Kkkk - SP-01



1) KINESIOPATHOLOGY:

( This is bad biomechanics the following can occur:

a) neuorpathology

b) myopathology

c) connective tissue pathology

d) vascular abnormalities

( Any of the above may cause the other to occur and creates a viscious cycle.

( This is why we consider the subluxation as a complex and not simply “a subluxation”. Many things occur when a joint becomes subluxated.

( 3 important and fundamental aspects to remember are the following:

a) inflammatory response occurs when the intracellular fluid of damaged cells spills into the extracellular fluid.

b) histopathology (pathoanatomy) describes how the cells are broken (ie: what it looks like)

c) biochemical abnormalities is a way of explaining that whe cells die, they change biochemistry and events such as chemotaxis occurs.

( Movement is LIFE !!

This is extremely important to understand. If there is a decrease in movement, then degeneration sets in. When this occurs the patient is likely to move even less, leading to even more degeneration.

( TISSUES INVOLVED WITH MOVEMENT:

There are many tissues involved some of which are:

a) Osseous tissues

b) Soft Tissues (CT)

c) CSF (Cerebrospinal fluid)

d) Dural Sac/Cord (Breig)

( Breig was a neurosurgeon who believed that a straight cervical spine was problematic and therefore set about correcting it by surgical intervention (he should have called the chiro). By correcting the straight cervical spine he was able to relieve his patients from much suffering.

His thought was that a straight cervical or slightly flexed cervical spine led to tightening (stretch) of the neural tube because it is tied to the dural sheath. Extension created a release and less tension. [ Then Dr. Bloom gave an example of a patient who beat her child, and how she could beet the tension building up. Correction of her spinal tension via “Chiropractic care” help her reduce her urge to beat her child]

Also in a straight cervical spine the joints are not loaded and slightly separated from each other. This causes all the weight to be carried by the Cervical disc and leads to degeneration of the disc.

( HYPO-HYPER-MOBILITY

( essentially Dr. Bloom referenced Motion segments (nachemson, SPINE 1979) as our position with regards to having hypermobility above and below a hypomobile segment

2) NEUROPATHOLOGY:

(Segmental Nerve:

( When we have a segmental nerve much pathology is occuring and much degeneration must occur before we have nerve involvement.

( When we talk of segmental nerve we talk about “DISC PATHOLOGY” and the following 3 scenarios may occur:

a) Chemical Radiculitis:

( It can occur when the disc herniates & cells break down fragments of the annulus become “angiogenic” ( create new blood vessels).

( Then inflammatory mediators are brought in and the whole area swells up (inflammatory spill over effect). This is an immobilizer effect and is protective.

( If the spill over effect is large enough then the nerve root may become involved and inflamed (the problem is not the nerve root; rather the fact that inflammatory mediators caused it to swell)

( The disc does not create the pain. The inflammatory response creates the pain.

( Therapuetic approach is through Chiropractic and restore intersegmental movement. We need to increase blood supply to move in fresh blood and remove old blood.

( If intersegmental motion is not restored then we have build up of fibroblasts and later on “dural Adhesions” (scar tissue from nerve to body of vertebra)

( We use an MRI or CT scan to determine the problem when a patient presents with nerve root symptomatology

( Trophic Substances (synapses):

( Within the nerve we find the transport of trophic substances. These substances are directly related to the growth & function of the target tissue. If you change the nerve supply to a tissue, that tissue will begin to change its function & physical qualities to align itself with the new nerve supply.

( The trophic substance is not affected by compression (Compression will cause sensory/motor deficits long before any trophic changes occur). It is mostly affected by chronic irritation of the nerve.

( Wear & Tear of Joints:

( The greatest amount of wear & tear occurs where an area of hypermobile joints meets an area of hypomobile joints (generally at the transitional zones). In the cervicals this will be around C5/C6 (because C7/T1 is not all that mobile).

( This wear and tear occurs because of the “translation of forces”.

2) NEUROPATHOLOGY:

(The Reflexes:

a) Somatovisceral: ( starts in the body wall and creates visceral response (spinogenic response)

b) Viscerosomatic: ( Starts as a visceral problem and refers to a body wall (gallbladder referring to the shoulder)

( If pain made worse by touching area, then most likely the problem is musculoskeletal in nature.

c) Somatosomatic: ( Starts as a spinal problem giving rise to a body wall issue (cervical subluxation leading to headaches)

( Dorsal Root Ganglion:

( Embryologically is important because it explains why we can feel certain pains in the body that at first do not appear to be linked to other body parts.

( Lateral Crest is composed of: DRG, Sympathetic Chain & Adrenal Medulla (ALL HOT WIRED TOGETHER)

( The Dorsal Root Ganglion (DRG) is considered the “Sensory Nerve Brain” & lies in the IVF (except for C1, C2). Although it is well protected from trauma, if the IVF becomes stenosed then irritation may set in on the DRG.

( If we have disc degeneration then we have compression of the DRG which leads to firing into the Spinal column. Moreover, this firng continues even after the stimulus is removed.

( A big problem that we have in the DRG is that it is highly vascular & there is NO Blood to Nerve Barrier. Moreover, the veinous plexus (Batson) has no valves in it. Veinous flow is dependant on movement. If we have a Hypomobile segment then we get pooling of bllod near the DRG. This leads to toxic substances in & around DRG (causes inflammation & SPONTANEOUS DISCHARGE into Spinal column)

( Polio affects mainly the motor neurons of the anterior horn.

( The Cranial Nerve Nuclei in the brain stem are actually Lower Motor Neurons.

|NERVE LOCATION |AMOUNT OF HG PRESSURE TO CAUSE CHANGE |

|DRG |5 mm Hg |

|Nerve Root |25 mm Hg |

|Sciatic Nerve |100 mm Hg |

3) MYOPATHOLOGY:

( It parallels Neuropathology & part of it is:

- Righting Reflex: Body wants to keep odontoid over 2nd sacral tubercle

- Tectospinal Tract Central Control: Body tries to keep eyes level to horizon

( Joint Immobilization:

- causes muscle atrophy (all muscles even those of spinal joints).

- A hypomobile joint will show physiological changes within 1 week & first things to go are the proteoglycans.

( Muscle Facilitation & Immobilization:

( Shortened muscles Decrease Tension Producing Ability (TPA)

( Lengthened muscles Increase Tension Producing Ability (TPA)

( Facilitation causes excessive Afferent Stimulation into CNS ( altered Efferent Info

3) CONNECTIVE TISSUE PATHOLOGY

( Immobilization:

( This is the greatest factor affecting connective tissue

( All of the following are implicated in Connective Tissues:

- Bone - Tendon - Annular fibres - Synovial fluid

- Ligaments - Cartilage - Nucleus Pulposis - Articular Capsules

- Fibro-fatty tissue (blood, skin, Fascia CSF)

( Joint Stiffness/Contracture:

( Synovial Fluid consolidates into Fibrofatty tissue and then into Fibrous tissue

( Articular cartilage shrinks with the decrease of proteoglycans

( Adhesions (interarticular) start building up

( Bone may ( Calcium due to ( weight bearing & vice versa

4) VASCULAR ABNORMALITIES:

( Arterial/Venous Blood supply:

( Today we talked about the importance of maintaining a good supply of blood to the spinal column as well as a good venous return. The DISCS are dependant on clean blood in order to maintain thei integrity.

( Without the blood supply/venous return symptoms of nerve root damage may be present. As an example “Lower extremity pain” may be caused by three possible mechanisms:

1) Piriformis syndrome

2) Chemical radiculitis (as discussed in first part of course)

3) Compression of Longitudinal Epidural vein

( In this thrid case the meninges with longitudinal vein gets compressed & restricts blood flow away from the Nerve.

( A number of experiments/studies have shown that occlusion of the Batson’s plexus leads to joint stiffness like symptoms ( Wright) & that herniations compress Longitudinal/epidural veins long before nerve roots (Theron&Moret)

( Batson’s Plexus:

( This is the venous return plexus that has no valves in it & is ( dependant on movement of intersegmental nature to drain the spine & meninges. If movement doesn’t occur we have pooling of blood And toxins become stuck in the area causing inflammation to occur.

5) INFLAMMATORY RESPONSE:

( The Inflammatory response can be considered like the sum of cellular & biochemical responses controlled by the vascular system. If the inflammation is chronic then tissue degeneration occurs & we have “Fibroblast” proliferation.

( We know that the inflammatory process is related to immobilization & that this process if brought to an extreme will lead eventually to ossification.

( Dr. Chann Gunn (MD) was instrumental in demonstrating that even normal appearing vertebrae on radiographs can be painful even before pathology is present (at least 30-40 % degeneration needs to occur to visualize). This is called “PRESPONDYLOSIS”.

( A diffuse disc problem (Prespondylosis) is felt like a pain across the back.

6) PATHOANATOMY (HISTOPATHOLOGY)

( Dr. Bloom skipped over this section. All we really need to know is that histologically we get cellular breakdown within hours of immobilization.

7) BIOCHEMICAL ABNORMALITIES:

( Bad Biomechanics & Tissue changes:

(( Essentially, Bad Biomechanics leads to Tissue changes. This has been described by both Adams & Lantz separately.

( The Collagen, Proteoglycans, & Hyaluronic Acid are the building blocks of soft tissues. If the tissues are damaged & inflammation sets in then the connective tissues release “Bradykinins & Histamines”

( Substance P is produced in the DRG & is found floating around in the periphery of nerves even after a subluxation is corrected. It can stay around for up to 6 weeks & will lower nocicpetor firing threshold. Because of this reason we must explain to patient that after the adjusting there may be some slight discomfort.

8) SPINAL LEARNING:

( The spinal column is capable of learning new things. Explain to patients how their bodies have been held in improper positions for so long that one adjustment is not going to be enough (Give example of thumb over thumb in hand prayer position).

( With the bad biomechanics we have sensory changes on the paraspinal structures which lead to changes in the Reflex Pathways causing:

- myospams -edema - immobility

- chronic pain - recurrent injury - resistance to TX

( Mechanism of Sponolearning:

( Nocicepetors fire into the CNS causing altered movement patterns.

( Abnormal afferents go to brain leading to Abnormal motor control

( Abnormal motor control signals abnormal afferent information (Adjustment done here)

( Then we have abnormal “learned” movement patterns

( Sponolearning & Subuxation:

( Bad Biomechanics leads to Low grade tissue damage

( Then we have release of Sub.P, bradykinin, prostglandin, K+ etc

( This is followed by nocicetor firing & inflammation with swelling (edema0

( IMMOBILIZATION OCCURS with muscle spasms

( We then learn a new movement pattern

THIS IS SPONOLEARNING

( For the chiropractor this means that you must tell your patient that after being adjusted they will be using new muscles & that other muscles must be retrained. There will be a period of discomfort associated with this.

9) THE IV DISC & THE VSC

( The IVD is a fibrocartilagenous complex which connects two adjacent vertebral bodies together.

( It is composed of 3 components which are:

( Annulus fibrosis: - These are lamellae of collagen fibres that are angled at 60-65( from the vertical axis. Layers alternate in direction.

( In rotation 1/2 fibres tighten & the other half loosen up.

(( The discs are most vulnerable with rotation & flexion

( Nucleus pulposis: - This is not an encapsulated entity; but instead there is a slow transition from annulus to nucleus.

- It has its origin form the notochord & is avascular except for outer 1/3.

( This is the most hydrophilic region of the disc & in a normal adult contains 81% of water.

( It is reported that substantial nuclear degeneration occurs before the annular fibres rupture.

( Vertebral Endplates: - They are generally 1mm thick peripherally & become thicker as we go centrally.

- They are composed of hyaline & fibrocartilage

(They are the source of nutrition because they are porous & in contact with blood vessels in the vertebral body spongiosa. Nutrients & water enter while the metabolic wastes exit the IVD.

( There is generally no dense plate separating the endplate from the spongiosa. However, a Schmorl’s node may form due to a high load trauma. Then we have subchondral sclerosis which prevents the exchange from occuring. When this happens we begin to have a degenerative process take place.

( Height of disc & IVF size:

( The height of the disc is responsible for the IVF vertical size. It is most responsible for the size in the Lumbar (50%), Thoracic (25%), Cervicals (15%).

( The loss of height of disc is considered permanent.

( Osteo Arthritis is mainly caused by an increase in weight bearing & piezoelectric currents which lead to an increase in bone deposition.

( The MRI picks up the water concentratin in the Nucleus Pulposis. All healthy discs will be the same colour. White discs have lots of water & radioopacity is areas of less water (dessication). [THESE AREAS WOULD ACTUALLY LOOK NORMAL ON AN XRAY IN THE BEGINNING SAGES OF DETERIORATION].

(( Movement keeps the disc properly hydrated.

( Innervation of the IVD:

( ALL around generally: Outer 1/3 Vasomotor (sympathetic), Proprioceptive, Nociceptive, Mechanoreceptive

( Posterior disc: Recurrent meningeal nerve (most problems arise here)

( Anterolateral Only: Br. of Gray Rami Communicans & Br. Sympathetic chain

( Posterolaterally Only: Br. of anterior primary division & Br. of Gray Rami Communicans & communicating Rami of Sympathetic chain

9) THE IV DISC & THE VSC

( Disc Disruption:

( May be of the following types:

- Circumferential separating adjacent lamellae

- Radial going from deep lamellae to superficial lamellae

- Protrusion, also known as Bulging or Herniation

- Extrusion, where the Nuclear Material is now located outside the Annulus Fibrosis. Here it will create inflammation, angiogenesis & auto immune responses.

( Cauda Equina syndrome is where we have a loose piece of nuclear material floating around in the Spinal canal causing the following symptoms:

- constipation, inability to urinate, BILATERAL LEG Pain (must D.D. this to eliminate vascular, endocrine, scleroderma, B12 deficiency, & ovarian problems)

- patient will have localized pain, muscle spasms & sensory loss near sacral nerve areas.

( Compressive Forces:

( In a healthy discs compressive forces are transmitted to the endplates.

( In unhealthy discs the compressive force goes to the Annulus & it may rupture. However, the endplate willl fracture first causing a Schmorl’s node in the Vertebral body. When this happens, then the Nuclear material goes into a highly vascular area & inflammation sets in!!

( Once this happens, then we have subchondral sclerosis of the area & reduce the flow of metabolic wastes/nutrients.

( Treatment protocol for Schmorl’s node is to keep the joint moving as much as possible to prevent “subchondral sclerosis”

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SYMTOMATOLOGY OF CHEMICAL RADICULITIS

1. Stabbing pain (proximal or distal to radiculitis)

2. Impaired motor function ( atrophy/weakness (initially spasms)

3. Impaired sensory function ( numbness/parasthesia

4. Impaired reflexes ( diminished reflexes

WHEN YOU TAKE A XRAY MAKE SURE TO DO BOTH CLOSE UP WORK & THEN STEP BACK ABOUT 7 FEET TO GET THE OVERALL PICTURE.

THIS WILL HELP YOU SEE THINGS MUCH MORE CLEARLY

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