four-pOint ordinal scale. The last four items are not included in the measure as

LlFEware System Domains

they do not fit the expected hierarchy. These items are tracked as they are of clinical interest. The raw rating is

Physical Function

transformed into a 0-100 point rating through Rasch anal­ ysis. where 100 represents no pain with these character­

Physical function is measured using the Body Movement

istics. The LVAS measures the perceived quantity of pain. It

and Control (BMC) measure and the Effort measure. BMC is

ranges from a to 100. with a representing the worst imag­

a lO-item measure that asks patient to rate difficulty in

inable pain and 100 representing no pain.

performing: personal care. lifting. walking distance. travel­ ing duration, rising from a low seat. climbing stairs, ex­ tended sitting. extended standing. reaching and grasping at eye level. and bending or kneeling to the floor. Each item is rated on an ordinal scale. The BMC is transformed into an equal-interval measure using Rasch analysis. It ranges from a to 100. with 100 representing the upper limit of the

175

Copyrighted Material

Patient Outcome and Follow-Along Measures

Other Dimensions

Reports

Other dimensions of function measured by the L1FEware

The L1FEware system is Internet-driven. Subscribers can

system are satisfaction with adequacy and quality of sleep;

enter the data directly on-line or can fax questionnaire

primary and secondary roles in life and satisfaction with

responses

level of accomplishment of each (expressed in percentage);

Rehabilitation (UDSMR) for immediate analysis. (UDSMR,

physical and cognitive fatigue; and impact of dysfunction

a division of UB Foundation Activities, Inc., is located in

on occupational, vocational, and social role participation.

to

the

Uniform

Data

System for

Medical

Amherst, New York.) Subscribers can further analyze their own data by downloading converted data from their as­ sessment forms into computer spreadsheet software and

Administration

can also e-mail information from L1FEware directly to physicians and referral sources.

Data are collected through a self-administered question­ naire and clinician interview completed in 10-20 minutes.

Case Profile Report

The same questionnaire is used for initial and follow-up

In this summary report (see Fig. 12.2), measures are shown

visits. If the patient is incapable of completing the ques­

graphically. The

tionnaire, the clinician may query the patient.

specified threshold of clinical significance. It is different

expected

value

represents

the

pre­

for each measure and for each item within a measure.

Assessment Forms

Case History Report This report (see Fig. 12.3) tracks a patient's function over and response

multiple assessments. Higher is better. Green bars indicate

choices. The respondents have to mark the appropriate

that the measure is greater than the pre-specified thres­

choice as they would in a multiple choice examination.

hold of clinical significance.

The forms pose questions,

statements,

Patients can fill out the forms on-line or on paper. The musculoskeletal assessment form is shown in Figure

Patient- Specific Report

12.1 a-d. Supplementary measures are available with this

This narrative report (see Fig.12.4) provides a detailed

form for assessing the shoulder, knee, ankle, hand, and

description of each item within a selected measure. It

temporomandibular joints. Other forms have been devel­

uses Rasch analysis to determine whether the respondent

oped specific to neurological, cardiopulmonary, and cogni­

is doing better or worse than the expected value for each

tive disorders.

item. It can help identify specific problems that need to be addressed. For example, if the respondent with back pain is having difficulty getting up from a sitting position, that might be a specific area that can be addressed during therapies.

176

Copyrighted Material

UFEware System Domains

LlFEWARE® MUSCULOSKELETAL ASSESSMENT FORM 23700

I

Drnitial Ornterim DDischarge o Follow-up

Patient:

I#

The following is to be completed by clinical staff only

# of proc's:

of visits:

Subscriber

Patient

Assessment Date

Problem Onset

Code

Identification #

(mm/dd/yyyy)

(mm/dd/yyyy)

[IJI [IJI I I I I I

OIJ-[IJ-I I I I I

LI I I I I

0 000 1 000 2 000 3 000 4 000 5 000 6 000 7 000 8 000 9 000

0 0000 1 0000 2 0000 3 0000 4 0000 5 0000 6 0000 7 0000 8 0000 9 0000

00 00 00 00 00 00 00 00 00 00

0 00 1 00 2 00 3 00 4 00 5 00 6 00 7 00 8 00 9 00

0000 0000 0000 0000 0000 0000 0000 0000 0000 0000

0000 0000 0000 0000 0000 0000 0000 0000 0000 0000

00 00 00 00 00 00 00 00 00 00

[IJ/[IJ/I I I I I 0 00 1 00 2 00 3 00 4 00 5 00 6 00 7 00 8 00 9 00

00 00 00 00 00 00 00 00 00 00

0000 0000 0000 0000 0000 0000 0000 0000 0000 0000

C/O

[IJ 0 00 1 00 2 00 3 00 4 00 5 00 6 00 7 00 8 00 9 00

The following questions on this and remaining pages are to be answered by the patient What category best describes your current problem (fill in only one):

o Pain in low back

o Pain in neck

o Shoulder related

o Elbow related

o Hip related

o Knee related

o Foot/ankle related

0 Other

o Hand/wrist related

What is your marital status (fill in only one):

o Married

o Cohabitating

0 Separated

0 Divorced

o Other

o Single

0 Widowed

Who lives with you and where do you live (fill in only one):

o Live alone

o Live with family

0 Live with friends

0 Live in an assissted living environment

What is your current employment status (fill in only one):

o Employed

o Homebound employment

o Homemaker

o Sheltered

o Volunteer

o Cannot find work

o Student

o Worker's Compensation

o Unemployed

o Retired (age 60+)

o Retired (age

Cervical Spine

Fig. 13.6e Reconstructed (T views com­ paring one right and left side.

e

b

a

Fig. 13.7 Standard radiographs of the cervical spine. a

Fig. 13.8 Schematic representation of the measurements for the width of the spinal canal.

A-P view.

b Lateral view.

10mm

C2

7 7

Retrotracheal space (e s ophagu s)

Fig. 13.9 Technique for measuring the retropharyngeal and retro­ tracheal space according to Penning (1980).

191

Copyrighted Material

Imaging Studies of the Spine

A major contribution came from the American spinal Normal

Constitutional

Canal stenosis:

Canal stenosis:

canal

canal stenosis

Transverse

Vertebral body

pedicle

hypertrophy

surgeon JW Fielding, who introduced cineradiography to visualize normal and abnormal cervical spinal motion (Fielding, 1957). His clear depiction and graphic represen­ tations of the relationship between the cervical interverte­ bral disks and the apophyseal joints during flexion, extension, and side-bending as well as rotation have as much validity today as they did when they were initially presented (Fielding, 1957) (Fig. 13.11 ). The pioneering work by the Dutch radiologist, Lourens Penning was a major contribution to the understanding of

Fig. 13.10 Schematic view of a different presentation of spinal canal stenosis in the cervical spine as represented in the lateral view. Constitutional canal stenosis secondary to hypoplasia of the

the functional pathology of the cervical spine. His disserta­ tion was a treatise about the degenerative process and its etiology of the uncovertebral joints in the cervical spine

laminae is the most frequent form. Canal stenoses due to trans­

(Penning, 1960). This was followed by his seminal study in

versely-oriented pedicles or due to vertebral body hypertrophy are

1963 on the normal and abnormal ranges of motion in the

relatively rare. (After Wackenheim and Dietemann, 1985a.)

cervical spine (Penning and Tondury, 1963). Technological advances have resulted in the use of CT scans and magnetic imaging to study motion of the cervical spine. In the past, technical difficulties (projections that were unable to visualize the upper cervical spinal joints) stood in the way of detailed analysis. Newer technologies have allowed further study, especially that of axial rotation (Dvorak and Panjabi, 1987b: Dvorak et aI., 1987a, c: Ono et aI., 1984: Penning and Wilmink, 1987a,b).

Functional Radiographic Diagnosis of the Cervical Spine: Flexion and Extension Based on our own studies (Dvorak et al., 1988d) and Frohlich (1988), there is a significant difference between active and passive motion at all spinal levels in flexion and extension. Fig.13.11 Motion behavior in a final segment in relation to the facet (apophyseal joint) during flexion and extension motion as well as side-bending in rotation in the mid-cervical spine (Fielding,

1957).

Passive radiographic examination provides the most relevant and reliable information. One of the limiting fac­ tors is the pain that would typically appear at the extreme of motion. This may be due to muscle spasm and is quite often reported in the radiological reports associated with a "straightening of the curve." However, more importantly,

Functional Radiographic Studies of the

the pain may actually be due to segmental instability. Thus

Cervical Spine

it is helpful to encourage the patient to relax as much as possible during the examination. Even with such prepara­

A significant number of patients who experience neck pain

tion, the passive functional radiographic study may not

with movement, will not have objective evidence of an

provide much additional information in a patient with

underlying structural abnormality. For this reason, func­

advanced degenerative changes in the presence of segmen­

tional radiographic studies have been employed. The goal

tal hypomobility.

is to determine whether the patient's pain can be objec­

The contraindications for passive flexion and extension

tively correlated with segmental or regional motion limi­

motion studies include a history of recent cervical spine

tations (e.g., hypomobility) or excesses (hypermobility).

trauma, chronic polyarthritis, as well as suspected primary

Bakke (1931) was the first to use radiographic studies to

space-occupying lesions or metastases.

evaluate motion at the cervical spine. De Seze et al. (1951)

The study is performed with the patient standing and

and Buetti-Bauml (1954) presented the first systematic

the left side of the body placed against the film plate. The

functional radiographic results.

distance between the film and the roentgen ray tube is

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Copyrighted Material

Cervical Spine

1.5 m. The focus of the beam is upon the mid cervical spine. The patient should be as relaxed as possible, with the shoulders lowered maximally. The patient is stabilized between two padded supports placed anterior to the sternum and posterior to the mid thoracic spine. This helps facilitate a neutral patient posi­ tion. One should be careful not to introduce rotation, in order to maintain clear visualization of the vertebral bodies. Initially, the patient is instructed to carefully nod his or her head, which introduces a nutation motion (flexion) at CO-Cl and C1-C2. From this flexed position, further flexion is introduced to the neck until the maximal allowable flexion position is reached by the patient. In this final, actively engaged position, the first radiograph is taken. For the passive examination, the radiologist wears a lead apron, lead gloves, and lead glasses. The left hand of the

Fig. 13.12 E xa m ination technique for passive flexion and extension

radiologist is placed over the posterior portion of the pa­

views u sing functional radiographic diagnosis in the cervical spine

tient's head and the parietal region, while the right hand is

(Dvorak et aI., 1988d; Frohlich, 1988).

placed over the patient's chin. After introducing maximal passive inclination (flexion) at CO-C1 and C1-C2, the oper­ ator introduces maximal passive flexion to the remainder of the cervical spine. In this position, the second radiograph is taken. Once the flexed radiograph has been taken, the head is guided passively into maximal reclination (that is, exten­ sion motion) at CO-C1 and C1-C2, followed by maximal allowable extension introduced to the neck by the radi­ ologist's guiding hand. Every care should be taken that the hand guides the head and neck into these positions in a slow, careful, and precise manner (Fig. 13.12).

Fig. 13.13 Passive (a) flexion and (b) extension views during func­

tional examination. The cervicothoracic junction should be view­ able, requiring that the patient lower the shoulders as much as

If pain is elicited or exacerbated during the functional

possib le .

examination, it may be necessary to reschedule the patient. In our experience, low-dose analgesic or nonsteroidal anti­ inflammatory may help facilitate the execution of the

spine are the graphic method and the computer-assisted

study. Again, it is emphasized that if there is pain associ­

method. They are described as follows.

ated with the passive maneuver, consideration should be given to the potential presence of segmental instability. If

The Graphic Method

the patient reports the onset of dizziness, nausea, or other

This method was originally described by Penning in 1960.

autonomic symptoms, further diagnostic neurologic eval­

The flexion view is projected onto the normal film of

uation may be warranted.

24

x

36 cm size and the extension view onto one of

18

x

24 cm. The radiographic film of the extension view is

Representative flexion and extension views utilizing the functional radiographic examination protocol just de­

placed upon that of the flexion view while the spinous

scribed are shown in Fig. 13.13.

processes and the vertebral bodies of C7 are matched as

The original method presented by Penning (1960) has

much as possible. Subsequently, a line is drawn following

been found to be the most useful and reliable method, as

the edge of the seventh cervical vertebra in the extension

well as

the computer-assisted

method presented by

view and the flexion view. This procedure will then be

Dvorak et al. (1988d). The techniques introduced by Bakke

repeated for each vertebra superior to C7. The angle created

(1931), De Seze (1951), Buetti-Bauml (1954) have not been

between the two lines thus marked on the films in the

able to reproduce data sufficiently consistently (Frohlich,

maximal flexion and extension position will determine

1988; Dvorak et aI., 1988d).

the degree of range of motion between maximal passive

The two current procedures used to measure passive

flexion and extension.

segmental and regional range of motion in the cervical

193

Copyrighted Material

Imaging Studies of the Spine

Computer-assisted Method The contours of the vertebral body are outlined and the intersections of the lines are digitized for each vertebra in

II ' \ )-'(f\ \.. /"'"' \ \ /

the flexion and extension views (Fig. 1 3.14). The method is

Cl

.

I

.//' .....-/ I

/::ft:)

C2

-

! . 'V/",,,----, '" .,../

repeated four times to obtain an acceptable average value

'\'

and in order to minimize human "entry error" (Panjabi et al.,1992b).

\

A specifically designed computer program then ana­

--.. @

lyzes the superimposition of the vertebral bodies and the differences with respect to extension and flexion (Yale Biomechanics Laboratory, Department of Orthopedics and Rehabilitation/Spine Unit, Schulthess-Clinic, Zurich). The geometric fundamentals used for the final calculation of the rotation and translation motions and the center of rotation are presented in Fig. 1 3.15. Normal values for flexion and extension motion are summarized in Tables 1 3.1 and 1 3.2 (Dvorak et al., 1 988d,

Fig. 1 3.14 Landmarks for the computer·assisted method used to

1991a, 1993).

determine segmental motion. The landmark of the axis is some· what difficult because the osseous structures cannot always be clearly defined.

are those that deviate by more than one or two standard

Pathological values for hypomobility and hypermobility deviations from the normal value for each segmental level. For example, as demonstrated in Figs. 1 3.16a-e, a pro­ nounced segmental hypomobility is demonstrated in the functional diagram and the associated radiograph films.

Y

The differences between the active and passively per­

Rx

formed motions are clearly evident.

'"'

\8

>5

38-44

>54

>8

(0-(1

4.0

(1-(2

43.0

(2-(3

3.0

-2.7-8.7

>9

>6

(3-(4

6.5

1.2-11.8

>12

>6

(4-(5

6.8

1.3-12.0

>12

>6

(5-(6

6.9

1.3-12.7

>13

>6

(6-C7

5.4

0-10.8

>11

>6

C7-Tl

2.1

-2.8-7

many patients revealed an increased rotation to the left.

lia. demyelinating diseases. spondylitis, and prevertebral

which may be an indication of a lesion of the right alar

soft-tissue abnormalities such as abscesses, the MRI study

ligaments. Patients who demonstrated paradoxical rota-

is superior to conventional computed tomography.

tion exhibited a greater rotation to the contralateral side.

The MRI study allows specific measurements of the

A paradoxical rotation means that the more superior seg­

width as well as the overall diameter of the cervical spinal

ments rotate less than the inferior segments. Again. this

canal. The cranial migration distance determines the dis­

may be a result of loss of normal ligamentous function.

tance between the axis to the occiput, i. e., the foramen magnum (Fig. 13.23). The tip of the occiput and the clivus are connected by

Magnetic Resonance Imaging

drawing a line between these two structures. A line per­

The MRI of the cervical spine is particularly well suited for

the axis. The average value of the cranial migration distance

pendicular to this line is then directed to the lower edge of evaluation of the soft tissues, the spinal cord, and nerve

(( MD) is 38.7 mm (standard deviation 2.9 mm, range

roots. This allows the evaluation of potential compression

33-46 mm) (Dvorak, 1989). A superior migration distance

due to a space-occupying lesion. Disk herniations are also

of less than 31.5 mm is indicative of cranial migration of the

usually well demonstrated with MRI. When there is suspi­

axis or basilar impression.

cion of extradural or intramedullary tumors. syringomye­

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Imaging Studies of the Spine

performed with the head being passively guided to max­ imal flexion and then extension. The extreme positions are supported with specific wedges. The extreme positions are delimited only as far as the patient allows them to be Clivus

Occiput _ _

;r

_

achieved without much pain or other symptomatology. Axial cuts for a functional MRI study are performed only

_-=-f-�2cGre

c=:::::::.

J

(1-

when there is suspected spinal cord compression as deter­ mined in the sagittal views. The duration of the functional

-- Redtund-Johnett
, I

y

\l

\\ \V Course and Relationships The rectus capitis lateralis muscle joints the posterior cer­ vical intertransverse muscles (lateral portion) (Fig. 17.89), to become their most superior member. Its medial surface

Fig. 17.90 Palpatory approach to the posterior cervical intertrans­

borders the ventral ramus of the first cervical nerve, while

verse muscles.

laterally the muscle adjoins the posterior belly of the di­ gastric muscle and the trunk of the facial nerve.

Innervation Ventral rami of C1.

Action Side-bending (lateral flexion) of the head.

Palpatory Ap proach The examiner palpates around the transverse process of the atlas from a posteroinferior direction. To obtain contact with the occiput, pressure is applied anteriorly. Conse­ quently, the fingertip is between the atlas and the occiput,

Fig. 17.91 Palpatory approach to the posterior c ervical intertrans­

and light pressure is exerted on the muscular insertions

verse muscles (lateral portion).

according to their directions (Fig.17.91).

SRS Correlation The posterior cervical intertransverse muscles (lateral por­ tion) are correlated with the lateral rectus capitis muscle of the cervical spine.

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Functional Examination and Treatment of Muscles

Posterior Cervical Intertransverse Muscles (Medial Portion) Origins and Insertions The medial portion of the posterior cervical intertransverse muscles attaches between the posterior tuberosities of the transverse processes, somewhat more posteriorly than does the lateral portion. The most superior segments are between (2 and (1 (at the transverse process of (1, be­ tween the obliquus capitis inferior muscle and the splenius cervicis muscle). The most inferior portion is located be­ tween the first rib and C7 (inferior surface of the posterior tubercle) (Figs. 17.92, 17.93).

Course and Relations Practically the same as the lateral portion of the posterior cervical intertransverse muscles.

Innervation Dorsal rami of the cervical nerves (2-(7.

Fig. 17.92 Posterior cervical intertransverse muscles (medial por­

Action

tion).

Lateral flexion of the vertebrae to the side of the contracted muscle.

Palpatory Approach Palpation is the same as for the lateral portion of the posterior cervical intertransverse muscles. The palpatory differential diagnosis can be difficult in such a small region, but can become evident from the overall presentation of the SRS.

Fig. 17.93 Suboccipital muscles.

1 2

Sternocleidomastoid

7

Rectus capitis anterior

Splenius capitis

Longus capitis

3

Longissimus capitis

8 9

4

Rectus capitis lateralis

5

Rectus capitis posterior major

6

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Obliquus capitis superior

Rectus capitis posterior minor

10 11 12

Semispinalis capitis Trapezius Obliquus capitis inferior

Muscles of the Posterior Regions of the Neck and Bock

Thoracic Intertransverse Muscles Three pairs of these muscles are normally present, the rest being either ligamentous or absorbed in the long muscu­ lature, mainly the longissimus muscle.

Origin and Insertion These are short muscles, which are principally located between the individual transverse processes, from the in­ ferior margin of the superior thoracic transverse process to the superior border of the inferior thoracic transverse pro­ cess. The last muscle often divides into two portions, aris­ ing from the inferior surface of the transverse process of

T1l

and reaching the mamillary and accessory processes of

T12 (Fig. 17.94). This bifurcation can sometimes continue into the lum­ bar spinal region. Thus, the continuation of the thoracic intertransverse muscles into the lumbar spinal region is formed by the medial lumbar intertransverse muscles, which in turn are divided into a medial and a lateral por­ tion. This is of no relevance to the diagnosis, however.

Course and Relations These muscles belong to the deep and short autochthonous musculature and therefore lie beneath the rest of the muscles. At the last thoracic and lumbar vertebrae, they nestle between the longissimus muscle (lateral) and the multifidus muscle (medioposterior).

Innervation Dorsal rami of the segmental nerves.

Action Side-bending (lateral bending) of the corresponding verte­ brae.

Palpatory Approach Palpation of these small and deep spondylogenic units in

Fig. 17.94 Course of the thoracic intertransverse muscles.

the thoracic region and especially the differentiation from neighboring tendinoses is very difficult. The fingertip is placed over the origin and insertion of the muscle. Between

the palpatory pressure is perpendicular. When the finger

these two ends the center of the muscle is identified, and

approaches either attachment, the palpatory pressure that

according to the section of the muscle, the muscle is pal­

is applied should follow the direction that is along the

pated either perpendicular to its axis or along the muscle

longitudinal axis of the muscle fibers as they approach

fibers. At the center of the muscle, or at the muscle belly,

the respective origin or insertion.

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Functional Examination and Treatment of Musdes

Medial Lumbar Intertransverse Muscles The medial lumbar intertransverse muscles exist typically as a single unit. From their respective insertions, however, they may divide into a medial (Fig.17.95a) and a lateral portion (Fig. 17.95b).

Origin Transverse processes of the vertebrae. They arise between the superior edge of the adjoining mamillary process ante­ riorly, and the root of the costal process and the superior edge of the accessory process. They normally do not reach below the fifth lumbar vertebra (Fig. 17.96).

Insertion Transverse processes of the vertebrae. They insert at the inferior margin of the accessory process, and the tendinous arch to the inferior border of the mamillary process (17.96).

Course and Relations

Fig. 17.95a Medial lumbar

Fig. 17.95b Lateral lumbar

inter transverse muscles.

intertransverse muscles.

The sagittally oriented muscle belly lies in the deep muscle layer between the longissimus muscle (lateral) and the multifidus muscle (medioposterior and dorsal).

Innervation Dorsal rami of the related spinal nerves.

Action Side-bending (lateral flexion) of the attached vertebra to­ ward the same side as the contracted muscle.

Palpatory Approach Palpation of this muscle is difficult and possible only in isolated circumstances, because of its close proximity to the transversospinal system. The muscle often causes paraver­ tebral lumbar pain. Considering the anatomical arrange­ ment, the general principles of the palpatory technique apply here as well (Fig. 17.97). Fig. 17.96 Detailed view of the origins and insertions of the medial lumbar intertransverse muscles.

1

Mamillary processes

2

Accessory process

3 4

Connective tissue connections/bridging

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Dorsal ramus of spinal nerve

Muscles of the Posterior Regions of the Neck and Back

Lateral Lumbar Intertransverse Muscles Origin Transverse processes of the vertebrae. They arise from the superior margin of the costal process. from the tip to its root. near the exit of the spinal nerve dorsal ramus. The most inferior muscle originates at the lateral mass of Sl (Figs. 17.95b. 17.96).

Insertion Transverse processes of the vertebrae. The muscle located most superiorly inserts at the lateral tubercle of T12 and the lumbocostal ligament: all others insert at the inferior border. reaching to the tip of the costal process (Fig. 17.96). Fig. 17.97 Palpation of the medial lumbar intertransverse muscles.

Innervation Dorsal rami of the respective spinal nerves.

Action Side-bending (lateral flexion) of the attached vertebra to­ ward the same side as the contracted muscle.

Palpatory Approach Myotendinosis

of

the

lateral

lumbar

intertransverse

muscles must be distinguished from the corresponding ipsilateral segmental irritation zones by further provoca­ tion testing. It is best to palpate from both sides Simultaneously. Both thumbs reach around and below the sacrospinal system

Fig. 17.98 Palpation of the lateral lumbar intertransverse muscles.

and do not press directly on the tip of the costal processes but rather between the two costal processes in order to palpate them inferiorly and superiorly (Fig. 17.9B).

SRS Correlation The lateral lumbar intertransverse muscles are associated with the upper thoracic spine. They are often involved in the SRS event and palpatory access is usually easy. Thus. they are of practical importance for the beginner both for diagnosis and therapy.

Comments The Quadratus lumborum muscle and the lumbar longissi­ mus muscle must be diagnostically differentiated from each other.

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FunctIonal Examination and Treatment of Musdes

Interspinales Muscles The interspinales muscles are completely present in the cervical and lumbar spine region only. These short muscles span the spinous processes between adjacent vertebra, but are not present throughout most of the thoracic region. In the thoracic region, these muscles exist only to T4 and then again inferior to Tl1. Normally between T4 and TlO, there are no interspinales muscles. Instead there is only the interspinous ligament, which stretches from one spinous process to the next.

Origin Inferior surface of the spinous processes of (2-T3 and Tll-S1.

Insertion Superior surface of the spinous process directly below the respective origin-vertebra, (3-T4, Tl2-S2.

Course and Relations Practically longitudinal; in the cervical region there are muscle pairs related to the bifurcated spinous processes (Fig. 17.99).

Innervation Dorsal rami of the respective spinal nerves.

Action Extension of the vertebral column.

Fig. 17.99 Course of the interspinales muscles.

Palpatory Approach In the cervical region, the muscles are easily palpated with the head slightly flexed. Generally, the origins are palpated lateroinferiorly

and

the

insertions

laterosuperiorly

(Fig. 17.100).

Supraspinous ligament The supraspinous ligament stretches superficially across the tips of the spinous processes, from (3 to S3 (Fig. 17.100).

Fig.17.100 Course of the interspinous ligament.

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Muscles of the Anterior and Lateral Regions of the Neck

Muscles of the Anterior and Lateral Regions of the Neck Table 17.3 Muscles of the anterior and lateral regions of the neck Anterior/ Lateral neck muscle

•

Sternocleidomastoid

Comments Clinical examination is done together with evaluation of trapezius and levator sea pule muscles.

Prevertebral Muscles •

Lateral group

Scalene group

The scalenes represent the superior contin­

•

Anterior scalene

uation of the Intercostal muscles.

•

Middle scalene

Scalene muscles are important for rib

•

Posterior scalene

function and their clinical evaluation of neck and shoulder-arm pain, especially in pres­ ence of a rib 1 dysfunction and/or dysfunc­ tion of T1 (anterior/middle scalenes); less common is involvement of rib 2 and/or T2.

Prevertebral muscles •

Medial/Paramedian group

•

Longus colli

For anatomical reasons, the rectus capitis

•

Longus capitis

anterior and lateralis muscles are covered

•

Rectus capitis anterior

under intertransverse muscles (see

•

Rectus capitis lateralis

pp.655-658). The recti muscles are innervated by the ventral rami of the (1 spinal nerve.

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Functional Examination and Treatment of Muscles

Sternocleidomastoid Muscle This large, rounded muscle passes obliquely across the side of the neck from manubrium to mastoid. It is twisted 900 around its longitudinal axis in a screwlike manner so that 10

the inferior portion is directed anteriorly and the superior portion laterally. At its origin, the tendon of the sternoclei­ domastoid muscle is divided into a clavicular and a sternal portion. (Fig. 17.101).

Origin •

Stemal portion: Here, the muscle arises as a rounded, strong tendon from the anterior surface of the manu­ brium of the sternum, immediately medial and some­ what inferior to the sternoclavicular joint (Fig. 17.101).

•

Clavicular portion: This portion is made up of muscular and tendinous aponeurotic fibers. It arises from the superior surface and the posterior border of the sternal

Fig. 17.101 Course of the sternocleidomastoid muscle.

end of the clavicle. The origin extends from the lateral margin of the sternoclavicular joint through the medial one-third of the clavicle. The flat muscle belly slides under the inferior surface of the sternal portion and gains bull< in the superior direction (Fig. 17.101).

Insertion Inserts at the outer surface of the mastoid process, extend­ ing from the tip to the superior border and further to the center of the superior nuchal line (Figs. 17. 53, 17.101).

Course and Relations The sternocleidomastoid muscle is covered to a great ex­ tent by the platysma muscle. From its origin to its insertion, the muscle passes superficially and obliquely across the anterior side of the neck, thereby dividing the neck region into anterior and lateral regions or two triangles.

Innervation Spinal accessory nerve and contributions from the cervical plexus

(C2-C3).

Fig. 17.102 Motor end plates (with kind permission of Dr. J. Cho­ miak).

1

Motor End Plates The sternocleidomastoid muscle is a nonpennate muscle with two motor end plates (Fig. 17.102).

Sternocleidomastoid

Action When contracted bilaterally, it flexes the head and neck. When contracted unilaterally, it side-bends the head to­ ward the side of the contracted muscle and rotates it into the opposite side.

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Muscles of the Anterior and Lateral Regions of the Neck

Palpatory Approach The origin of the sternal portion at the manubrium is best palpated superiorly and laterally. The examination starts by locating the sternoclavicular joint and then moving medi­ ally until the muscle or tendinous fibers are palpated. The clavicular portion is palpated by reaching around the pos­ terior margin of the clavicle in a hooklike manner. The homologous insertion tendinoses are palpated as follows: starting at the tip of the outer surface of the mastoid, the examiner follows along the insertion up to the superior nuchal line. Fig. 17.103 Length testing of the sternocleidomastoid-step l.

SRS Correlation

The sternocleidomastoid muscle consists of four different myotenones, which are correlated with dysfunctions in the mid-thoracic spine.

Evaluation of Muscle Length Examination Procedure The patient is sitting. The examiner stands behind the patient and fixates the shoulder with one hand while at the same time localizing the clavicular and sternal inser­ tions of the sternocleidomastoid muscle with the index

Fig. 17.104 Length testing of the sternocleidomastoid-step 2.

finger. The patient's trunk rests against the examiner's thighs (Fig. 17.103). The examiner places his other hand over the patient's parietal region, and then carefully intro­ duces as much flexion to the head as possible, followed by maximal side-bending to the opposite side (Fig 17 104) In .

.

.

the final step, the head and neck are minimally rotated toward the same side as the muscle that is being examined. During this maneuver, the examiner evaluates the tension of the muscle insertion at the sternum and clavicle (Fig. 17.105).

Positive Findings 1. Soft end-feel at the extreme (barrier) of motion, with

Fig. 17.105 Length testing of the sternocleidomastoid-step 3.

prominent muscle contour and tenderness at the in­ sertion: this would indicate a functional shortening of the sternocleidomastoid muscle, often in conjunction with increased use of the accessory respiratory muscu­ lature; it may occasionally be observed in patients with

artery, for instance. Further work-up is necessary and may require referral to the appropriate specialist. 3. Vertigo that becomes apparent immediately upon the

pulmonary disorders. 2. The patient may complain of vertigo that gets slowly

introduction of this maneuver: this may represent a

worse during the examination: this may indicate po­

cervicogenic type of vertigo, but nonetheless differen­

tential circulatory compromise related to the vertebral

tiation to other causes may prove to be challenging.

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Functional Examination and Treatment of Muscles

Stretching of the Sternocleidomastoid Muscle NMT 2 (Figs. 117.4a-c) Indications •

Pain: There is occasional pain in the cervical spine and arm (cervicobrachialgia), which is often seen in associ­

1

ation with segmental dysfunctions in the cervical or thoracic spine. •

Motion testing: Cervical spine side-bending and rotation restriction; soft end-feel. Thorax mobility, i. e., "pump handle" movement in upper ribs is often restricted, especially in patients with obstructive lung disease or emphysema.

•

Muscle testing: The sternocleidomastoid muscle is shortened. Frequently, the descending portion of the trapezius muscle and the scalene muscles are shortened

a

as well (a).

Patient Positioning and Set- up •

Patient is supine with the head beyond the examination table and resting on the physician's thighs (physician is seated).

•

The muscle is maximally stretched by introducing pas­ sive cervical spine rotation and side-bending to the opposite side

(b).

Treatment Procedure •

The shortened sternocleidomastoid muscle is con­ tracted isometrically during inhalation, with the patient

b

looking in a superior direction. •

During the postisometric relaxation phase, the muscle is passively stretched, primarily by accentuating the side­ bending component, less the rotation component. This occurs during exhalation with the patient looking infe­ riorly

(e).

Comments • •

The individual stretching steps are rather small. The treatment procedure should be immediately ter­ minated when signs of possible vertebral artery com­ pression develop, as expressed by vertigo, nausea, or c

spontaneous nystagmus. •

This stretching technique should only be applied after any segmental dysfunction has been treated with the appropriate techniques so that there is no longer any hard end-feel present.

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Muscles of the Anterior and Lateral Regions of the Neck

Posterior Scalene Muscle

Scalene Muscles

The posterior scalene muscle lies in the posterior triangle of

Anterior Scalene Muscle

the neck.

Origin This muscle arises as four tendons from the anterior tu­ bercles of the transverse processes of (3-(6. The strongest

Origin The muscle arises from the posterior tubercles of the trans­

and rather "fleshy" tendinous slip arises from the anterior

verse processes of (6 and C7, occasionally those of (4 and

tubercle (tuberculum caroticum) of (6 (Fig. 7.106).

(5 (Fig. 17.108).

Insertion

Insertion

Tile muscle inserts at the scalene tubercle and the adjoin­

This muscle inserts as a thin aponeurosis at the outer sur­

ing ridge on the upper surface of the first rib, between the

face of the second rib, behind the tubercle for the serratus

subclavian artery and vein (Figs. 17.106, 17.107).

anterior muscle (Fig. 17.108).

Course and Relations

Middle Scalene Muscle

Not surprisingly, the spatial arrangement of the scalene The middle scalene muscle occupies the floor to the poste­

muscles can be deduced from their names:

rior cervical triangle. •

The anterior scalene muscle lies lateral to the inferior

•

The middle scalene muscle lies posterior and lateral to

•

The posterior scalene muscle lies posterior to the middle

portion of the longus colli muscle.

Origin Posterior margin of the groove for the spinal nerve and the posterior tubercles of the transverse processes of (2, (3-C7 (Fig. 17.106).

the scalene anterior muscle. scalene muscle. The fiber direction of the three muscles is lateral and

Insertion

inferior. In contrast to the anterior and middle scalene

This muscle inserts along the entire upper surface of the

muscles, the posterior scalene muscle traverses the first

flrst rib between the groove for the subclavian artery and

rib and inserts at the second rib.

the tubercle of the rib. There are tendinous insertions that

When palpating, the examiner should always be aware

also attach to the fascia associated with the first intercostal

of the close proximity of the scalene muscles and the sub­

space (outer thoracic surface). On occasion the middle

clavian artery and the brachial plexus.

scalene may also insert at the superior edge of the second rib (Fig. 17.107).

Fig. 17.106 Scalene muscles.

Fig. 17.107 Muscle attachments

Fig. 17.108 Posterior scalene.

at the first rib.

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Functional Examination and Treatment of Musdes

Innervation The ventral rami of the cervical spinal nerves between 0 and e8.

Action Bilateral contraction results in flexion of the cervical spine. Unilateral contraction results in bending to the side of the contracted muscle, with simultaneous rotation of the neck into the opposite direction. When the celvical spine is held stationary, the muscle raises the second rib.

Palpatory Approach

Fig 17 1 09 Length testing of the scalenes (patient seated. oper­ .

The origin tendinoses at the anterior and posterior tubercles are palpated anteriorly and inferiorly. The origins can easily

.

ator behind patient; head cradled with one hand while the other hand palpates over the muscles at the insertion of the anterior scalene).

be reached with the palpating finger or fingers. The inser­ tions at the first rib (anterior and middle scalene muscles) are palpated superiorly, behind the clavicle in the thoracic inlet. It should be noted that the patient may find this palpatory procedure extremely uncomfortable, especially when placing untoward pressure upon the brachial plexus (Fig. 17.109). The insertion of the posterior scalene muscle is palpated at the second rib, from posterior and superior, about two-finger widths lateral to the tip of the transverse process of T2. Since palpation is through the trapezius muscle, the palpatory findings are not easily elicited.

SRS Correlation The myotendinosis of the anterior scalene muscle may "pull" the involved spinal segment anteriorly (anterior

Fig. 17.110 Length testing of the scalene muscles. Gui de the pa­

segmental or somatic dysfunction). This is similar to the

tient's head to the opposite side by side-bending away from the

myotendinosis of the longus colli muscle and may actually exacerbate such by displacing the vertebra anteriorly even more. The scalene muscle myotenones are correlated with

side that is being tested; introduce extension of the head and neck and rotate the head away. (Memory aid: side-bend and rotate away from the side of the muscles to be tested.)

the mid-thoracic spine.

Comments

Positive Findings

The clinically described "elevated first rib" is in part, or

1. Soft end-feel at the motion barrier (extreme of move­

possibly entirely, due to the action of the scalene muscles.

ment). Perceptible increase in tissue tension immedi­ ately lateral to the sternocleidomastoid muscle. Mus­

Examining the Scalene Muscle for length (length Testing)

cular imbalance with shortening of the scalene muscles, often in combination with a shortened sternocleido­ mastoid muscle. 2. Localized pain in the region of the lateral triangle in the

The patient is seated. The palpating finger of the other hand

neck. occasionally radiating toward the arms. Pseudora­

localizes the anterior and middle scalene muscles at their

dicular pain radiation may be present. This must be dif­

attachment(Fig.17.109). The physician then places one hand

ferentiated from the so-called thoracic outlet syndrome.

flat over the patient's forehead and extends the neck and

3. Slowly progressive dizziness may indicate shortening of

rotates the head away in the opposite direction (Fig. 17.110).

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the sternocleidomastoid muscle.

Muscles of the Anterior and Lateral Regions of the Neck

Stretching of the Scalene Muscles NMT 2 (Figs. 117.5a-c) Indications •

mobilization procedure, such as reported dizziness,

Pain: Chronic cervicobrachialgia often with paresthesias during the night. Occasionally. there may be the classic

•

•

nausea, or nystagmus. •

If there is concurrent first rib restriction or segmental

signs of the scalenus anticus syndrome (both neurologic

dysfunction in the cervicothoracic spine, these areas

and vascular, possibly elicited with the Adson test).

should be treated first in order to facilitate the proper

Motion testing: Restricted mobility of the first rib and

stretch in the absence of a reflexive end-feel. If the

the upper thorax during exhalation. Restricted cervical

descending portion of the trapezius muscle is also found

spine extension and side-bending with soft end-feel.

to be shortened, it should be stretched before the sca­

Muscle testing: The scalene muscles are shortened. Often

lene muscles.

the descending portion of the trapezius muscle and the sternocleidomastoid muscle may be concurrently shortened as well

(a).

Note: In many cases there is prominent upper thorax (ster­ nal) respiration especially in the presence of obstructive lung disease or emphysema.

Patient Positioning and Set-up •

The patient is supine with his head beyond the exami­ nation table and resting on the physician's thigh (the physician is seated).

•

Maximal stretch is introduced by carefully extending,

L-________________________________

________

a

side-bending and rotating the neck to the side opposite of the tested muscle

(b).

Treatment Procedure •

The shortened scalene muscles are isometrically con­ tracted as much as possible (during inhalation, with concurrent upward gaze).

•

During the postisometric relaxation phase and with the cervical spine fixated, the first rib and the clavicle are translated in an inferior direction by the physician (during exhalation and downward gaze).

•

b

Subsequently the range of extension and side-bending motion in the cervical spine is increased

(c).

Note: While stretching the muscle, the physician should also introduce some carefully dosed traction to the cervical spine.

Comments •

The treatment procedure should be terminated if signs of possible vertebral artery compression or sympathic nerve irritation appear with positioning or during the

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Functional Examination and Treatment of Muscles

Longus Colli and Longus Capitis Muscles These two long muscles are found on the anterior surfaces of the vertebral bodies.

SRS Correlation Due to its reflexogenic correlation to the upper thoracic spine, the longus colli muscle takes part in the spondylo­

longus Colli Muscle

genic event and can cause an anteriorly abnormal position of a cervical vertebra. The examiner should observe the

The longus colli muscle has several parts.

response of the irritation zone upon provocative testing in the cervical spine.

Origin •

Superior portion: The anterior tubercle and anterior

longus Capitis Muscle

surface of the transverse processes. •

Inferior portion: Lateral side of the vertebral bodies of

The longus capitis muscle lies lateral to the longus colli

(5-C7 and the anterolateral portion of the vertebral

muscle.

bodies of T1-T3 (always strong) (Fig. 17.111).

Origin Insertion •

The transverse processes of (3-(6, between the origins of

Superior portion: The tubercle on the anterior arch of the

the longus colli muscle and anterior scalene muscle

atlas and the vertebral bodies of (2-(4, immediately

(Fig. 17.111 ).

next to the longitudinal ligament. •

lnfelior portion: The most inferior side on the anterior surface of the transverse processes of (5-(7.

Insertion On the occipital bone. At the pharyngeal tubercle, about one-half of a finger-width from the anterior condyle at the

Action

occiput, the basilar part of the occipital bone.

Bilateral contraction results in flexion of the cervical spine, and unilateral contraction results in side-bending of the head to the side of the contracted muscle.

Innervation Ventral rami of (1-(3.

Innervation Action

Ventral rami of the spinal nerves (2-(6.

Flexion of the head.

Palpatory Approach After displacing the sternocleidomastoid muscle, the ten­ dinoses at the muscle origin can be palpated superome­

Palpatory Approach Similar to the longus colli muscle, the origins are palpated from a superior direction (Fig. 17.114). The insertion at the

dially. The origins of the inferior portion cannot be palpated due

occiput cannot be easily palpated. To test for possible myo­

to the position and course of the scalene muscles. The in­

tendinosis in the muscle belly, the orientation is best at the

sertion at (1 can be palpated inferiorly. This may be con­

(3 level. The recognition of myotendinosis in the longus

fused with the zone of irritation of(1.To reach the insertions

system is of therapeutic importance. Myotendinosis is re­

at (2-(4, the finger presses deeply between the sternoclei­

sponsible for the anterior component of the abnormal po­

domastoid muscle and the pharynx (Figs. 17.112 and 17.113).

sition.

Because of the anatomical location and relation to the pharynx, palpation is difficult and therefore not always useful for diagnosis.

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Muscles of the Anterior and Lateral Regions of the Neck

Fig.17.111 Longus colli and longus capitis muscles.

Fig. 17.112 Lateral neck muscles.

1

Longus colli

1

Sternocleidomastoid

2

Longus capitis

2

Longus colli

Fig. 17.113 Palpation of the longus colli.

Fig. 17.114 Palpation of the longus capitis.

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functional Examination and Treatment of Muscles

Muscles of the Thoracic Cage and the Abdominal Wall Table 17.4 Muscles of the thoracic cage and the abdominal wall

Thorace eage

•

Pectoral muscles

Comments

•

Serratus anterior

1.

•

levatores costarum (Iongi et breves)

·cage" actually refers to the term

•

Respiratory diaphragm

·basket" -a less restrictive and

In the German language. the word

more mobile term.

2.

The respiratory diaphragm. often overlooked in the standard phys­ ical examination. assumes a key role in the evaluation and treat­ ment in manual medicine.

Abdominal wall

•

External and internal obliques

•

Transversus abdominis

•

Rectus abdominis

•

Quadratus lumborum

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Muscles of the Thoracic Cage and the Abdominal Wall

Pectoralis Major Muscle The pectoralis major muscle is generally divided into three parts according to its origin at the clavicle, the sternum, and the abdomen.

Origin •

Clavicle: The clavicular fibers arise from the anterior surface of the medial half of the clavicle.

•

Sternum: The sternal portion originates from the sternal membrane and the costal cartilage between the second and sixth ribs.

•

Abdomen: The weakest part, the abdominal portion of this muscle, takes its origin from the anterior layer of the rectus sheath in the uppermost area (Figs.

17.115 and

17.116a).

Insertion Inserts at the lateral lip of the intertubercular (bicipital) groove of the humerus. The muscle attaches via a tendon in

Fig. 17.115

Course of the

pectoralis major muscle.

which the fibers cross and form an anterior and a posterior lamina. The fibers of the abdominal portion attach most proximally (Fig. 17.115).

Course and Relations The fibers of the abdominal portion run rather vertically from inferior to superior, whereas the fibers of the sterno­ costal and clavicular portions are arranged more in a hor­ izontal fashion (Fig. 17.116a).

Motor End Plates The pectoralis muscle is a nonpennate muscle whose fibers converge toward its insertion at the proximal humerus. The two end plate zones of this muscle course between the different muscle origins (Chomiak 2003) (Fig. 17.116b).

Innervation Clavicular head via the lateral pectoral nerve (C5, C6, sternal head via the medial pectoral nerve (CB,

0),

T1). Fig. 17.116a

Action As a whole, the pectoralis major muscle is able to adduct and internally rotate the arm. The sternalcostal fibers can extend an already flexed arm. The muscle can also assist deep inhalation (accessory respiratory muscle).

Pectoralis major muscle-course and relations.

1 2

Pectoralis major (clavicular portion)

3

Pectoralis major (abdominal portion)

4

Serr atu s anterior

Pectoralis

major (sternocostal

5

External abdominal oblique

6

Deltoid

7

Latissimus

portion)

dorsi

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Functional Examination and Treatment of Muscles

Palpatory Approach This superficial muscle is relatively easy to access at the anterior surface of the thorax. The muscle is usually pal­ pated by following it from its origin at the thorax to its insertion at the humerus in accordance with the fibers' direction.

length Testing of the Pectoralis Major Muscle Procedure The supine patient flexes the legs slightly at the hip and knees to minimize untoward pull in direction of the pelvis. The patient's thorax is stabilized by the examiner's hand placed broadly over it (Fig. 17.117). With the other hand the examiner abducts the patient's arm. In the healthy person, and in the absence of shoulder pathology, the examiner should be able to guide the patient's arm beyond the hor­ izontal plane. The degree of range of motion for this move­ ment is evaluated (Fig. 17.118).

Fig.

Positive Findings

17.116b Motor end plates in the pectoralis major (with kind

permission by Dr. J. Chomiak).

1. Decreased range of motion for abduction and/or exten­ sion at the shoulder with soft end-feel. This is probably due to a shortened pectoralis major muscle.

1 2 3

Pectoralis major (sternocostal portion) Serratus anterior External abdominal oblique

2. Decreased range of motion for abduction or extension with hard end-feel. This may be caused by structural

3. Pain during the maneuver or at the extreme (barrier) of

joint changes, such as a tight capsule seen in ankylosing

movement. This requires a detailed examination of the

spondylitis.

shoulder to determine the cause of the pain.

Fig. 17.117 Length testing of the pectoralis-step 1.

Fig.

Copyrighted Material

17.118 Length testing of the pectoralis-step 2.

Muscles of the Thoracic Cage and the Abdominal Wall

Stretching of the Pectoralis Major Muscle NMT 2 (Figs.117.6a-c) Indications •

Pain:

Pain in the axilla at the extreme of arm abduction

and external rotation. The insertions at the ribs are quite tender to palpation (a). •

Motion testing:

Diminished arm abduction and external

rotation with soft end-feel. •

Muscle testing: The pectoralis major muscle is shortened with characteristic pain on stretch. Often, there is si­ multaneous shortening of the descending portion of the trapezius muscle and weakening of the medial shoulder blade fixator muscles.

a

Patient Positioning and Set- up •

The patient is supine, lying close to the edge of the

•

The physician stands at the patient's head, fixating the

•

The other hand takes hold of the patient's arm, intro­

examination table. patient's thorax with one hand and the forearm. ducing abduction and external rotation in order to stretch the muscle maximally

(b).

Treatment Procedure •

The physician provides the resistant force to the pa­ tient's arm.

•

Optimal isometric contraction of the pectoralis major muscle is performed by the patient

•

L-______________

____

________

b

(b).

During the postisometric relaxation phase, the arm is passively abducted, utilizing additional slight traction. The increase in angular mobility is a result of the stretch of the muscle

(e).

Comments •

If there is a painful joint, this technique should not be

•

Modification: The physician places one hand broadly

utilized until later in the course of treatment. over the muscle belly, which during the postisometric relaxation phase is stretched along its longitudinal axis. Even though this technique contradicts the treatment

c

principles delineated for NMT 2, it is, in addition to possibly using NMT 3, the only technique that allows pectoralis major muscle stretching in the presence of a painful shoulder joint.

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Functional Examination and Treatment of Muscles

Anterior Serratus Muscles Origin The anterior serratus muscle arises by nine, sometimes

10,

strong fascicles from the convex portion of the body of ribs

I-IX occasionally rib X. The four most inferior fascicles slide below the insertions of the external abdominal oblique muscle (Figs. 17.119,

17.120).

Insertion The muscle inserts at the costal surface of the medial margin of the scapula, between the superior and inferior angle. Fibers arising from the first and second rib insert at the superior angle, and those arising from the third and fourth rib insert at the center of the medial margin. The remaining muscle fibers. the strongest. arise from ribs v-X in a fan-shaped pattern. They insert at the inferior angle of the scapula (Figs. 17.119.

17.120).

Fig. 17.119 Course of the serratus anterior (origins and insertions).

Innervation Long thoracic nerve from

(5-C7.

Motor End Plates The serratus muscle comprised a number of nonpennate muscle fibers. The S-shape arrangement of the motor end plates corresponds with the course of the long thoracic nerve (Fig.

17.121 ) .

Action The anterior serratus muscle draws the scapula forward. away from the vertebral column. The inferior fibers in particular rotate the scapula so that the glenoid cavity points in a superior direction (abduction of the arm beyond the horizontal).

Palpatory Approach

Fig. 17.120 Anterior serratus muscles-course and relations.

Even in the absence of any involvement (e. g.. "muscle

1

Serratus anterior

spasm"), the fibers at the origin are relatively easily pal­

2 3 4

Subscapularis

pable at the fourth rib and below. The muscle is approached from a posterior direction along the lateral thorax wall

latissimus dorsi Pe ctoralis minor

(Fig. 17.122). When palpating the muscle insertion. the scapula is lifted off the rib cage at inferior angle. The finger follows along the muscle along the medical costal surface far superior as possible (Figs.

17.12J. 17.124).

SRS Correlation Most often involved in the spondylogenic event are the myotenones associated with a dysfunction at the sixth and seventh ribs. These myotenones are also responsible for the corresponding abnormal position of the ribs.

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Muscles of the Thoracic Cage and the Abdominal Wall

Fig.17.121 Motor end plates (with kind permission of Dr. J. Cho­

Fig. 17 .122 Palpation of the serratus anterior; patient seated, arm

miak).

elevated.

1

Serratus anterior

2

External abdominal oblique

Fig. 17.123 Palpation of the serratus anterior; patient prone; muscle localization.

Fig. 17.124 Palpation of the serratus anterior; patient prone; sta­ bilizing the shoulder with one hand and reaching under the scapula from medial.

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Functional Examination and Treatment of Muscles

Levatores Costarum Longi et Brevis Muscles The levatores costarum muscles are relatively short but quite strong and are found (as the name implies) alongside the thoracic spine. They owe their name to their action of

Innervation The respective intercostal nerves of T1 through T11.

lifting the ribs. There are 12 pairs of short levatores costarum muscles, while there are only four pairs of the long levatores costa­

Action

rum muscles,which act upon the inferior-most four ribs. In

Although the levatores costarum muscles insert at the ribs,

this context, they are discussed together even though they

they belong functionally to the deep back muscles. Bilateral

represent different SRS correlations.

contraction results in extension of the thoracic spine. Uni­ lateral contraction results in rotation of the spine to the opposite side and side-bending of the vertebral column to

Origin

the same side as the contracted muscle.

Arises from the transverse processes between C7 to T11. At (7 it arises from the posterior tubercle of the transverse process. Between T1 and Tn it arises from the tip of the

Palpatory Approach

transverse process along its inferior margin and occasion­

The close relationship of the muscles to both the longissi­

ally from its base.

mus thoracis muscle at the origin and the iliocostalis thora­ cis muscle at the insertion, which cover these small muscles to a large extent, requires a precise palpatory approach.

Insertion

First the thumb locates the myotendinosis associated with

The levatores costarum muscles insert at the superoposte­

the muscle by pressing on the muscle perpendicular to the

rior surface of the ribs between the tubercle and the costal

direction of the fibers. Once the muscle is identified, the

angle. The short levatores costarum muscles insert at the

examiner palpates along the muscle in order to determine

outer surface of the rib immediately below their respective

the presence of tendinotic changes (Fig. 17.127).

origins. In contrast, the long levatores costarum muscles skip the rib immediately inferior and therefore insert two ribs below their respective origin (Figs. 17.125 and 17.126).

SRS Correlation These muscles, which have a very small diameter, are often responsible for segmental vertebral and rib dysfunctions,

Course and Relations

which have occasionally been described in the past as a

The levatores costarum muscles are found at the same level

"blocked rib." Provocation testing may be necessary to

as the deep short muscles of the back, e. g., the intertrans­

determine such a rib lesion. The pattern and behavior in

verse and rotatores muscles. Thus, they lie under the

response to provocative testing associated with a finding of

muscle masses of the long and superficial back musculature

an irritation zone dictates the direction of treatment both

(see Fig. 1 5.17, the cross-section of the thoracic spine).

for the segmental and the rib dysfunctions.

Following the muscles from their origin at the spine to the insertion at the ribs, the muscles fibers course from a superior and medial position to inferior and lateral (Figs. 17.125,17.126).

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Muscles of the Thorocic Cage and the Abdominal Wall

Fig. 17.126 Levatores costarum longi et brevis muscle-course and relations.

1

Ilioscostalis thoracis

2

Short and long components of the illioscostalis thoracis

3

Spinalis

4

Longissimus thoracis

Fig. 17.125 Course of the levatores costarum.

Fig. 17.127 Palpation of the short and long components of the

Left: Short components

illioscostalis thoracis.

Right: Long components

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Functional Examination and Treatment of Muscles

Diaphragm Overview The respiratory diaphragm forms an arched musculotendi­ nous partition between the thorax and the abdomen (Figs. 17.128, 17.129a, b, 17.130 a,b). This division is both structural and functional in that the rhythmic contraction of this muscle in synchrony with the breathing cycle changes its shape from a dome structure during exhalation to a nearly a flat septum at the extreme of inhalation. It is a broad muscle with a number of originating attachments that involve the sternum, the costal cartilage and bony portions of the lower six ribs, and the lumbocostal liga­ ments (or arches) and two crura (a left and a right crus). The various muscle fibers converge from their respective origins towards one central tendon that has the appearance of a cloverleaf with three leaflets. Of these, the right leaflet is the largest and the left is the smallest. It is noteworthy that the pericardium does not simply rest on the central tendon but is actually tightly connected with it. Thus, the heart is being pushed up and directly

Fig. 17.128 Position of the diaphragm and ribs at full inspiration

pulled down in synchronous response to the diaphragmatic

and expiration. (From Schuenke. Thieme Atlas of Anatomy Vol.

movement. In addition to these and similar direct mechan­ ical implications, the diaphragm participates in an array of neuroregulatory and motility-related processes with po­

I,

2007.) Thoracic cage, anterior view. Note the different positions of the diaphragm at full inspiration (red) and full expiration (blue). During a physical examination, the posterior lung boundaries can be iden­

tential significant clinical ramifications. Liu et al. (2004)

tified by percussion (tapping the body surface). The respiratory

presented an animal study wherein a crural diaphragm

movement of the diaphragm from end- expiration to end- inspira­

inhibition during esophageal distension correlated with

tion should be determined; it is approximately 4-6 cm.

contraction of the esophageal longitudinal muscle. Katz et al. (2001) reported a frequent yet often unrecognized cause of respiratory failure in the newborn, the "respiratory flut­

(a) Lumbocostal arches - Lateral arcuate ligament:

ter syndrome." It is characterized by the occurrence of

This represents a thickening of the lumbo­

respiratory flutter, dysphagia, laryngomalacia, and gastro­

dorsal fascia and arches across the anterior surface of the quadratus lumborum muscle

esophageal reflux in a neonate.

spanning between the anterior portion of the

In manual medicine, the diaphragm assumes a central role as dysfunction of this muscle may affect regions quite

transverse process ofLl (medially) and the tip

distant from the thoraco-Iumbar junction, such as the

of the 12 th rib laterally between.

thoracic inlet area above and the pelvic diaphragm below,

-

Medial arcuate ligament:

as well as influencing other muscles, including the inter­

This represents a thickening of the fascia of

costals. the transversus abdominis, the iliopsoas, quadratus

the psoas, and arches across the anterior sur­

lumborum and abdominal muscles, and the many fascial

face of the psoas muscle spanning between

connections.

the bodies ofLl andL2 (medially) and anterior portion of the respective transverse process of the same vertebra (laterally).

Origin (Fig. 17.131) 1.

(b) Crura

Costal part: inner surfaces of the lower six costal carti­

- Left crus:

lages via fleshy slips that interdigitate with the trans­

Originates from body and disks of L 1 andL2; it

verse abdominis muscle.

is shorter than the right crus.

2. Sternal part: dorsal aspect of the xiphoid process 3. Lumbar part via (a) two lumbocostal arches and (b) two

-

Right crus: Originates from bodies and disks of Ll, L2 and L3; it is longer than the left crus.

crura

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Muscles of the Thoracic Cage and the Abdominal Wall

Internal intercostal

Manubrium

mu scles Vena caval

Transversus

aperture

Esophageal

tiloracis

aperture

tendon

Esophageal

ligament

aperture

Body of sternum Costal part

Costal part of diaphragm

lateral arcuate

T1 a vertebral

ligament

body

of diaphragm

Central tendon

Median a rc uate

Central

Lumbar part of

(quadratus

diaphragm,

arcade)

T12 vertebral body

Aortic

left crus

Medial arcuate ligament

aperture

Aortic apenure

(psoas arcade)

Costal arch

Transversus Quadratus

Transversus

abdominis

lumborum

abdominis

Psoas major Psoas minor

Ilia c us

Piriformis

Iliopsoas

Sacrospinous ligament (coccygeus muscle) Gluteus

Pubic symphysis

maximus

Ce nt ra l te ndon Inferior vena cava

T8 vertebral body

Median arcuate

Inferiorvena cava

...-,-,;::r-.r--

liga ment

Esophagus Crural sl i ng Aor ta

Esophagus T1 Overtebral body b

--:''l�e.,....---..,�--

T12vertebral body

Fig. 17 .130 Position and shape of the diaphragm, anterior view.

Aorta

Coronal section with the diaphragm in an intermediate position. (From Schuenke, Thieme Atlas of Anatomy Vol. 1,2007.) b

a

Fig. 17.129 Position and shape of the diaphragm, viewed from the left side. (From Schuenke, Thieme Atlas of Anatomy Vol. I, 2007.) Midsagittal section demonstrating the right half of the body. The diaphragm is in an intermediate position at end-expiration. a

corresponding to the following landmarks in the lower thoracic aperture

(inferior vena cava) and in the lumbar part of the diaphragm (esophageal and aortic apertures).

b Enlarged view of the diaphragmatic apertures, with vessels transected. The vena caval aperture is located to the right of the median plane, the esophageal and aortic apertures to the

The apertures in the diaphragm are depicted at vertical positions spine: vena caval aperture

The apertures are located in the region of the central tendon

left.

T8 vertebral body, esophageal

T10 vertebral body, aortic aperture

T12 vertebral

body.

b The diaphragmatic apertures and the structures that they trans­ mit.

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Functional Examination and Treatment of Muscles

Space Defined by the Crura

Insertion (Fig. 17.131)

From left to right, the aorta, the cisterna chili, and the

Central tendon

azygous vein are located between the crura. However, the

vein is rather behind the right crus more so than between the crura.

Course and Relations

Thoracic Surface Abdominal Surface

The pericardium (remember: it is directly fixed to the dia­

The abdominal surface of the diaphragm is occupied to a

phragm through the central tendon) and the heart occupy

great part by the liver. The stomach occupies the abdominal

the central leaflet of the central tendon. The pleura and

surface to the left and anterior, while the spleen is to the

lung rest laterally. The muscular portion itself stretches

left and posterior. The kidneys lie inferior to and on either

over and is in contact with the costal cartilages, the ribs

side of their respective crus. The suprarenal gland lies on

and internal intercostal muscles anteriorly and with the

the crus. The celiac ganglion rest on the crus of the dia­

upper portion of the quadratus lumborum and psoas

phragm, medial to the suprarenal gland.

muscles posteriorly.

Sternocostal

Sternum

triangle Vena caval

Sternal part of

(Larrey's cleft)

diaphragm

aperture

Rectus abdominis

/

Central tendon

Median

Costal part of

arcuate ligament

diaphragm

Aortic aperture Esophageal aperture

External oblique

Lumbar pan of diaphragm,

Lumbar part of diaphragm. right cr us Internal oblique

1'11.11

left crus

\ !l.T\'t1

triangle

Lumbocostal (Bochdalek's triangle)

Transversus abdominis

:

The characteristic pain pattern is referred anterolater­ ally at the level of the mid-thorax. The pain may also

.:..

project to the region between the shoulder blades, usually between the inferior angle of the scapula and the lower cenlical region (a). •

____

__ __

__ __

______ ______ ____

________ L____

I

a

Motion restriction and provocation testing: Quite fre­

quently scapular motion is restricted due to the associ­ ated myofascial restrictions. Hyperabduction of the arms or bringing the elbows together behind the back may elicit the characteristic pain pattern. •

Palpatory localization: The trigger points are palpated

under the scapula at the attachment of the individual muscle slips to the respective ribs. The palpatory as­ sessment further helps determine the extent and se­ verity of potential fascial restrictions ("adhesions") be­ tween the thorax and scapUla.

Patient Positioning and Set-Up •

b

Variation 1: The patient is in the side-lying position

(lateral Sims position) with the involved side facing away from the table. The physician stands behind the patient •

(b).

Variation 2: The patient can also be treated in the supine

position. Here. the physician stands next to the patient on the same side as the incriminated muscle. The physician elevates the patient's arm

(e).

c

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Myofascial Trigger Point Treatment

Technique N: Myofascial release ("fascial separation").

Treatment Procedure

Myofascial release addressing the fascia between the sub­

Technique I: Active, repetitive muscle contraction and

scapularis and serratus anterior muscles is performed. The

relaxation. The trigger point is carefully compressed by the

patient. under careful guidance by the physician, is re­

physician while the patient is instructed to actively and

quested to perform all shoulder motions that are possible

repetitively protract and relax his shoulder.

from this position. When discovering a very painful trigger

Technique II: Stroking massage of connective tissue.

to switch to technique I.

point while performing this technique, it is recommended After introducing an adequate preparatory stretch to the incriminated muscle (the muscle that harbors the trigger point is carefully stretched within the patient's pain toler­ ance), the physician performs a deep stroking type of mas­

Comments

Technique IV is a very effective maneuver for treating the

sage applied to the muscle fibers at their insertion to the

scapular fascial restrictions. The serratus anterior and three

correspond ing rib.

other trunk muscles, namely, the middle scalene muscle, the fourth-layer rotator muscles of the thoracic spine, and

Technique III: "Fascial release." Generalized stretching of

the superior portion of the abdominal muscles, are the

the fascia associated with the lateral muscular slips.

major culprits for posterior thoracic pain.

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Myo(asdal Trigger Point Treatment

Quadratus Lumborum Muscle (Figs. 118.9a-c) Indications •

Pain referral pattern:

The pain is usually reported by the

patient as a "deep low back pain." Trigger points located in proximity to the spine are usually "deep" and project the pain distally in an inferior direction toward the sacrum and the ischial tuberosity. The superficial trigger points, which are generally located more laterally, characteristically refer the pain toward the side of the pelvis and in particular the region of the iliac crest and the greater trochanter, as well as the superior groin, especially when the point is more proximal/superior.

// v. v

v

,

•

v

\)

)

J

/

J

Pain arising from the superficial, more superiorly lo­ cated points may also be projected to the lower abdo­

a

men (a). •

Motion restriction and provocation testing:

Motion test­

ing reveals reduced contralateral side-bending motion due to shortening of the incriminated muscle. Side-bending motion with the patient either sitting or standing (e.g., loaded positions) may exacerbate or precipitate the patient's presenting pain, while unload­ ing the spine may reduce the pain. Particular lumbo­ sacral movements such as simultaneous trunk rotation/ side-bending toward one side and forward flexion may exacerbate the pain, as this may have been the initial precipitating motion. •

Palpatory localization: The physician is seated behind the patient. Starting laterally from the iliocostalis muscle, the quadratus lumborum muscle is approached by moving medially until the trigger point is encoun­ tered. This may require that the physician introduce

b

some side-bending, either toward the side of the in­ criminated trigger point (for easier access) or to the opposite side in order to introduce additional stretch, depending on the individual situation. The lateral (superficial) trigger points are located just below the 12th rib or directly above the iliac crest. The deep (medial) trigger points lie in close proximity to the transverse processes of the lumbar vertebrae (b).

Patient Positioning and Set-Up •

The patient is seated on a stable stool with his legs supported on the floor,

or

may sit astride the examina­

tion table. •

Alternatively, the patient may be positioned prone. c

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Copyrighted Material

Myofascia/ Trigger Point Treatment

Technique III: "Fascial release." This technique may not

Treatment Procedure

always be possible since the space between the 12rh rib and

Technique I: Active, repetitive muscle contraction and relaxation. While slight

pressure

(e. g.,

the pelvic crest may be too narrow for access.

appropriately

dosed compressive force) is applied to the localized trigger

Technique IV: Myofascial release ("fascial separation").

point by the physician, the patient is requested side-bend

This technique can be utilized especially when addressing

his trunk alternately toward and away from the muscle that

the fascial structures between the iliocostalis and quadra­

harbors the trigger point (c).

tus lumborum muscles.

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774

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Huber.

Index Page numbers in italics refer to illustrations

A

biomechanics 51

abdominal wall muscles 672, 684

exercises 34

external oblique 684, 685

myofascial trigger point treatment

arthrosis

function 51-53, 52

acromioclavicular (AC) joint 265,

injury to 53-54

265

alpha motor neurons 95-96

carpometacarpal joint, degenerative

analgesics see pharmacologic treat­

282-284,284

ment of chronic pain

hip 299

internal oblique 683,684-686

anatomic barrier (AB) 9

posttraumatic 269, 269

rectus abdominis 686-687, 687

angular motion 5-6,6

742,742

myofascial trigger point treatment

743,743

strength and endurance assessment 687,688

see also arthritis

atlantoaxial joint (C 1-C 2 ) 47 -49

ankle examination 588-591,588-591

coupled movement 49

passive motion testing 589,589

flexion and extension 49,52-53

translation evaluation 590,590

functional treatment

transversus abdorilinis 685, 686,

functional treatment 598-599,

mobilization without impulse 356,

687

598-599

356

strengthening of 688-689

abscess, epidural 225

acetaminophen 108

Achilles tendinitis 326

acoustic neuroma 227

acromioclavicular (AC) joint

ankylosing spondylitis 165,234

NMT1 359, 359

anterior cruciate ligament (ACL)

NMT2 361-362,361-362,365,365

examination 579-581,579-581

insufficiency 580,580

tears 312-314

treatment 305

arthrosis 265,265

anterior drawer sign (ADS) 581, 581

NMT1 509, 509

anterior serratus muscles 676,676, 677

translation evaluation 503,503

see also shoulder

active motion testing

myofascial trigger point treatment

738-739, 738

anticoagulation therapy 166

NMT3 363-364,363-364,366,366

self-mobilization 360,360

irritation zone 332,333

range of motion 50

rotation 49, 53

evaluation 345-348, 345-348

side-bending 49, 53

evaluation 344,344

see a/so cervical spine

anticonvulsants 109

atlanto-occipital joint (CO-C 1 ) 44-47,

axial rotation 345,345

antidepressants 109,111

44,45

inclination and reclination 341,341

apophyseal joints

cervical spine 335-336, 335,336

elbow 511, 511, 514, 514

hand 525,525

articular neurology 81-87

joint capsule receptors 81-83

functional treatment

mobilization without impulse 355,

355

hip 556-557, 556,564,564

cervical spine 54-55

NMT1 357,357

knee 574-575,574-575

mobilization with impulse 19

self-mobilization 358, 358

lumbar spine 429, 429

mobilization without impulse 16-17

irritation zone 332

pelvic girdle 454, 454

see also facet joints

nutation motion 45

ribs 404,404

Arnold-Chiari malformation 240,240

range of motion 48

sacroiliac joint 454,454

arthritis

rotation 47

shoulder 484, 484,490-492,

acromioclavicular joint 265

490-492

elbow 275-276

painful arc 487-488,487-488

glenohumeral 263-264,264

thoracic spine 403, 403

great toe 319

wrist 525, 525

hip 291

see also motion testing

actual physiologic barrier (APhB) 9

Side-bending 46-47,46,47

evaluation 344,344

see also cervical spine

atlas 48

cruciform ligament of 53,53

septic 295

injury to 53-54

thumb 282

posterior arch 331

adductor brevis muscle 704-705

see also osteoarthritis; rheumatoid

tra nsverse process 331

adductor longus muscle 704

arthritis

see also atlantoaxial joint ( C 1-C2 ) ;

arthroplasty

atlanto-occipital joint (CO-C 1 ) ; cer­

adductor magnus muscle 705

adhesive capsulitis 261-262

see also shoulder

adolescent idiopathic scoliosis 244

affective state assessment 175

alar ligaments 50, 51-53,51

elbow 268, 268

vical spine

complications 269

ATPase stain 88-89, 88

outlook 269, 270

atrophy, muscle fibers 89,90,91-93

knee 308-309,309

arthroscopy, knee 306,307,308

selective 89, 89, 91-93

attachment tendinoses 130

775

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Index

avascular necrosis 289

palpation 531,531

NMB 375,375, 384,384,386,386

femoral head 289,300-301

translation evaluation 541-543,

C1-C 2 363-364,363-364, 366,

knee 309

541-543

366

Legg-Calve-Perthes disease 293

see also wrist

C2-C 3 368,368

axial system 41-42,41,42,43

carpal tunnel 278

self-mobilization 382,382,392,

axis 54

carpal tunnel syndrome (CTS) 276-279,

392

degenerative changes 63

278

spinous process 331

carpometacarpal joints

see also atlantoaxial joint (C 1-C2); cervical spine

CO-C 1 358,358

degenerative arthrosis 282-284,284 translation evaluation 544-546, 544-546 cervical intertransverse muscles

B Baastrup syndrome 205

computed tomography 196-199 functional computed tomogra­ phy 197-198

anterior 654,654

neutral position 196-197,198

posterior 656, 656, 658,658

rotation evaluation 198-199,

back muscles 606

cervical migraine 163

back pain

cervical spine 44-61

evidence base in manual medicine

C 1-C 2 360,360 imaging studies 187-201

biomechanics 44-50,54-61

167-170

coupling patterns 58-59, 59

possible neural mechanisms

range of motion 58-60, 58,61, 199

199 functional radiographic studies 192-196 flexion and extension 192-194, 192-196

85-87

bony landmarks 331-332,331

see also pain

disk herniation 161

magnetic resonance imaging

examination 335-354

199-201

Bankart lesion 266 barriers of motion 8-9,9, 88-89,88 end-feel at 14-16 joint localization at 9 Barsony view 204,204,205 Bechterew disease 165,234

active motion testing 335-336, 335,336 axial rotation 345,345

187-191 irritation zones (IZ) 332-334,

341

332-334

forced axial rotation with side­

biceps femoris muscle 718, 718

bending 348, 348

stretching of 720, 720

functional MRI 200,200,201 plain radiographs 187-189,

inclination and reclination 341,

benzodiazepines 109

bone palpation 138

side-bending 196, 196,197

passive motion testing 337-338, 33

338,351-353,351-353

provocation maneuvers 334, 334 ligaments 51-54 injury to 53-54 nerve root syndromes 221

bone scans 213

axial rotation 343, 343,346-347,

palpation 331

bony landmarks

346,347

soft-tissue injury 162-163

cervical spine 331-332,331

inclination and reclination 342,

acute 162

lumbar spine 425

342

chronic 163

pelvic girdle 448

joint play 343, 343

stenosis 162,189,190-191,192

sacroiliac joint 448

rotation C 2-C 3 349, 349

see also atlantoaxial joint (C 1-C2);

shoulder 482,482-483

rotation in extension 339,339

thoracic spine 393, 394

Side-bending 344, 344

atlant a-occipital joint (CO-C 1) cervicogenic headache 228-231

borreliosis 224

translatory gliding 350,350,354,

botox injections 121

354

characteristics 230

Bottle sign 526, 526

vertebral artery 340,340

criteria for 230

bracing,scoliosis 248 Brown-Sequard syndrome 224,225

functional treatment 355-392 mobilization with impulse

bunion 317

370-374,370-374,377-380,

bursitis

377-380,387-391,387-391

olecranon 273-274

mobilization without impulse

retrocalcaneal 326

369-370,369-370,376,376

c

presentation 229-231 cervicogenic vertigo 163,226 see also vertigo Chapman's points 143

C 1-C 2 356, 356

chondrolysis 289 claw toe 321

NMT1 381,381,392,392 CO-C 1 357,357

261

C1-C2 359,359

carpal bones

factors in formation of 229 hypotheses 229

Co-C 1 355,355

calcifying tendinitis,shoulder 259-261, capitate translation 543,543

anatomy 228-229

NMT2 375,375,383,383,385,385 C 1-C 2 361-362,361-362,365,

clinical instability see instability coccyx 448 Cadman test 486, 486 coefficient of friction 6,6 cognitive behavioral therapy 111-112

mobilization without impulse 552,

365

cold treatment 39

552

C2-C 3 367,367

collateral ligaments,knee 578,578

776

Copyrighted Material

Index

deltoid muscle 723, 723, 724

outlook 269, 270

arthroplasty 269

depression 110-111

simultaneous shoulder and elbow

disk herniation 172

destructive zone 8

hip replacement surgery 299

developmental dysplasia of the hip

complications 1,3,171-172

knee replacement surgery 309

289-291,291

phrenic nerve paresis/palsy 172

diaphragm 680-683, 680-682

vertebral artery dissection 172

disk see intervertebral disk

see also risks

disk herniation 56,56,113

compression

destruction 268-269 electrotherapy 39 scoliosis 248 end-feel assessment 142 at motion barrier 14-16

acute 15-16, 56

median nerve 276

as complication 172

nerve root 216, 219

cervical 161

spinal cord 200, 200, 201

lumbar 160,211,212

compression tests

hard 15,15 soft 15,15 epicondy I itis lateral 270-271

nerve root compression 219

medial 272-273

see also elbow

median nerve 529,529

muscle pathology and 90-93

ulnar nerve 529, 529

thoracic 220

epidural abscess 225

see also intervertebral disk

epilepsy 228

computed tomography

disseminated idiopathic skeletal hy­

erector spinae muscles 619-633,

neutral position 196-197, 198

perostosis (DISH) 235

619-620, 624

rotation evaluation 198-199, 199

distal radioulnar joint

cervical spine 196-199

functional computed tomography

mobilization without impulse

iliocostalis 629-630, 629,630 longissimus capitis 627-628,628

197-198

548-550,548-550

longissimus cervicis 627,628

lumbar spine 210-211

translation evaluation 538-539,

longissimus lumborum 621-622,

thoracic spine 203,203

538-539

621

see also wrist

concave rule 10,10 congenital dislocation of the hip (CDH)

distraction therapy 111

longissimus thoracis 623-625,623, 626

289

dizziness 226-228

myofascial trigger point treatment

consent, informed 171

documentation requirements 173

744-745,744

convex rul.e 10,10

dorsal nerve root ganglion 85-86

spinalis 631,631-632

core-targetoid fibers 90, 90,92

draftsmen's elbow 273

treatment 633, 633 examination see neuro-musculoskele­

corticosteroids 109

Duchenne sign 557

costotransverse joints 65,66

duck walk 570, 570

tal (NMSK) examination

costovertebral joints 65,66

Dupuytren contracture 279-281,280,

exercise

COX inhibitors 100,102,104-108

281

Scheuermann disease management

coxa plana 293

Durlacher-Morton disease 323

250-251

coxalgia 196

dynatomes 217,218

scoliosis management 248

see also home exercise program;

coxarthrosis 291, 296 crepitus 6 cruciate ligaments see anterior cruciate

reconditioning and training

E

therapy

ligament (ACl); posterior cruciate liga­

eicosanoid biosynthesis 99, 700

extensor digitorum brevis muscle 597,

ment (PCl)

elastic zone 8

597

cruciform ligament of the atlas 53, 53

elbow 268-276

injury to 53-54 cubital pain syndrome 270

arthritis 275-276 examination 481,481,510-519

extensor muscles of the wrist see wrist extensors external oblique abdominal muscle

cuboid translation 593,593,596,596

active motion testing 511,511,514,

cuneiform translation 594-595,594-595

514

myofascial trigger point treatment

cyclooxygenase (COX) 99

passive motion testing 512,512,

742,742

COX inhibitors 100,102,104-108

514-515,514-515

isoforms 105-106,105

varus and valgus stress testing 513,

684,685

see also abdominal wall muscles extramedullary, intraspinal tumors 222

513

functional treatment 520-522

D

lateral epicondylitis 270-271

F

de Quervain disease 281-282

medial epicondylitis 272-273

FABER-Test 453, 453

deconditioning, pain and 153-154,153

olecranon bursitis 273-274

facet joints

degenerative changes 13-14,13,63,

surgical interventions 268-269

231-232

arthroplasty indications 268

assessment 138-139 cervical spine 54, 54, 57

pain and 158,159

complications 269

inclination 54,54, 57, 57

see also specific disorders

history 268

movements 57,57,58,58

777

Copyrighted Material

Index

facet joints

functional radiographic studies

degrees of freedom 43-44

cervical spine 192-196

inclination 54. 54.57.57.64

flexion and extension 192-194.

lumbar spine 66

192.193-196 computer-assisted method 194

mobilization-with-impulse 19

graphic method 193

mobilization-without-impulse 16-17 thoracic spine 64

lumbar spine 207-210.208-209

see also apophyseal joints fasciae.palpation 138 fascial release 30 fascial separation 30

active motion testing 525.525 finger power 536.536 median nerve function to thumb 526.526 passive motion testing 535.535 selective finger extension 537.537 ulnar nerve function 527-528. 527-528 functional treatment 553-554.

G

553-554

gamma motor neurons 95-96

Hawkin's test 255

fast-twitch (type II) muscle fibers

ganglia. wrist 284-285

headache see cervicogenic headache

87-88.142

gastrocnemius muscle 721

heat treatment 39

femoral head. avascular necrosis 289.

gate-control theory 100-101.101

heel pain 324-328

300-301

gibbus deformity 249

femoropatellar gliding 586. 586

glenohumeral joint

fibromyalgia 237-238 tender points 143 fingers

hemarthrosis 15.16

instability 267

hemivertebra 240.241 herpes zoster infection 224 hip 287-301

553-554.553-554

translation evaluation 498-500. 498-500

strength testing 536. 536

see also shoulder gluteal muscles 707 -711 gluteus maximus 707.708

flat foot 328-330.330 foot 317-330

exercises 35

acquired flat foot 328-330. 330

myofascial trigger point treatment

deformities of lesser toes 321-322.

74 9.749

322

strengthening of 710-711

examination 588-597

herniation see disk herniation

passive motion testing 486.486

selective extension 537.537

see also hand

subcalcaneal pain 324-326.326

arthritis 263-264.264 evaluation 495-496.495-496

mobilization without impulse

retrocalcaneal pain 326-328.328

gluteus medius 708. 709

adult disorders 288.296-301 avascular necrosis of the femoral head 300-301 fractures 296. 296 osteoarthritis (OA) 296-299.298. 299 childhood disorders 288. 289-295 developmental dysplasia 289-291. 291

extensor digitorum brevis muscle

exercises 35

Legg -Calve- Perthes disease

597.597

myofascial trigger point treatment

293-294.294

passive motion testing 589. 589

750-751.750.753.753

septic arthritis 295

rotation 591.591

strengthening of 710-711

slipped capital femoral epiphysis

translation evaluation 592-596.

gluteus minimus 708.710.710

592-596

myofascial trigger point treatment

functional treatment 600-602

750-751.750.753.753

hindfoot joints 600. 600

strength and endurance assessment

toe joints 601-602.601-602

710.711

hallux rigidus 319-320.320

golfer's elbow 272

(SCFE) 292-293 tumors 289 examination 555-564 active motion testing 556-557. 556.564.564 muscle strength 564.564

hallux valgus of the great toe

Golgi tendon organs 94

passive motion testing 559-563.

317-318

gonarthrosis. knee 308-309.309

559-563

heel pain 324-328

Guentz sign 56.56

retrocalcaneal pain 326-328.328

Guillain-Barre syndrome 224

subcalcaneal pain 324-326.326 Morton neuralgia 323-324.324 Forestier disease 235 fractures hip 296.296 Salter-Harris fracture type I 292 vertebral 164 Froment sign 528. 528 frozen shoulder see adhesive capsulitis

functional treatment 565-568. 565-568

H

total hip replacement surgery 299.

Haglund syndrome 326

299

hallux rigidus 319-320.320

hip/thigh adductor muscles

hallux valgus of the great toe 317-318

704-705

hamate translation 543.543

adductor brevis 704-705

hammertoe 321.322

adductor longus 704

great toe 317

functional computed tomography

hamstring muscles see ischiocrural

197-198

(hamstring) muscles

functional magnetic resonance imaging

hand

200.200. 201

static testing 556 forces 298

adductor magnus 705 NMT2 706. 706 home exercise program 754-764 muscle strengthening 762-764

examination 523-547

778

Copyrighted Material

muscle stretching 756-761

Index

l1ypermobility 166 segmental 157,166

internal oblique abdominal muscle 683, wall muscJes

joint motion 78-80,7 9,80

see also specific joints

interphalangeal joints

hypomobility, segmental 151

passive motion testing 535, 535

cervical spine 194,195, 198 pain intensity and 151-152,151

nociceptors 82-83,82

see also abdominal

lumbar spine 207 pain and 157-158,157

mechanoreceptors 81-82

684-686

joint play 6-7 cervical spine 3 43,343, 3 47,347

translation 547 interspinales muscles 662,662 intertransverse muscle group 653-661,

sacroiliac joint 451,451 juvenile arthritis 236

653

anterior cervical 654,654

K

iliac crest 448

lateral rectus capitis 657, 657

iliacus muscle 696

posterior cervical 656, 656, 658, 658

King classification of scoliosis curves

rectus capitis anterior 655,655

246

myofascial trigger point treatment

thoracic 659,659

748,748

iliocostalis muscle 629-630,629

intervertebral disk

iliocostalis cervicis 629,630

bulging 212, 212

iliocostalis lumborum 629,630

cervical 55

iliocostalis thoracis 629,630

tears 55-56, 55, 56

myofascial trigger point treatment

dehydration 56-57

74 4-745, 744

extrusion 212,213

iliolumbar ligament 458-461, 459

sequestration 213

Kleijn hanging test 63 knee 301-316 cruciate ligament tears 312-316 anterior (ACL) 312-314 posterior (pel) 314-316 examination 569-583 active motion testing 574-575, 574-57 5

functional testing 460,460

innervation 84

provocation testing 461, 461

protrusion 212,213

eruciate ligaments 579-582,

see also

579-582

iliopsoas muscle 694-696,694

disk herniation

collateral ligaments 578, 578

exercises 36

intramedullary space-occupying le­

duck walk 570,570

iliacus 696

sions 222-223

passive motion testing 574-576,

length testing 696-697,697

irritation zones 128,129,132,134 cervical spine 332-334,332-334

myofascial trigger point treatment

provocation maneuvers 334, 334

748-749, 748-749

psoas major 694-695

lumbar spine 425- 427, 426

psoas minor 696

provocation maneuvers 427

stretching of 698-699,698-699

pubic bone 450

imbalance 226-228

provocation maneuvers 450

impulse techniques 4

ribs 395-396, 395, 396 provocation maneuvers 396

inflammation ankylosing spondylitis 165

sacroiliac joint/pelvis 4 48-449, 449

574-576

patellar function 573,573 patellar translation 571-572, 571-572

translation evaluation 583,583 varus and valgus stress testing 578, 57 8

functional treatment 584-587 femoropatellar gliding 586,586 proximal tibiofibular joint 587,587

chronic rheumatoid arthritis 166

provocation maneuvers 449, 449,

instability 304, 579,57 9

sacroiliac joint 205

457,457

meniscus injury 311-312

inflammatory pain 99,100

sternum 396,396

osteonecrosis 309-310,310

informed consent 171

thoracic spine 394-395, 394,395

patients older than 45 years 307 -309

infraspinatus muscle

provocation maneuvers 395

strength testing 491,491

ischemia 227

tear/rupture 257, 258

ischiocrural (hamstring) muscles

injection therapy, myofascial trigger

718-719, 718

points 30

biceps femoris 718, 718

instability 13-14,14,78-80,80

length testing 719, 719

functional assessment 307 pain localization 307 temporal profile of symptoms 307 patients younger than 45 years 302-307

meniscal tears and ligament rup­

cervical spine 196

semimembranosus 718, 719

ture 303-304,303,305

definition 78

semitendinosus 718-719, 718

patellar syndromes 302-303

knee 304

stretching of 720, 720

lumbar spine 207, 208,209 pain and 155-156, 156

patellar-bone reconstruction 306,

J

306

patellar instability syndromes 302

Jobe test 490,490

rheumatoid arthritis and 236

joint capsule

shoulder 267 evaluation 494- 496,494-496 apprehension test 494, 494

surgical treatment 305-309, 305 knee replacement 308-309,309

evaluation 579, 579

innervation 83, 83, 84 palpation 138

postoperative rehabilitation 306-207

kyphosis 249

see also Scheuermann disease

receptors 81-83,82

779

Copyrighted Material

Index

L labral tear 266 Lachman sign 579.579 Lasegue test 16 lateral epicondylitis 270-271

see also elbow lateral mass triangle (LMT) 188 lateral rectus capitis muscle 657.657 lateral sacral angle 448 latissimus dorsi muscle 611-612. 671. 612

exercises 34 leg length difference evaluation 452. 452.558.558

Legg-Calve-Perthes disease 293-294. 294

levator scapulae muscle 613-614. 613 length testing 614.614 myofascial trigger point treatment 734-735.734

treatment 615.615 levatores costarum muscles 678.679 L'hermitte sign 237 LlFEwareSM system 174-185 administration 176 assessment forms 176.177-180 case study 184-185 domains 175-176 mood and affective state 175 pain 175 physical function 175 measures 175 Rasch analysis 174-175 reports 176.181-183 case history report 176.182 case profile report 176.181 patient-specific report 176.183 ligaments cruciform. of the atlas 53.53 injury to 53-54 knee examination 304 collateral ligaments 578. 578 cruciate ligaments 579-582. 579-582

rupture 303-304 injury mechanisms 304 treatment 304. 305 sacroiliac joint 72. 76 iliolumbar 458-461.459 functional testing 460.460 provocation testing 461.461 posterior sacroiliac 464-465.464 functional testing 465.465 sacrospinous 462-463.462 functional testing 463.463 sacrotuberous 466.466

supraspinous 662. 662

mobilization without impulse

see also alar ligaments

435-437.435-437

limb joints

NMT1 445.445

mobilization with impulse 19.20

NMT2 435.435. 437.437. 446.446

mobilization without impulse 17.

NMT3 447.447

17

self-mobilization 445. 445

load-displacement diagram 7.8

imaging studies 203-211

locked knee syndrome 311

computed tomography 210-211

longissimus capitis muscle 627-628.

functional studies 207-210.

628

208-209

longissimus cervicis muscle 627. 628

magnetic resonance imaging

longissimus lumborum muscle

210-211.210.211

myelography 210-211.211

621-622.621

length testing 622.622

plain radiographs 203-207.

longissimus thoracis muscle 623-625.

204-208

irritation zones 425-427.426

623.626

endurance test 625.626

provocation maneuvers 427

myofascial trigger point treatment

muscle origins and insertions 427

744-745.744

nerve root syndromes 221-222

longus capitis muscle 670.671

palpation 425.425

longus colli muscle 670.671

spondylolisthesis. with spondylosis

lordosis 249

164

low-frequency electric current treat­

stenosis 161.211.225-226.226

ments 39

lunate translation 541-542.541-542

lower limb 287-330

Lyme disease 224

examination 555.569.569 muscles 693

see also ankle; foot; hip; knee lumbar intertransverse muscles lateral 661.661 medial 660.660 lumbar spine anular tears 214 biomechanics 66-68

M macrotrauma 13.13 magnetic resonance imaging (MRI) cervical spine 199-201 functional MRI 200.200.201 lumbar spine 210-211.210.211 thoracic spine 203. 203

coupled movements 66. 67

mallet toe 321

flexion and extension 66. 68

manipulation 4

range of motion 66-67.66.68.207. 209

objective documentation of 66-68

see also manual medicine; mobiliza­ tion-with-impulse (MWITH) manual medicine documentation requirements 173

rotation 66. 68

effectiveness 167-170

side-bending 66. 68

evidence base 167-170

bony landmarks 425

history 1.167

bulging disks 212.212

outcomes 2-3

disk extrusion 213.213 disk herniation 160.211.212 nerve root compression 219

measures 174-185 quality control 172-173 recent international perspective 1-2

disk protrusion 212.213

requirements of individual practi­

examination 428-435

tioners 170

active motion testing 429.429

see also manipulation; mobilization;

passive motion testing 430-433.

myofascial trigger point therapy;

430-433

neuromuscular therapy (NMT)

springing test 434.434 static examination 428.428 functional treatment 435-448

mastoid process 331 Mathiass test 625.626 mechanoreceptors 81-82. 82

mobilization with impulse

central interactions of impulses 84.85

438-444.438-444

reflexes 84-85.85.86

780

Copyrighted Material

Index

type I receptors 81-82 type II receptors 82 type III receptors 82 medial epicondylitis 272-273 see also elbow

median nerve 278 compression/entrapment 276-279 compression test 529,529 functional evaluation 526,526

elbow 520-521.520-521

moth-eaten fibers 90. 90

proximal radioulnar joint 522,522

selective atrophy of one fiber type

foot 600-602,600-602

89,89

hand 553-554,553-554

split fibers 90,91

hip 565-568,565-568

target fi bers 89-90,90

knee 584-587,584-587

type grouping 89, 89

lumbar spine 435-437, 435-437

postcontraction sensory discharge 96

ribs 415-416,415-416,418-420,

slow-twitch (type I) fibers 87-88,142

428-420

strength see muscle strength assess­

Medical Rehabilitation Follow Along

sacroiliac joint 467-470,467-470

ment

(MRFA) 175

shoulder 504-507,504-507

tension control 95, 96

Meniere disease 227 meniscal tears, knee 303-304,311-312

sternoclavicular joint 508, 508 synovial joints of extremities 17,18

see also specific muscles

muscle length

examination 304

thoracic spine 406-408,406-408,

control of 95-96,95

injury mechanisms 304

414,414,435-437.435-437

determination 603

treatment 304,305 surgery 305-307,305,306

wrist 548-552. 548-552

iliopsoas 696-697,697

see also manual medicine

ischiocrural (hamstring) 719, 719

meniscoids 55

mood assessment 175

metacarpophalangeal joints

MOlton neuralgia 323-324,324

longissimus lumborum 622,622

mobilization without impulse

moth-eaten fibers 90,90

pectoralis major 674, 674

553-554,553-554

motion barriers see barriers of motion

piriformis 712-713. 713

passive motion testing 535,535

motion testing 135

levator scapulae 614, 614

quadratus lumborus 691,691

metamizol 108

pain and 142

rectus femoris 700-701.701

metastatic bone disease 223

range of motion assessment

scalene 668, 668

metatarsal joints, translation evalua­

140-142,141

sternocleidomastoid 665,665

tion 595-596,595-596

end-feel 142

suboccipital muscles 643,643

microtrauma 13,13

quality of range of motion 141-142

tensor fasciae latae 716

migraine, cervical 163

quantity of range of motion

miner's elbow 273

140-141

trapezius 608.609 see also musc1e(s)

mobility gain 10, 11

sacroiliac joint 77

mobilization 4

scoliosis 247

Golgi tendon organs 94

see also active motion testing: pas­

motor end plates 94-95,94,95

see also manual medicine: mobiliza­

tion-with-impulse (MWITH): mobi­

sive motion testing

lization-without-impulse (MWOUT):

motor end plates 94-95,94,95

neuromuscular therapy (NMT): self­

multifidus muscle 648-650, 648, 649

mobilization

cervical spine 648

muscle receptors 93-95

muscle spindles 93-94.94 muscle relaxants 109 muscle spasm 98,129 muscle strength assessment 603

mobilization-with-impulse (MWITH) 4,

lumbar spine 648

5,19,19,20

myofascial trigger point treatment

fingers 536.536

cervical spine 370-374,370-374,

746.746

gluteal muscles 71, 711

377-380,377-380,387-391,

pathological changes 90-92

hip 564,564

387-391

thoracic spine 648

limb joints 19,20

multiple sclerosis 228

lumbar spine 438-444,438-444

muscle(s) 604, 605

ribs 417. 417.421-423, 421-423

evaluation goals 603

abdominal wall muscles 687,688

longissimus thoracis endurance test 625.626

shoulder 484,484,489-492, 489-492

risks 1 2

fast-twitch (type II) fibers 87-88,142

shoulder blade fixator muscles

sacroiliac joint 471-478, 471-478

function

617-618,617

spine 19

assessment 135,142-143

thoracic spine 387-391, 387-391.

pain and 158,159

see also muscle(s)

muscle tone

409-414,409-414

hypertonic 603

control of 96-98,97

see also manual medicine

imbalance, pain and 155, 155

evaluation 138

mobilization-without-impulse

length see muscle length

(MWOUT) 4.5,16-17,17,18

nociceptive muscle afferents 96-98

musculoskeletal examination see

ankle 598-599,598-599

palpation 138,140

neuro-musculoskeletal (NMSK) exami­

cervical spine 369-370.369-370.

pathological c hanges 89-93

nation

myospasm and 129,130

atrophy of a large fiber group 89,

music therapy 112

(0-( 1 355, 355

90

myelography, lumbar spine 210-211,

(1-( 2 356,356

core-targetoid fibers 90, 90

211

376,376

781

Copyrighted Material

Index

myelopathy, cervical 236-237 myofascial pain syndromes 118-121 see also myofascial trigger points

myofascial release 30 myofascial tissue changes 603 myofascial trigger point therapy 28-31, 728-753

associated ultrasound treatment 30

erector spinae muscles 744-745,74 4 external abdominal oblique 742,742 gluteal muscles 749-751,749-750, 753,753

iliacus 748,748 injection therapy 30 levator scapulae 734-735,734 manual trigger point techniques 28-30

active repetitive contraction and relaxation 29-30 fascial release 30 myofascial release 30 passive muscle stretch 30 multifidus 746, 746 obliquus capitis inferior 729,729 piriformis 752, 752 psoas 747, 747 quadratus lumborum 740-741,740 rectus abdominis 743,743 rectus capitis major and minor 728, 728

rotatores 746,746 scalene 731-732, 731 semispinalis capitis 730. 730 semispinalis cervicis 730. 730 serratus anterior 738-739. 738 sternocleidomastoid 733,733 trapezius 736-737.736-737 myofascial trigger points 118.119-120 evaluation 143.603 pain referral patterns and 121 palpation 118 treatment options 121 twitch response 143 types of 118 see

also myofascial trigger point

therapy myofibrillar ATPase stain 88-89.88 myospasm 129,130 myotendinosis 122,129-131.130.132 lumbar spine 426 systematic 131 myotendinous junction 138 myotenones 130-131. 131

ischiocrural (hamstring) muscles

N

720.720

navicular translation 592.592

levator scapulae muscle 615,615

neck muscles 606, 663

lumbar spine 435. 435. 437,437,

see also specific muscles

446.446

necrosis

pectoralis major muscle 675.675

femoral head 289,300-301

piriformis muscle 714. 714

osteonecrosis of the knee 309-310,

quadratus lumborum 692.692

310

rectus femoris muscle 702-703.

Neer test. modified 255

702-703

nerve root

ribs 424. 424

compression 216,219

scalene muscles 669.669

syndromes 219

sternocleidomastoid muscle 666.

cervical 221

666

lumbar 221-222

tensor fasciae latae 717,717

symptomatology 219. 221-222

thoracic spine 407-408,407-408,

see also specific syndromes

435.435. 437. 437

neuralgia. Morton 323-324.324

trapezius muscle 610.610

neurinoma 223

triceps surae 722.722

neuro-musculoskeletal (N MSK) exami­

wrist extensors 727, 727

nation 135-144,136

NMT 3: utilization of reciprocal in­

examination levels 148,148

Ilibition of antagonists 26.27.28

functional muscle evaluation 135,

cervical spine 375,375. 384.384 .

142-143

386.386

motion testing 135,140-142

(1-( 2 363-364.363-364 .366.

observation 137

366

palpation 135.137-140

(2-(3 368.368

provocative tests 135,144 selection of diagnostic/laboratory studies 136. 144 neurogenic amyotrophy 223.224

lumbar spine 447. 4 47 neuropathic pain 99. 109 neutral zone 8 increased 10-11

neuroleptics 109 neuroma acoustic 227 Morton 323-324.324 neuromuscular therapy (NMT) 21-28 NMT 1: utilization of antagonist muscles 23.24

degenerative changes 13-14,13 NMDA receptors, WDR neuron 101 nociceptive pain 99 nociceptive reaction 14,14 reconditioning therapy and 31 nociceptors 82-83,82, 96-98 central interactions of impulses 84,

acromioclavicular joint 509.509

85

cervical spine 381.381,392.392 (0-( 1 357,357 (1-(2 359.359

lumbar spine 445. 4 45 ribs 419-420,419 -420 sacroiliac joint 468-469. 468-469.

reflexes 84-85.85.86 noninflammatory soft-tissue rheuma­ tism 130.130 NSAlDs 104-105.106-108 nuchal line inferior 331

479,479

thoracic spine 392. 392 NMT 2: utilization of postisometric relaxation phase of shortened

superior 331 nuclear medicine studies 213 nucleus pulposus 56.56 dehydration 56-57

muscles 23-26,25,26

pain and 86

cervical spine 375.375. 383.383. 385.385 (1-(2 361 -362,361 -362,365. 365 (2-(3 367.367

erector spinae muscles 633,633 hip/thigh adductors 706. 706 iliopsoas muscle 698-699, 698 -699

782

Copyrighted Material

o obliquus capitis inferior muscle 642-643,6 42.643

myofascial trigger point treatment 729.729

Index

obliquus capitis superior muscle 642.

pain reaction 14. 14

642, 643

patellar pain syndromes 302

psoas major 695. 695

observation 137

provocation by palpation 149-150.

quadratus lumborum 690.691

occipitoatlantal joint see atlantoaxial

150

rectus capitis posterior 640.641

joint (( 1-( 2 )

see also provocation testing

posterior serratus 636.637

rectus femoris 700

occiput 331,331

pseudo-spinal 238-239

rhomboid major/minor 617,617

olecranon bursitis 273-274

psychologic aspects 110-112

rotatores 651

omarthritis 263

cognitive behavioral therapy

scalene 668

omarthrosis 263

111-112

semispinalis 645.646-647

opioids 102-104

range of motion testing and 142

soleus 721

reconditioning therapy and 31

spinalis thoracis 631. 632

orthoses, scoliosis 248

referred 114-115. 114.115.116-117

splenius 634

osteoarthritis

side-effects 104

treatment selection and 146.149-158

sternocleidomastoid 665.665

elbow 275

see also myofascial pain syndromes:

tensor fasciae latae 716

hip 296-299,298,299

pseudoradicular syndrome: spondy­

trapezius 608. 609

surgical intervention 299 knee surgical intervention 308-309 thumb 282 osteomalacia 233

logenic reflex syndrome painful arc. shoulder 487-488.487-488

wrist extensors 726 myofascial trigger points 118

palmar fasciitis 279

objective 139

palmar fibrosis 279

pain provocation 149-150,150

palpation 135,137-140

see also provocation testing

osteonecrosis of the knee 308-309,309

carpal bones 531. 531

pelvic girdle 448

osteophytes 15

cervical spine 331-332

sacroiliac joint 77.448

osteoporosis 164,232-233

definition 137

iliolumbar ligament 458

diaphragm 683

posterior sacroiliac ligament 464.

osteotomy, proximal tibia 308,308

lumbar spine 425, 425

464

outcome measures 174-185

muscle 140

sacrospinous ligament 462

signs and symptoms 232-233

abdominal wall muscles 684. 686.

p

sacrotuberous ligament 466

687

structures examined 138-139

anterior serratus 676. 677

subjective 139

Paget disease 233-234

deltoid 723. 724

thoracic spine 393-394

pain 214-215

gastrocnemius 721

ulnar nerve 519. 519

assessment 175, 214-215

gluteal 707, 708.709.709,710

wrist extensors 530.530

drug treatment see pharmacologic

hip/thigh adductors 704-705

treatment of chronic pain

iliacus 696, 696

inflammatory 99, 100

iliocostalis 629-630.630

ankle 589, 589

intensity 149

interspinales 662

cervical spine 337-338.337. 338.

intertransverse

351-353,351-353

degenerative changes 158, 159

wrist flexors 532. 532 passive motion testing

history and 149,149

cervical 654. 654,656.657.658

instability and 155-156, 156

lumbar 660.661.661

346,347

muscle function and 158. 159

thoracic 659

inclination and reclination 342.

axial rotation 343, 343, 346-347.

muscle imbalance and 155,155

ischiocrural (hamstring) 718, 719

342

neurologic deficits and 152-153.

lateral rectus capitis 657.657

joint play 343. 343 rotation (2-(3 349. 349

152

latissimus dorsi 611-612. 612

physical functioning and 153-154.

levator scapulae 614.614

153

levatores costarum 678, 679

foot 589. 589

psychosocial factors 154.154

longissimus capitis 628

hand 535. 535

segmental hypermobility and

longissimus cervicis 627

hip 559-563,559-563

157-158.157

longissimus thoracis 625. 626

knee 574-576, 574-576

segmental hypomobility and

longissimus lumborum 621, 621.

lumbar spine 430-433.430-433

151-152.151

elbow 512. 512.514-515,514-515

622

pelvic girdle 451.451

knee 307

longus capitis 670, 671

sacroiliac joint 451. 451

mechanisms 85-87. 99-101

longus colli 670. 671

shoulder 485-486. 485-486

multifidus 649

thoracic spine 398. 398,403, 403

gate-control theory 100-101. 101 muscle 96-98

obliqulls capitis superior 642, 642,

neuropathic 99.109

643

with active assistance 402,402 wrist 530-531. 530- 531.533-534,

nociceptive 99

pectoralis major 674

533-534

organ-related 238-239

piriformis 712. 713

see also motion testing

783

Copyrighted Material

Index

patella bone reconstruction 306. 306

functional evaluation 573.573

translation evaluation 571-572.

571-572

see also knee patellar syndromes 302-303

examination 302-303

instability syndromes 302

pain syndromes 302

pathologic barrier (PB) 9.15

Patrick test 453. 453

pectoralis major muscle 67 3-674.67 3.

674

length testing 674. 674

stretching of 675. 675

pelvic girdle 69-7 8

bony landmarks 393.448

examination 451-456

active motion testing 454

passive motion testing 451. 451

Patrick of FABER-Test 453. 453

imaging 203-211

irritation zones 448-449

provocation maneuvers 449

microscopic 69

palpation 448

pelvic torsion 205. 205

Perthes disease 293

pes planus 328

Phalen test 529. 529

pharmacologic treatment of chronic

pain 102-109

COX inhibitors/NSAIDs 104-108

opioids 102-104

phrenic nerve paresis/palsy. as com­

plication 172

physical therapies 39-40

physiologic barrier (PhysB) 8-9.15

piriformis muscle 712-713.712.713

length testing 712-713. 713

myofascial trigger point treatment

752.752

provocation testing 713

stretching of 714. 714

pitcher's elbow 272

plantar fasciitis 324

plastic zone 8

polyarthritis. chronic 200. 200. 201

elbow 268.268

polymyalgia rheumatica 236

polyradiculitis 224

posterior cruciate ligament (PCl)

examination 57 9.57 9.582.582

tears 314-316

posterior drawer sign (PDS) 582.

posterior sacroiliac ligament 464-465.

464

functional testing 465. 465

palpation 464. 464

posterior serratus muscles 636-637.

Q quadratus lumborum muscle 690-691. 690.691

exercises 35

length testing 691. 691

myofascial trigger point treatment

636. 637

posterior superior iliac spine (PSIS) 448

prostaglandin synthesis 99-100. 100

see also cyclooxygenase (COX) provocation testing 10.11.135.144

cervical spine 334.334

lumbar spine 427

palpation and pain provocation 149-150.150

pelvic girdle 449

piriformis muscle 713

pubic bone 450

reclination/cervical extension 62-63

ribs 396

sacroiliac joint 7 7.449. 449.457.457

iliolumbar ligament 461.461

thoracic spine 395

proximal acetabulofemoral disorder 289

proximal motor neuropathy 234

proximal radioulnar joint

mobilization without impulse 522.

522

translation evaluation 517.517

see also elbow

proximal tibia osteotomy 308. 308

proximal tibiofibular joint

mobilization without impulse 587.

587

translation evaluation 583.583 see a/so knee

pseudoarthrosis. supracondylar hume­

rus 269.269

pseudoradicular syndrome 122-125

lower body syndromes 123

reflex syndromes associated with

trunk and viscera 123

sternal syndrome 122. 122.123

symphyseal syndrome 124-125.124.

125.126

pseudospondylolisthesis 242.243 psoas muscle myofascial trigger point treatment 747. 747

psoas major 694-695

psoas minor 696

pubic bone irritation zones 450

provocation maneuvers 450

localization of 456. 456

582

740-741. 740

stretching of 692. 692

quality control 172-173

quality of life (QOl) 174

measurement see UFEwaresM system R

radicular syndromes 219

symptomatology 219.221-222

see also specific syndromes radiocarpal joint translation 540.540 radiographs cervical spine 187-189

anterior-posterior CAP) view

187-188.188.189.191

lateral view 187 -188.187.189.189. 191

oblique view 189.189

lumbar spine 203-207.204-20 8

Scheuermann disease 250

scoliosis 247. 248

thoracic spine 201.202 see also functional radiographic

studies

radioulnar joint see distal radioulnar joint; proximal radioulnar joint range of motion see motion testing; specific joints Rasch analysis 174-175

reconditioning and training therapy

31-38

abdominal oblique muscles 34

gluteus maximus muscles 35

gluteus medius muscles 35

iliopsoas muscle 36

latissimus dorsi muscle 34

pain and31

quadratus lumboriJm muscles 35

shoulder elevation 33

tensor fasciae latae muscles 35

trunk extension and rotation 36

trunk side-bending movements 37.

37-38

rectus abdominis muscle 686-687.687

myofascial trigger point treatment

743.743

see also abdominal wall muscles

rectus capitis anterior muscle 655.655

rectus capitis posterior major muscle

640.640.641

784

Copyrighted Material

Index

myofascial trigger point treatment

increased neutral zone and 13-14

sacroiliactitis 205

728,728

pain reaction 14

sacrospinous ligament 462-463, 462

rectus capitis posterior minor muscle

repetitive mobilizations into the

640-641,640,641

plastic zone 14,14

myofascial trigger point treatment 728,728 rectus femoris muscle 700-701, 700,

sacrotuberous ligament 466,466

see also complications

Salter-Harris fracture type I 292

force-distance diagram 7

length testing 700-701,701

sausage sign 211. 211 scalene muscles 667-668,667 anterior 667

rotator cuff strength testing 489-492, 489-492

stretching of 702-703,702-703

palpation 462

velocity of mobilization force and 12 roll-and-glide motions 5-6, 6

701

functional testing 463, 463

length testing 668, 668

referred pain 114-115,114, 115,

tear 256-259, 258

middle 667

116-117

tendinopathy 253-255

myofascial trigger point treatment

myofascial trigger points and 121

reflexes 84-85,85, 86

see also shoulder

rotatores muscles

731-732,731 posterior 667 -668

Reiter syndrome 234

myofascial trigger point treatment

relaxation therapy 111

746,746

scaphoid translation 541,541

resting position (R) 9

rotatores breves 651-652, 652

scapular triangle 394

retrocalcaneal pain 326-328,328

rotatores longi 651-652, 652

Scheuermann disease 249-251

retrodental pannus 200,200

rule of threes 395

retropharyngeal space measurement

189,191

retrotracheal space measurement 189,

stretching of 669, 669

differential diagnosis 250

etiology 250

examination 250

s

pathogenesis 250

191

sacral hiatus 448

presentation 250

reversed Lasegue test 16

sacroiliac joint 69,448

radiography 250

rheumatoid arthritis 236-237,236,237

arthrosis 204

treatment 250-251

elbow 275

bony landmarks 448

schwannomas 222

inflammation of vertebral column

degenerative changes 235

scoliosis 244-249

166

examination 76-78,451-457

adolescent idiopathic 244

simultaneous shoulder and elbow

active motion testing 454,454

biomechanical considerations 244

destruction 268-269

adjunct examinations 78

classification 245,246

rheumatologic disorders 234-238

flexion tests 77,455,455

clinical presentation 246

rhizarthrosis 282-284,284

muscle testing 77

etiology 244

rhomboid major muscle 616-617, 616

palpation of soft tissues 77

examination 246-247

rhomboid minor muscle 616-617, 616

passive motion testing 451,451

landmark measurements 247

Patrick of FABER-Test 453,453

motion testing 247

ribs 65-66

evaluation 404-405

active motion during inhalation

range of motion testing 77

muscle fiber changes 244-246

spine test 77-78,454,454

natural history 249

and exhalation 404,404

function 72-76, 73,74, 75

progression 249

individual rib motion testing dur­

functional treatment 467 -479

radiography 247,248

ing respiratory effort 405,405

functional treatment 415-424

mobilization with impulse

thoracic spine changes 245

471-478,471-478

treatment 247-249

mobilization with impulse 417,417,

mobilization without impulse

electrical stimulation 248

421-423,421-423

467-470,467-470

exercise 248

mobilization without impulse

415-416,415-416,418-420,

NMT1 468-469,468-469,479,479

imaging 204,204, 205

418-420

inflammatory changes 205

NMT1 419-420,419-420

innervation 76, 76

NMT2 424, 424

irritation zones 448-449,449

irritation zones 395-396,395,396

provocation maneuvers 396

risks 12-14

provocation testing 77,449,449,

457,457

ligaments 72, 76

observation 248

orthoses 248

surgery 248-249

segmental hypermobility 157,166

pain and 157-158,157

self-mobil ization

cervical spine 358,358,360,360,382, 382,392,392

amplitude of mobilization force and

iliolumbar 458-461,459

(0-( 1 358,358

13

posterior sacroiliac 464-465,464

( 1-( 2 360,360

cond itions with potentially increased

sacrospinous 462-463, 462

risk 160-166

sacrotuberous 466, 466

degenerative changes affecting elas­

open-profile shaped 73, 73

tic tissue structures and 13-14,13

tight-profile shaped 73, 73

lumbar spine 445,445

thoracic spine 392, 392

semimembranosus muscle 718, 719

stretching of 720, 720

785

Copyrighted Material

Index

semispinalis muscle 644-647.644 myofascial trigger point treatment

skin stroke test 139

spondyloarthrosis 204

SLAP (superior labrum anterior poste­

spondylogenic reflex syndrome (SRS) 127-132

730. 730

rior) lesion 266-267

semispinalis capitis 646-647.646.

slipped capital femoral epiphysis

irritation zone 129.132. 134

647

(SCFE) 292-293

muscle correlations

semispinalis cervicis 644-645.644

slow-twitch (type

semispinalis lumborum 644

87-88. 142

gluteal 707. 709.710

semispinalis thoracis 644-645. 644

soft-tissue injury

iliocostalis 630

semitendinosus muscle 718-719.718 stretching of 720. 720 septic arthritis of the hip 295

I) muscle fibers

cervical spine 162-163

anterior serratus 676

lateral rectus capitis 657

acute 162

levator scapulae 614

chronic 163

levatores costarum 678

seronegative spondyloarthropathy

soft-tissue techniques 1.5

longissimus capitis 628

(SNSA) 234-235

soleus muscle 721

longissimus cervicis 627

somatic dysfunction 126-127.133

longissimus lumborum 622

myofascial trigger point therapy

spinal artery occlusion 224

longissimus thoracis 625

738-739. 738

spinal canal width 189.191.192

serratus anterior muscle 676.676.677

serratus posterior inferior muscle 636-637.636

see also stenosis spinal cord 220

longus colli 670 multifidus 650 obliquus capitis inferior 643

serratus posterior superior muscle 636.

circulatory changes affecting 224

obliquus capitis superior 642

636

compression 200. 200.201

piriformis 712

short nuchal muscles see suboccipital

malformations 164

posterior serratus 637

muscles shoulder 252-267 acromioclavicular (AC) joint arthro­ sis 265. 265 adhesive capsulitis 261-262 bony landmarks 482.482-483 calcifying tendinitis 259-261.261

spinal nerves 55

psoas major 695

anatomy 216-217. 216.217.218

rectus capitis anterior 655

joint capsule innervation 83.83

rectus capitis posterior major 640

spinalis muscle 631.631-632 spinalis thoracis 631 spine biomechanics 41-61

rectus capitis posterior minor 641 rhomboid 617 rotatores 651 scalene 668

elevation 33

axial system 41-42.41.42.43

examination 481-503

cervical spine 44-61

spinalis 631

active motion testing 484.484.

coupled movements 44.49.65

splenius 634

490-492.490-492

lumbar spine 66-68

sternocleidomastoid 665

thoracic spine 64-66

trapezius 608

painful arc 487-488. 487-488 muscle strength assessment 484.

congenital malformations 240

484.489-492.489-492

deformities 243-251

shoulder blade fixator muscles 617-618.617 passive motion testing 485-486. 485-486 functional treatment 504-509

kyphosis 249-251 lordosis 249 scoliosis 244-249 imaging studies 186-213 celvical spine 187-201

semispinalis 645.647.647

myospasm 129.130 myotendinosis 129-131.130 spondylolisthesis 241-243 lumbar spine 164 spondylolysis 241-242.242 lumbar spine 164.204 spondylophytes 15

mobilization without impulse

mobilization-with-impulse 19

504-508.504-508

mobilization-without-impulse

spontaneous spinal epidural hema­

NMT1 509. 509

16-17

toma (SSEH) 224-225

spondyloptosis 241.241

glenohumeral arthritis 263-264.264

rotation 21.22.23

spray-and-stretch. myofascial trigger

instability 267

see also cervical spine; lumbar spine;

points 121

thoracic spine

springing test

evaluation 494-496.494-496 apprehension test 494.494

Spine Motion Analyzer 59. 60.67.68

lumbar spine 434.434

neurogenic amyotrophy 223.224

spine test 77 -78. 454.454

thoracic spine 401.401

rotator cuff tear 256-259.258

splenius muscles 634.635

stenosing tenosynovitis 281

rotator cuff tendinopathy 253-255

splenius capitis 634. 635

stenosing tenovaginitis 281

simultaneous shoulder and elbow

splenius cervicis 634.635

stenosis 242-243

destruction 268-269

split fibers 90. 91

cervical spine 162.189.190-191.192

SLAP (superior labrum anterior pos­

spondyloarthropathy

lumbar spine 161.211.225-226.

terior) lesion 266-267 side-effects see complications

muscle correlations lateral lumbar intertransverse 661

skin palpation 138.139-140

psoriatic 234

skin rolling test 139-140

seronegative (SNSA) 234-235

786

Copyrighted Material

226 sternal syndrome 122.122.123 sternoclavicular joint evaluation 501-502.501-502

Index

mobilization without impulse 508,

mobilization without impulse 600,

508

600

see also shoulder

translation evaluation 592-594,

magnetic resonance imaging 203,

592-594

203

sternocleidomastoid muscle 664-665, 664

computed tomography 203,203

tarsometatarsal joints, mobilization

length testing 665,665

without impulse 600, 600

myofascial trigger point treatment

tender points 127,128,143

733,733 stretching of 666,666 sternum 396 irritation zones 396,396 strength assessment see muscle

imaging studies 201-203

fibromyalgia syndrome 143 tendinitis

plain radiographs 201,202 irritation zones 394-395,394,395 provocation maneuvers 395 muscle origins and insertions 397 palpation 393-394,394,395

Achilles 326 calcifying,shoulder 259-261,261 tendinosis 134

strength assessment

shoulder 253-255

student's elbow 273

see also myotendinosis

scoliosis 245 three-dimensional coordinate system 41 -42,41,42,43 thrust techniques 4

see also mobilization-with-impulse

subcalcaneal pain 324-326,326

tennis elbow 270

suboccipital muscles 638-639, 639

TENS (transcutaneous electric nerve

thumb see hand

length testing 643, 643

stimulation) 39

toe disorders

rnyofascial trigger point treatment

tensor fasciae latae muscle 715-716,

hallux rigidus 319-320,320

728-729,728-729

715

hallux valgus of the great toe

(MWITH)

obliquus capitis inferior 642-643,

exercises 35

317-318

642,643

length testing 716

lesser toes 321-322,322

obliquus capitis superior 642,642,

stretching of 717, 717

mobilization without impulse

643

therapeutic window 148, 148

rectus capitis posterior major 640,

thermotherapy 39

total hip replacement surgery 299,

640, 641

thoracic cage muscles 672

299

rectus capitis posterior minor 640-641,640, 641 subscapularis muscle strength testing 492,492 tear/rupture 257, 258

see also specific muscles

601-602,601-602

complications 299

thoracic intertransverse muscle 659,

traction marks 207

659

training therapy see reconditioning and

thoracic spine

training therapy

biomechanics 64-66

translatory motion 6

superior labrum anterior posterior

axial rotation 64

transversospinalis muscle group

(SLAP) lesion 266-267

coupled movements 65,65

644-652

supracondylar humerus pseudoarthro­

flexion and extension 64

transversus abdominis muscle 685,

sis 269,269

range of motion 64, 65,65

686,687

supraspinatus ligament 662,662 supraspinatus muscle evaluation 490,

side-bending 64 bony landmarks 393, 394

strengthening of 688-689

see also abdominal wall muscles

490

disk herniation 220

trapezium translation 543, 543

supraspinatus tendon

examination 398-402

trapezius muscle 607-608, 607

calcification 261

active motion testing 403,403

length evaluation 608, 609

tear/rupture 256,257,258, 258

passive motion testing 398,398,

myofascial trigger point therapy

403,403

736-737,736-737

surgical treatment 215 scoliosis 248-249

with active assistance 402, 402

stretching of 610,610

rotation 400, 400

trauma, vertigo and 228

symphyseal syndrome 124-125,124,

side-bending 399, 399

treatment plane 9-10

125,126

springing test 401, 401

treatment risks see risks

swimmer's shoulder 253

synoviaI cyst 284

functional treatment 406-414,

treatment selection 145-159

synovial joints, mobilization without

435-437

Trendelenburg sign 287,287,556-557

impulse 17,17

mobilization with impulse

syringomyelia 223,223

387-391,387-391,409-414,

systematic myotendinosis 131

419-414

trigger point therapy see myofascial

mobilization without impulse

trigger point therapy

T

triceps surae muscle 721 NMT2 722, 722

406-408,406-408,414,414,

trigger points see myofascial trigger

435-437,435-437

points

talocrural joint see ankle

NMT1 392,392

triquetrum translation 542,542

talus translation 590,590

NMT2 407-408,407-408,435,435,

trunk

target fibers 89-90,90

437,437

extension and rotation 36

tarsal joints

self-mobilization 392,392

side-bending movements 37,37-38

787

Copyrighted Material

Index

tumors. extramedullary intraspinal

course of 6 1. 61

de Quervain disease 281-282

222

cervical spine rotation and 6 1 -62.

degenerative arthrosis. carpometa­

twitch response 143

62

carpa l joint 282-284. 284

type grouping 89. 89

motion testing 340. 340

type I (slow-twitch) muscle fibers

provocation tests 62-63. 340. 340

280. 281

87-88. 142

spontaneous dissection as complica­

examination 523-543

Dupuytren contracture 279-281.

type II (fast-twitch) muscle fibers

tion 172

active Illation testing 525. 525

87-88.142

ultrasound examination 63-64

distal radioulnar joint 538-539.

vertebral column

u ulnar nerve compression test 529. 529

functional evaluation 527-528.

527-528

palpation 519. 519

ultrasound

538-539

bony malformations 164

passive motion testing 530-531.

inflammation. chronic rheumatoid

530-531. 533-534. 533-534

arthritis 166

radiocarpal joint 540. 540

vertebral fractures

functional treatment 548-552

pathologic 164

ganglia 284-285

see also carpal bones

vertigo 226-228

associated disorders 227-228

wrist extensors 725-726. 725

cervicogenic 163. 226

extensor carpi radialis brevis 726

treatment 30. 39-40

differential diagnosis 227

extensor carpi radialis longus

vertebral artery examination 63-64

examination 227

725-726

upper limb 252

examination 481. 481

vestibular neuronitis 227

extensor carpi ulnaris 726

Viking disease 279

isometric contraction against resist­

muscles 693

see also elbow; hand; shoulder; wrist

ance 518. 518

NMT2 727. 727

w

palpation 530. 530

WDR ( wid e dynamic range) neuron

v

varus and valgus stress testing

elbow 513. 573

knee 578. 578

vertebral artery 55. 61-64. 63

wrist flexors. palpation 532. 532

100- 10 1

whiplash-associated disorder (WAD)

79-80

wrist 276-285

carpal tunnel

z zero-force barrier (ZFB) 8

syndrome (ITS)

276-279. 278

788

Copyrighted Material

zygapophyseal joints see apophyseal

joints; facet joints