The degenerative changes of spondylosis, osteophytic ...



MOBILISATION OF THE SPINE

Notes on examination, assessment and clinical method

Gregory P. Grieve

Churchill Livingstone, 4th Ed. 1984

Chapter 15

The degenerative changes of spondylosis, osteophytic trespass, fibrosis, acquired stenosis, spinal root irritation, secondary contracture of soft tissue, segmental instability and segmental stiffness (for one reason or another) provide the major bulk of what we might term a family of 'abnormalities of movement', and since only I in 10 000 subjects progresses to the stage, of myelography and major surgical procedures, i.e. 0.01 per cent conservative treatment is of the utmost importance.

A most superficial survey of the daily case-load of accident and emergency, orthopaedic, rheumatology, rehabilitation and sports injury clinics, and the multifarious needs of these patients with vertebral and peripheral joint pain in terms of passive and active movement techniques of one kind or another, suggests that to see manipulation proper as only the production of a click by facet-joint (or any other joint) gapping, is greatly to restrict its considerable and rightful place in physical medicine.

There is ample evidence that nociceptor activity giving rise to pain also generates extensive reflex effects; there is similar evidence that the simple passive movement of joints likewise generates reflex effects.

It is untrue that treatment by mobilisation and manipulation can be adequately discussed only on a mechanical cause-and-effect relationship; while we continue to regard musculoskeletal joint problems as simple mechanical ones, while we conceptualise only like mechanical engineers, our potential for better results will remain restricted.

Millions of asymptomatic individuals are walking about with mechanical joint problems.

We have every reason for progressing to the point where we begin to think like telecommunication engineers -since the most basic acquainteriance with spinal joint neurophysiology and recent research findings indicate that the phenomenon of joint pain and its relief by mechanical techniques involve effects which transcend simple mechanical ones, e.g. widespread reflex changes in the degree of facilitation in spinal motor neurone pools, voluntary and smooth muscle tone, vasomotor and sudo-motor tone and alterations in pulse rate, cardiac output and blood pressure.

If we add to this the effects of treating chronic changes at the junctional vertebral regions, and that of modulating the chronic changes in texture and extensibility of the soft tissues, simple therapeutic concepts of 'putting back' things which are 'out', or hoping to routinely deal with joint pain by manoeuvres restricted to a single segment, begin to be seen as inadequate.

There are many alternatives to high-velocity thrust techniques.

Confident, gentle and skilful handling by whatever technique is a very powerful therapeutic weapon, and therapists who handle their patients with insight and understanding, and examine them attentively with care for detail, have already won half the battle; willy-nilly, they have already been psychologically cast by the patient in the role of 'the sympathetic handler who will make me better', and the confident and skilful therapist fulfils the role, satisfying a deep and unconscious psychological need. Only so far as this powerful psychological need is concerned, the actual clinical method of handling pales into insignificance; so much so that, even should the therapist not make the patient sign- and symptom free, the burden of pain may be considerably relieved, and the patient calmed and reassured.

Although treatment of a single segment is often sufficient in the very early stages of dysfunction of that segment, where none existed before, the greater majority of joint problems present as a complex of chronic changes.

There is no magic in the manipulator's hand, there is no mystique of manipulation. But there is, a central mystery, and it lies in the variety of responses of the abnormal joint to the different things we do in the way of treatment by passive and active movement of one kind and another.

Joints cannot read books, or understand theories about technique; what suits one joint problem will not suit another. We must learn to be humble in the face of this mystery, we must learn to listen to what the abnormal joint is trying to tell us -in short, we must learn to assess.

Questions of rationale

There is a disconcerting gap between observed mechanical effects of localised mobilisation techniques, extension postures, manipulation and/or traction on the one hand, and on the other precisely why our procedures relieve symptoms and restore function. In short, we simply do not know, and it is perhaps a disadvantage to students to suggest or imply that we do.

The best that can be said, about the precise means of therapeutic success, following any mobilisation, manipulation or other technique directed to a particular vertebral segment or district, is neatly and truly expressed by O'Brien"', who suggested the phrase 'modifying the local environment.

This is as far as our certain knowledge goes. 10 For example, cervical, thoracic and lumbar rotation techniques are some of the oldest and most useful procedures known to therapists. Since Caxton (1422-1491)*, it has been difficult to find a manipulation' text which does not include them. Like spinal traction, the technique of regional lumbar rotation (Figs. 11.36, 15.1) is a prime example of manipulation being all things to all men; it is as old as the hills, and to the best of the author's knowledge there is no school of manipulation in the teaching of which it does not form part of the technique repertoire, in one guise or another. There are many slight variations of technique, of hand placing and method of contact with the patient; the effects are variously described as 'restoring the normal configuration of the disc', 'shifting the nerve root off the disc', or 'correcting' unilateral sacroiliac joint asymmetry. Our difficulties arise because the techniques may indeed do just this, but the correlation between what has actually happened in the large family of soft tissue and joint structures influenced by the manipulation and what we may believe, or hope, has happened, is manifestly sketchy.

Any reasonably comprehensive review of the many modern texts on manipulation soon reveals that variations of technique, and the reasons for these, can sometimes be as plausible as the variety of explanations of effect.

Haldeman" has tabulated some hypotheses, from times past to the present, of the nature of therapeutic effects of manipulative therapy:

Theory Author

1. Restore vertebrae to normal position Galen (1958)

2. Straighten the spine Pare (1958)

3. Relieve interference with blood flow Still (1899)

4. Relieve nerve compression Palmer (1910)

5. Relieve irritation of sympathetic chain Kunert (1965)

6. Mobilise fixated vertebral units Gillet (1968)

7. Shift a fragment of intervertebral disc Cyriax (1975)

8. Mobilise posterior joints Mennell (1960)

9. Remove interference with De Jarnette (1967)

cerebrospinal fluid circulation

10. Stretch contracted muscles, causing Perl (1975)

relaxation

11. Correct abnormal somatovisceral Homewood (1963)

reflexes

12. Remove irritable spinal lesions Korr (1976)

13. Stretching or tearing of adhesions Chrisman et al. (1964)

around the nerve root

14. Reduce distortion of the annulus Farfan (1973)

Speculation and hypothesis, however well informed and rationally-conceived, 'remain such, and teaching students how to perceive, and bow to discriminate between fact and fancy, is much more important than 'teaching them how to manipulate'.

Benign joint problems are successfully treated in many ways, and there is no single universal system or philosophy of treatment. The mere presence of physiotherapists and manual therapists, osteopaths, orthopaedic physicians, chiropractors, naturopaths and bone-setters makes the point-besides the existence of various factions within these groups.

Thus it is wise to look at all aspects of work in this field because, in differing proportions, there is something valuable to learn from each.

As manual therapists get the experience to gainfully compare the rationale and treatment methods of others in the field, they will note how differing examination methods, and differing emphases on the relative importance of positive findings, accurately reflect differing views."

Forms of extrapolation on the few available facts, and hypotheses, also vary considerably, a clear indication that our certain knowledge is all too limited.

There are particular ways of examining, allied to particular emphases in treatment and particular techniques. Examples of these are:

a. placing prime importance upon evidence of chronic muscle imbalance, or soft tissue dysfunction"

b. accurately noting the distribution and behaviour of pain, in relation to particular physiological movements and/or postures of the lumbar spine"'

c. as above, including careful manual testing of accessory segmental movements, and noting their effects (if any) on the behaviour of symptoms"'

d. a particular emphasis on which segmental movements, i.e. flexion, extension, rotation, of a vertebra may be restricted, and in what way

e. observing the incidence of particular patterns of movement limitation in different joints, then formulating ideas and treatment rationale on this basis." The absence of particular and common patterns also has import in this school of thought

f. special importance attaching to notions of possible 'malposition' or 'mal-alignment' of vertebrae, and the possible neurophysiological consequences. Hence X-rays are given more importance than just a means to exclude neoplastic and other diseases or gross mechanical defects."

While these shorthand descriptions cannot be completely fair, they do give a salient principle of the different approaches mentioned. All philosophies of manipulative treatment incorporate all of the factors outlined above in varying degree, yet a recognisable emphasis on one or another of them will often easily identify the faction to which an individual clinician belongs.

The effort to understand others' rationale and procedure is well worth while, giving a more comprehensive grasp of the whole context of this work, besides improving one's own effectiveness, of course.

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